1. DYSPEPSIA Leena Patel 1/2/12

2. OVERVIEW • Statistics • Red flags • Management • H-pylori testing and treatment

3. STATISTICS • 5% of adults/year consult their GP for dyspepsia symptoms • 1% will go on to have endoscopy • Of these: • 80% will have non-ulcer dyspepsia or reflux • 13% will have a peptic ulcer • <3% will have malignancy

4. SYMPTOMS • Nausea • Vomiting • Bloating • Belching • Epigastricpain • Retrosternal pain • Early satiety • Chronic cough

5. ALARM SYMPTOMS • Progressive dysphagia • Persistent vomiting • Progressive unintentional weight loss • Iron deficiency anaemia • Epigastric mass • Chronic GI bleeding • Suspicious barium study

6. ENDOSCOPY • Refer patient of ANY age with ≥1 of the above listed alarm symptoms • Refer patients >55 years of age with new onset unexplained dyspepsia which is persistent (4-6 weeks) even without alarm symptoms TRY TO AVOID USING PPI/H2RA FOR 2 WEEKS PRIOR TO ENDOSCOPY

7. ENDOSCOPY RESULTS • UPPER GI MALIGNANCY • PEPTIC ULCER DISEASE (GASTRIC/DUODENAL) • NON-ULCER DYSPEPSIA • GORD WITH/WITHOUT OESOPHAGITIS

8. MANAGEMENT Divided into: • Uninvestigated dyspepsia • H-pylori eradication • GORD, PUD, NUD

9. MEDICATION INDUCED • NSAIDS • Steroids • Bisphosphonates • Calcium channel blockers • Nitrates • Theophyllines

10. LIFESTYLE • Healthy balanced diet • Avoid/reduce fatty food, caffeine, chocolate • Weight reduction • Smoking cessation • Reduce alcohol intake • Avoid late meals • Raise end of bed • Try antacids/alginate therapy for intermittent symptoms

11. UNINVESTIGATED DYSPEPSIA • H-pylori testing and treat with eradication/PPI OR • Treat with high dose PPI for 1 month and then test for H-Pylori if still symptomatic NICE suggests either way is acceptable • Both treatments equally effective and cost effective (BMJ 2008) • Advises treat and test if still symptomatic

12. H-Pylori TESTING • Carbon 13 urea breath test, stool antigen and serology • Serology is less accurate but can be done whilst on a PPI • Breath test and antigen test have similar and high sensitivity and specificity • Before either breath/antigen test: • Avoid antibiotics for 4 weeks • Avoid PPI/H2RA for 2 weeks • Patient should fast for 6 HOURS prior to breath test • Avoid retesting due to high false positive, breath test if have to

13. ERADICATION REGIMES • Standard triple therapy • Full dose PPI + amoxicillin (1g BD) + clarithromycin (500mg BD) • Full dose PPI + metronidazole (400mg BD) + clarithromycin (250mg BD) • 7 day treatment • 77% effective at eradication • Sequential treatment • 10 day treatment • Full dose PPI • Amoxicillin (1g BD) for the first 5d • Metronidazole + clarithromycin (500mg BD) for next 5d • 93% effective at H-pylori eradication

14. UNINVESTIGATED DYSPEPSIA • If relapse following successful treatment, consider low dose PPI with regular review • If symptoms fail to respond to PPI/eradication treatment, consider a trial of H2 receptor antagonist or prokinetic for 1 month and then review

15. GORD, NUD, PUD • If peptic ulcer disease or non-ulcer disease on endoscopy, then test for H-Pylori and eradicate if present • If GORD, or H-Pylori negative PUD or NUD, then 1-2 month course of PPI, doubling dose of PPI for 1month if not responding • Consider 1 month trial of H2RA/prokinetic if still not responding • Repeat endoscopy for H-Pylori positive GU.

16. Risks of long term PPI treatment • Hip fractures and calcium malabsorption • Vitamin B12 malabsorption • Iron malabsorption • Hypomagnesaemia • Atrophic gastritis (esp. if H-pylori +ve) • ?pneumonia

17. Summary • Red flags • Don’t forget medication induced dyspepsia, consider alternatives • Lifestyle advice • Regular review of PPI treatment due to potential risks of long term treatment