BSG Guidelines Management of Dyspepsia Dr Terry Wong

BSG Guidelines Management of Dyspepsia Dr Terry Wong Consultant Gastroenterologist Guys and St Thomas’ Hospital

Recommendation Grading • A >1 meta-analysis, systematic review or body of evidence from RCTs • B high quality case control or cohort studies, or extrapolated from a meta-analysis, systematic review or RCTs • C lesser case control or cohort studies • D expert opinion or case series / reports

Dyspepsia Introduction • Dyspepsia is not a diagnosis but a collection of • • symptoms including; upper abdo discomfort, heartburn, retrosternal pain, anorexia, nausea, vomiting, bloating, fullness and early satiety Prevalence in the Western societies is quoted at being between 23 – 41% 4% of GP consultations are for dyspepsia 10% of these are referred to hospital 2% of entire adult population receive either an OGD or a barium meal each year

Causes of Dyspepsia • Normal • Gastritis, Duodenitis, HH • GORD • DU • GU • Oesophageal, Gastric Ca 30% 10 -17% 10 -15% 5 -10% 2%

Rationalisation of Endoscopy • Patients with dyspepsia in whom endoscopy is inappropriate – Those < 55 y with uncomplicated dyspepsia – Patients with known DU who have responded appropriately to medication – Those who have recently had an OGD for the same symptoms • “Test and treat” has replaced the “test and scope” strategy in patients <55 y – Pros = – Cons = A approporiate for PU, reduction of relapse, may benefit H. pylori associated non-ulcer dyspepsia, potential reduction in Cancer risk increases antibiotic exposure, may miss significant GORD and Barretts oesophagus (although therapy here should be directed at symptom control as treatment directed at healing does not prevent the known complications)

H. Pylori Ix • Serology • • • A – Simple, useful, less specific than other methods – Instant / near tests are less accurate and not recommended 13 C Urea Breath Test B – 13 C or 14 C cleaved by the H. pylori urease and then monitored in the exhaled breath – Best test for identification – Best to ensure eradication Endoscopic Clo Test B – Cheap, accurate but endoscopy not always necessary – Recommended in all patients with newly found PU Faecal Ag Tests –?

Rationing of Endoscopy • • • Death from diagnostic OGD = 1 in 2 -10, 000 The incidence of gastric Ca is age related OGD is recommended in all patients >55 y – with new onset uncomplicated dyspepsia – for > 1/12 duration Most patients with gastric cancer have “alarm symptoms” OGD is recommended in all patients with “alarm symptoms” – National Cancer Guidelines request Ix within 2/52 • These include dyspeptic patients with: – – – – – Unintentional weight loss GI Bleeding Previous gastric surgery Epigastric mass Previous gastric ulcer Unexplained Fe deficiency Dysphagia or Odynophagia Persistent continous vomiting Suspicious barium meal D C

Treatments • Pre – Endoscopy – – <55 y = >55 y = Test and treat Pre-treatment with anti- secretory drugs may mask significant diagnosis D therefore BSG recommend witholding or stopping pre-treatment 4/52 before OGD • Oesophagitis • Lifestyle advice – weight loss, propping up head end of bed Medication – Symptom relief – 4/52 course of PPIs recommended by NICE Follow-up – ? Long term management of Barretts – Repeat OGD only recommended to review • Healing of oesophageal ulcers • Dilatation of strictures • Anaemia secondary to GORD • • D

Treatments • Functional Dyspepsia • Lifestyle advice – little benefit (stop smoking) • Medication – – D Recommends H. pylori eradication D Cochrane review May 2000 showed resolution of symptoms in 9% after H. pylori eradication therapy – Symptomatic control with anti-secretory agents is recommended especially in ulcer like or reflux like symptoms B – Stop NSAIDS D – Reassurance may be sufficient D

Treatments • Duodenal Ulcers / Erosive Duodenitis • • 95% associated with H. pylori Advise confirmation, although this may be unneccssary • • HP +ive DU A st 1 Line B – PPI bd or Ranitidine bismuth citrate – Amoxicillin 500 mg-1 g bd Metronidazole 400 -500 mg bd – Clarithromycin 500 mg bd 2 nd Line – PPI bd – Bismuth Subcitrate 120 mg qds – Metronidazole 400 -500 mg tds – Tetracycline 500 mg qds Follow Up – Urease breath test in all symptomatic >1/12 after finishing HP eradication therapy – In asymptomatic patients further OGD + follow up is then unneccessary unless symptoms recur or persist – In those where symptoms recur after an initial response = repeat urease breath test and treated if necessary with an alternative regime. If HP persists biopsy for C+Sensitivity D – Low dose PPI maintainance only necessary in persistent HP infections or those at risk of NSAID complications • • • HP -ive DU Medication – Antisecretory therapy = Cimetidine 800 mg is cheapest – Stop NSAIDS + consider COX 2 Follow Up – OPA nesseccary only if DUs not associated with NSAIDS D

Treatments • Gastric Ulcer • 70% are associated with H. pylori, most of the rest are assoc with NSAIDS • HP +ive GU – – – • • Eradication therapy A Antisecretory agents for 2/12 (as GUs take longer to heal) D If ongoing NSAIDS are necessary consider prophylactic PPI or misoprostol • NICE guidance on COX 2 antagonists HP –ive GU – 2/12 of antisecretory therapy – NICE guidance re COX 2 antagonists Follow Up – Repeat OGD in all untiil ulcer healing – Surgery if GU has not healed by 6/12 D D

Resource Requirements • Easy access for GPs to organise urease breath • • • tests Aim to provide rapid access to endoscopy for all those meeting criteria Aim to provide endoscopy access within 2 weeks for those with alarm symptoms 1 laboratory in each major city must be able to provide facilities for full bacteriological assessment of HP sensitivity and resistance

Summary • Test and Treat strategy • Age cut off increased to 55 yrs • Increased use of urease breath test • Confirms use of NICE guidance on PPIs

Diagnostic algorithm

The step-down approach to the management of reflux disease The ‘step-down’ approach provides rapid symptom relief, is efficient for GPs, and may be the preferred choice for the empirical therapy of reflux disease Full-dose PPI Half-dose PPI H 2 antagonist Antacid/ alginate Kinnear M et al. 1999 : NICE 2000

NICE recommends… “regular maintenance dose of most PPIs will prevent recurrent GORD symptoms in 70%-80% of patients and should be used in preference to 1 the higher healing does” 1. NICE guidance to the NHS on the use of PPIs in the treatment of dyspepsia, July 2000

AGA Guidelines • Age cut off is <45 • Management options – – 1) Empirical treatment 2) Immediate OGD 3) Test and scope * 4) Test and treat • * may be preferential in areas with a high background • incidence of gastric Ca Scope <45 y HP-ive who fail 2/12 of treatment using an antisecretory preparation and then a prokinetic agent (cisapride)