BSG Guidelines Management of Dyspepsia Dr Terry Wong Consultant Gastroenterologist Guys and St Thomas’ Hospital

Recommendation Grading A >1 meta-analysis, systematic review or body of evidence from RCTs B high quality case control or cohort studies, or extrapolated from a meta-analysis, systematic review or RCTs C lesser case control or cohort studies D expert opinion or case series / reports

Dyspepsia Introduction Dyspepsia is not a diagnosis but a collection of symptoms including; upper abdo discomfort, heartburn, retrosternal pain, anorexia, nausea, vomiting, bloating, fullness and early satiety Prevalence in the Western societies is quoted at being between 23 – 41% 4% of GP consultations are for dyspepsia 10% of these are referred to hospital 2% of entire adult population receive either an OGD or a barium meal each year

Causes of Dyspepsia Normal 30% Gastritis, Duodenitis, HH 30% GORD 10-17% DU 10-15% GU 5-10% Oesophageal, Gastric Ca 2%

Rationalisation of Endoscopy Patients with dyspepsia in whom endoscopy is inappropriate Those < 55y with uncomplicated dyspepsia Patients with known DU who have responded appropriately to medication Those who have recently had an OGD for the same symptoms “Test and treat” has replaced the “test and scope” strategy in patients <55y A Pros = approporiate for PU, reduction of relapse, may benefit H.pylori associated non-ulcer dyspepsia, potential reduction in Cancer risk Cons = increases antibiotic exposure, may miss significant GORD and Barretts oesophagus (although therapy here should be directed at symptom control as treatment directed at healing does not prevent the known complications)

H.Pylori Ix Serology A Simple, useful, less specific than other methods Instant / near tests are less accurate and not recommended 13C Urea Breath Test B 13C or 14C cleaved by the H.pylori urease and then monitored in the exhaled breath Best test for identification Best test to ensure eradication Endoscopic Clo Test B Cheap, accurate but endoscopy not always necessary Recommended in all patients with newly found PU Faecal Ag Tests ?

Rationing of Endoscopy Death from diagnostic OGD = 1 in 2-10,000 The incidence of gastric Ca is age related OGD is recommended in all patients >55y D with new onset uncomplicated dyspepsia for > 1/12 duration Most patients with gastric cancer have “alarm symptoms” OGD is recommended in all patients with “alarm symptoms” C National Cancer Guidelines request Ix within 2/52 These include dyspeptic patients with: Unintentional weight loss GI Bleeding Previous gastric surgery Epigastric mass Previous gastric ulcer Unexplained Fe deficiency Dysphagia or Odynophagia Persistent continous vomiting Suspicious barium meal

Treatments Pre – Endoscopy <55y = Test and treat >55y = Pre-treatment with anti-secretory drugs may mask significant diagnosis D therefore BSG recommend witholding or stopping pre-treatment 4/52 before OGD Oesophagitis Lifestyle advice weight loss, propping up head end of bed Medication Symptom relief 4/52 course of PPIs recommended by NICE D Follow-up ? Long term management of Barretts Repeat OGD only recommended to review Healing of oesophageal ulcers Dilatation of strictures Anaemia secondary to GORD

Treatments Functional Dyspepsia Lifestyle advice Medication little benefit (stop smoking) D Medication Recommends H.pylori eradication D Cochrane review May 2000 showed resolution of symptoms in 9% after H.pylori eradication therapy Symptomatic control with anti-secretory agents is recommended especially in ulcer like or reflux like symptoms B Stop NSAIDS D Reassurance may be sufficient D

