1. Dyspepsia

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

3. The problem of dyspepsia 25 - 40 % prevalence, and increasing 25% of these seek help from GP 2 % population have endoscopies p.a. 0.45 % on long term PPIs £500 million pa (E&W) £ 2-3 billion Europe

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

5. Endoscopic diagnoses in dyspepsia % Westbrook at al, 2001

6. What all patients worry about

7. GORD

8. Gastro-oesophageal junction

9. Causes of GORD

10. Diagnosis of GORD

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

12. Barrett’s Oesophagus

14. Barrett’s Adenocarcinoma

15. ©Cancer Research UK European age-standardised mortality rates for oesophageal cancer in UK, 1979-1999

16. 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

17. Gastric Ulcer

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

19. Duodenal Ulcer

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

21. 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)

22. Functional Dyspepsia

23. Gastric cancer

24. Age standardised (European) incidence and mortality by sex, stomach cancer, UK, 1979-2001 © Cancer Research UK

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

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

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

29. Delays for gastric cancer

30. Stage of gastric cancer

31. Number of consultations

32. Route of referral

33. Upper GI 2 week cancer referral cancers

34. Cancer risk in 2WW referrals % cancer

35. 2 week UGI cancer referrals

36. Community Care & Pharmacy

37. General Advice

39. GP management of Dyspepsia

40. Irritable Bowel Syndrome

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

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

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

44. Faecal calprotectin

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

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

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

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

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

53. 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

54. 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*

55. 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