Professional Documents
Culture Documents
Cancer is a rare cause of dyspeptic symptoms Cancer is a rare cause of dyspeptic symptoms
< 2 % < 2 %
Diagnostic test: endoscopy or radiography? Diagnostic test: endoscopy or radiography?
Radiography :
96 %
70 %
Endoscopy :
Dooley Dooley et al. et al., , Ann Intern Med Ann Intern Med 1984; 101: 538 1984; 101: 538--45 45
(C)
NSAID and/or
Regular ASA
Use?
NSAID Management
No
NO
YES
YES
YES
First Visit
(A)
Other possible causes ?
Consider : Consider :
-- Cardiac Cardiac
-- Hepatobiliary Hepatobiliary
-- Medication Medication--induced induced
-- Dietary indiscretion Dietary indiscretion
-- Other Other
Treat as appropriate Treat as appropriate
Uninvestigated Dyspepsia Uninvestigated Dyspepsia
Investigate Investigate
(endoscopy recommended) (endoscopy recommended)
(B)
Age >50 or alarm features?
- Vomiting
- Bleeding anemia
- Abdominal mass/
unexplained weight loss
- Dysphagi a
Sander et al., CMAJ 2000; 162 (Suppl): S123
Patients with uninvestigated dyspepsia Patients with uninvestigated dyspepsia
who are regular users of NSAIDS who are regular users of NSAIDS
(including ASA) should be identified, (including ASA) should be identified,
and if there are no alarm features, and if there are no alarm features,
they can be managed without initial endoscopy they can be managed without initial endoscopy
Recommendation Recommendation
(grade C recommendation, consensus) (grade C recommendation, consensus)
Patients who use NSAIDs Patients who use NSAIDs
Hp infection is the most common cause of
peptic ulcers
Most GERD patients do not have macroscopic Most GERD patients do not have macroscopic
esophagitis esophagitis
Initial treatment can be started based on Initial treatment can be started based on
symptoms of reflux in primary care symptoms of reflux in primary care
Endoscopy is not a useful diagnostic Endoscopy is not a useful diagnostic gold standard gold standard for for
GERD, nor 24 GERD, nor 24--hour pH monitoring hour pH monitoring
A reliable interpretation of the term heartburn is A reliable interpretation of the term heartburn is
key for the diagnosis of GERD key for the diagnosis of GERD
The effectiveness of lifestyle modifications and antacids for the treatment The effectiveness of lifestyle modifications and antacids for the treatment
of GERD is not proven. Patient with mild GERD symptoms may derive of GERD is not proven. Patient with mild GERD symptoms may derive
benefit from these treatment benefit from these treatment
Treatment recommendations for patients with a dominant symptom of
heartburn or acid regurgitation, or both, are as follows :
(a) PPI
(b) H
2
RA
(c) Prokinetic agent
(grade C recommendation, consensus) (grade C recommendation, consensus)
(grade C recommendation, consensus) (grade C recommendation, consensus)
Patients should be reassessed after 4 weeks of therapy
(grade A recommendation, level I evidence) (grade A recommendation, level I evidence)
Recommendation Recommendation
(C)
NSAID and/or
Regular ASA
Use?
(D)
Is dominant symptom
heartburn and/or
Regurgitation ?
NSAID Management
Treat as reflux
Treat as Hp positive
No
NO
NO
NO
YES
YES
YES
YES
YES
First Visit
(A)
Other possible causes ?
Consider : Consider :
-- Cardiac Cardiac
-- Hepatobiliary Hepatobiliary
-- Medication Medication--induced induced
-- Dietary indiscretion Dietary indiscretion
-- Other Other
Treat as appropriate Treat as appropriate
Uninvestigated Dyspepsia Uninvestigated Dyspepsia
Investigate Investigate
(endoscopy recommended) (endoscopy recommended)
(B)
Age >50 or alarm features?
