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Dyspepsia – assessment

Dyspepsia origin from Greek word dyspeptos : dys- bad , pepsis -digestion A definition proposed by Crean et al more than two decades ago is still considered one of the most comprehensive and it describes dyspepsia as an ” episodic recurrent or persistent abdominal pain or discomfort or any other symptoms referable to the upper alimentary tract , excluding bleeding or jaundice , of duration 4 week or longer “

it can encompass a variety of symptoms and presentations like epigastric discomfort , bloating , early satiety , belching , nausea and heartburn symptoms are localised by the patient to the epigastric region and flanks symptoms are attributable to the upper gastrointestinal tract references to dyspepsia have been found in writings of Hippocrates and Galen – ie it has been present for a long time dyspepsia is a symptom and not a disease the symptoms of dyspepsia may be acute e.g in gastroenteritis or chronic

How common –common problems – seen by both primary care physicians and gastroenterologists systemic reviews have reported that 20 % of the population has dyspepsia globally other reports mention that dyspepsia affects up to 40 % of adults each year and about 10 % of those affected seek medical help ( Lloyd et al 2013 ) most papers agree that the prevalence is in excess of 30 % rates of new onset dyspepsia varies between 1-5 % and the rate of resolution is about 6 % – this implies that the prevalence remains stable dyspepsia accounts for 2-5 % of all consultations in primary care Functional dyspepsia or non-ulcer dyspepsia is the commonest cause of dyspeptic symptoms in the Western World and increasingly in other parts of the world as well uninvestigated dyspepsia- overall global prevalence is estimated to be about 21 %

risk factors –smoking alcohol consumption ( conflicting evidence ) concomitant irritable bowel syndrome use of non-steroidal antiinflammatory drugs and or aspirin female gender H.pylori positive individuals role of ethnicity is not clear bad dietary habits ( it is not clear what is a bad diet ) low socioeconomic status ( possible link )

Morbidity and mortality –dyspepsia does not affect life expectancy ie dyspepsia is not associated with increased mortality symptoms negatively impact on QoL heavy economic burden on healthcare systems – in the US it is estimated that it costs 18 billion $s per year.

How often when did it start pattern ( for e.g relation to food , time ) family h/o upper GI malignancy lifestyle factors as 
○ smoking 
○ alcohol any precipitating factors as
○ coffee , chocolate , tomatoes
○ stress , anxiety , depression has the patient been investigated – if so what was the diagnosis ? medications direct questioning for ALARM symptoms as
○ unexplained weight loss ○ recurrent vomiting ○ progressive dysphagia ○ odynophagia ○ GI blood loss and family h/o upper GI cancer

Palpate the abdomen for massses and tenderness Signs of anaemia Check weight- to assess for weight loss FBC – anaemia or a raised platelet count LFT- hepatobiliary disease Amylase- pancreatic disease Helicobacter pylori – stool / breath test.

non- ulcer ( functional dyspepsia )- up to 70 % gastro-esophageal reflux disease ischaemic heart disease peptic ulcer disease 15-25 % reflux esophagitis 5-15 % carbohydrate malabsorption cholelithiasis or choledocholithiasis chronic pancreatitis systemic disorders intestinal parasites gastric or esophageal cancer < 2 % chronic mesenteric ischaemia inflitrative disease of the stomach drug induced for e.g NSAIDs , aspirin , steroids , bisphosphonates , calcium antagonists , theophyllines.

NICE guidance on endoscopy-Offer a 2 week direct access upper GI endoscopy for 
oesophageal cancer for people
 with dysphagia or aged 55 and over with weight loss + any of the following
○ upper abdominal pain
○ reflux
○ dyspepsia
 Consider non-urgent direct access upper GI endoscopy to access for oesophageal cancer in people with haematemesis
 Consider non-urgent direct access upper GI endoscopy to assess for oesophageal cancer in people over 55 or over with
○ treatment resistant dyspepsia or
○ upper GI pain with low hemoglobin levels or
○ raised platelet count with any of following – nausea , vomiting , weight loss , reflux , dyspepsia , upper abdominal pain
○ Nausea and vomiting with any of the following- weight loss , reflux , dyspepsia , upper abdominal pain.

