DYSPEPSIA

IRISH A. TIMBAL
OBJECTIVES

 To discuss the epidemiology, clinical features,

diagnosis, and treatment of dyspepsia based on
NICE guidelines.
 To be able to recognize the warning signs and
symptoms of dyspepsia
LEARNING OBJECTIVES

 Define Dyspepsia
 Discuss the types of dyspepsia
 Enumerate predisposing factors leading to the disease
 Enumerate pharmacologic and non pharmacologic
management of dyspepsia
 Educate the patient regarding the importance of non-
pharmacologic regimen
GENERAL DATA

This is a case of RS, 48 years old, male, married,

Filipino, Roman Catholic, born on September 28,
1971, currently residing at Project 4, Quezon City,
consulted for the first time at East Avenue Medical
Center on January 16, 2020.
CHIEF COMPLAINT

Epigastric pain
HISTORY OF PRESENT ILLNESS

Four days prior to consult, px experienced epigastric pain

which was characterized as squeezing, intermittent pain with a
scale of 7/10, non-radiating, and was confined at epigastric area
associated with sour sensation, burning pain in the chest
aggravated by food intake. No episode of vomiting, palpitation,
and difficulty of breathing. Patient noted that he was fond of
drinking caffeinated beverages every morning. No medicine and
consult was done.
HISTORY OF PRESENT ILLNESS

Few hours prior to consult, patient still felt the following

symptoms:
(+) Heartburn (-) Anorexia (-) Vomiting (-) Early satiety
(-) Nausea (+) Bloatedness (+) Epigastric pain (+) Reflux
(-) Post prandial pain
(-) Hematemesis, melena, hematochezia, abdominal
enlargement
PAST MEDICAL HISTORY

 No known history of hypertension

 No known history of Diabetes Mellitus
 No known history of kidney disease, bronchial
asthma, tuberculosis
 No previous hospital admission and surgical
operations
 No known allergies and psychiatric condition
FAMILY HISTORY

 Hypertension – Father, mother

 No family history of diabetes mellitus, stroke, heart
and kidney disease, thyroid disorders, bronchial
asthma, skin disease, tuberculosis, and cancer
 GENOGRAM
GUIMMAYEN – SALIGANAN
JANUARY 16, 2020
Ronald Wenceslao Guimmayen Saliganan
LEGENDS:
Male
M. ?
I Female
Hypertension
Cornelio, 90 Rione, 84 Pneumonia
II
M. ?

Mildred, 59 Edwin, 56 Bonifacio, 54 Ronald, 48 Rowena, 47

III

Roel, 26 Robert, 24 Rose, 21 Jose, 18 Rhyen, Rhynen, Rab, JR, 8

17 14 12
SOCIAL HISTORY
 Non-smoker
 Alcohol: Occasional
 (-) Illicit drug use
 Exercise:Walking and balling
 Daily water intake: 7-8 glasses of water a day
 Habit:Watching TV
 Food preference: Fruits, sour food, oily food
 Coffee once a day, softdrinks once a day
 (+) skipping of meals
 (-) binge eating
 Occupation: Factory worker
REVIEW OF SYSTEMS

GENERAL
(-) fever (-) chills (-) anorexia (-) weight loss
SKIN
(-) rashes (-) jaundice (-) pruritus (-) dryness (-) hair loss
(-) nail problems
HEENT
(-) headache (-) blurring of vision (-) doubling of vision (-) photophobia
(-) flashing of lights (-) sore eyes (-) eye discharge
(-) increased lacrimation (-) eye tightness (-) ear discharge (-) otalgia
(-) haring loss (-) tinnitus (-) colds (-) nasal congestion (-) epistaxis
(-) sinus pain (-) facial pain (-) hoarseness (-) itchy nose/throat
(-) sore throat (-) dysphagia (-) dental caries (-) gum pain/bleeding
(-) neck mass
REVIEW OF SYSTEMS

