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Family Medicine Seminar
Dyspepsia
Let’s GO
Case
Study
Approach
Knowledge
If you Don’t know it, you will Not see it
Case Study
As a family physician
Family Physician
Family Medicine
• Consultation in family
medicine practice
• To establish rapport
with the patient
• To find out risk factors
• To find out possible
cause
•
Hi Doc !
Establish
Rapport
Hello
Ahmed !
Prepare the setting
Introduce yourself, call by name , smile , hand shaking
Verbal / non-verbal
Hello
Ahmed !
Hi Doc !
Show as
possible
Empathy
Respect
Confidentiality
Eye contact
Silence and understanding of the patient
Mr. Ahmed
• 40 yrs old
• Saudi
• From Abha
• Father of 4 children
• Teacher
What's
Wrong
with you
Ahmed ?
I don’t
feel good
doctor
Presenting
complaint
What do you mean ??
Tell me more
pain
•
•
•
•
Intermittent
6 months
epigastric
Retrosternal burning
sensation
Regurgitation
Nausea
Let me ask
you few
questions
Ahmed
OK
doctor
Analysis
Bio-Psych-Social
Bio-Psych-Social
Bio
6-month history of intermittent upper gastrointestinal symptoms. He describes
an epigastric and retrosternal burning sensation but finds it difficult to decide
in which of these areas symptoms are predominant. He occasionally notices
regurgitation and feels nauseated. Eating, swallowing, postural change, or
exercise do not influence her symptoms. Antacids provide some relief.
Unremarkable past history and family history.
Psycho
He feels unwell but the pain does not affect his life or his sleeping frequently
Social
He is smoker for >15 years , school teacher and a father of 4 children
Acute GI bleeding
Progressive weight loss
Persistent vomiting
IDA
Epigastric mass
Progressive dysphagia
I don’t
think it is
bad
ICEE
What do
you think
you have ?
Idea/Concern/Expectation/Effect
Sure doctor
OK Ahmed,
May I examine
you please
On Examination :
Was vitally stable
Obese: BMI= 32
No signs of anemia
No jaundice
Abdomen is soft and lax and
not distended
No abdominal mass
No abdominal tenderness
Let’s GO
Case
Study
Approach
Knowledge
If you Don’t know it, you will Not see it
Approach
What Do you Think Ahmed Has ???
History:
• Complaint:
– Epigastric pain.
• Analysis of complaint:
–
–
–
–
–
–
Onset.
Duration.
Nature, quality.
Radiation.
Course.
Aggravating & relieving factors.
Risk factor and History
• Past medical Hx:
– Previous ulcer, GI bleed
– DM, hypo/hyperthyroidism, parathyroid dis.
– Colitis, diverticulosis, liver disease
– Previous Upper GI series, OGD, Abdo U/S
– Anxiety, stress, depression.
Risk factor and History
Drug Hx:
- iron, NSAIDs, bisphosphonates, antibiotics, etc.
Life style Hx:
•
•
•
•
Diet (fatty, big meals)
Smoking
Alcohol use
Exercise
• Family Hx:
Analysis
Bio-Psych-Social
• Psychosocial:
• Ideas
- Ideas and beliefs of the patient towards his illness
• Concern - Patient might think that this complaint is due to cancer, ulcer
or other serious disease, he might also feel concern that he could not
work because of this problem.
• Expectations:
• Patient may expect any of the following:
• Reassurance
• Investigation, endoscopy - Barium meal
• Peferral
• Sick leave
Risk factor and History
• Effect on life:
– You need to explore the effect of this problem on his
family, work, etc.
• Depression, anxiety and stress:
– Screen your patient for depression, anxiety and stress
and go in details when needed.
• Supporting system:
– Sources of support at home, work, friends, community.
• Vital signs:
Weight
Height.
Blood Pressure.
Pulse.
Respiratory rate,
Temperature .
Respiratory & Cardiovascular
Examination.
• Signs anemia
– Brittle nails
– Cheilosis
– Pallor palpebral mucosa or
nail beds
• Other
– Teeth (loss enamel)
– Lymphadenopathy Virchow’s node
– Acanthosis nigrans
– Hypo/Hyperthyroid
• Abdominal Examination:
– Epigastric tenderness
– Palpable mass
– Distention
– Colon tenderness
– Jaundice
– Murphy’s sign
– Stool for OB
– Hernia
Let’s GO
Case
Study
Approach
Knowledge
If you Don’t know it, you will Not see it
Knowledge
Dyspepsia...
It is a group of
symptoms
characterized by
upper abdominal
discomfort,
retrosternal pain,
vomiting, heartburn,
upper abdominal
fullness and feeling
full earlier than
expected when eating.
Prevalence:
Surveys carried out in western countries
reported that:
between 23-41%. Only 25% of dyspeptic
populations visit their own doctors (About 4%
of G.P.)
Only 10% of the patients with dyspepsia are
referred to hospital .
Differential Diagnosis:
Functional
Organic
50 – 70%
30 – 40%
•Medications (ASA/NSAIDS, Abx)
•Gastroparesis
Peptic
Ulcer 521%
Esophagitis
0-18%
•Cholelithiasis, Choledocholithiasis
•Pancreatitis (acute or chronic)
Gastric
cancer 13%
•Carbohydrate malabsorption
•Ischemic bowel
•Other GI malignancy (ep. Pancreatic
Organic
cancer)
•Systemic disease (DM, Thyroid,
Parathyroid, CTD)
•Intestinal parasite
Risk Factors:
Obesity.
Smoking.
Anxiety, depression.
Fatty meal.
Junk food.
functional Dyspepsia...
Functional Dyspepsia
• The most common cause overall.
