Practice Guidelines

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Practice Guidelines clinical pathway on
management of Dyspepsia
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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

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Dyspepsia

• Presence of 1 or more of the following symptoms
  (Rome III Committee)
• Postprandial fullness
• Early satiety
• Epigastric pain or burning

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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

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4 Major Causes

• Chronic peptic ulcer disease
• Gastroesophageal reflux (/- esophagitis)
• Functional dyspepsia (NUD)
• Malignancy

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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

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Review of Current Literatures

• Peptic ulcer is found in 5-15 of patients
• Gastric or esophageal Adenocarcinoma is
  identified in lt2 of all patients who undergo
  endoscopy for dyspepsia
• Upper gastrointestinal malignancy becomes more
  common after age 55 years

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Review of Current Literatures

• Absence of alarm features has a negative
  predictive value of gt97
• Chronic infection with H. pylori is associated
  with gt80 of peptic ulcers and gt1/2 of gastric
  cancers

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Patient Profile

• 30 year old, male
• Burning epigastric pain
• No alarm symptoms

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Empiric PPI Therapy

• Empiric therapy with proton pump inhibitors for
  4- 6weeks
• Reassurance
• No further investigations if symptoms improve
• Out patient clinic follow-up

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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

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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)

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Treat accordingly
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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 PPImetronidazolebismu
  thtetracycline

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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

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Unresponsive Functional Dyspepsia

• Reevaluate diagnosis
• Consider gastroparesis, biliary or pancreatic
  diseases, IBS, anxiety disorder
• Limited data on use of antidepressants,
  prokinetic agents

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References

• Talley NJ, Vakil NB, Moayyedi P American
  Gastroenterological Association Technical Review
  Evaluation of Dyspepsia. Gasteroenterology 2005, 1
  291756-1780.  
• American Gastroenterological Association Medical
  Position Statement Evaluation of Dyspepsia
  Gastroenterology 2005, 1291753-1755. 
• Lam SK, Talley NJ Report for the 1997 Asia
  Pacific. Consensus Guidelines on the management
  of H. pylori. Journal Gasteroenterology
  Hepatology 1998, 131-2.  
• American Society for Gastrointestinal Endoscopys
  The role of endoscopy in dyspepsia.
  Gastrointestinal Endoscopy 2007, 61071-1075
• Sleisenger and Fordtrans Gastrointestinal and
  Liver Disease 8th Edition

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Prepared by

• Dr. Ernesto Olympia
• Dr. Benjamin Benitez
• Dr. Patricia Prodigalidad
• Dr. William Rodriguez

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Thank you and good day.
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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

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Need for in-patient work-up and care

• Severity of dyspepsia
• Alarm symptoms present
• Need for additional lab tests and imaging studies

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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