Esophageal cancer –Esophageal cancer is the 6th leading cause of death from cancer and 8th most common cancer in the world Has an aggressive nature and poor survival rate with 5 year survival rate of about 15-25 % two predominant subtypes- adenocarcinoma ( in Europe and USA ) and squamous cell carcinoma ( S E Asia , Africa ) it has good prognosis if picked up early the most important risk factors for esophageal carcinoma are low intake of fruits and vegetable and fruits , drinking drinks and hot liquids , reducing the intake of nutritional supplements such as selenium and zinc , smoking , excessive consumption of alcohol , past medical history , obesity and exposure to some environmental factors

Functional dyspepsia –Rome III defines functional dyspepsia as the presence of symptoms thought to originate in the gastroduodenal region , in the absence of any organic , systemic or metabolic disease that is likely to explain them routine diagnostic investigations including endoscopy , fail to identify any causal structural or biochemical abnormalities symptoms should be present for atleast 3 months further divided into two categories postprandial distress syndrome ( PDS ) and Epigastric pain syndrome ( EPS ) Explain and reassure patient of the non-fatal nature of the illness as individuals with functional dyspepsia suffer significant morbidity and expend significant resources through both direct and indirect costs.

Gastroesophageal reflux disease- GORD is common with heartburn and regurgitation occurring atleast weekly in upto 26 % if the European population it happens when the reflux of stomach contents causes troublesome symptoms and or complications ( reflux of the contents of stomach is a normal physiological event ) results from multiple factors that cause dysfunction of the lower oesophageal sphincter with obesity and the development of hiatus hernia being the central concepts GORD is a risk factor for Barrett’s oesophagus and oesophageal carcinoma Complications of GORD include ◘ erosive oesophagitis ◘ Barrett’s oesophagus ◘ peptic stricture Proton pump inhibitors are the first line treatment for GORD.

Peptic ulcer disease –Most cases are linked to H Pylori infection and the use of NSAIDS About 2/3rd of patients with PUD are asymptomatic epigastric pain associated with dyspepsia , bloating , abdominal fullness , nausea or early satiety are among the commonly seen symptoms urea breath test and stool antigen tests are accurate in identifying H. pylori infection and can be used to confirm cure eradication therapies include standard triple therapy , sequential therapy , quadruple therapy and levofloxacin based triple therapy complication of peptic ulcer disease include bleeding , perforation , gastric outlet obstruction and gastric cancer

Proton-pump inhibitors –In Scotland omeprazole was the most commonly prescribed drug by volume in 2014-15 It is said that they are often prescribed without an appropriate indication and continued indefinitely without a review Long term PPI use is considered to be associated with risks as
◘ clostridium difficile infection
◘ increased risk of osteoporosis ( use of PPIs is a risk factor for development of osteoporosis and osteoporotic fractures )
◘ increased mortality in older patients
◘ acute interstitial nephritis
◘ hypomagnesemia
◘ vitamin B12 deficiency
◘ rebound acid hypersecretion syndrome
◘ community acquired pneumonia
◘ hyponatremia PPIs are generally well tolerated with most common reported SEs being headaches , nausea , abdominal pain , constipation , flatulence , diarrhoea , rash and dizziness If prescribing PPIs- consider the following
◘ offer lifestyle advise to all
◘ use short-term for e.g 4-8 weeks and document the indication
◘ review PPI treatment -stepping down to lowest effective dose / using as needed or discontinuation 
◘ review long term use- offer an annual review Indications for long term use include
◘ Barrett’s oesophagus
◘ oesophageal stricture dilatation
◘ severe oesophagitis complicated by past strictures , ulcers or haemorrhage
◘ previous peptic ulcer with major haemorrhage
◘ Zollinger -Ellison syndrome
◘ gastric protection for NSAID treatment in high risk patients
◘ use of medications which increase the likelihood of upper GI events as aspirin , anticoagulants , corticosteroids and antidepressants as SSRIs
◘ serious underlying co-morbidities as CVD , hepatic or renal impairment , diabetes , hypertension

