Dyspepsia

Dr. Indra Wijaya, SpPD, M.Kes Department of Internal Medicine FM-UPH/RS.Siloam Karawaci

Dyspepsia: the size of the problem

1525% of the general population Up to 5% of primary care visits are due to dyspepsia Most patients have no detectable abnormality Endoscopy findings and symptoms do not correlate

Talley, J Clin Gastroenterol 2001; 32: 28693. Locke, Ballieres Clin Gastroenterol 1998; 12: 43542. Par, Can J Gastroenterol 1999; 13: 64754. van Bommel et al., Postgrad Med J 2001; 77: 51418. Talley et al., BMJ 2001; 323: 12947.

Dyspepsia covers a range of symptoms

GERD

DYSPEPSIA
PAIN OR DISCOMFORT
centred in upper abdomen

IBS

UNINVESTIGATED ORGANIC

INVESTIGATED FUNCTIONAL (or idiopathic) (use of the term non-ulcer is discouraged)

Talley et al., Gut 1999; 45(Suppl II): II3742.

Definition of dyspepsia (Rome II)

Pain or discomfort occurring centred in the upper abdomen

Talley et al., Gut 1999; 45(Suppl II): II3742. Malfertheiner, Eur J Gastroenterol Hepatol 1999; 11(Suppl 1): S259.

Gastritis
Peptic ulcer disease
(Includes NSAID-induced ulcers)

Acid reflux Oesophagitis

Strictures

Barretts oesophagus

Oesophageal adenocarcinoma

Duodenitis Duodenal ulcer

Prevalence

Reflux esophagitis Normal 33.6% 23.9% 2% Cancer

20.8% Gastritis/duodenitis

19.9% Peptic ulcer disease

Richter 1991

Functional Dyspepsia (Rome I)

Dysmotility-like dyspepsia 11

Ulcer-like dyspepsia
51 (24%)

21 (10%)

(5%)

27 (13%) 36 (17%)

7 (3%)

Unspecified dyspepsia n=50 (23%)

10 (5%)

Reflux-like dyspepsia
Talley et al 1992

Definition of Functional Dyspepsia (Rome II)

Twelve weeks or more (within the last 12 months) of persistent or recurrent dyspepsia and evidence that organic disease likely to explain the symptoms is absent (including at upper endoscopy)
Dyspepsia subgroups
Ulcer-like (predominantly pain) Dysmotility-like (predominantly discomfort)

Unspecified (non-specific, no predominant symptom)

Talley et al., Gut 1999; 45(Suppl II): II3742. Malfertheiner, Eur J Gastroenterol Hepatol 1999; 11(Suppl 1): S259.

Definition of Functional Dyspepsia (Rome III)

At least 3 months, with onset at least 6 months previously, of 1 or more of the following:

Bothersome postprandial fullness Early satiation Epigastric pain Epigastric burning And No evidence of structural disease

Uninvestigated dyspepsia vs functional dyspepsia

Uninvestigated dyspepsia

All symptomatic patients, regardless of whether a cause has been sought

Functional dyspepsia

Symptomatic patients in whom an organic cause has been sought and excluded

Talley et al., Gut 1999; 45(Suppl II): II3742.

Management of uninvestigated dyspepsia

Uninvestigated Dyspepsia
(A) Other possible causes ?
No
(B) Age >50 or alarm features? - Vomiting - Bleeding anemia - Abdominal mass/ unexplained weight loss - Dysphagia

YES

Consider : - Cardiac - Hepatobiliary - Medication-induced - Dietary indiscretion - Other Treat as appropriate Investigate (endoscopy recommended)

YES

First Visit

NO

(C) NSAID and/or Regular ASA Use?

NO

YES

NSAID Management

(D) Is dominant symptom heartburn and/or Regurgitation ?

YES

Treat as reflux

NO

(E) Hp test positive? 1. UBT 2. Serology

YES

Treat as Hp positive

Older patients and with alarm features

America > 45 years
Canada > 50 years Indonesia > 55 years Cancer is a rare cause of dyspeptic symptoms <2%

Specialist management of uninvestigated dyspepsia Endoscopy with biopsies

and
treat accordingly!

Talley et al., BMJ 2001; 323: 12947

Hp test and treat strategy

Hp infection is associated with - duodenal ulcer 90 95 % - gastric ulcer 60 80 % - gastric cancer
Uncertainty as to whether Hp plays a role in dyspepsia in the absence of ulcers

Testing for Hp infection

Infection can be detected by: - invasive (endoscopy based) - non invasive (UBT or serologic testing)
Serologic testing cannot be used to determine cure as the IgG antibodies remain detected for a long time after eradication UBT has a high (+)ve and (-)ve predictive value (both > 95 %)
Gisbert et al. Aliment Pharmacol Ther 2004;20:100117

Hp eradication therapy
Triple Therapy for 7-14 days: - PPI + AC (best) - PPI + AM - PPI + MC (if penicillin allergic) - PPI + MT (if clarithromycin allergic) Quadruple Therapy for 14 days: - PPI + BMT PPI (bid) B (4x2 tablets/day) M (4x250 mg/day) T (4x500 mg/day)
PPI = Lansoprazole 30 mg; Omeprazole 20 mg; Pantoprazole 40 mg A = Amoxicillin 1000 mg B = Bismuth subsalicylate (2 tablets) C = Clarithromycin 250 (or 500 mg if treatment failure) M = Metronidazole 500 mg (250 mg in BMT combination therapy) T = Tetracyclin 500 mg

Sander et al., CMAJ 2000; 162 (Suppl): S123

Hp eradication therapy

PRIMARY MANAGEMENT OF NEW ONSET UNINVESTIGATED DYSPEPSIA IN INDONESIA

EXCLUDE BY HISTORY : BILLIARY PAIN, IRRITABLE BOWEL, REFLUX DYSPEPSIA IF < 2 4 WKS. DIETARY ADVICE, OBSERVE REVIEW CURRENT MEDS.

AGE > 55 YRS WITHOUT ALARM FEATURES

TREATMENT TRIAL : 2 WKS ANTACIDS ANTISECRETORY PROKINETICS FAILURE OR EARLY RELAPSE

SUCCESS

FOLLOW UP

ALARM SYMPTOMS
RELAPSE SPECIALIST REFFERAL : GASTROENTEROLOGIST INTERNAL MED./PED. WITH ENDOSCOPIC FACILITIES

SEROLOGIC Hp TESTING NEG. POS. FINAL EVALUATION AFTER 8 WKS > 3 X RELAPSE