DYSPEPSIA Leena Patel 1/2/12

OVERVIEW Statistics Red flags Management H-pylori testing and treatment

STATISTICS 5% of adults/year consult their GP for dyspepsia symptoms 1% will go on to have endoscopy Of these:  80% will have non-ulcer dyspepsia or reflux  13% will have a peptic ulcer  <3% will have malignancy

SYMPTOMS Nausea Vomiting Bloating Belching Epigastric pain Retrosternal pain Early satiety Chronic cough

ALARM SYMPTOMS  Progressive dysphagia  Persistent vomiting  Progressive unintentional weight loss  Iron deficiency anaemia  Epigastric mass  Chronic GI bleeding  Suspicious barium study

ENDOSCOPY  Refer patient of ANY age with ≥1 of the above listed alarm symptoms  Refer patients >55 years of age with new onset unexplained dyspepsia which is persistent (4-6 weeks) even without alarm symptoms TRY TO AVOID USING PPI/H2RA FOR 2 WEEKS PRIOR TO ENDOSCOPY

ENDOSCOPY RESULTS UPPER GI MALIGNANCY PEPTIC ULCER DISEASE (GASTRIC/DUODENAL) NON-ULCER DYSPEPSIA GORD WITH/WITHOUT OESOPHAGITIS

MANAGEMENT Divided into: Uninvestigated dyspepsia H-pylori eradication GORD, PUD, NUD

MEDICATION INDUCED  NSAIDS  Steroids  Bisphosphonates  Calcium channel blockers  Nitrates  Theophyllines

LIFESTYLE Healthy balanced diet Avoid/reduce fatty food, caffeine, chocolate Weight reduction Smoking cessation Reduce alcohol intake Avoid late meals Raise end of bed Try antacids/alginate therapy for intermittent symptoms

UNINVESTIGATED DYSPEPSIA H-pylori testing and treat with eradication/PPI OR Treat with high dose PPI for 1 month and then test for H-Pylori if still symptomatic NICE suggests either way is acceptable  Both treatments equally effective and cost effective (BMJ 2008)  Advises treat and test if still symptomatic

H-Pylori TESTING Carbon 13 urea breath test, stool antigen and serology Serology is less accurate but can be done whilst on a PPI Breath test and antigen test have similar and high sensitivity and specificity Before either breath/antigen test:  Avoid antibiotics for 4 weeks  Avoid PPI/H2RA for 2 weeks  Patient should fast for 6 HOURS prior to breath test  Avoid retesting due to high false positive, breath test if have to

ERADICATION REGIMES Standard triple therapy  Full dose PPI + amoxicillin (1g BD) + clarithromycin (500mg BD)  Full dose PPI + metronidazole (400mg BD) + clarithromycin (250mg BD)  7 day treatment  77% effective at eradication Sequential treatment  10 day treatment  Full dose PPI  Amoxicillin (1g BD) for the first 5d  Metronidazole + clarithromycin (500mg BD) for next 5d  93% effective at H-pylori eradication

UNINVESTIGATED DYSPEPSIA If relapse following successful treatment, consider low dose PPI with regular review If symptoms fail to respond to PPI/eradication treatment, consider a trial of H2 receptor antagonist or prokinetic for 1 month and then review

GORD, NUD, PUD If peptic ulcer disease or non-ulcer disease on endoscopy, then test for H-Pylori and eradicate if present If GORD, or H-Pylori negative PUD or NUD, then 1-2 month course of PPI, doubling dose of PPI for 1month if not responding Consider 1 month trial of H2RA/prokinetic if still not responding Repeat endoscopy for H-Pylori positive GU.

Risks of long term PPI treatment Hip fractures and calcium malabsorption Vitamin B12 malabsorption Iron malabsorption Hypomagnesaemia Atrophic gastritis (esp. if H-pylori +ve) ?pneumonia

Summary Red flags Don’t forget medication induced dyspepsia, consider alternatives Lifestyle advice Regular review of PPI treatment due to potential risks of long term treatment