PULMONARY
(-) cough (-) hemoptysis (-) dyspnea (-) SOB (-) pleuritic chest pain
(-) back pain
CARDIAC
(-) chest pain (-) easy fatigability (-) orthopnea (-) PND
GU
(-) dysuria (-) hematuria (-) genital discharge (-) genital pruritus
(-) urinary frequency (-) nocturia (-) weak/slow stream (-) intermittency
(-) hesitancy (-) urgency (-) incontinence (-) incomplete voiding
(-) straining (-) flank pain (-) suprapubic pain
 REVIEW OF SYSTEMS
HEMA
(-) easy bruisability (-) bleeding tendency (-) delayed wound healing
PVS
(-) claudication (-) varicose vein (-) edema
ENDO
(-)polyphagia (-) polydipsia (-) polyuria (-) heat/cold intolerance (-) excessive sweating
NEURO
(-) insomnia (-) memory loss (-) disorientation (-) change in sensorium
(-) change in mood (-) speech defect (-) syncope (-) numbness
(-) pins and needles sensation (-) tremors (-) involuntary movements
(-) sleep disturbance
PSYCHIATRIC
(-) nervousness (-) suicidal ideation (-) depression (-) hallucinations
(-) sleep disturbance
MSK
(-) joint pain (-) muscle pain (-) cramps (-) lumps/mass (-) swelling
VITAL SIGNS AND ANTHROPOMETRIC
MEASUREMENT

ANTHROPOMETRIC
VITAL SIGNS
MEASUREMENT
BP 110/70 mmHg Weight 67.5 kg
MAP 83 mmHg Height 165 cm
24.8 kg/m2
RR 17 cpm BMI Overweight

HR 88 bpm IBW 61.4 kg

Temperature 36.4 °C Waist 78 cm
O2 Sat 98% Hip 87 cm
W/H Ratio 0.89
PHYSICAL EXAM

GENERAL
Conscious, coherent, not in cardiorespiratory distress
SKIN
(-) pallor (-) cyanosis (-) rashes (-) jaundice
(-) pruritus (-) dryness (-) hair loss (-) nail problem (-) nevi
PHYSICAL EXAM
HEENT Anicteric sclerae, pink palpebral
conjunctivae, no naso-aural discharge, no
tonsillo-pharyngeal congestion, neck is
supple with no cervical lymphadenopathy
LUNGS (-) mass/lesion, symmetrical chest
expansion, no lagging, no retraction, clear
breath sounds
HEART Adynamic precordium, PMI at 5th LICS
MCL, normal rate regular rhythm, (-)
murmur
PHYSICAL EXAM

ABDOMEN Flabby, no lesion, normoactive bowel

sound, soft, non tender
EXTREMITIES Grossly normal extremities, <2 seconds
capillary refill

GENITALIA Not assessed

RECTAL EXAM Patient refused
SPECIAL TEST Not assessed
PHYSICAL EXAM

NEURO EXAM
CEREBRAL EXAM
Conscious, coherent; oriented to time, place, and
person
GCS 15 (E 4 V 5 M 6)
PHYSICAL EXAM
CRANIAL
NERVES
CN I Not assessed
CN II, III PERRLA
CN III, IV, VI Normal ROM of extraocular muscles
CN V Clenches teeth symmetrically, intact facial
expression
CN VII Symmetrical fascie
CN VIII Intact audition
CN IX, X Uvula at the midline
CN XI Shrugs both shoulder symmetrically
CN XII Tongue protrudes in midline, no fasciculations
PHYSICAL EXAM

NEURO EXAM
CEREBERRAL EXAM
Normal gait
Able to perform finger to nose test
Able to perform rapid alternating hand movements
Able to perform heel to shin test
PHYSICAL EXAM

