DYSPEPSIA AS A HOT TOPIC

•	PAIN IN UPPER ABDOMEN/ CHEST.
•	OFTEN AFTER MEAL
•	NOT A DIAGNOSIS BUT INCLUDES ANOREXIA, NAUSEA, VOMITING, BLOATING, FULLNESS, EARLY SATIETY, HEARTBURN.

REPRESENTS MANY DISEASES- PEPTIC ULCER, OESOPHAGITIS, GASTRIC CA

PREVALENCE
23-41% IN WESTERN SOCIETIES
4% OF GP CONSULTATIONS ARE FOR DYSPEPSIA (10% OF THESE REFERRED)
2% OF ADULT POPULATION HAVE ENDOSCOPY/ BARIUM MEAL EACH YEAR

MANAGEMENT OPTIONS
•	EMPIRICAL TREATMENT OF DYSPEPSIA WITH MEDICATION
•	ENDOSCOPY FOR ALL - NOT COST EFFECTIVE
•	ENDOSCOPY FOR THOSE WITH ALARM SYMPTOMS - INCREASES DIAGNOSTIC YIELD WITHOUT MISSING SERIOUS CAUSES
•	TEST AND TREAT - MOST COST EFFECTIVE AS PER 3 RCTs COMPARED TO ENDOSCOPY

BRITISH SOCIETY OF GASTROENTEROLOGY GUIDELINES: HELICOBACTER PYLORI

•	‘TEST AND TREAT’ - TREAT RATHER THAN SCOPE PATIENTS UNDER 55 WITH UNCOMPLICATED DYSPEPSIA ON THE BASIS OF A POSITIVE H.PYLORI TEST, (RATHER THAN PREVIOUS POLICY OF ‘TEST AND SCOPE’). FOR REMAINDER - SYMPTOMATIC TREATMENT.
•	LACK OF H.PYLORI IS A GOOD PREDICTOR OF THE ABSENCE OF PEPTIC ULCER/ GASTRIC CANCER
•	13C UREA BREATH TEST IS BEST TEST FOR IDENTIFICATION AND CONFIRMATION OF ERADICATION. (RATHER THAN SEROLOGY/ BIOPSY)

BRITISH SOCIETY OF GASTROENTEROLOGY GUIDELINES: INDICATIONS FOR ENDOSCOPY

1. DYSPEPTIC PATIENT WITH ALARM SYMPTOMS						
•	UNINTENTIONAL WEIGHT LOSS (>3kg)	
•	GI BLEEDING
•	PREVIOUS GASTRIC SURGERY
•	EPIGASTRIC MASS
•	PREVIOUS GASTRIC ULCER
•	UNEXPLAINED IRON DEFICIENCY ANAEMIA
•	DYSPHAGIA
•	SUSPICIOUS BARIUM MEAL
•	PERSISTENT CONTINUOUS VOMITING	

2. ANY PATIENT OVER 55 (PREVIOUSLY 45) WITH  RECENT (<1 YEAR) ONSET DYSPEPSIA OF AT LEAST 4 WEEKS DURATION

NICE GUIDELINES ON THE USE OF PROTON PUMP INHIBITORS
1. DOCUMENTED PEPTIC ULCER 

	TEST FOR H. PYLORI (95% DU, 70% GU)
	POSITIVE: 	ERADICATE (CURED WITH ADEQAUTE TREATMENT)
			AVOID LONG TERM ACID SUPPRESSION
	NEGATIVE:	LOWEST DOSE OF PPI THAT RELIEVES SYMPTOMS

(LONG TERM ACID SUPPRESSION SHOULD BE AVOIDED ONCE HP ERADICATED - LOW DOSE PPI MAINTENANCE NEEDED ONLY IN THOSE WITH PERSISTENT H.P. INFECTION OR THOSE AT RISK OF SERIOUS COMPLICATIONS WHILE RECEIVING NSAIDS - IN THESE INSTANCES, CONSIDER COX II)

2.NSAID-INDUCED ULCER

	IF MUST CONTINUE NSAID, ADD  PPI
	WHEN HEALED, STEP DOWN TO MAINTENANCE

3. SEVERE GORD

	HEALING DOSE OF PPI UNTIL SYMPTOMS SETTLE
	THEN STEP DOWN TO LOWEST DOSE THAT CONTROLS

4. NON-ULCER DYSPEPSIA (NO CAUSE FOR DYSPEPSIA AFTER INVESTIGATIONS)	

	SHOULD NOT BE ROUTINELY TREATED WITH PPI
	MAY TRY LOWEST DOSE OF PPI

5. MILD DYSPEPSIA

	STEP UP AND DOWN - NO LONG TERM ACID SUPPRESSION WITHOUT A CONFIRMED DIAGNOSIS

6. PPI -WHERE HEALING IS REQUIRED, USE OPTIMAL DOSE INITALLY.

	ONCE ACHIEVED - USE LOWEST DOSE THAT CONTROLS SYMPTOMS	
	NB. GREATER  / PROLONGED ACID SUPPRESSION COMPARED TO H2 	ANTAGONISTS

SUMMARY

•	Under 55 with dyspepsia for the first time - medication initially
•	If still symptomatic, test for H.Pylori and if positive, eradicate
•	Treatment for H.Pylori infection without testing is not recommended as most patients treated will not be infected 
•	Cure should be taken as relief of symptoms

EVIDENCE

BMJ 324: 1012-1016

•	RCT in Canada
•	Test for H.Pylori and treat/ eradicate shows symptomatic benefit at 12 months compared to PPI alone

BMJ 324:999-1002

•	RCT in Glasgow: randomized to H.Pylori test or endoscopy
•	H.Pylori testing is as effective, safe, cheaper and less uncomfortable compared to endoscopy for patients with uncomplicated upper GI symptoms
•	Also found in another RCT
•	Testing shown to be a useful predictor of endoscopic diagnosis in patients with dyspepsia
•	If negative, can reassure that patient does not have ulcer and can treat empirically with acid suppression treatment
•	Positive tests are highly predictive of peptic ulcer disease

SCREENING (BMJ: 325:1399-1402)

Gastric Cancer

•	Second commonest cause of cancer mortality worldwide
•	Meta-analysis - patients infected with H.Pylori at 6 times increased risk of developing distal gastric adenocarcinoma than controls
•	Recent RCT - eradication improves gastric atrophy/ intestinal metaplasia (premalignant changes)
•	Benefits and harms of population screening and treatment for H.Pylori need to be evaluated in a RCT - need large numbers and long term follow up

Colorectal Cancer

•	Many cancers develop from polyps so detection and removal should reduce mortality
•	FOB: reduced mortality from CRC by up to 23% in 4 RCTs
•	Flexible sigmoidoscopy: currently being evaluated - recent UK study suggests this is acceptable, feasible and safe. Looks promising but data on death rates form CRC needed before such screening can be advocated. Uncertainty re age and frequency. May miss up to 30% of lesions as they occur beyond the reach of the endoscope.
•	Colonoscopy: will detect these lesions. However, more expensive, less acceptable, higher perforation rate. Currently being investigated in the USA.