References

  1. Gastrointestinal tract (upper) cancers – recognition and referral Scenario: Referral for suspected gastrointestinal tract (upper) cancer NICE guideline https://cks.nice.org.uk/gastrointestinal-tract-upper-cancers-recognition-and-referral#!scenario
  2. Madisch, Ahmed et al. “The Diagnosis and Treatment of Functional Dyspepsia.” Deutsches Arzteblatt international vol. 115,13 (2018): 222-232. doi:10.3238/arztebl.2018.0222 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5938438/
  3. ACG and CAG Clinical Gudeline ; Management of Dyspepsia by Paul M Moayyedi et al Am J Gastroenterol 2017 ; 112:988-1013 via https://www.cag-acg.org/images/publications/CAG_CPG_Dyspepsia_AJG_Aug2017.pdf
  4. Investigating dyspepsia Rocco Maurizio Zagari, Lorenzo Fuccio, Franco Bazzoli BMJ
    2008;337:a1400 https://www.bmj.com/bmj/section-pdf/186005?path=/bmj/337/7671/Clinical_Review.full.pdf
  5. Jones MP Evaluation and treatment of dyspepsia 
  6. Definition  , Pathogenesis , and Management of That Cursed Dyspepsia Pramoda Koduru et al Clinical Gastroenterology and Hepatology 2018 ; 16:467-479 https://www.cghjournal.org/article/S1542-3565(17)31063-7/pdf
  7. Etiology of dyspepsia: Implications for empirical therapy Richard H Hunt et al Can J Gastroenterol Vol 16 No 9 September 2002 https://core.ac.uk/download/pdf/188800903.pdf
  8. Update on the Evaluation and Management of Functional Dyspepsia Ryan a. Loyd, David a. McClellan Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013 medind.nic.in/iaa/t13/i7/iaat13i7p110.pdf
  9. Ford, A.C. and Talley, N.J. (2014). Epidemiology of Dyspepsia. In GI Epidemiology (eds N.J. Talley, G.R. Locke, P. Moayyedi, J. West, A.C. Ford and Y.A. Saito). Abstract doi:10.1002/9781118727072.ch15
  10. Ford AC, Marwaha A, Sood R, et al
    Global prevalence of, and risk factors for, uninvestigated dyspepsia: a meta-analysis
  11. Nwokediuko, Sylvester Chuks et al. “Functional dyspepsia: subtypes, risk factors, and overlap with irritable bowel syndrome in a population of african patients.” Gastroenterology research and practice vol. 2012 (2012): 562393. doi:10.1155/2012/562393 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3506890/
  12. Ghoshal, Uday C et al. “Epidemiology of uninvestigated and functional dyspepsia in Asia: facts and fiction.” Journal of neurogastroenterology and motility vol. 17,3 (2011): 235-44. doi:10.5056/jnm.2011.17.3.235

  13. Risk Factors for Dyspepsia: Systematic Review and Meta-Analysis Avantika Marwaha, Alexander C. Ford, Allen Lim, Paul Moayyedi ( Abstract )
  14. CKS Dyspepsia – unidentified cause How should I assess a person ? https://cks.nice.org.uk/dyspepsia-unidentified-cause#!diagnosisSub
  15. Domper Arnal, María José et al. “Esophageal cancer: Risk factors, screening and endoscopic treatment in Western and Eastern countries.” World journal of gastroenterology vol. 21,26 (2015): 7933-43. doi:10.3748/wjg.v21.i26.7933 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4499337/
  16. Yousefi, M., Sharifi-Esfahani, M., Pourgholam-Amiji, N., Afshar, M., Sadeghi-Gandomani, H., Otroshi, O., & Salehiniya, H. (2018). Esophageal cancer in the world: incidence, mortality and risk factors. Biomedical Research and Therapy, 5(7), 2504-2517. https://doi.org/10.15419/bmrat.v5i7.460
  17. Managing gastro-oesophageal reflux disease (GORD) in adults: an update https://bpac.org.nz/bpj/2014/june/gord.aspx
  18. Hopper AD. Improving the diagnosis and management of GORD in adults. Practitioner. 2015;259(1781):27‐3. ( Abstract ) https://pubmed.ncbi.nlm.nih.gov/26529827/
  19. Kavitt RT, Lipowska AM, Anyane-Yeboa A, Gralnek IM. Diagnosis and Treatment of Peptic Ulcer Disease. Am J Med. 2019;132(4):447‐456. doi:10.1016/j.amjmed.2018.12.009 ( Abstract ) https://pubmed.ncbi.nlm.nih.gov/30611829/
  20. Fashner J, Gitu AC. Diagnosis and Treatment of Peptic Ulcer Disease and H. pylori Infection. Am Fam Physician. 2015;91(4):236‐242. ( Abstract ) https://pubmed.ncbi.nlm.nih.gov/25955624/
  21. Guidance for Safe and Effective use of Proton Pump Inhibitors (PPIs)
    Background and RISKS associated with PPIs Barnsley Hospital NHS trust https://www.barnsleyccg.nhs.uk/CCG%20Downloads/Members/Medicines%20management/Area%20prescribing%20committee/201803-04%20-%20APC%20Memo%20Enclosure%20-%20Guidance%20for%20Safe%20and%20Effective%20use%20of%20Proton%20Pump%20Inhibitors%20-%20March-April%202018.pdf
  22. Andersen BN, Johansen PB, Abrahamsen B. Proton pump inhibitors and osteoporosis. Curr Opin Rheumatol. 2016;28(4):420‐425. doi:10.1097/BOR.0000000000000291 ( Abstract ) https://pubmed.ncbi.nlm.nih.gov/27224743/
  23. Mahadeva, Sanjiv, and Khean-Lee Goh. “Epidemiology of functional dyspepsia: a global perspective.” World journal of gastroenterology vol. 12,17 (2006): 2661-6. doi:10.3748/wjg.v12.i17.2661
  24. Evaluation and management of dyspepsia R. Christopher Harmon and David A. Peura Ther Adv Gastroenterol (2010) 3(2) 8798 DOI: 10.1177/1756283X09356590

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