5/5 5/5 +2 +2 100 100

5/5 5/5 +2 +2 100 100

MOTOR DTR SENSORY

SALIENT FEATURES
PERTINENT POSITIVE PERTINENT NEGATIVE
48 years old, male Non-smoker
Epigastric pain Non-alcoholic
• Characteristic: Squeezing (-) Fever
• Intermittent pain (-) Anorexia
• Pain scale of 7/10 (-) Vomiting
• Non-radiating, confined at epigastric area (-) Early satiety
Sour sensation (-) Nausea
Burning pain in the chest aggravated by food (-) Post prandial pain
(+) Bloatedness (-) DOB
(+) Reflux (-) Loss of appetite
Fond of drinking caffeinated beverages: coffee (-) Hematemesis
and softdrinks, once a day (-) Weight loss
Food preferences: Fruits, sour food and oily (-) Hematochezia
food (-) Melena
(+) Skipping of meals (-) Dysphagia
(-) Binge eating
DIFFERENTIAL DIAGNOSIS
DDX RULE IN RULE OUT DECISION
GERD Epigastric pain (-) Dysphagia Cannot be ruled
Burning pain in the (-) N/V out
chest (-) Regurgitation
Fond of drinking (-) Coughing
caffeinated and (-) Chest pain
carbonated drinks (-) Loss of appetite
Food preference:
Fruits, sour and
oily food
(+) reflux
Acute Gastritis Epigastric pain (-) N/V Cannot be ruled
(-) Loss of appetite out
(-) Hematemesis
No use of NSAIDs
DIFFERENTIAL DIAGNOSIS
DDX RULE IN RULE OUT DECISION
Peptic Ulcer Epigastric pain No hematemesis Cannot be ruled
Disease (+)Reflux No use of NSAIDs out
Squeezing in quality No previous
history of ulcer
(-) Weight loss

Esophagitis Epigastric pain (-) N/V Ruled out

(+) Heartburn (-) Odynophagia
(+) Reflux (-) Hoarseness
(-) Sore throat
(-) Cough
(-) Chest pain
(-) Dyspagia
(-) Mouth soes
WORKING DIAGNOSIS

Dyspepsia without alarm features

PLAN

 For wellness work-up: CBC w/ PC, BUN, creatinine, UA,

SGPT, SGOT, FBS, Lipid Profile, 12L ECG
 Omeprazole 40 mg/cap, 1 cap OD 30 minutes before
breakfast for 2 weeks
 Avoid spicy, acidic, caffeinated food and beverages, small
frequent meals
 Avoid skipping of meals
 Follow-up after 3 days
 Advised
DISCUSSION
NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE GUIDELINES
DYSPEPSIA

 Any chronic or recurrent discomfort in the

epigastric area described as bloatedness, fullness,
gnawing, or burning continuously or intermittently
for at least 2 weeks
 Symptom of the upper gastrointestinal tract (GI),
present for 4 weeks or more, including upper
abdominal pain or discomfort, heartburn,
acid reflux, nausea, or vomiting.

Reference:
Reference: Compendium of the Philippine Medicine 19th edition
NICE 2014
DYSPEPSIA

 1/3 of over 5,500 persons experienced dyspeptic

symptoms:
 acute dyspepsia in 6.5%
 chronic dyspepsia in 22.5%
 40% of Filipinos experience dyspeptic symptoms
 Prevalence was higher in women, and among smokers,
nonsteroidal anti-inflammatory drug users, and H pylori–
positive individuals
RISK FACTORS

 Old age
 Female sex
 Low body mass index
 H. pylori infection
 Use of aspirin or NSAIDs
 Low level education
 Smokers
 Alcoholics
TYPES OF DYSPEPSIA

 Organic dyspepsia – when there is a structural lesion to

account for dyspeptic symptoms.
 Functional dyspepsia – refers to patients with dyspepsia
where endoscopy (and other relevant tests) has ruled out
organic pathology that explains the patient’s symptoms.
 Postprandial distress syndrome (PDS)
 Epigastric pain syndrome (EPS)
ALARM SIGNS AND SYMPTOMS OF DYSPEPSIA
 New onset dyspepsia in subjects over 45-years-old.
 Family history of gastric cancer
 Anemia
 Unintentional weight loss
 Progressive dysphagia
 Odynophagia
 Recurrent or persistent vomiting
 Evidence of gastrointestinal bleeding
 Epigastric mass
ASSESSMENT
IMMEDIATE REFERRAL
 For people presenting with dyspepsia together with significant
acute gastrointestinal bleeding, refer them immediately (on the
same day) to a specialist.
MEDICATION REVIEW
 Review medications for possible causes of dyspepsia such as
calcium antagonists, nitrates, theophyllines, bisphosphonates,
corticosteroids and NSAIDs.
DIFFERENTIAL DIAGNOSIS
 Think about the possibility of cardiac or biliary disease as part of
the differential diagnosis.
COMMON ELEMENTS OF CARE
ADVICE ON LIFESTYLE AND AVOIDING PRECIPITANTS
 Offer simple lifestyle advice, including advice on healthy eating,
weight reduction and smoking cessation.
PROVIDING INFORMATION
 Provide people with access to educational materials to support
the care they receive.
PSYCHOLOGICAL THERAPIES
 Cognitive behavioral therapy and psychotherapy
DRUG THERAPY
 Avoid long-term, frequent-dose, continuous antacid therapy
WHEN TO REFER?

