Doctor my belly hurts, what`s wrong?

Doctor my belly hurts, what's wrong?
Doctor my belly hurts,
what’s wrong?
Luis Rivero Pinelo MD, LMCC, CCFP, FCFP, Fellow SRPC, CSPQ
Shawville - Quebec
Clinical Case 2
31 year old female with a 6 month history of heartburn, acid reflux mostly at
night occasionally nausea. Not significant past medical history, OTC anti-acid
medication relieves partially his symptoms.
Clinical Case 1
42 year old male with 1 year history of intermittent pain in the upper abdomen,
mostly after meals. Localized pain, no alarm symptoms (GI bleeding, no weight
loss, excessive vomiting). He denies bowel changes (constipation, diarrhea), no
early satiety, bloating.
Patient reports occasional heartburn mostly lying recumbent on bed, after
eating a large meal meals or bending forward. He is otherwise a healthy and
takes no medication.
Clinical Case 3
48 year old female complains of at least six month history of epigastric pain
radiated to right upper quadrant and right scapular area mostly after eating
fatty-grease meals.
She is obese, hypertensive and with several members in the family known
biliary problems
Clinical case 4
Definition of Dyspepsia
64 year old male wit a long standing history of GERD, shows complaining of
difficulty swallowing mostly solid food (meat, noodles, rice), states needs to
push food down drinking water.
He has no problems with soft meals or fluids. His appetite is good and very
little change on weight. Patient denies excessive vomiting, hematemesis,
melena.
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Doctor my belly hurts, what's wrong?
Definition of Dyspepsia
The Canadian Dyspepsia Group defines Dyspepsia as: “A symptom
complex of epigastric pain or discomfort thought to originate in the
upper GI tract and it may include any of the following symptoms:
Heartburn, acid regurgitation, excessive burping/belching,
abdominal bloating, nausea feeling, early satiety or slow digestion.
Definition of Dyspepsia
Dyspepsia is not a diagnostic, but a symptom complex of the upper
gastrointestinal tract . The term describes a heterogeneous group of
symptoms with numerous underlying causes.
Definition of Dyspepsia
Primary care physicians treat most patients with Dyspepsia. An
estimated 7% of the average of the Canadian Family physician’s
practice is devoted to the management of Dyspepsia and 23% of
these patients are presenting for the first time.
Demographics
It is very common in the adult Western population with prevalence
rates ranging from 19% to 41% in several epidemiological studies.
Dyspepsia is a common condition in Canada with a prevalence
estimated at 29% that significantly diminishes the quality of life of
those affected.
Nature Reviews Gastroenterology & Hepatology11, 207–208 (2014)doi:10.1038/nrgastro.2014.19
Prevalence et causes de la Dyspepsia
Les données épidémiologiques montrent que la dyspepsie, qui inclut souvent le pyrosis comme
symptôme associe, est un problème fréquent dans la population/en médecine ambulatoire:
• Au cours d’une année, 1% de la population adulte rapporte un épisode inaugural de dyspepsie
et 25% présentent une dyspepsie chronique ou récurrente
• 25% des individus présentant une dyspepsie consultent un médecin
• La dyspepsie motive environ 5% des consultations de médecine générale ambulatoire
• La prévalence de l’ulcère gastroduodénal est de 1-2% dans la population générale
• 5-10% de la population présente dans sa vie un ulcère gastroduodénal
• La prévalence du RGO est de 20-40% dans la population générale
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Doctor my belly hurts, what's wrong?
Other Statistic data:
Other Statistic data:
Canada is ranked as the 12th largest consumer of indigestion and
heartburn remedies in the world. In 2008, Canadian sales were $164
million. This is a substantial increase from 2003 in where sales
totaled just $108 million.
Worldwide sales for indigestion and heartburn remedies totaled
$CDN 9.1 billion in 2008.
Other Statistic data:
Other Statistic data:
Patients concerns about indigestion costs the Canadian health care system $460 million
each year.
In the 1980s, the average length of hospital stay for dyspeptic patients was 7 days. Since
2002, this has decreased to 5 days reducing the economic burden of this disease by
$16.3 million per year).
The risk for developing Barrett's esophagus in dyspeptic patients is higher than
for non-dyspeptic patients. The disease is considered a premalignant condition
that may lead to progressive dysplasia and adenocarcinoma.
Uninvestigated Dyspepsia in primary care
Other Statistic data:
Objectives in dealing with Dyspepsia patients in primary care:
In Canada, the majority of dyspepsia sufferers have erosive esophagitis
which responds well to acid suppressive prescription drugs.
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Reduction or suppression of symptoms
Early diagnosis of significant disease
Avoiding over-treatment attitudes
Help controlling medical and non-medical expenses.
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Doctor my belly hurts, what's wrong?
Uninvestigated Dyspepsia in primary care
Alarm symptoms in the dyspeptic patient prompting referral/endoscopy:
•Odynophagia, Dysphagia
•Gastrointestinal bleeding
•Persisting vomiting
•Epigastric mass
•Previous gastric surgery (more than 10 years)
•Unintentional weight loss
•Iron deficiency anemia
Clinical management tool for
uninvestigated Dyspepsia
Clinical management tool for
uninvestigated Dyspepsia
A thorough history-taking and physical examination is mandatory
Are there other possible causes for the symptoms?
