dyspepsia. what is dyspepsia? ‘pain or discomfort related to eating or drinking that can be...
TRANSCRIPT
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Dyspepsia
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What is dyspepsia?
‘pain or discomfort related to eating or drinking that can be attributed to the upper gastro-intestinal tract’
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The problem of dyspepsia
• 25 - 40 % prevalence, and increasing• 25% of these seek help from GP• 2 % population have endoscopies p.a.• 0.45 % on long term PPIs• £500 million pa (E&W)• £ 2-3 billion Europe
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Drugs that cause dyspepsia
• NSAIDS• Bisphosphonates• Steroids
• Metformin
• Calcium antagonists• Theophyllines• Nitrates
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Endoscopic diagnoses in dyspepsia
0
10
20
30
40
50
60
GERDPUDFunctionalBenign strictureCancer
%
Westbrook at al, 2001
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What all patients worry about
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GORD
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Gastro-oesophageal junction
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Causes of GORD
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Diagnosis of GORD
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Complications of GORD
• Stricture• Barrett’s Oesophagus• Oesophageal adenocarcinoma• Extra-oesophageal
– Asthma– Cough– Pharyngitis
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Barrett’s Oesophagus
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Barrett’s Oesophagus
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Barrett’s Adenocarcinoma
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©Cancer Research UK
European age-standardised mortality rates for oesophageal cancer in UK, 1979-1999
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Anti-reflux surgery (ARS)
• Helps 90%• Lasts about 10 years• 50% still need PPI• Morbidity in 10% (dysphagia, bloating)• Laparoscopic probably better – but no evidence
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Gastric Ulcer
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Gastric ulcer - causesGastric ulcer - causes
H. pylori 60%NSAIDs 30%Carcinoma 5%Others 5%
- neoplasia- Crohn’s- stress- ZE syndrome
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Duodenal Ulcer
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Duodenal ulcer - causesDuodenal ulcer - causes
H. pylori 85%NSAIDs 10-14%Rare causes 1%
- Zollinger Ellison- Crohn’s- Stress
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Giving NSAIDs in patients with or at risk of peptic ulcer
• Avoid NSAID if possible• Consider COX2 inhibitors
– Beware cardiovascular risks• Hypertension• MI• CVA
• Add PPI to COX2 inhibitor• Add PPI to ‘low-risk NSAID’ (ibuprofen)
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Functional Dyspepsia
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Gastric cancer
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Age standardised (European) incidence and mortality by sex, stomach cancer, UK, 1979-2001
© Cancer Research UK
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Five year relative survival rates by sex, stomach cancer
© Cancer Research UK
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ALARM symptoms
• Abdominal swelling (Anaemia)
• Loss of weight
• Anorexia
• Recurrent symptoms*
• Melaena/Haematemesis
• Swallowing problems
*Only if age >55 years
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Audit characteristics
• 1170 practices – 14% of practices– 71% of cancer networks
• April 2009 – April 2010• Represents 8% of cancers registered that year
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Delays for gastric cancer
0
10
20
30
4050
60
70
80
90
100
0 14 31 62 182
PatientGPHospital
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Stage of gastric cancer
No spreadLocalDistantNo data
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Number of consultations
0
5
10
15
20
25
30
35
40
0 1 2 3 4 5 or more
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Route of referral
Emergency2WWRoutinePrivateOther
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Upper GI 2 week cancer referral cancers
Oesophagus
GastricPancreas
Biliary
Colon
NHL
Unknown primary
Others
Lung
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Cancer risk in 2WW referralsCancer risk in 2WW referrals
0
5
10
15
20
25
30
25 35 45 55 65 75 85
MaleFemale
% c
ance
r
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2 week UGI cancer referrals
0
200
400
600
800
1000
1200
2001 2002 2003 2004 2005 2006
ReferredCancers
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Community Care & Pharmacy
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General Advice
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General Advice
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GP management of Dyspepsia
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Irritable Bowel Syndrome
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Diagnosis
• Pain associated with bowels• Longstanding• History of dysenteric illness• Associated conditions
– Fibromyalgia– Headache– CFS– Non-cardiac chest pain
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Warning signs
• Short history• Weight loss• Nocturnal diarrhoea• Incontinence • Rectal bleeding• Age >50• Abnormal blood tests
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Blood tests
• FBC, CRP, UE, LFT (incl Ca), TSH, tTG, B12, folate
• Rectal examination
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Faecal calprotectin
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Faecal calprotectin
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Faecal calprotectin
• Useful to diagnose IBD• Not useful to confirm IBS (at present)• May miss other important diagnoses
– Cancer– Bile acid malabsorption– Diverticulosis
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Management of DP-IBS
• Avoid bran• Reduce non-soluble fibre• Reduce lactose (use soy or rice products)• Loperamide• Anti-spasmodics• Amitriptyline
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Management of CP-IBS
• Increase dietary fibre (20-30g)• Unprocessed wheat bran• Increase fluids• Bulking laxatives
– Ispaghula husk• Consider citalopram
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Pain in IBS
• Hypnotherapy beneficial• Cognitive Behavioural Therapy beneficial• Acupuncture not proven• Citalopram/amitriptyline may help
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FODMAPs
• Fermentable• Oligosaccharides• Disaccharides• Monosaccharides• And• Polyols (sorbitol, sweeteners)
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Category A (suspected lower GI cancer)
Any patient over the age of 50 with change in bowel habit/diarrhoea (>6 weeks but <6 months) who has one or more of the following features:
Weight loss, iron deficiency anaemia, tenesmus, strong family history of bowel cancer (in first degree relative aged <60), abdominal mass, mass on PR
Action: Refer as 2WW to Colorectal Dept
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Category B (Organic diarrhoea)
Any patient presenting with diarrhoea, not fulfilling ‘A’, who has any of the following features:
Bloody stools, frequent loose stools ++, incontinence, nocturnal diarrhoea, strong family history of IBD, raised CRP, positive TTG
Action: Refer to Dept of Gastroenterology
*Urgent referral or emergency admission is recommended for patient who may have a severe colitis, typical patients may have 6 or more bloody stools per day, fever, tachycardia and anaemia*
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Category C (Probable IBS)
Patient below the age of 40 who has altered bowel habit, abdominal pain or discomfort that is relieved by defaecation, bloating but in the absence of category A and B features.
Action: Does not require referral for confirmation of diagnosis. To exclude inflammatory bowel disease, perform faecal calprotection test. Only refer if positive. Do not carry out faecal calprotectin within 1 week of gastrointestinal infection (will be raised).
Manage as per IBS guidelines