This document provides guidelines for evaluating and managing patients presenting with dyspepsia. Dyspepsia is defined using Rome III criteria and affects 25% of the population, accounting for substantial healthcare costs. Initial evaluation involves detailed history and physical exam to identify underlying causes and alarm features requiring urgent evaluation. Initial management involves trial of PPI for 8 weeks and testing/treating H. pylori infection. Patients with persistent symptoms after initial treatment require endoscopy to identify structural diseases.
This document provides guidelines for evaluating and managing patients presenting with dyspepsia. Dyspepsia is defined using Rome III criteria and affects 25% of the population, accounting for substantial healthcare costs. Initial evaluation involves detailed history and physical exam to identify underlying causes and alarm features requiring urgent evaluation. Initial management involves trial of PPI for 8 weeks and testing/treating H. pylori infection. Patients with persistent symptoms after initial treatment require endoscopy to identify structural diseases.
This document provides guidelines for evaluating and managing patients presenting with dyspepsia. Dyspepsia is defined using Rome III criteria and affects 25% of the population, accounting for substantial healthcare costs. Initial evaluation involves detailed history and physical exam to identify underlying causes and alarm features requiring urgent evaluation. Initial management involves trial of PPI for 8 weeks and testing/treating H. pylori infection. Patients with persistent symptoms after initial treatment require endoscopy to identify structural diseases.
This document provides guidelines for evaluating and managing patients presenting with dyspepsia. Dyspepsia is defined using Rome III criteria and affects 25% of the population, accounting for substantial healthcare costs. Initial evaluation involves detailed history and physical exam to identify underlying causes and alarm features requiring urgent evaluation. Initial management involves trial of PPI for 8 weeks and testing/treating H. pylori infection. Patients with persistent symptoms after initial treatment require endoscopy to identify structural diseases.
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Approach to the patient with
dyspepsia DEFINITION Rome III criteria, one or more of the following • Postprandial fullness
• Early satiation (inability to finish a normal
sized meal)
• Epigastric pain or burning
DISEASE BURDEN • 25% of the general population experience dyspepsia within a year
• Up to 5% of primary care visits are due to
dyspepsia
• Responsible for substantial health care costs
• Significantly affects quality of life
ETIOLOGY • 25 % of patients - underlying organic cause Most common: gastro-esophageal reflux disease ,peptic ulcer disease, NSAID induced and gastric malignancy
• 75 % of patients - functional dyspepsia with no
evidence of structural disease to explain the symptoms INITIAL EVALUATION Detalied history: • necessary to narrow the differential diagnosis • to identify : GERD, NSAID-induced dyspepsia, and patients with alarm features DIFFERENTIAL DIAGNOSIS Consider: • cardiac • hepatobiliary sources • medication-induced symptoms • possible dietary indiscretion • lifestyle or other causes PHYSICAL EXAMINATION • usually normal, except for epigastric tenderness • Carnett sign to differentiate pain arising from the abdominal wall from pain due to inflammation of the underlying viscera.
Other findings: • a palpable abdominal mass • lymphadenopathy (eg, left supraclavicular or periumbilical in gastric cancer) • pallor secondary to anemia LABORATORY TESTS • Routine blood counts and blood chemistry (including liver function tests ) to identify patients with : alarm features (e.g. iron deficiency anemia)
underlying metabolic diseases that can cause
dyspepsia (eg, diabetes, hypercalcemia) DIAGNOSTIC STRATEGIES AND INITIAL MANAGEMENT • based on the presence or absence of alarm features , patient age, and the local prevalence of H. Pylori infection
• Upper endoscopy - gold standard
• Patients with H. pylori should receive
eradication therapy in addition to treatment based on the underlying diagnosis INITIAL MANAGEMENT • Patients with GERD and NSAID-induced dyspepsia should be treated with an empiric trial of proton pump inhibitors (PPI) for 8 weeks and NSAIDs should be discontinued
• Further evaluation if they continue to have
symptoms after 8 weeks of PPI therapy or earlier if they have alarm features ALARM SYMPTOMS • Anemia (iron deficiency) • Loss of weight(unintentional) • Anorexia • Recent onset of progressive symptoms • Melaena / haematemesis • Swallowing difficulty • Palpable mass/ History of gastric cancer AGE? • A European consensus statement recommends endoscopy in adults > 45 years old who present with persistent dyspepsia • The AGA guidelines > 55 years old • The need for local national dyspepsia guidelines The only good H. Pylori is a dead one
• H. pylori - an etiologic factor in PUD
• Testing for H. pylori should be performed with a urea
breath test or stool antigen assay
• Most dyspeptic patients who are H. pylori positive and who
are treated with appropriate antibiotic therapy persist with dyspeptic symptoms (NNT=1/14)
• Patients who have continued symptoms after successful
eradication of H. pylori should be treated with antisecretory therapy with a proton pump inhibitor for 4-8 weeks ANTISECRETORY THERAPY • Empiric anti-secretory therapy without H. pylori testing/treatment - recommended in areas of very low prevalence for H. pylori (<5 percent) and may also be considered in areas with prevalence of 5 to 10 percent
• PPI therapy is more effective in relieving
symptoms of dyspepsia than H2 antagonists PERSISTENT SYMPTOMS • endoscopic evaluation should be considered in patients who have not previously undergone an upper endoscopy
• biopsies should be obtained for H. pylori and to
rule out celiac disease
Further evaluation for an alternate diagnosis
should be considered based on the patient’s symptoms FUNCTIONAL DYSPEPSIA • continued symptoms of dyspepsia for 3 months
• symptom onset at least 6 months before
diagnosis
• no evidence of structural disease to explain the