If yes, consider:
•Cardiac
•Hepatobiliary
•Medication induced (NSAIDS, Bi-phosphonates, Potassium)
•Dietary
•Life style or others
Clinical management tool for
uninvestigated Dyspepsia
Other there other possible causes for the symptom?
If not:
Age more than 50 or alarm features?
If yes:
If age not more than 50 or alarm features:
NSAID and or regular ASA use?
Investigate/ refer (prompt endoscopy is the recommended method)
Médicaments le plus souvent responsables de la
dyspepsie
Patients with uninvestigated dyspepsia who are regular
users of NSAIDS including ASA should be identified, and
if no alarm symptoms they can be managed without initial
endoscopy.
•Aspirine et anti-inflammatoires non stéroïdiens
•Antibiotiques (macrolides/métronidazole)
•Théophylline
•Digitale
•Stéroïdes
•Suppléments de potassium
•Suppléments de fer
•Colchicine , Niacine , Quinidine T
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Doctor my belly hurts, what's wrong?
Clinical management tool for
uninvestigated Dyspepsia
Clinical management tool for
uninvestigated Dyspepsia
If heartburn or acid reflux are dominant symptoms:
If no NSAID or ASA use:
Is dominant symptom heartburn and/or acid reflux?
Klauser et al. found that when heartburn or acid reflux are dominant symptoms, they
have a high specificity(89% and 95% respectively)
Heartburn symptom alone has a sensitivity of 84 % diagnostic of GERD and
heartburn + acid reflux have a diagnostic accuracy of 94%. Therefore treat as GERD
for 4 to 8 weeks.
If heartburn or acid reflux are dominant symptoms:
Treat as GERD
Remember, controlled studies showed that empirical treatment with H2
Blockers showed higher costs and lower patient satisfaction as lower acid
control than PPI’s that should be the first line treatment plus or minus
Prokynetics. Hygienic- dietary changes controversial.
Helicobacter Pylori
Treat as GERD
Four week trial in younger than 50 without alarm symptoms. If no response BID
PPI’s for one to two months, if symptoms do not resolve, GI consult for further
investigation (Refractory Dyspepsia).
If not, test for H. Pylori:
Helicobacter Pylori was identified in 1982 by two Australian
scientists, Robin Warren and Barry Marshall as a causative
factor for ulcers. In their original paper, Warren and Marshall
contended that most gastric ulcers and gastritis were caused by
colonization with this bacterium, not by stress or spicy food as
had been assumed before.
The Center for Disease control and Prevention (CDC), estimates
that approximately two-thirds of the world population harbours
the bacteria.
The bacteria is the second most common cause of Peptic Ulcer
Disease after NSAID use and was classified as a Carcinogen type 1
by the WHO. (MALT)
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Doctor my belly hurts, what's wrong?
If not, test for H. Pylori:
If not, test for H. Pylori:
In Canada the overall prevalence of H. Pylori is 30 % to 40% (higher
in native communities). Socio-economic status has a big role.
Developing countries show a prevalence close to 100%.
Helicobacter Pylori testing could be done by endoscopy (gold
standard) C13 Urea Breath Test (UBT) or serology
(ELISA).The first consistently superior with a high Positive
and Negative Predicted Value (above 90%) against 75 to 80%
and highly dependent of the prevalence of H. Pylori infection.
Treatment regimes for H. Pylori Eradication (From Sander
Van Zanten et al.)
Remember:
Serology test are appropriate in the initial work up of the patient.
However it can not be used to see if the infection has been
eradicated because the test remains positive for at least one year
even if the bacteria was eradicated.
Sensibilité, spécificité et valeurs prédictives des différentes méthodes utilisées pour la recherche d’Helicobacter Pylori VPP
VPN
Test respiratoire
Sensibilité
95%
Spécificité
95%
95%
95%
Sérodiagnostic
85%
80%
50 – 75%
90%
Triple Therapies (PPI + 2 antibiotic):
- PPI + Clarithro + Amoxicillin
Eradication rate +- 90%
or
- PPI + Clarithro + Metro
If Penicillin allergy 75%
eradication rate > side
Quadruple Therapy:
- PPI + Bismuth + Metronidazole + If macrolide intolerance
or
Tetracyclin
triple therapy failure
H. Pylori “Test and treat” strategy
For uninvestigated dyspepsia in patients younger than 50 year old
and no alarm symptoms is recommended . H.P. infection is
associated with 90 to 95% of Duodenal ulcers and 60 to 80% of
Gastric ulcers. Can. Dys. recommendation.
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Doctor my belly hurts, what's wrong?
Age/sex adjusted gastric cancer probability in Canada
In 1994, the International Agency for Research on Cancer
Working Group stated: “H. pylori infection is estimated to be
present in 35 to 60% of cases of gastric cancer based on the
evidence from case controlled studies.
Age (years); probability (%)
Gender
30
40
50
60
70
80
90
Men
-
-
0.1
0.2
0.6
1.1
1.4
Women
-
-
0.1
0.1
0.3
0.6
0.8
Points to bring with you:
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Dyspepsia is an extremely common condition
Primary Care Physicians treat most patients with dyspepsia
Two thirds of dyspepsia cases are functional, one third organic
Stratify patient population (younger or older than 50)
Screen for alarm symptoms
Refractory dyspepsia, older than 50 and or presence of alarm symptoms prompt swift referral
PPI’s are the corner stone on medical management
Remember H. Pylori plays a big causal role.
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