- Vomiting
- Bleeding anemia
- Abdominal mass/
unexplained weight loss
- Dysphagi a
(E)
Hp test positive?
1. UBT
2. Serology
Hp Hp test and treat strategy test and treat strategy
Hp infection is associated with
- duodenal ulcer 90 95 %
- gastric ulcer 60 80 %
- gastric cancer
Option for the treatment of younger patients w/o alarm features: Option for the treatment of younger patients w/o alarm features:
Uncertainty as to whether Hp plays a role in
dyspepsia in the absence of ulcers
Serologic testing cannot be used to determine cure Serologic testing cannot be used to determine cure
as the as the IgG IgG antibodies remain detected for a long antibodies remain detected for a long
time after eradication time after eradication
UBT UBT has a high (+) has a high (+)ve ve and ( and (--))ve ve predictive value predictive value
(both > 90 %) (both > 90 %)
Noninvasive methods are recommended Noninvasive methods are recommended
for the detection of for the detection of H. pylori H. pylori in patient aged 50 years or less in patient aged 50 years or less
with uninvestigated dyspepsia who have no alarm features with uninvestigated dyspepsia who have no alarm features
Recommendation Recommendation
(grade B recommendation, level II (grade B recommendation, level II--2 evidence) 2 evidence)
Hp stool antigen Hp stool antigen is the preferred test is the preferred test
No more serology No more serology
Recommendation Recommendation
((AGA guidelines from 2005 AGA guidelines from 2005))
Stool Stool aantigen ntigen iis s tthe he rrecommended ecommended ttest est
TTest with est with stool stool antigen antigen before before prescribing prescribing PPPI PIss
do not have alarm symptoms do not have alarm symptoms
have not been using NSAIDS have not been using NSAIDS
who are not > 55 who are not > 55 yrs yrs
(C)
NSAID and/or
Regular ASA
Use?
(D)
Is dominant symptom
heartburn and/or
Regurgitation ?
NSAID Management
Treat as reflux
Treat as Hp positive
Treat as Hp Negative
No
NO
NO
NO
NO
YES
YES
YES
YES
YES
First Visit
(A)
Other possible causes ?
Consider : Consider :
-- Cardiac Cardiac
-- Hepatobiliary Hepatobiliary
-- Medication Medication--induced induced
-- Dietary indiscretion Dietary indiscretion
-- Other Other
Treat as appropriate Treat as appropriate
Uninvestigated Dyspepsia Uninvestigated Dyspepsia
Investigate Investigate
(endoscopy recommended) (endoscopy recommended)
(B)
Age >50 or alarm features?
- Vomiting
- Bleeding anemia
- Abdominal mass/
unexplained weight loss
- Dysphagi a
(E)
Hp test positive?
1. UBT
2. Serology
Sander et al., CMAJ 2000; 162 (Suppl): S123
There is good evidence that antacids are ineffective There is good evidence that antacids are ineffective
for functional dyspepsia, and they are not recommended for functional dyspepsia, and they are not recommended
for the treatment of uninvestigated dyspepsia for the treatment of uninvestigated dyspepsia
in patients subsequently found to be in patients subsequently found to be H. Pylori H. Pylori negative negative
Recommendation Recommendation
(grade B recommendation, level I evidence) (grade B recommendation, level I evidence)
SSPECIALIST PECIALIST RREFFERAL EFFERAL ::
PPRIMARY RIMARY MMANAGEMENT ANAGEMENT OF OF NNEW EWOONSET NSET
UUNINVESTIGATED NINVESTIGATED DDYSPEPSIA YSPEPSIA IN IN IINDONESIA NDONESIA
IIFF <2 <2 4 W 4 WKS KS..
DDIETARY IETARY AADVICE DVICE, O , OBSERVE BSERVE
RREVIEW EVIEWCCURRENT URRENT MMEDS EDS..
