Dyspepsia Resident Teaching Rounds Steve Radke August 11, 2003 References: Ontario Program for Optimal Therapeutics, Ontario Guidelines for PUD and GERD Guidelines 2000 Sander et al, “Evidence based approach to the management of uninvestigated dyspepsia in the era of H. pylori. CMAJ, June 13, 2000;162 (12 Suppl)

Dyspepsia n Introduction n PUD/GERD - overview n Investigations n Approach to dyspepsia n NSAID induced PUD n Recurrent PUD n Take home messages

Dyspepsia n - pain or discomfort in upper abdomen heartburn acid regurgitation excessive burping/belching abdominal bloating, nausea n overall prevalence 29% –DU or GU % –Reflux esophagitis % –Esophageal or gastric CA - < 2%

PUD n Lifetime incidence: men 10%, women 4% n classic sxs: –localized epigastric pain –usually intermittent –often relieved with food n poor correlation b/n sxs and ulcers

PUD n Etiology: –H. pylori associated with 90-95% DU, 60-80% GU –NSAIDs including ASA –smoking, ETOH –benign or malignant tumors

GERD n Retrosternal burning and regurgitation –89-95% specificity for GERD –worse after meals –exacerbated by position –transiently relieved by antacids n atypical presentations: –hoarseness, cough, asthma, dysphagia n poor correlation b/n sxs and grade of esophagitis most patients have no findings on endoscopy

GERD n Complications: –esophagitis –stricture –Barrett’s esophagus –esophageal adenocarcinoma –occurs in % of pts n Drug-Induced GERD anticholinergics (e.g.. TCA), CCB, nitrates, benzos, opioids, OCP, bisphosphinates

Investigations n endoscopic tests –histology, culture, rapid urease test n non-endoscopic –urea breath test, serology

H. Pylori Serology n NPV - 90% n PPV - decr. as prevalence decr. –results in increased risk of false positive –< 50 yo, PPV 52-72% n Remains positive >6-12 months post Rx –not recommended to confirm eradication

Urea Breath Test n PPV - 90% n NPV - 90% - irrespective of incidence n C13, C14 n preferred test –C13 - not covered by OHIP –C14 - only available in few major centres n can be used to confirm eradication NB: pt must be > 4 wks post Rx, and > 1 week off of PPI or H2RA

Approach to Dyspepsia n See handout n Red Flags: “ABCDV” n A - age >50, anemia, abdo mass n B - bleeding (GIB) n C - constitutional sxs n D - dysphagia n V - vomiting

NSAID induced PUD n Prevention: –PPI –cytoprotective agent - mesoprostol 200ug tid –High dose H2RA - ranitidine 300mg bid –COX-2? n 2 or more of: –Previous GIB –Previous peptic ulcer –Age >75 yo –Hx of cardiovascular dz

PUD recurrence n If H. pylori +ve –recurrence rate <5% / yr –confirm with UBT or endo. (not serology) –treat with alternate regime that does NOT have the same 2 ABx as initial Rx - x 14d n If H. pylori -ve –review NSAID use, smoking, etoh –refer for endoscopy

Take home messages: n Red flags - “ABCDV” n Retrosternal burning and regurgitation –89-95% specificity for GERD n H. pylori serology - limitations n Consider prevention in high risk pts taking NSAIDS (including ASA) n Always consider scope