1. Dyspepsia MAHSA KHODADOOSTAN-- GASTROENTROLOGIST

2. Patient is a 34 y/o lady who comes to your clinic because of epigastric pain since 5m ago She complains of bloating and early satiety too There is no alarm symptom in her history She use no drug Her physical examination is normal

3. IT OCCURS IN APPROXIMATELY 25 PERCENT OF THE POPULATION EACH YEAR, MOST AFFECTED PEOPLE DO NOT SEEK MEDICAL CARE Approach to the patient with dyspepsia

4. DEFINITION ( Rome III Committee ) one or more of the following symptoms :  Postprandial fullness ( termed postprandial distress syndrome )  Early satiation ( meaning inability to finish a normal sized meal or postprandial fullness )  Epigastric pain or burning ( termed epigastric pain syndrome )  Heartburn is the point of contraversy

5. ETIOLOGY

6. Alarm symptoms Unintended weight loss Persistent vomiting Progressive dysphagia Odynophagia unexplained anemia or iron deficiency Hematemesis Palpable abdominal mass or lymphadenopathy Family history of upper gastrointestinal cancer Previous gastric surgery Jaundice NPV=99%

7. CLINICAL APPROACH History  Ulcer-like or acid dyspepsia (eg, burning, epigastric hunger pain with food, antacid, and antisecretory agent relief)  Dysmotility-like dyspepsia (with predominant nausea, bloating, and anorexia)  Unspecified dyspepsia Physical examination :usually normal  Carnett test  A palpable mass

8. Routine laboratory tests Routine blood counts and blood chemistry S/E

9. Endoscopy  Advantage:  Gold standard test to exclude gastroduodenal ulcers, reflux esophagitis, and upper gastrointestinal cancers.  Beneficial because up to 40 percent of patients have an organic cause of dyspepsia.  It also provides reassurance to patients

10. Endoscopy  Disadvantage:  Expensive  Invasive  Not cost-effective in young patients without alarm symptoms  Rarely, endoscopic complications

11. Empiric treatment with acid suppression  Disadvantage:  Cost advantage is lost with symptom recurrence or lack of response.  High rate of symptom recurrence may promote inappropriate long-term medication use.  May delay diagnostic testing, may mask the symptoms of malignant ulcers.  Likely to provide the least patient reassurance.  Rarely, serious side effects (gynecomastia, hematologic disorders).

12. Empiric treatment with acid suppression  Advantage:  Least expensive strategy.  Rapid symptom relief,  High response rate,  May reduce the number of endoscopies.

13. Patient is a 34 y/o lady who comes to your clinic because of epigastric pain since 5m ago She complains of bloating and early satiety too There is no alarm symptom in her history She use no drug Her physical examination is normal

14. Initial management of dyspepsia

15. What do you do for our patient? Endoscopy High dose PPI Anti HP antibody

16. HP serology was positive.what do you do?

17. You treat H.Pylori but symptoms are constant?

18. HP serology was positive.what do you do? You treat H.Pylori but symptoms are constant? Test for HP eradication

19. HP serology was positive.what do you do? You treat H.Pylori but symptoms are constant? Test for HP eradication UBT is negative

20. Management of dyspepsia based on age and alarm features

21. Endoscopy in patients who have failed empirical therapy

22. Management of functional dyspepsia

23. Patient was a 60 y/o lady who was refered to me because of constant epigastric pain She mentioned 6kg wt loss since 3m ago She was anemic with ferritin =5 What is the best diagnostic test?

25. Patient is a 57 y/o man who was refered to our centre because of epigastric pain.he complains of dysphagia too.his wt is 67kg now and was 75kg about 3m ago Upper gi endoscopy was performed:

27. Be careful Unfortunately Unfortunately age of cancer is decreasing in our population age of cancer is decreasing in our population