Download Dyspepsia

Dyspepsia
Cengiz Pata
Department of Gastroenterology
Yeditepe University, Istanbul
The Case
40 year old female
6 months of intermittent epigastric burning
with occasional nausea but no vomiting
Denies weight loss
Eating does not change her symptoms
She denies any changes in her bowel
habits
The Case
PMH: HTN
SH: denies tobacco, EtOH, or IVDA
FH: DM, HTN
Meds: HCTZ
All: NKDA
Exam: Unremarkable except moderate
epigastric tenderness
What is Dyspepsia?
Epigastric pain
Indigestion
Fullness
Early satiety
Bloating
Belching
Nausea
Retching
What is Not Dyspepsia?
Heartburn
– Almost always a sign of GERD and not
included in evaluation/guidelines of
dyspepsia.
Defining Dyspepsia (AGA)
Chronic or recurrent pain or discomfort
centered in the upper abdomen
Patients with predominant or frequent
(>1/wk) heartburn or acid regurgitation are
considered to have GERD until proven
otherwise and are not considered to have
dyspepsia
Why is Dyspepsia Important?
Prevalence is 25% - 40% per year
Accounts for 5% of all PCP referrals
Accounts for 50% of gastroenterologists
workload
$2 Billion is spent on acid-suppressing
drugs each year in the US
Differential Diagnosis
Functional Dyspepsia
(60%)
PUD (25%)
GERD
Biliary Pain
Chronic Abdominal Wall
Pain
Gastric CA
Esophageal CA
Other Abdominal
Malignancy
Gastroparesis
Pancreatitis
Carbohydrate
Malabsorption
Meds (NSAIDS,
Narcotics, etc.)
Infiltrative Diseases
Metabolic Disturbances
Hepatoma
Ischemic Bowel Disease
Systemic Disorders
Parasites
Making the Diagnosis
Can the clinical history distinguish between
organic and functional dyspepsia?
Moayyedi et al., JAMA 2006; 295: 1566-1576
– Rational clinical exam series
– Meta-analysis of 15 studies evaluating clinicians and
computer models in using symptoms and physical
exam findings in diagnosing the cause of dyspepsia
Dyspepsia defined as any upper GI symptoms
AGA Guidelines – Step 1
AGA Guidelines – Step 2
Alarm Symptoms:
–
–
–
–
–
Weight loss
Progressive dysphagia
Recurrent vomiting
Evidence of GI bleed
Family history of
malignancy
AGA Guidelines – Step 3
AGA Guidelines – Step 4
Functional Dyspepsia
Diagnostic Criteria (Rome II):
– At least 12 weeks, which need not be
consecutive, in the preceding 12 months of:
1) Persistent or recurrent dyspepsia
2) No evidence of organic disease that is likely to
explain symptoms; and
3) No evidence that dyspepsia is exclusively
relieved by defecation or associated with onset of
a change in stool frequency or form (not irritable
bowel).
Diagnostic methods for H. pylori
Diagnostic
method
Main indication
Sensitivity (%)
Specificity (%)
Histology
Diagnosis
90
90
Culture
H. pylori antibiotic
sensitivities
80-90
95
Rapid urease
test
Endoscopy room
diagnosis
90
90
Serology
Screening and
diagnosis
90
90
Urea breath
test
To confirm
eradication
95
100
The principle of the urease test
NH2
C
2NH4+ + HCO3-
O + 2H2O + H+
Urease
NH2
Urea
CLOtest
pH change
The principle of the 13C- or 14C-urea breath test
Reproduced with permission from Mr Phil Johnson, Bureau of Stable Isotope Analysis,
Brentford, UK.