• Defined as:
– at least 12 weeks (need not be consecutive) within
the last 12 months of:
• Dyspepsia
• No evidence of organic disease
• Dyspepsia not exclusively relieved by defecation or
associated with change in stool frequency or form
(i.e. not IBS).
Pathophysiology
• The pathophysiology of dyspepsia is not well
understood.
• Researchers have focused on several key
factors:
– (Motility Disorders) vs .( Nonmotility Disorders).
– Psychosocial factors.
Abnormal Fundic Relaxation in Response
to Meal in Functional Dyspepsia
Normal
Fundic
accommodation
or receptive
relaxation
Meal
Functional
dyspepsia
Impaired fundic
accommodation
with a redistribution of
food to antrum
Stress
Behavioural
Factors
Local Factors:
Gastritis
H. pylori infection
Abnormal Motility
• Decreased antral motility
• Impaired fundal relaxation
NONMOTILITY DISORDERS
• with motility disorders, there is little correlation
between symptoms and severity of duodenitis, and
no relationship between treatment and
improvement of mucosal appearance on endoscopy.
• One of the most prevalent theories currently being
evaluated is the possible involvement of H. pylori
infection in non-ulcer dyspepsia (as in ulcer disease).
PSYCHOSOCIAL FACTORS
• Patients with nonulcer dyspepsia are more likely to have symptoms of
anxiety and depression than are healthy persons or patients with
ulcers.
•
Multiple somatic complaints also are more common in patients who
have nonulcer dyspepsia.
• A history of child abuse has been linked to the symptoms of nonulcer
dyspepsia.
•
Stress from life events also has been correlated with these symptoms
and has been linked to exacerbations of nonulcer dyspepsia.
Investigations
Specific investigations
- Depend on expected cause:
• Usually we use the invasive procedure (endoscopy)
to exclude the serious causes epically with patents
have alarm symptoms:
• Alarm symptoms:
–
–
–
–
–
Age > 45
Weight loss
Bleeding
Palpable mass
Dysphagia
Specific investigations
• Peptic ulcer disease :
– Hx : Past history of ulcers, NSAIDs, Smoking.
– Dx: Endoscopy (0.99 specificity)
• Gastric ulcer or Duodenal ulcer :
• Dx : Endoscopy (0.98 specificity)
Specific Investigations:
• Gastroesophygeal reflux ( GERD):
– Hx : Heartburn or regurgitation symptoms, aggravated
when supine, chronic cough
Dx:
– Omeprazole Test (0.89 specificity)
– Endoscopy.
– 24 Hrs PH – monitoring
,
Specific investigations
Gastric Cancer:
– Hx .Older (>50),unexplained wt. loss, dysphagia,
smoker
Dx : Endoscopy
Helicobacter pylori infection :
-
Urea breath test.
Stool antigen test.
Serum IGg antibody test.
Whole- blood antibody test .
Key Points
• Step One: Hx & Px
– attempt to establish a specific diagnosis
• Step Two: Consider Cancer
– urgent endoscopy if red flags
• Step Three: Treat for Non-Ulcer Dyspepsia
– Test & Eradicate H. pylori
– Acid suppression or Prokinetics x 1 month
• Step Four: Endoscopy
– Endoscopy if still symptomatic
• Step Five:
– Post-Endoscopy Management
MANGEMENT
management
Management:
• Clarification; Explanation:
– Nature of the problem.
– What is ulcer & non-ulcer dyspepsia.
– Prognosis:
• Ulcer dyspepsia can be treated effectively.
• Non-ulcer remains recurrent since the cause is unclear.
Management:
• Reassure:
• Advice:
–
–
–
–
–
–
–
Quit smoking
Stop / reduce caffeine
Stop / reduce EtOH
Hold medications associated w/ dyspepsia
NSAIDS, ASA
Avoid foods and other factors precipitate symptoms
Better eating habits.
Management:
•Prescription:
Gastroesophegeal reflux diseas GERD:
2- Proton
pump
inhibitor (
PPI)
1- Histamine -2
receptor
antagonist ( H2RR
)
Normal dose for 2-4 wks and follow up.
Helicobacter pylori eradication
• Regimen A:
PPI
Amoxicillin
Clarithromyc
in
- Duration: 2 weeks and follow up.
- 50% have mild side effect .
- 0.1 – 0.5% have pseudomembranous colitis.
In Saudi Arabia:
According to the latest studies :
1- clarithromycin 500mg BID – 10 days
2- amoxicillin 1000mg BID – 10 days
3- omeprazole 20mg BID – 6/52
clarithromycin
1000mg BID – 10 days
500mg BID – 10 days
amoxicillin
omeprazole
20mg BID – 6/52
Regimen B:
1- Bismuth subsalicylate ( 2 tablets 4 times /day)
2- Metronidazole. ( 250 mg 4 times /day)
3- tetracyclin ( 500 mg 4 times /day)
4- H2RR (normal dose ) or PPI ( high dose ).
- Duration : 2 weeks and follow up.
Peptic ulcer ( H.Pylori negative )
- H2RR or PPI :
For duodenal ulcer : normal dose .
For gastric ulcer : H2RR normal dose or double.
Duration : 4 - 8 weeks and follow up.
Treatment of functional Dyspepsia
•
•
•
•
Reassure.
Modify Life style and avoid risk factor .
Psycho social Hx ( screen for depression )
Prescribe non pharmacological and
pharmacological treatment.
• Observation and follow up .
Functional dyspepsia
- H2RR or PPI ( normal dose).
- Duration : 4 weeks and follow up.
Prevention:
•
•
•
•
•
Lifestyle modification. (eating habits),
Psychosocial state: screen for depression.
Stop smoking,
Regular exercises.
Avoid irrational use of NSAIDs.
The End…