EEXCLUDE BY XCLUDE BY HHISTORY ISTORY ::
BBILLIARY ILLIARY PPAIN AIN, ,
IIRRITABLE RRITABLE BBOWEL OWEL, R , REFLUX EFLUX
FFAILURE AILURE OR OR
EEARLY ARLY RRELAPSE ELAPSE
FFINAL INAL EEVALUATION VALUATIONAAFTER FTER 8 W 8 WKS KS
>3 X R >3 X RELAPSE ELAPSE
RRELAPSE ELAPSE
FFOLLOW OLLOWUUPP
SSUCCESS UCCESS
PPOS OS..
AAGE GE >55 Y >55 YRS RS
WITH WITH AALARM LARM FFEATURES EATURES ::
NNEG EG..
SSEROLOGIC EROLOGIC Hp T Hp TESTING ESTING
AANTACIDS NTACIDS
AANTISECRETORY NTISECRETORY
PPROKINETICS ROKINETICS
GGASTROENTEROLOGIST ASTROENTEROLOGIST
IINTERNAL NTERNAL MMED. ED./P /PED. WITH ED. WITH
EENDOSCOPIC NDOSCOPIC FFACILITIES ACILITIES
TTREATMENT REATMENT TTRIAL RIAL : 2 W : 2 WKS KS
AGE <55 Y AGE <55 YRS RS
WWITHOUT ITHOUTAALARM LARM FFEATURES EATURES
DYSPEPSIA DYSPEPSIA
FFEVER EVER
HHEMATEMESIS / EMATEMESIS / MMELENA ELENA
J AUNDICE J AUNDICE
BW BW
NSAIDs NSAIDs
SSTRONG TRONG FFEAR EAR OF OF SSERIOUS ERIOUS DDIS IS. .
FFAMILY AMILY HHISTORY : ISTORY : GGASTRIC ASTRIC CCA. A.
SSEVERE EVERE VVOMITING OMITING
EERADICATION RADICATION TTHERAPY HERAPY
RREEVALUATE EEVALUATE : E : ENDOSC NDOSC.,PA, Hp C .,PA, Hp CULTURE ULTURE
RREEVALUATE : EEVALUATE : EENDOSC., NDOSC.,PA PA, , CLO CLO
CLO ( CLO (), PA ( ), PA ())
QQUADRUPLE UADRUPLE TTREATMENT REATMENT
MMANAGEMENT ANAGEMENT OF OF DDYSPEPSIA YSPEPSIA IN IN RREFFERAL EFFERAL CCENTER ENTER
FFROM ROM AALGORHYTM LGORHYTM 11 UGI E UGI ENDOSCOPY NDOSCOPY
CLO ( CLO (), PA ( ), PA ()) CLO ( CLO (), PA ( ), PA ())
CLO ( CLO (), PA ( ), PA ())
NNOO EERADICATION RADICATION
EEMPIRIC MPIRIC TTREATMENT REATMENT
FFIND IND OOTHER THER CCAUSES AUSES
SSUCCESS UCCESS FFAILURE AILURE
FFAILURE AILURE
Hp E Hp ERADICATION RADICATION AACCORDING CCORDING
TO TO THE THE RRESISTANCY ESISTANCY TTEST EST
DYSPEPSIA DYSPEPSIA
CLO T CLO TEST EST, PA , PA
EEVALUATION VALUATION 4 W 4 WKS KS. .
AAFTER FTER EERADICATION RADICATION
Note : Note :
CCASE ASE SSELECTION ELECTION ::
1. Strongly recommended : 1. Strongly recommended :
DU DU
GU GU
Post resection of early gastric Ca Post resection of early gastric Ca
MALT lymphoma MALT lymphoma
2. Recommended : 2. Recommended :
Ulcer Ulcer--like dyspepsia like dyspepsia
Severe chronic gastritis Severe chronic gastritis
NSAIDs gastritis NSAIDs gastritis
Severe erosive gastritis Severe erosive gastritis
Hypertrophic gastritis Hypertrophic gastritis
CCASE ASE SSELECTION ELECTION
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