Doctor my belly hurts, what s wrong?

Transcription

1 Doctor my belly hurts, what s wrong? Luis Rivero Pinelo MD, LMCC, CCFP, FCFP, Fellow SRPC, CSPQ Shawville - Quebec 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 2 Clinical Case 3 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. 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 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.

2 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. 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. 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. Nature Reviews Gastroenterology & Hepatology11, (2014)doi: /nrgastro 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. 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

3 Worldwide sales for indigestion and heartburn remedies totaled $CDN 9.1 billion in 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. 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 In Canada, the majority of dyspepsia sufferers have erosive esophagitis which responds well to acid suppressive prescription drugs. Objectives in dealing with Dyspepsia patients in primary care: Reduction or suppression of symptoms Early diagnosis of significant disease Avoiding over-treatment attitudes Help controlling medical and non-medical expenses.

4 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 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 Other there other possible causes for the symptom? If not: Age more than 50 or alarm features? If yes: Investigate/ refer (prompt endoscopy is the recommended method) If age not more than 50 or alarm features: NSAID and or regular ASA use? 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

5 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. If heartburn or acid reflux are dominant symptoms: 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). 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. If not, test for H. Pylori: 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)

6 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%. If not, test for H. Pylori: 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. 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 Sensibilité, spécificité et valeurs prédictives des différentes méthodes utilisées pour la recherche d Helicobacter Pylori Sensibilité Spécificité VPP VPN Test respiratoire 95% 95% 95% 95% Sérodiagnostic 85% 80% 50 75% 90% 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.

7 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/sex adjusted gastric cancer probability in Canada Age (years); probability (%) Gender Men Women Points to bring with you: 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.