Download Dyspepsia Clnical Pathway Final v01102009

PRACTICE GUIDELINES &
CLINICAL PATHWAY ON
MANAGEMENT OF DYSPEPSIA
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
Dyspepsia
Presence of 1 or more of the following symptoms
(Rome III Committee):
 Postprandial fullness
 Early satiety
 Epigastric pain or burning
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
4 Major Causes:
 Chronic peptic ulcer disease
 Gastroesophageal reflux (+/- esophagitis)
 Functional dyspepsia (NUD)
 Malignancy
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
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
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
Patient Profile
 30 year old, male
 Burning epigastric pain
 No alarm symptoms
Empiric PPI Therapy
 Empiric therapy with proton pump inhibitors
for 4- 6weeks
 Reassurance
 No further investigations if symptoms
improve
 Out patient clinic follow-up
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
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)
<55 y/o and below, no
alarm features
>55 y/o or
<55 y/o w/ 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)
Treat accordingly
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
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
Unresponsive Functional
Dyspepsia
 Reevaluate diagnosis
 Consider: gastroparesis, biliary or pancreatic
diseases, IBS, anxiety disorder
 Limited data on use of antidepressants,
prokinetic agents
References
 Talley NJ, Vakil NB, Moayyedi P: American Gastroenterological




Association Technical Review: Evaluation of Dyspepsia.
Gasteroenterology 2005, 129:1756-1780.
American Gastroenterological Association Medical Position
Statement: Evaluation of Dyspepsia
Gastroenterology 2005, 129:1753-1755.
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,
6:1071-1075
Sleisenger and Fordtran’s Gastrointestinal and Liver Disease 8th
Edition
THANK YOU AND GOOD DAY.
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
Need for in-patient work-up
and care
 Severity of dyspepsia
 Alarm symptoms present
 Need for additional lab tests and imaging
studies
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