Treatments Duodenal Ulcers / Erosive Duodenitis 95% associated with H.pylori Advise confirmation, although this may be unneccssary HP +ive DU A 1st Line B PPI bd or Ranitidine bismuth citrate Amoxicillin 500mg-1g bd Metronidazole 400-500mg bd Clarithromycin 500mg bd 2nd Line PPI bd Bismuth Subcitrate 120mg qds Metronidazole 400-500mg tds Tetracycline 500mg qds Follow Up Urease breath test in all symptomatic >1/12 after finishing HP eradication therapy In asymptomatic patients further OGD + follow up is then unneccessary unless symptoms recur or persist In those where symptoms recur after an initial response = repeat urease breath test and treated if necessary with an alternative regime. If HP persists biopsy for C+Sensitivity D Low dose PPI maintainance only necessary in persistent HP infections or those at risk of NSAID complications HP -ive DU Medication Antisecretory therapy = Cimetidine 800mg is cheapest Stop NSAIDS + consider COX 2 D OPA nesseccary only if DUs not associated with NSAIDS

Treatments Gastric Ulcer 70% are associated with H.pylori, most of the rest are assoc with NSAIDS HP +ive GU Eradication therapy A Antisecretory agents for 2/12 (as GUs take longer to heal) D If ongoing NSAIDS are necessary consider prophylactic PPI or misoprostol NICE guidance on COX 2 antagonists D HP –ive GU 2/12 of antisecretory therapy NICE guidance re COX 2 antagonists Follow Up Repeat OGD in all untiil ulcer healing Surgery if GU has not healed by 6/12 D

Resource Requirements Easy access for GPs to organise urease breath tests Aim to provide rapid access to endoscopy for all those meeting criteria Aim to provide endoscopy access within 2 weeks for those with alarm symptoms 1 laboratory in each major city must be able to provide facilities for full bacteriological assessment of HP sensitivity and resistance

Summary Test and Treat strategy Age cut off increased to 55yrs Increased use of urease breath test Confirms use of NICE guidance on PPIs

Diagnostic algorithm

The step-down approach to the management of reflux disease The ‘step-down’ approach provides rapid symptom relief, is efficient for GPs, and may be the preferred choice for the empirical therapy of reflux disease Antacid/ alginate H2-antagonist Half-dose PPI Full-dose PPI Step-down – an evidence-based approach to the management of reflux disease Much debate has surrounded the relative merits of the 'step-up' and 'step-down' approaches to the management of reflux disease. The Genval workshop recommended that, for initial therapy of oesophagitis, the most effective approach is to start patients with a PPI, followed by trials of stepping down to the lowest class while still controlling symptoms. This management strategy is also considered to be the most cost-effective by the Genval workshop. 1 The British Society of Gastroenterology dyspepsia guidelines state that, whatever approach is taken, attempts should be made to titrate to the drug that provides relief from symptoms at the lowest cost with the least influence on normal physiology.2 Dent et al. 2001 suggest that the most effective therapy should be administered first. The rapid symptom control achieved should offset the higher initial drug cost and reduce the need for repeat consultation.3 Other guidelines, such as the Paris consensus statement,4 recommend a step-up approach to the treatment of reflux disease. No data are available comparing the two approaches but both agree that the primary goal should be to control the symptoms of reflux disease within a short period of time.5 References 1. Dent J, Brun J, Fendrick AM, et al. Gut 1999; 44 Suppl 2: S1–S16. 2. BSG, Dyspepsia management guidelines. Guidelines in Gastroenterology Sept 1996 3. Dent J, Jones R, Kahrilas P. et al. BMJ 2001; 322: 344-347. 4. Conference de Consensus Franco-Belge. Gastroenterol Clin Biol 1999; 23: 56–65. 5. Heading RC. Prescriber 2000: March; 95–101. Kinnear M et al. 1999 : NICE 2000

NICE recommends… “regular maintenance dose of most PPIs will prevent recurrent GORD symptoms in 70%-80% of patients and should be used in preference to the higher healing does” 1 1. NICE guidance to the NHS on the use of PPIs in the treatment of dyspepsia, July 2000

AGA Guidelines Age cut off is <45 Management options 1) Empirical treatment 2) Immediate OGD 3) Test and scope * 4) Test and treat * may be preferential in areas with a high background incidence of gastric Ca Scope <45y HP-ive who fail 2/12 of treatment using an antisecretory preparation and then a prokinetic agent (cisapride)