1. BSG Guidelines Management of Dyspepsia
Dr Terry Wong
Consultant Gastroenterologist
Guys and St Thomas’ Hospital

2. Recommendation Grading
A >1 meta-analysis, systematic review or body of evidence from RCTs
B high quality case control or cohort studies, or extrapolated from a meta-analysis, systematic review or RCTs
C lesser case control or cohort studies
D expert opinion or case series / reports

3. Dyspepsia Introduction
Dyspepsia is not a diagnosis but a collection of symptoms including; upper abdo discomfort, heartburn, retrosternal pain, anorexia, nausea, vomiting, bloating, fullness and early satiety
Prevalence in the Western societies is quoted at being between 23 – 41%
4% of GP consultations are for dyspepsia
10% of these are referred to hospital
2% of entire adult population receive either an OGD or a barium meal each year

4. Causes of Dyspepsia Normal 30% Gastritis, Duodenitis, HH 30%
GORD %
DU %
GU %
Oesophageal, Gastric Ca 2%

5. Rationalisation of Endoscopy
Patients with dyspepsia in whom endoscopy is inappropriate
Those < 55y with uncomplicated dyspepsia
Patients with known DU who have responded appropriately to medication
Those who have recently had an OGD for the same symptoms
“Test and treat” has replaced the “test and scope” strategy in patients <55y A
Pros = approporiate for PU, reduction of relapse, may benefit H.pylori associated non-ulcer dyspepsia, potential reduction in Cancer risk
Cons = increases antibiotic exposure, may miss significant GORD and Barretts oesophagus (although therapy here should be directed at symptom control as treatment directed at healing does not prevent the known complications)

6. H.Pylori Ix
Serology A
Simple, useful, less specific than other methods
Instant / near tests are less accurate and not recommended
13C Urea Breath Test B
13C or 14C cleaved by the H.pylori urease and then monitored in the exhaled breath
Best test for identification
Best test to ensure eradication
Endoscopic Clo Test B
Cheap, accurate but endoscopy not always necessary
Recommended in all patients with newly found PU
Faecal Ag Tests ?

7. Rationing of Endoscopy
Death from diagnostic OGD = 1 in 2-10,000
The incidence of gastric Ca is age related
OGD is recommended in all patients >55y D
with new onset uncomplicated dyspepsia
for > 1/12 duration
Most patients with gastric cancer have “alarm symptoms”
OGD is recommended in all patients with “alarm symptoms” C
National Cancer Guidelines request Ix within 2/52
These include dyspeptic patients with:
Unintentional weight loss
GI Bleeding
Previous gastric surgery
Epigastric mass
Previous gastric ulcer
Unexplained Fe deficiency
Dysphagia or Odynophagia
Persistent continous vomiting
Suspicious barium meal

8. Treatments Pre – Endoscopy <55y = Test and treat
>55y = Pre-treatment with anti-secretory drugs may mask significant diagnosis D therefore BSG recommend witholding or stopping pre-treatment 4/52 before OGD
Oesophagitis
Lifestyle advice
weight loss, propping up head end of bed
Medication
Symptom relief
4/52 course of PPIs recommended by NICE D
Follow-up
? Long term management of Barretts
Repeat OGD only recommended to review
Healing of oesophageal ulcers
Dilatation of strictures
Anaemia secondary to GORD

9. Treatments Functional Dyspepsia Lifestyle advice Medication
little benefit (stop smoking) D
Medication
Recommends H.pylori eradication D
Cochrane review May 2000 showed resolution of symptoms in 9% after H.pylori eradication therapy
Symptomatic control with anti-secretory agents is recommended especially in ulcer like or reflux like symptoms B
Stop NSAIDS D
Reassurance may be sufficient D

