Dyspepsia – Recent guidelines The Dyspepsia Guideline

Dyspepsia April 2002 BSG Full Summary

NICE Guideline  August 2004

March 2003 SIGN

 Primary care led
Dr Tanay Sheth
August 2004 NICE  228 pages
GP Revised June 2005
 466 references
GPSI/Hospital Practitioner

The Dyspepsia Guideline Case Studies Case 1 Uncomplicated dyspepsia in Young pt

Young
Dyspepsia?

 Dyspepsia definition Alison Smith ♀39

6w Upper abdo pain, some
 Referral for Endoscopy 
retrosternal pain
 H pylori – Tests, Treatment  No alarm signs
 Treatment  PMH: Migraine, Obesity
 DH: Ibuprofen prn Medication
 Uninvestigated dyspepsia Lifestyle
 SH: EtOH 24u w-1
 Specific conditions: GORD, PUD, NUD  Exam: Mild epigastric tenderness
 Long-
Long-term care How should I manage her?
Does she need Gastroscopy?

1
 Dyspepsia – Definition Dyspepsia – Important problem Dyspepsia – Causes
Any symptom of Upper GI Tract ≥4w  Common
including:  40% adults suffer; 5% consult; 1% referred annually
 Upper abdominal pain/discomfort
 Heartburn/acid reflux
 Significant impact on QoL
 Nausea/vomiting

Dyspepsia symptoms poorly predict:

 Underlying pathology in 1°
 Expensive
1° care
 Significant disease  NHS: £600M y-1
 Patients: £100M y-1

Dyspepsia – Causes Dyspepsia – Causes Dyspepsia – Causes

Gastric cancer Oesophageal cancer Gastric cancer Oesophageal cancer Gastric cancer Oesophageal cancer
2% 1% 2% 1% 2% 1%
Peptic ulcer Misc Peptic ulcer Misc Peptic ulcer Misc
3% 5% 3% 5% 3% 5%

Duodenal ulcer Duodenal ulcer Duodenal ulcer

5% 5% 5%

Gastric ulcer Gastric ulcer Gastric ulcer

5% 5% 5%

Oesophagitis Normal/Minor changes Oesophagitis Normal/Minor changes Oesophagitis Normal/Minor changes

19% 60% 19% 60% 19% 60%

Findings at Endoscopy: England 1994 (Source: Hospital Episode Statistics) Findings at Endoscopy: England 1994 (Source: Hospital Episode Statistics) Findings at Endoscopy: England 1994 (Source: Hospital Episode Statistics)

2
 Dyspepsia – Causes Common elements of care 1 Common elements of care 2
Gastric cancer Oesophageal cancer Medication review Lifestyle advice
Peptic ulcer
2% 1%
Misc
 Look for possible causes  Simple advice:
3% 5% NSAIDs CCB  Eat healthily, Lose weight, Stop smoking
Duodenal ulcer Corticosteroids Nitrates  Avoid known precipitants (if associated with symptoms):
5%
Bisphosphonates Theophyllines  Smoking, Alcohol, Coffee, Chocolate, Fatty foods
 Raising head of bed, Main meal well before bed may
Gastric ulcer
5%
 If referral required, suspend NSAID help

Differential diagnosis Self-

Self-treatment with Antacid/Alginate prn may continue to be
Consider: appropriate for immediate symptom relief
 Cardiac disease
Oesophagitis
19%
Normal/Minor changes
60%  Biliary disease Educational materials
Findings at Endoscopy: England 1994 (Source: Hospital Episode Statistics)

Dyspepsia without Alarm signs Common elements of care 3 Helicobacter pylori

Inadequate response to PPI
 Routine endoscopy not necessary  Offer H2RA or Prokinetic

Recurrent or Long-
Long-term dyspepsia
 Test & treat for H pylori  Regular review (minimum annually)
 Encourage and empower pts to reduce use of
or prescribed medication stepwise:
 Lowest effective dose
Empirical PPI Full dose, 1m  On-
On-demand use
 Return to self-
self-treatment with antacid/alginate
 Consider managing previously investigated patients
without new alarm signs according to previous
endoscopic findings

