Dyspepsia

What is dyspepsia? ‘pain or discomfort related to eating or drinking that can be attributed to the upper gastro-intestinal tract’

The problem of dyspepsia % prevalence, and increasing 25% of these seek help from GP 2 % population have endoscopies p.a % on long term PPIs £500 million pa (E&W) £ 2-3 billion Europe

Drugs that cause dyspepsia NSAIDS Bisphosphonates Steroids Metformin Calcium antagonists Theophyllines Nitrates

Endoscopic diagnoses in dyspepsia % Westbrook at al, 2001

What all patients worry about

GORD

Gastro-oesophageal junction

Causes of GORD

Diagnosis of GORD

Complications of GORD Stricture Barrett’s Oesophagus Oesophageal adenocarcinoma Extra-oesophageal –Asthma –Cough –Pharyngitis

Barrett’s Oesophagus

Barrett’s Adenocarcinoma

©Cancer Research UK European age-standardised mortality rates for oesophageal cancer in UK,

Anti-reflux surgery (ARS) Helps 90% Lasts about 10 years 50% still need PPI Morbidity in 10% (dysphagia, bloating) Laparoscopic probably better – but no evidence

Gastric Ulcer

Gastric ulcer - causes H. pylori 60% NSAIDs30% Carcinoma 5% Others 5% - neoplasia - Crohn’s - stress - ZE syndrome

Duodenal Ulcer

Duodenal ulcer - causes H. pylori85% NSAIDs 10-14% Rare causes 1% - Zollinger Ellison - Crohn’s - Stress

Giving NSAIDs in patients with or at risk of peptic ulcer Avoid NSAID if possible Consider COX2 inhibitors –Beware cardiovascular risks Hypertension MI CVA Add PPI to COX2 inhibitor Add PPI to ‘low-risk NSAID’ (ibuprofen)

Functional Dyspepsia

Gastric cancer

Age standardised (European) incidence and mortality by sex, stomach cancer, UK, © Cancer Research UK

Five year relative survival rates by sex, stomach cancer © Cancer Research UK

ALARM symptoms Abdominal swelling (Anaemia) Loss of weight Anorexia Recurrent symptoms* Melaena/Haematemesis Swallowing problems *Only if age >55 years

Audit characteristics 1170 practices –14% of practices –71% of cancer networks April 2009 – April 2010 Represents 8% of cancers registered that year

Delays for gastric cancer

Stage of gastric cancer

Number of consultations

Route of referral

Upper GI 2 week cancer referral cancers

Cancer risk in 2WW referrals % cancer

2 week UGI cancer referrals

Community Care & Pharmacy

General Advice

GP management of Dyspepsia

Irritable Bowel Syndrome

Diagnosis Pain associated with bowels Longstanding History of dysenteric illness Associated conditions –Fibromyalgia –Headache –CFS –Non-cardiac chest pain

Warning signs Short history Weight loss Nocturnal diarrhoea Incontinence Rectal bleeding Age >50 Abnormal blood tests

Blood tests FBC, CRP, UE, LFT (incl Ca), TSH, tTG, B12, folate Rectal examination

Faecal calprotectin

Useful to diagnose IBD Not useful to confirm IBS (at present) May miss other important diagnoses –Cancer –Bile acid malabsorption –Diverticulosis

Management of DP-IBS Avoid bran Reduce non-soluble fibre Reduce lactose (use soy or rice products) Loperamide Anti-spasmodics Amitriptyline

Management of CP-IBS Increase dietary fibre (20-30g) Unprocessed wheat bran Increase fluids Bulking laxatives –Ispaghula husk Consider citalopram

Pain in IBS Hypnotherapy beneficial Cognitive Behavioural Therapy beneficial Acupuncture not proven Citalopram/amitriptyline may help

FODMAPs Fermentable Oligosaccharides Disaccharides Monosaccharides And Polyols (sorbitol, sweeteners)

Category A (suspected lower GI cancer) Any patient over the age of 50 with change in bowel habit/diarrhoea (>6 weeks but <6 months) who has one or more of the following features: Weight loss, iron deficiency anaemia, tenesmus, strong family history of bowel cancer (in first degree relative aged <60), abdominal mass, mass on PR Action: Refer as 2WW to Colorectal Dept

Category B (Organic diarrhoea) Any patient presenting with diarrhoea, not fulfilling ‘A’, who has any of the following features: Bloody stools, frequent loose stools ++, incontinence, nocturnal diarrhoea, strong family history of IBD, raised CRP, positive TTG Action: Refer to Dept of Gastroenterology *Urgent referral or emergency admission is recommended for patient who may have a severe colitis, typical patients may have 6 or more bloody stools per day, fever, tachycardia and anaemia*

Category C (Probable IBS) Patient below the age of 40 who has altered bowel habit, abdominal pain or discomfort that is relieved by defaecation, bloating but in the absence of category A and B features. Action: Does not require referral for confirmation of diagnosis. To exclude inflammatory bowel disease, perform faecal calprotection test. Only refer if positive. Do not carry out faecal calprotectin within 1 week of gastrointestinal infection (will be raised). Manage as per IBS guidelines