BSG Guidelines Management of Dyspepsia By Matt Johnson

Recommendation Grading A>1 meta-analysis, systematic review or body of evidence from RCTs A>1 meta-analysis, systematic review or body of evidence from RCTs Bhigh quality case control or cohort studies, or extrapolated from a meta-analysis, systematic review or RCTs Bhigh quality case control or cohort studies, or extrapolated from a meta-analysis, systematic review or RCTs Clesser case control or cohort studies Clesser case control or cohort studies Dexpert opinion or case series / reports Dexpert 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 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% Prevalence in the Western societies is quoted at being between 23 – 41% 4% of GP consultations are for dyspepsia 4% of GP consultations are for dyspepsia 10% of these are referred to hospital 10% of these are referred to hospital 2% of entire adult population receive either an OGD or a barium meal each year 2% of entire adult population receive either an OGD or a barium meal each year

Causes of Dyspepsia Normal30% Normal30% Gastritis, Duodenitis, HH30% Gastritis, Duodenitis, HH30% GORD10-17% GORD10-17% DU10-15% DU10-15% GU5-10% GU5-10% Oesophageal, Gastric Ca2% Oesophageal, Gastric Ca2%

Rationalisation of Endoscopy Patients with dyspepsia in whom endoscopy is inappropriate 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 <55yA “Test and treat” has replaced the “test and scope” strategy in patients <55yA –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 SerologyA SerologyA –Simple, useful, less specific than other methods –Instant / near tests are less accurate and not recommended 13C Urea Breath TestB 13C Urea Breath TestB –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 TestB Endoscopic Clo TestB –Cheap, accurate but endoscopy not always necessary –Recommended in all patients with newly found PU Faecal Ag Tests Faecal Ag Tests –?

Rationing of Endoscopy Death from diagnostic OGD = 1 in 2-10,000 Death from diagnostic OGD = 1 in 2-10,000 The incidence of gastric Ca is age related The incidence of gastric Ca is age related OGD is recommended in all patients >55y D 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” Most patients with gastric cancer have “alarm symptoms” OGD is recommended in all patients with “alarm symptoms” C OGD is recommended in all patients with “alarm symptoms” C –National Cancer Guidelines request Ix within 2/52 These include dyspeptic patients with: 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 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 Oesophagitis Lifestyle advice Lifestyle advice –weight loss, propping up head end of bed Medication Medication –Symptom relief –4/52 course of PPIs recommended by NICE D Follow-up Follow-up –? Long term management of Barretts –Repeat OGD only recommended to review Healing of oesophageal ulcers Healing of oesophageal ulcers Dilatation of strictures Dilatation of strictures Anaemia secondary to GORD Anaemia secondary to GORD

Treatments Functional Dyspepsia Functional Dyspepsia Lifestyle advice Lifestyle advice –little benefit (stop smoking)D Medication Medication –Recommends H.pylori eradicationD –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 NSAIDSD –Reassurance may be sufficientD

Treatments Duodenal Ulcers / Erosive Duodenitis Duodenal Ulcers / Erosive Duodenitis 95% associated with H.pylori 95% associated with H.pylori Advise confirmation, although this may be unneccssary Advise confirmation, although this may be unneccssary HP +ive DUA HP +ive DUA 1 st LineB 1 st LineB –PPI bd or Ranitidine bismuth citrate –Amoxicillin 500mg-1g bdMetronidazole mg bd –Clarithromycin 500mg bd 2 nd Line 2 nd Line –PPI bd –Bismuth Subcitrate 120mg qds –Metronidazole mg tds –Tetracycline 500mg qds Follow Up Follow Up –Urease breath test in all >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+SensitivityD –Low dose PPI maintainance only necessary in persistent HP infections or those at risk of NSAID complications HP -ive DU HP -ive DU Medication Medication –Antisecretory therapy = Cimetidine 800mg is cheapest –Stop NSAIDS + consider COX 2 D Follow Up Follow Up –OPA nesseccary only if DUs not associated with NSAIDS

Treatments Gastric Ulcer Gastric Ulcer 70% are associated with H.pylori, most of the rest are assoc with NSAIDS 70% are associated with H.pylori, most of the rest are assoc with NSAIDS HP +ive GU HP +ive GU –Eradication therapyA –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 antagonistsD NICE guidance on COX 2 antagonistsD HP –ive GU HP –ive GU –2/12 of antisecretory therapy –NICE guidance re COX 2 antagonists Follow Up Follow Up –Repeat OGD in all untiil ulcer healing –Surgery if GU has not healed by 6/12D

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

AGA Guidelines Age cut off is <45 Age cut off is <45 Management options 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 * 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) Scope <45y HP-ive who fail 2/12 of treatment using an antisecretory preparation and then a prokinetic agent (cisapride)