3
 H pylori – Non-
Non-invasive tests H pylori – Eradication therapy Case 2 Complicated dyspepsia
 British National Formulary - Section 1.3 Brian Smith ♂44
Test Sensitivity Specificity PPV1 Unit cost
 3m Progressive epigastric pain,
Wt↓
Wt↓ 10kg, Occasional vomiting
Lab Serology 92% 83% 64.3% £9.61
 First line
 PMH: Nil of note Alarm signs
13C-Urea Breath Test 2 94.7% 95.7% 87.9% £18.80  PAC500 / PMC250 1w
 DH: Nil
 85% effective
mAb Stool Ag test2 97.6% 95.9% 88.7% £11.43  Exam: ?Epigastric
?Epigastric mass
pAb Stool Ag test2 92.4% 91.9% 79.1% £11.43

1
 Second line
assuming prevalence 25%
2
2 week washout period following PPI necessary before test  PPI + TriK dicitratobismuthate + Tet + Met 2w

Dyspepsia without Alarm signs –

Dyspepsia with Alarm signs Case 3 Uncomplicated dyspepsia in Older pt
Older pts
Dyspepsia,
Dyspepsia, plus: Old
Charlie Smith ♂75  URGENT (2 week) REFERRAL for those ≥55y
IMMEDIATE (same day) REFERRAL  8w Epigastric pain, Heartburn with Recent-
Recent-onset, Persistent, Unexplained
Significant Acute GI bleeding
 No alarm signs dyspepsia alone
URGENT (2 week) REFERRAL Medication
Progressive unintentional Weight loss Unexplained Worsening dyspepsia, in:
 PMH: Hypertension
Progressive Dysphagia Barrett’s oesophagus  DH: Aspirin, Amlodipine,
Amlodipine,
Persistent Vomiting Intestinal metaplasia
Simvastatin
Chronic GI Bleeding Dysplasia
Iron deficiency Anaemia Atrophic gastritis  Exam: Mild epigastric tenderness
Epigastric mass Peptic ulcer surgery >20y ago
Suspicious Barium meal

NB Pts should be off PPI/H2RA for minimum 2 weeks prior to endoscopy

4
 Uninvestigated
Medication
review

Dyspepsia – Treatment Specific conditions 1

Dyspepsia Lifestyle
advice
Response

No response
or relapse Gastro-
Gastro-oesophageal reflux
disease (GORD)
Response
 Full-
Full-dose PPI 1-1-2m
Test and
Treat
treat
No response  Inadequate response:
or relapse Double-
Double-dose PPI or
Relapse Full dose Response
H2RA/Prokinetic 1m
PPI 1m  Recurrent sx:
sx: Lowest
No response effective dose PPI
 Surgery not routine
Low-dose H2RA or
treatment
Response
Prokinetic  Oesophageal stricture
as required 1m dilatation: Long-
Long-term full-
full-
No response dose PPI
Review Self-care

Specific conditions 2 Specific conditions 3 Summary: What’

What’s new
Peptic ulcer disease (PUD) Non-
Non-ulcer dyspepsia (NUD)  Broader definition of Dyspepsia
 H pylori +ve:
ve: Eradication
 H pylori –ve:
ve: Full-
Full-dose PPI 1-
1-  H pylori test & treat →  Symptom management (rather than striving
2m Low-
Low-dose PPI/H2RA 1m for Endoscopic diagnosis) is appropriate for most
 NSAID: Stop NSAID
 No routine re-
re-testing for
Young pts
 High risk (previous ulcer) pts
continuing NSAID: H pylori  Alarm signs and Age are major determinants
Gastroprotection for need for endoscopy
 Persistent/recurrent sx:
sx:
 GU: Repeat Gastroscopy and H
pylori testing 6-
6-8w Lowest effective dose →  Long-
Long-term management emphasizes managing
 Unhealed ulcer: Consider non-
non- On-
On-demand use → Self-Self-
expectations and patient empowerment
adherence, malignancy, H
care
with On-
On-demand use of medication and Self-
Self-
pylori false –ve,
ve, inadvertent treatment
use NSAID etc, rare causes (eg(eg
Z-E, Crohn’
Crohn’s)