DYSPEPSIA

Abegail Abundo
Preresidency
• OBJECTIVE:
To learn the clinical pathways to improve outcomes of patients with
dyspepsia in family and community medicine
 DYSPEPSIA
BACKGROUND
• Any chronic or recurrent discomfort in the epigastric area (bloatedness,
fullness, gnawing or burning continously or intermittently)
• 2 weeks
• 40% of adult population may suffer from despeptic symptoms
 SAMPLE CASE

General Data: Flores J. 41 year old, RC, came in ambulatory

accompanied by his sister

Chief Complaint: Epigastric pain for 2 weeks

 SAMPLE CASE

HPI: Two weeks PTC, patient had epigastric pain with no

associated symptoms. One week PTC, patient
epigastric pain persisted but this time radiating to
whole abdomen and flank area, scale of 10/10,
stabbing in character aggravated after eating.
• Omeprazole was taken for 5 days and afforded temporary relief. Few
hours PTC, above symptoms persisted but this time with 2 episodes of
non projectile vomiting hence consult done.
 DYSPEPSIA
(RECOMMENDATION)
• Patients with upper GI pain or discomfort should have a detailed
history (weight loss, hematemesis, hematochezia, melena, dysphagia,
odynophagia, vomiting, NSAID intake, alcohol intake, smoking, frequent
complaints, depression, anxiety, personal or family history of
gastrointestinal disease (genogram).
 DYSPEPSIA
(RECOMMENDATION)
• Physical Examination
• Ruleout: Organic pathology
• To look for alarm clinical features like anemia, abdominal tenderness or
mass, jaundice, melena, etc..
 DYSPEPSIA
(RECOMMENDATION)
• If patient

* With history of previous dyspepsia treatment

* More than 45 years old
* Long term use of NSAID

** Request for non invasive test**

** Start therapeutic trial of prokinetic treatment
for 1-2 weeks or ppi depending on the symptoms.
 DYSPEPSIA
(INTRODUCTION)

• Risk Factors:
*Females
* H.Pylori Infection
* Smokers
* NSAID users

After Endoscopy: More than 75% with dyspepsia

don’t have obvious structural abnormality.
 DYSPEPSIA
(INTRODUCTION)
• American and European Multidisciplinary working group and local
Family Medicine Research Group, Inc. Clinical practice Guideline

1. Patients with alarm symptoms should undergo prompt endoscopy

2. Those without alarm symptoms, non invasive testing for H.Pylori

is recommended
 DYSPEPSIA
(INTRODUCTION)
3. Empiric trial of acid suppression with PPI is recommended if H.
Pylori testing is not feasible
4. Prokinetics are not currently recommended as first line of therapy
for un-investigated dyspepsia
5. Test and Treat is preferable in pt with moderate to high prevalence
situations and empiric ppi low prevalence situations
 DYSPEPSIA
(INTRODUCTION)
6. If empiric treatment with PPI fails, consider changing or adding
another drug class or increase dose
7. If still fails, endoscopy maybe considered
8. If there is improvement in symptoms patients may be treated on either
on demand or intermittent basis
 GRADING OF
RECOMMENDATION
A I- Based on published evidence that is a well done randomized
controlled trial and the panel of expert voted unanimously for the
recommendation

A II- Level of evidence is based on an observational study but the panel

still unanimously considered recommendation
 GRADING OF
RECOMMENDATION
A III- level of evidence is just an opinion but the panel still unanimously
recommend it
 DYSPEPSIA
(NOTES ON THE
RECOMMENDATION)
• First Visit :

All patients with upper gastrointestinal pain or discomfort should have

a detailed hx focusing on wt loss, hematemesis, hematochezia, melena,
dysphagia, odynophagia, vomiting,
 DYSPEPSIA
(NOTES ON THE
RECOMMENDATION)
• NSAID intake, alcohol intake, smoking, frequent medical complaints,
depression, anxiety, personal or family history of GI disease

