1. Clinical features of Upper GI origin More than 4 weeks duration Pain induced or worsened by food 40% of adults have in a life time Generally benign – promote self care Symptoms are poor predictors Employ a broader definition 1

2. GI Bleeding (same day endoscopy) Progressive Weight loss Progressive Dysphagia Persistent Vomiting Iron Deficiency Anemia (IDA) Mass in the Epigastrium Suspicious Barium meal images Patient may be of any age 2

3. Dyspepsia Abdominal pain Bloating Nausea Early satiety Burping Boriborygmi Reflux Disorder Acid regurgitation Heartburn Epigastric pain Burping Water brash Dysphagia 3

4. Goals of Treatment Relieve pain Prevent complications Minimize Recurrence BleedingPerforationObstruction 4

5. Dyspepsia Alarm Signs Present No Alarm Signs Age > 55 Age  55 First Step UGI Endoscopy UID Rx Empirical 5

6. No Alarm Signs Age < 55 years UID- Rx. Empirically Test for H.pylori & Rx Second Step 6

7. Alarm Signs Present or > 55 Suspend NSAIDs Review Medications Order UGI Endo Classify Dx. Third Step 7

8. UGI Endo Dx NUD & CG GERD PUD (GU/DU) GI Ca Fourth Step 8

9. UIDMedication Full PPI for one month PPI or H2RA – one month EndoscopyLifestyle Rx. of UID 9

10. NUD Medication H.pylori test and treat Low dose PPI or H2RA 1 m No repeat Endoscopy Lifestyle Rx. of NUD Persistent Sx, low dose PPI, self-care 10

11. Complications of GERD Esophagitis Peptic stricture Barrett’s Esophagus Esophageal ulceration Upper GI bleed Adenocarcinoma 11

12. 1 Lifestyle and medications Full dose PPI for two month 2 Double dose PPI for one month Prokinetic in addition to PPI 3 H2RA or prokinetic for one month Review diagnosis if no response 4 Low dose maintenance treatment Return to self care with antacids Rx. of GERD 12

13. H.pylori testing UBT Accurate Costly Availability Dx and F/up Rx affects it C 13 labeled Stool Ag Acceptability Dx and F/up Rx effects it Serology Card test ? ELISA IgM Rx no effect Not for F/up 13

14. 1 Lifestyle and medications H.pylori tests– UBT, Stool Ag, Ab (IgM) 2 H.Pylori + Eradicative treatment + PPI Full dose PPI for 2 months + 1 month 3 Stop NSAIDs –  dose, Selective drugs Gastro-protection - Mesoprostol 4 Repeat UGI Endo after 8 weeks Non healing ulcers – see next for causes Rx. of PUD 14

15. Treatment of H.pylori Combination therapy is the rule Eradication of H.pylori essential Ulcers don’t heal if infection persists Regimen consists of 3 drugs for 7-14 d – Full dose PPI – BID + – Clarithromycin 500 mg BID + – Amoxycillin 1 g BID / Metro 400 BID Combination packs improve compliance 15

16. Non Healing PUD Non compliance with medicines 1 Ulcer turning malignant 2 False –ve H.pylori – empirically treat for it 3 Inadvertent NSAID or ulcerogenic drugs 4 Rare causes – ZE, MALT, Chron’s, MEN 1 5 16

17. FDReassurance Behavioural Suppress Acid prokinetics Depression medications Lifestyle Rx. of FD 17

18. Medications NSAIDs (not low dose aspirin) Steroids (oral - not inhalations) Theophyllines (all types) Bisphosphonates (calcium metabolism) Calcium Antagonists Immediately suspend medicines Or reduce to minimum required dose Selective COX 2 - Celecoxibe 18