1. DYSPEPSIA

2. Dyspepsia Implies chronic GORD IBS Ulcers Gall Stones Cancer ‘Functional’

3. Dyspepsia Perspective 10% of all GP consultations 9,000 endoscopies per year at Walsgrave, waiting time up to 9 months Pragmatism in treatment and algorrhythms

6. Dyspepsia GORD Heartburn Waterbrash Volume reflux Response to PPIs Dysphagia Diagnosis?? Management

7. OSOPHAGITIS

8. Laparoscopic Fundoplication Normal Subject

9. Laparoscopic Fundoplication 24 hour trace of severe GOR

10. Laparoscopic Fundoplication Interpretation of 24h tape of severe GOR

11. Dyspepsia IBS Abdominal pain - sites Bloating Distension Variable bowel habit Relation to stress How to talk to them!

12. Dyspepsia Ulcers DUs - Foregut Nature of pain The 3 best features of history … GUs …. The two big causes Treatment Remember NSAIDs

13. Abdominal Pain 2002

14. Dyspepsia Gall Stones SEVERE foregut pain duration distribution vomiting recovery Other vague symptoms.......

15. Dyspepsia Cancer ‘New’ dyspepsia Cancer age group ‘Alarm’ symptoms or signs Dilemma Surgery?? Results??

16. 16 Common dyspeptic cancers Oesophagus Stomach Pancreas Liver mets 16

17. * ENDOSCOPY STRICTURES *

18. Dyspepsia ‘Functional’ Upper abdominal pain Investigations negative Relation to food, stress Vomiting unusual

21. Investigation (The conventional sequence) But really what is the question Cancer?? Or reassurance Cause of dyspepsia Helicobacter status Does it really matter?? - answer Or just treat and see?? What conditions not

24. WHICH INVESTIGATION? –QUESTION MUCOSA / THERAPEUTICS ANATOMY / FUNCTION MOTILITY FUNCTION / REFLUX -INVESTIGATION ENDOSCOPY BARIUM SWALLOW CT MANOMETRY OESOPHAGEAL Ph PPI TEST

25. ACHALASIA DIAGNOSIS MANOMETRY - BARIUM

26. Implies chronic GORD IBS Ulcers Gall Stones Cancer ‘Functional’ (Alcoholic gastropathy) DYSPEPSIA Implies chronic GORD IBS Ulcers Gall Stones Cancer ‘Functional’