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Practice Guidelines & clinical pathway on management of Dyspepsia

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Presentation on theme: "Practice Guidelines & clinical pathway on management of Dyspepsia"— Presentation transcript:

1 Practice Guidelines & clinical pathway on management of Dyspepsia

2 Clinical Scenario 30 year old, male Call center representative
Epigastric pain Denies any alarm features Smoker; alcohol and coffee drinker Unremarkable past medical & family history Direct epigastric tenderness

3 Dyspepsia Presence of 1 or more of the following symptoms (Rome III Committee): Postprandial fullness Early satiety Epigastric pain or burning

4 Assessment & Diagnosis
Based on history and physical and exam Consider or rule out: Dietary indiscretion Medication induced Cardiac disease Gastroparesis Hepatobiliary disorders Other systemic disease

5 4 Major Causes: Chronic peptic ulcer disease
Gastroesophageal reflux (+/- esophagitis) Functional dyspepsia (NUD) Malignancy

6 Stratify Patients Age (55 or less/ above 55)
Presence of alarm features Family history of upper GI cancer Unintended weight loss GI bleeding, unexplained anemia Progressive dyspepsia, odynophagia Persistent vomiting Palpable mass or lymphadenopathy Jaundice

7 Review of Current Literatures
Peptic ulcer is found in ~5-15% of patients Gastric or esophageal Adenocarcinoma is identified in <2% of all patients who undergo endoscopy for dyspepsia Upper gastrointestinal malignancy becomes more common after age 55 years

8 Review of Current Literatures
Absence of alarm features has a negative predictive value of >97% Chronic infection with H. pylori is associated with >80% of peptic ulcers and >1/2 of gastric cancers

9 Patient Profile 30 year old, male Burning epigastric pain
No alarm symptoms

10 Empiric PPI Therapy Empiric therapy with proton pump inhibitors for 4- 6weeks Reassurance No further investigations if symptoms improve Out patient clinic follow-up

11 Failed Empirical Therapy
No response to therapy after 7-10 days Symptoms has not resolved after 6-8 weeks EGD with biopsy for H. pylori Organic disease (PUD, GERD, CA) Treat accordingly

12 Normal EGD (Functional Dyspepsia)
Reassurance Lifestyle changes Treat H. pylori if present H. pylori regimen: PPI 40 mg 2x a day Amoxicillin 1G 2x a day Clarithromycin 500mg 2x a day (10-14 days)

13 <55 y/o and below, no alarm features
Empiric PPI therapy Response Failed empirical therapy EGD with biopsy for H. pylori Functional dyspepsia Reassurance Lifestyle modifications Treat H. pylori if (+) Organic disease (PUD, GERD, CA) >55 y/o or w/ alarm features Treat accordingly

14 H. Pylori Follow -up Patients who remain symptomatic after initial course of treatment should be retested 4 weeks after completion of the course Urea breath test or stool antigen test Some success in using previous triple therapy Switch to another regimen: PPI+metronidazole+bismuth+tetracycline

15 Unresponsive Functional Dyspepsia
Persistent dyspeptic symptoms Not infected with H. pylori or have been rendered free of H. pylori Do not respond to short course of PPI therapy (-) negative findings on endoscopy

16 Unresponsive Functional Dyspepsia
Reevaluate diagnosis Consider: gastroparesis, biliary or pancreatic diseases, IBS, anxiety disorder Limited data on use of antidepressants, prokinetic agents

17 References Talley NJ, Vakil NB, Moayyedi P: American Gastroenterological Association Technical Review: Evaluation of Dyspepsia. Gasteroenterology 2005, 129:    American Gastroenterological Association Medical Position Statement: Evaluation of Dyspepsia Gastroenterology 2005, 129:   Lam SK, Talley NJ: Report for the 1997 Asia Pacific. Consensus Guidelines on the management of H. pylori. Journal Gasteroenterology & Hepatology 1998, 13:1-2.   American Society for Gastrointestinal Endoscopy’s The role of endoscopy in dyspepsia. Gastrointestinal Endoscopy 2007, 6: Sleisenger and Fordtran’s Gastrointestinal and Liver Disease 8th Edition

18 Prepared by: Dr. Ernesto Olympia Dr. Benjamin Benitez
Dr. Patricia Prodigalidad Dr. William Rodriguez

19 Thank you and good day.

20 Test-and-Treat Approach
Test for H. pylori (Urea Breath Test or Stool Antigen Test) Treat if (+) Trial of PPI therapy if (-) Do endoscopy if no symptom improvement

21 Need for in-patient work-up and care
Severity of dyspepsia Alarm symptoms present Need for additional lab tests and imaging studies

22 Possible Scenario 50 year old with CAD on ASA
Severe epigastric pain, weakness, melena Pale Will need: Hospital admission for medical management Early endosocopy, CBC Blood transfusion

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