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