• Physical Examination: To ruleout organic pathology and to look for

alarm clinical features
 DYSPEPSIA
(PATHWAY TASK)
• Pathway Decision
> (+) organic/structural problem based on significant PE finding, refer
to specific clinical pathway (A-III)

> Probable motility problem if prominent history of bloatedness,

dysphagia and vomiting (A-III)
 DYSPEPSIA
(PATHWAY TASK)

> Probable acid related problem if prominent hx of epigastric pain,

NSAID and alcohol intake and reflux symptoms (A-III)

> Undifferentiated upper GI problem (A-III)

 DYSPEPSIA
(PATHWAY TASK)
Laboratory
> H. Pylori Test if with history of previous dyspepsia treatment, > 45
y/o or long term use of NSAID (A-II)

> Upper Abdominal Ultrasound, liver function test, pancreatic

amylase if organic problem is considered (A-III)
 DYSPEPSIA
(NOTES ON THE
RECOMMENDATION)
• Pharmacologic Interventions
> Probable Motility Problem – prokinetic tx for 1-2 weeks
> Probable Acid Related Problem- PPI or H2 blocker for 1-2 weeks
(A-1)
> Undifferentiated upper GI problem- combination of prokinetic and
ppi and h2 blocker for 1-2 weeks
 DYSPEPSIA
(PATHWAY TASK)
* Patient Intervention
1. Educate the patient about GI disorder
2. Explain the medications
3. Lifestyle Modification

*Family Intervention – Inquire and recommend family members lifestyle

activities
 DYSPEPSIA
(PATHWAY TASK)
• Continuing Care
1. Follow up after 1-2 weeks
2. Offer family wellness package
 DYSPEPSIA
(PATHWAY TASK)
• Second Visit
> Review and note any change in history and physical examination
> Review the results of laboratory tests and response to empiric
treatment

Pathway Decisions: If there is symptom improvement with the therapeutic

trial, continue until 4 weeks
 DYSPEPSIA
(PATHWAY TASK)
• If no symptoms improvement, refer for GI endoscopy
• If (+) H.Pylori test is + start eradication treatment
• + UTZ and other lab test, manage accordingly
 DYSPEPSIA
(PATHWAY TASK)
• Non Pharmacologic Intervention
>Family Intervention: Enhance recommendation for family members
appropriate lifestyle activities
>Community Interventions- Recommend participation in appropriate
community lifestyle activities like alcoholics Anonymous
 DYSPEPSIA
(PATHWAY TASK)
• Continuing Care
Follow up after 1 month until upper GI symptom is resolved
 DYSPEPSIA
(PATHWAY TASK)
• Continuing Visit

History and PE
> Review and note any change in history
> Repeat and note any change in PE focusing on the upper GI tract
> Review the results of endoscopy and other laboratory tests
 DYSPEPSIA
(PATHWAY TASK)
• Path Decision
(+) Endoscopy for bleeding peptic ulcer and other serious organic
problem, consider transfer of care to gastroenterologist
If there is (+) response of tx trial and H.Pylori eradication continue
with current care
 DYSPEPSIA
(PATHWAY TASK)
• Laboratory
Repeat request H. and\\\ Pylori test, endoscopy or upper abdominal
ultrasound, liver function test pancreatic amylase if organic problem
was considered after3-6 months to monitor response to treatment
 DYSPEPSIA
(PATHWAY TASK)
• Pharmacologic Interventions
Improved symptoms
- Self management with the same medications for symptoms recurrence

With upper gastrointestinal organic problem

- Refer to gastroenterologist and manage according to available clinical
pathway
 DYSPEPSIA
(PATHWAY TASK)
• Non Pharmacologic Interventions
1. Enhance Education about the disease
2. Educate the patient on self management for symptom recurrence
3. Enhance lifestyle modification

Continuing Care: Follow up after 1 month until GI symptom is resolved

and every 6-12 months
• End……………….
 DYSPEPSIA
(NOTES ON THE
RECOMMENDATION)
N