Approach to Uninvestigated Dyspepsia.pptx
- 1. Presented by- Dr. Praveen Kumar Rao APPROACH TO UNINVESTIGATED DYSPEPSIA
- 2. •Nature, frequency, and chronicity of the symptoms. •Degree of weight loss. •Assessment of symptoms or signs of a systemic disorder and of the patient’s family and personal history. History and Physical Examination
- 3. •Specific attention should be given to a history of heartburn. •Burning pain confined to the epigastrium is a cardinal symptom of dyspepsia and not considered heartburn unless it radiates retrosternally. •The presence of frequent and typical reflux symptoms should lead to a provisional diagnosis of GERD rather than dyspepsia. •The possible presence of overlapping IBS should also be assessed. Johnsson F, Roth Y, Damgaard Pedersen NE, Joelsson B. Cimetidine improves GERD symptoms in patients selected by a validated GERD questionnaire. Aliment Pharmacol Ther 1993; 7:81-6
- 4. Laboratory Testing •Most clinicians will consider routine tests after the age of 45 to 55. •Serum amylase level, antibodies for celiac disease, stool testing for ova and parasites and for Giardia antigen.
- 5. Initial Management Strategies •Most guidelines and recommendations advocate prompt endoscopy when risk factors for an organic cause of dyspepsia (e.g., NSAID use, age at least 45 to 55, alarm symptoms) are present. •Majority of patients who do not have a risk factor for an organic cause of dyspepsia remains a matter of debate. Talley NJ, Vakil NB, Moayyedi P. American Gastroenterological Association technical review on the evaluation of dyspepsia. Gastroenterology 2005; 129:1756-80.
- 6. Available options include- (1) prompt diagnostic endoscopy followed by targeted medical therapy. (2) noninvasive testing for Hp infection, followed by treatment based on the result (“test and-treat” strategy). (3) empirical antisecretory drug therapy
- 7. Prompt Endoscopy and Directed Treatment •Diagnostic upper GI endoscopy allows direct detection of organic causes of dyspepsia, such as peptic ulcer, erosive esophagitis, or malignancy. •Peptic ulcer or erosive esophagitis will receive antisecretory drug therapy, and in those with a negative upper endoscopy result, functional dyspepsia and nonerosive GERD are empirically treated with antisecretory drug therapy. Mitchell RM, Collins JS, Watson RG, Tham TC. Differences in the diagnostic yield of upper gastrointestinal endoscopy in dyspeptic patients receiving proton-pump inhibitors and H2-receptor antagonists. Endoscopy 2002; 34:524-6.
- 8. •Endoscopy has been claimed to detect gastric cancer at an early curable stage. •Functional dyspepsia and GERD recur after treatment will be referred for endoscopy. •Guidelines advocate initial endoscopy in all patients having age (usually age 45 to 55) to detect a potentially curable upper GI malignancy. Dyspepsia: Managing dyspepsia in adults in primary care. North of England Dyspepsia Guideline Development Group (UK). Newcastle upon Tyne (UK): University of Newcastle upon Tyne; 2004 Aug 01
- 9. Test and Treat for Hp Infection •Majority of peptic ulcers is the most important risk factor for gastric cancer. •Hp in PUD advocates noninvasive testing for Hp in young patients (<45 to 55 years of age) with uncomplicated dyspepsia. •Positive test result should receive eradication therapy, Negative test result should be treated empirically, with a PPI. •Eradication of Hp eliminate chronic gastritis lead to a reduction in the risk of Hp–associated gastric cancer. Malfertheiner P, Megraud F, O’Morain C, et al. Currentvconcepts in the management of Helicobacter pylori infection: The Maastricht III Consensus Report. Gut 2007; 56:772-81.
- 10. •Whether eradication of Hp causes or worsens GERD has long been debated, but a 2013 RCT eradication in Hp– positive patients with GERD failed to demonstrate any worsening of GERD. •Antibiotic use-inducing resistance . •Serologic tests are cheaper but least accurate. •If the prevalence of Hp in a population is less than 60%, the fecal antigen test and urea breath test for Hp are preferred. Vakil N, Rhew D, Soll A, Ofman J. The cost-effectiveness of diagnostic testing strategies for Helicobacter pylori. Am J Gastroenterol 2000; 95:1691-8.
- 11. •A meta-analysis of studies comparing a test-and- treat strategy with empirical antisecretory drug therapy of dyspepsia found little difference. •The test and- treat strategy as an initial approach to uninvestigated dyspepsia is most likely to be beneficial in areas where the Hp infection rate is high, where the hp infection rate is high. Ford AC, Moayyedi P, Jarbol DE, et al. Meta-analysis: Helicobacter pylori “test and treat” compared with empirical acid suppression for managing dyspepsia. Aliment Pharmacol Ther 2008; 28:534-44.
- 12. Empirical Antisecretory Drug Therapy • Widely used in uninvestigated dyspepsia. • It controls symptoms and heals lesions in most patients with underlying GERD or PUD and may be beneficial in up to 1/3rd of patients with functional dyspepsia. • PPIs > H2RAs, and response occurs within 2 weeks. • Disadvantages of empirical PPI therapy are rapid symptomatic relapse and rebound gastric hypersecretion. • A meta-analysis of studies that compared a test and- treat approach in dyspepsia found little difference in symptom resolution. Delaney B, Ford AC, Forman D, et al. Initial management strategies for dyspepsia. Cochrane Database Syst Rev 2005; CD001961.
- 13. Recommendations •(<age 45 to 55)- initial endoscopy cannot be recommended •But can be reconsidered if the patient has a family history of cancer, or has emigrated from an area with a high incidence of gastric or esophageal cancer. •high prevalence (>20%) of Hp infection, the test-and- treat approach remains attractive.
- 14. •Tests of choice are the urea breath test or the fecal antigen test for Hp. •Hp–positive patients should be given a 7- to 14-day course of Hp eradication therapy. •In those who are Hp–negative, a PPI can be prescribed for 1 to 2 months.
- 15. •In populations where the prevalence of Hp infection is low, empirical antisecretory drug therapy (PPI for 1 to 2 months) appears to be the preferred option. •Patients who fail to respond to these initial approaches, should undergo endoscopy. •In patients older than age 45 to 55 without alarm features, most guidelines recommend initial diagnostic endoscopy.
- 16. Additional Investigations •Testing for celiac disease and Giardia infection in patients with refractory symptoms, like weight loss. •In patients with severe pain or weight loss, abdominal US or CT can be used to rule out pancreaticobiliary disease and screen for mesenteric ischemia. •In cases of severe postprandial fullness, and especially in cases of refractory nausea and vomiting, a gastric emptying test using scintigraphy or a breath test can be considered.
- 17. •When a severe delay in gastric emptying is detected, a small bowel x-ray can rule out mechanical obstruction. •In cases of refractory intermittent epigastric pain or burning, esophageal pH with impedance monitoring is useful for diagnosing atypical manifestations of GERD not responding sufficiently to empirical antisecretory drug therapy. •Electrogastrography, barostat studies, or simple nutrient challenge tests have been used as research tools but have no established role in the clinical management of patients with dyspepsia.