1. Dyspepsia Ilan Lenga, former CMR and David Cherney, former CMR MSH AIMGP 2004

2. Objectives By the end of this seminar you will: –have a working definition of dyspepsia –know the main causes of dyspepsia –have a rational, cost-effective, evidence- based approach to dyspepsia

3. References AGA Guidelines for Management of Dyspepsia NEJM Review Article “Management of Non-Ulcer Dyspepsia” 339(19); 1376-81 Clinical Evidence Dec 2001 CMAJ 2000;162 (12 Suppl) OPOT Guidelines for PUD & GERD

4. US vs. Canadian Guidelines CMAJ guidelines agree with AGA AGA slightly easier to follow

5. What is Dyspepsia? indigestion bloating early satiety nausea vomiting epigastric discomfort fullness upset stomach heartburn stomachache queasiness

6. Everyone knows what it is, but no one knows what to call it! Multiple definitions in the literature Rome Criteria II (def’n for research purposes) –pain or discomfort in midline upper abdomen “Discomfort” = negative feeling which can be characterized by: fullness early satiety bloating nausea

7. Incidence Occurs in 25% of the population per year Of these 20-25% seek medical attention Accounts for 2-5% of primary care physicians’ workload

8. Differential Diagnosis Organic 40% Functional =“Non-Ulcer Dyspepsia” 60%

9. Organic Causes Peptic Ulcer Disease GERD Gastric cancer Medications (ASA/NSAIDS, Abx) Gastroparesis Cholelithiasis, Choledocholithiasis Pancreatitis (acute or chronic) Carbohydrate malabsorption Ischemic bowel Other GI malignancy (ep. Pancreatic cancer) Systemic disease (DM, Thyroid, Parathyroid, CTD) Intestinal parasite Most common organic causes, according to AGA

10. Non-Ulcer Dyspepsia The most common cause overall Defined as: –at least 12 weeks (need not be consecutive) within the last 12 months of: Dyspepsia No evidence of organic disease Dyspepsia not exclusively relieved by defecation or associated with change in stool frequency or form (i.e. not IBS)

11. Management

12. Step One History & Physical for Specific Etiologies

13. Risk Factors and Past Hx Risk Factors –Smoker, NSAID use, Heavy EtOH, FHx ulcer Personal Hx –Previous ulcer, GI bleed –DM, hypo/hyperthyroidism, parathyroid dis. –Colitis, diverticulosis, liver disease –Anxiety, stress, depression –Previous Upper GI series, OGD, Abdo U/S

14. History & Physical PUD –Past history of ulcers, NSAIDs, Smoking GERD –Heartburn or regurg symptoms, aggravated when supine, chronic cough Gastric Cancer –Older (>50), wt. loss, dysphagia, smoker, long-standing GERD

15. History & Physical Biliary Tract disease –Episodic RUQ pain > 1 hr, associated with meals, post-prandial Meds –iron, NSAIDs, bisphosphonates, antibiotics, etc. Metabolic disorder/Gastroparesis –DM, Hyper or Hypo -Thyroidism, Hyperparathyroidism

16. History & Physical IBS –Rome criteria Pain relieved with defectation more freq stools at onset of pain abdominal distention passage of mucus sense of incomplete evacuation

17. Examination Fever, weight loss, hypotension, tachycardia Abdo –Epigastric tenderness –Palpable mass –Distention –Colon tenderness –Jaundice –Murphy’s sign –Stool for OB Signs anemia –Brittle nails –Cheilosis –Pallor palpebral mucosa or nail beds Other –Teeth (loss enamel) –Lymphadenopathy - Virchow’s node –Acanthosis nigrans –Hypo/Hyperthyroid.

18. Step Two Explicitly Consider: Could this patient have cancer?

19. Red Flags Age > 45 Weight loss Bleeding Anemia Dysphagia

20. Dyspepsia Clinical evaluation Exclude by History: GERD; biliary; IBS; Meds; aerophagia From AGA Guidelines Manage appropriately  45 years and no red flags >45 or red flags Endoscopy + -

21. Step 3 Treat for Non-Ulcer Dyspepsia

22. The Role of H. pylori in Non- Ulcer Dyspepsia Association between H. pylori & Non-Ulcer dyspepsia not clear Role in pathogenesis disputed

23. The Evidence 2 RCT’s comparing “Test All & Eradicate” vs. Endoscopy-guided management for relief of symptoms 1st RCT –500 patients with >2 weeks symptoms –Results: no difference in symptom free days reduced endoscopy rate in “test & eradicate” group (40% required f/u endoscopy)

24. The Evidence 2nd RCT –“test & eradicate” strategy reduced the number of symptomatic patients at 1 year ARR 13% (-6 to 31%) RR 0.82 (0.59-1.1)

25. The Evidence One systematic review (9 RCT’s, 2541 pt’s) looked at H. pylori eradication in people with proven non-ulcer dyspepsia (after endoscopy) Results: –Small, but statistically significant improvement in symptoms 3-12 months after Rx ARR 7% (3-10%) NNT 15 RR 0.91 (0.86-0.96)

26. Non-invasive tests for H. pylori *cannot discriminate between active & previous infection (therefore, do not use to diagnose recurrence)

27. Treatment of H. pylori Multiple Regimens UHN/MSH Guidelines... 1st line: Most cost-effective (for the hosp.) Lansoprazole 30mg BID Clarithromycin 500 BID Amoxicillin 1000mg BID Alternate regimens substitute metronidazole for amoxil (but some H.pylori are resistant) 7 days HP Pack

28. American College of Gastroenterology Position "There is no conclusive evidence that eradication of H. pylori infection will reverse the symptoms of nonulcer dyspepsia. Patients may be tested for H. pylori on a case-by-case basis, and treatment offered to those with a positive result."

29. What if H. pylori is negative? Minimal evidence supports: –H2 blockers –Proton Pump Inhibitors –Prokinetic agents metoclopramide, domperidone cisapride no longer available

30.  45 years and no red flags H. pylori Testing Treat H.p. Empiric H2, PPI, or prokinetic x 1 month +- From AGA Guidelines

31.  45 years and no red flags H. pylori Testing Treat H.p. Empiric H2, PPI, or prokinetic x 1 month fails Endoscopy Follow-up success +- From AGA Guidelines

32. Step 4 Endoscopy if still symptomatic

33. Step 5 Post-Endoscopy Management

34. Endoscopy Organic DiseaseH. pylori detectedFunctional Rx & Follow-upH2/PPI or prokinetic 4 weeks Switch to other agent Re-evaluate ? Behavioral/ Psychotherapy/ Antidepressant From AGA Guidelines fails success

35. Non-pharmacologic Tx Quit smoking Stop / reduce caffeine Stop / reduce EtOH Hold medications associated w/ dyspepsia –NSAIDS, ASA Avoid foods and other factors precipitate symptoms –Better eating habits Don’t eat late Therapy for –Stress –Anxiety –Depression Elevate head of bed? Stress-reducing activities –Exercise –Relaxation Reassurance

36. Summary

37. Key Points Step One: Hx & Px –attempt to establish a specific diagnosis Step Two: Consider Cancer –urgent endoscopy if red flags Step Three: Treat for Non-Ulcer Dyspepsia –Test & Eradicate H. pylori –Acid suppression or Prokinetics x 1 month Step Four: Endoscopy –Endoscopy if still symptomatic Step Five: –Post-Endoscopy Management