10. Treatments Duodenal Ulcers / Erosive Duodenitis
95% associated with H.pylori
Advise confirmation, although this may be unneccssary
HP +ive DU A
1st Line B
PPI bd or Ranitidine bismuth citrate
Amoxicillin 500mg-1g bd Metronidazole mg bd
Clarithromycin 500mg bd
2nd Line
PPI bd
Bismuth Subcitrate 120mg qds
Metronidazole mg tds
Tetracycline 500mg qds
Follow Up
Urease breath test in all symptomatic >1/12 after finishing HP eradication therapy
In asymptomatic patients further OGD + follow up is then unneccessary unless symptoms recur or persist
In those where symptoms recur after an initial response = repeat urease breath test and treated if necessary with an alternative regime. If HP persists biopsy for C+Sensitivity D
Low dose PPI maintainance only necessary in persistent HP infections or those at risk of NSAID complications
HP -ive DU
Medication
Antisecretory therapy = Cimetidine 800mg is cheapest
Stop NSAIDS + consider COX D
OPA nesseccary only if DUs not associated with NSAIDS

11. Treatments Gastric Ulcer
70% are associated with H.pylori, most of the rest are assoc with NSAIDS
HP +ive GU
Eradication therapy A
Antisecretory agents for 2/12 (as GUs take longer to heal) D
If ongoing NSAIDS are necessary consider prophylactic PPI or misoprostol
NICE guidance on COX 2 antagonists D
HP –ive GU
2/12 of antisecretory therapy
NICE guidance re COX 2 antagonists
Follow Up
Repeat OGD in all untiil ulcer healing
Surgery if GU has not healed by 6/12 D

12. Resource Requirements
Easy access for GPs to organise urease breath tests
Aim to provide rapid access to endoscopy for all those meeting criteria
Aim to provide endoscopy access within 2 weeks for those with alarm symptoms
1 laboratory in each major city must be able to provide facilities for full bacteriological assessment of HP sensitivity and resistance

13. Summary Test and Treat strategy Age cut off increased to 55yrs
Increased use of urease breath test
Confirms use of NICE guidance on PPIs

14. Diagnostic algorithm

15. The step-down approach to the management of reflux disease
The ‘step-down’ approach provides rapid symptom relief, is efficient for GPs, and may be the preferred choice for the empirical therapy of reflux disease
Antacid/
alginate
H2-antagonist
Half-dose PPI
Full-dose PPI
Step-down – an evidence-based approach to the management of reflux disease
Much debate has surrounded the relative merits of the 'step-up' and 'step-down' approaches to the management of reflux disease. The Genval workshop recommended that, for initial therapy of oesophagitis, the most effective approach is to start patients with a PPI, followed by trials of stepping down to the lowest class while still controlling symptoms. This management strategy is also considered to be the most cost-effective by the Genval workshop. 1 The British Society of Gastroenterology dyspepsia guidelines state that, whatever approach is taken, attempts should be made to titrate to the drug that provides relief from symptoms at the lowest cost with the least influence on normal physiology.2
Dent et al suggest that the most effective therapy should be administered first. The rapid symptom control achieved should offset the higher initial drug cost and reduce the need for repeat consultation.3
Other guidelines, such as the Paris consensus statement,4 recommend a step-up approach to the treatment of reflux disease. No data are available comparing the two approaches but both agree that the primary goal should be to control the symptoms of reflux disease within a short period of time.5
References
1. Dent J, Brun J, Fendrick AM, et al. Gut 1999; 44 Suppl 2: S1–S16.
2. BSG, Dyspepsia management guidelines. Guidelines in Gastroenterology Sept 1996
3. Dent J, Jones R, Kahrilas P. et al. BMJ 2001; 322:
4. Conference de Consensus Franco-Belge. Gastroenterol Clin Biol 1999; 23: 56–65.
5. Heading RC. Prescriber 2000: March; 95–101.
Kinnear M et al : NICE 2000

16. NICE recommends…
“regular maintenance dose of most PPIs will prevent recurrent GORD symptoms in 70%-80% of patients and should be used in preference to the higher healing does” 1
1. NICE guidance to the NHS on the use of PPIs in the treatment of dyspepsia, July 2000

17. AGA Guidelines Age cut off is <45 Management options
1) Empirical treatment
2) Immediate OGD
3) Test and scope *
4) Test and treat
* may be preferential in areas with a high background incidence of gastric Ca
Scope <45y HP-ive who fail 2/12 of treatment using an antisecretory preparation and then a prokinetic agent (cisapride)