Functional Dyspepsia
Rome III- similar to Rome II but now FD
is broken down into two subgroups based
on a complex of symptom features:
1) Postprandial distress syndrome
2) Epigastric pain syndrome
Pathophysiology of FD
Increased gastric acid
H. pylori infection
GI dysmotility (antral hypocontractility)
Decreased perception threshold
Autonomic dysfunction
Decreased gastric accommodation
Gastric myoelectric activity
Psychological factors
Pharmacological Treatment of
FD
Cochrane Meta-analyses (versus placebo):
– PPIs (RRR 13%, CI 4% - 20%)
– Prokinetics (RRR 33%, CI 18% - 45%)
Cisapride, Domperidone, Metaclopramide, Tegaserod
May be affected by publication bias
–
–
–
–
–
H2RAs (RRR 23%, CI 8% - 35%)
Bismuth salts (RRR 40%, CI –3% - 65%)
Antacids (RRR –2%, CI –36% - 24%)
Sucralfate (RRR 29%, CI –40% - 64%)
H. pylori eradication (RRR 10%, CI 6% - 14%)
Pharmacological Treatment of
FD
Itopride – Dopamine D2 antagonist with
acetylcholinesterase inhibitory actions
– Stimulates gastric motility
– Often used for FD in Japan
Holtmann G. et al. A Placebo-Controlled Trial of
Itopride in Functional Dyspepsia. NEJM. 2006;
354: 832-840
– Patients with Rome II diagnosis of FD
– Pts recruited from private physicians (PCPs?) and
one tertiary care center
Pharmacological Treatment of
FD
Psychological Treatment for FD
4 trials have evaluated CBT,
hypnotherapy, or psychotherapy
All show statistically improvement at 1
year
Cochrane Meta-analysis- insufficient
evidence as all trials likely underpowered
Guidelines for use of antibiotic
therapy in patients with
Helicobacter pylori infection
Treatment regimens for
eradication of Helicobacter
pylori
Therapeutic options
clarithromycin
2 x 250 - 500mg
PPI X 2
metronidazole
2 x 400 - 500mg
eradication rate
>80%
amoxycillin
2 x 1000mg
Treatment failures
Approach to the Management of
Patients with FD (Rome II)
Make a positive clinical diagnosis as early as possible
Determine why the patient having chronic symptoms has
presented on this occasion, and allay any unwarranted
fears that the patient may have
Do not over-investigate: an empiric therapeutic trial may
be appropriate initially especially in the younger patient
in the absence of risk factors for serious organic disease
After the evaluation, reassure the patient regarding the
absence of serious disease and reinforce the diagnosis
represents a recognized entity
Explain the pathogenesis of the dyspepsia symptoms as
far as possible
Psychological factors may contribute to the morbidity of
the disorder; these issues should be explored and
Approach to the Management of
Patients with FD (Rome II)
Advise the patient to avoid possible precipitating factors
where appropriate
Inquire if the patient would like medication for their
problem- not all patients will
Follow up with the patient at least once to determine
natural history or treatment response
Do not repeat investigations based on symptoms alone.
Diagnostic studies should depend on new or objective
findings
Some patients with severe symptoms or multisystem
complaints may benefit from counseling
Referral to a specialist in motility disorders and/or formal
psychological, psychiatric, and/or eating disorder
evaluation may be indicated for some patients
References
American Gastroenterological Association Medical Position Statement:
Evaluation of dyspepsia. Gastroenterology. 2005; 129: 1753-1755
Bytzer P. et al. Dyspepsia. Annals of Internal Medicine. 2001; 134: 815-822
Drossman D. et al. Rome II: The functional gastrointestinal disorders,
Degnon Associates, 2000
Holtmann G. et al. A Placebo-Controlled Trial of Itopride in Functional
Dyspepsia. NEJM. 2006; 354: 832-840
Moayyedi P. et al. Can the clinical history distinguish between organic and
functional dyspepsia? JAMA. 2006; 295: 1566-1576
Moayyedi P. et al. Pharmacological interventions for non-ulcer dyspepsia.
Cochrane Database of Systematic Reviews 2006, Issue 4.
Moayyedia P. et al. Eradication of Helicobacter pylori for non-ulcer
dyspepsia. Cochrane Database of Systematic Reviews 2006, Issue 2.
Soo S. et al. Psychological interventions for non-ulcer dyspepsia. Cochrane
Database of Systematic Reviews 2005, Issue 2.