Dyspepsia

What is dyspepsia?

pain or discomfort related to eating or drinking that

can be attributed to the upper gastro-intestinal tract
 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
 Drugs that cause dyspepsia

NSAIDS
Bisphosphonates
Steroids

Metformin

Calcium antagonists
Theophyllines
Nitrates
 Endoscopic diagnoses in dyspepsia

60

50
GERD
40
PUD
%
30 Functional
Benign stricture
20
Cancer
10

Westbrook at al, 2001

What all patients worry about
GORD
Gastro-oesophageal junction
Causes of GORD
Diagnosis of GORD
 Complications of GORD

Stricture
Barretts Oesophagus
Oesophageal adenocarcinoma
Extra-oesophageal
Asthma
Cough
Pharyngitis
Barretts Oesophagus
Barretts Oesophagus
Barretts Adenocarcinoma
European age-standardised mortality rates for
oesophageal cancer in UK, 1979-1999

Cancer Research UK
 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
Gastric Ulcer
 Gastric ulcer - causes

H. pylori 60%
NSAIDs 30%
Carcinoma 5%
Others 5%
- neoplasia
- Crohns
- stress
- ZE syndrome
Duodenal Ulcer
 Duodenal ulcer - causes

H. pylori 85%
NSAIDs 10-14%
Rare causes 1%
- Zollinger Ellison
- Crohns
- Stress
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)
Functional Dyspepsia
Gastric cancer
 Age standardised (European) incidence and
mortality by sex, stomach cancer, UK, 1979-2001

Cancer Research UK
Five year relative survival rates by sex,
stomach cancer

Cancer Research UK
 ALARM symptoms
Abdominal swelling (Anaemia)
Loss of weight
Anorexia
Recurrent symptoms*
Melaena/Haematemesis
Swallowing problems

*Only if age >55 years

 Audit characteristics

1170 practices
14% of practices
71% of cancer networks
April 2009 April 2010
Represents 8% of cancers registered that year
 Delays for gastric cancer

100
90
80
70
60 Patient
50 GP
40 Hospital
30
20
10
0
0 14 31 62 182
Stage of gastric cancer

No spread
Local
Distant
No data
 Number of consultations

40
35
30
25
20
15
10
5
0
0 1 2 3 4 5 or more
Route of referral

Emergency
2WW
Routine
Private
Other
Upper GI 2 week cancer referral cancers

Others
Unknown
primary

Oesophagus

NHL
Lung

Colon

Biliary Gastric
Pancreas
 Cancer risk in 2WW referrals

30

25

20 Male
% cancer

Female
15

10

0
25 35 45 55 65 75 85
 2 week UGI cancer referrals

1200

1000

800
Referred
600
Cancers
400

200

0
2001 2002 2003 2004 2005 2006
Community Care & Pharmacy
General Advice
General Advice
GP management of Dyspepsia
Irritable Bowel Syndrome
 Diagnosis

Pain associated with bowels

Longstanding
History of dysenteric illness
Associated conditions
Fibromyalgia
Headache
CFS
Non-cardiac chest pain
 Warning signs

Short history
Weight loss
Nocturnal diarrhoea
Incontinence
Rectal bleeding
Age >50
Abnormal blood tests
 Blood tests

FBC, CRP, UE, LFT (incl Ca), TSH, tTG, B12,

folate
Rectal examination
Faecal calprotectin
Faecal calprotectin
 Faecal calprotectin

Useful to diagnose IBD

Not useful to confirm IBS (at present)
May miss other important diagnoses
Cancer
Bile acid malabsorption
Diverticulosis
 Management of DP-IBS

Avoid bran
Reduce non-soluble fibre
Reduce lactose (use soy or rice products)
Loperamide
Anti-spasmodics
Amitriptyline
 Management of CP-IBS

Increase dietary fibre (20-30g)

Unprocessed wheat bran
Increase fluids
Bulking laxatives
Ispaghula husk
Consider citalopram
 Pain in IBS

Hypnotherapy beneficial
Cognitive Behavioural Therapy beneficial
Acupuncture not proven
Citalopram/amitriptyline may help
 FODMAPs

Fermentable
Oligosaccharides
Disaccharides
Monosaccharides
And
Polyols (sorbitol, sweeteners)
 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

 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*
 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