 Any age with gastro-esophageal symptoms that are non-

responsive to treatment or unexplained
 With suspected gastro-esophageal reflux disease who are
thinking about surgery
 With H. pylori that has not responded to second-line
eradication therapy
MANAGING UNINVESTIGATED DYSPEPSIA

 Offer H. pylori 'test and treat' to people with

dyspepsia
 Leave a 2-week washout period after PPI use
before testing for H. pylori with a breath test or a
stool antigen test.
 Offer empirical full-dose PPI therapy for 4 weeks
to people with dyspepsia
IF SYMPTOMS CONTINUE OR RECUR

 Offer H2 Receptor Antagonist therapy if there is an

inadequate response to a PPI
MECHANISM OF SIDE
CLASS DRUGS
ACTION EFFECTS
H2 Receptor Competitive inhibition at Headache, Cimetidine 400 mg BID
Antagonists the parietal cell H2 fatigue, Ranitidine 300 mg HS
receptor, suppresses acid myalgias, fever Famotidine 40 mg HS
secretion
H. PYLORI TESTING

 Test for H. pylori using a carbon-13 urea breath test or a

stool antigen test, or laboratory-based serology where its
performance has been locally validated.
 Perform re-testing for H. pylori using a carbon-13 urea
breath test. (There is currently insufficient evidence to
recommend the stool antigen test as a test of eradication.)
 Do not use office-based serological tests for H. pylori
because of their inadequate performance.
FIRST LINE TREATMENT FOR THE ERADICATION
OF H. PYLORI

 Offer people who test positive for H. pylori a 7-day, twice-

daily course of treatment with:
 Proton Pump Inhibitor and
 Amoxicillin and
 Either Clarithromycin or Metronidazole
 Choose the treatment regimen with the lowest acquisition
cost, and take into account previous exposure to
clarithromycin or metronidazole.
FIRST LINE TREATMENT FOR THE ERADICATION
OF H. PYLORI

 Offer people who are allergic to penicillin a 7-day, twice-

daily course of treatment with:
 Proton Pump Inhibitor and
 Clarithromycin and
 Metronidazole
FIRST LINE TREATMENT FOR THE ERADICATION
OF H. PYLORI

 Offer people who are allergic to penicillin and who have had
previous exposure to clarithromycin a 7-day course of
treatment with:
 Proton Pump Inhibitor and
 Bismuth and
 Metronidazole and
 Tetracycline
SECOND LINE TREATMENT
 Offer people who still have symptoms after first-line eradication
treatment a 7-day, twice-daily course of treatment with:
 Proton Pump Inhibitor and
 Amoxicillin and
 Either Clarithromycin or Metronidazole (whichever was not used
first-line)
 Offer people who have had previous exposure to clarithromycin and
metronidazole a 7-day, course of treatment with:
 Proton Pump Inhibitor and
 Amoxicillin and
 Tetracycline or, if a tetracycline cannot be used, Levofloxacin
SECOND LINE TREATMENT
 Offer people who are allergic to penicillin (and who have not had
previous exposure to a fluoroquinolone antibiotic) a 7-day, twice-daily
course of treatment with:
 Proton Pump Inhibitor and
 Metronidazole and
 Levofloxacin
 Offer people who are allergic to penicillin and who have had previous
exposure to a fluoroquinolone antibiotic a 7-day course of:
 Proton Pump Inhibitor and
 Bismuth and
 Metronidazole and
 Tetracycline
H. PYLORI EXCLUDED

 Offer either a low-dose PPI or an H2RA for 4 weeks

MECHANISM OF SIDE
CLASS DRUGS
ACTION EFFECTS
H2 Receptor Competitive inhibition at Headache, Cimetidine 400 mg BID
Antagonists the parietal cell H2 fatigue, Ranitidine 300 mg HS
receptor, suppresses acid myalgias, fever Famotidine 40 mg HS
secretion
IF SYMPTOMS CONTINUE TO RECUR

 Offer a PPI or H2RA to be taken at the lowest dose possible

to control symptoms.
 Discuss using PPI treatment on an 'as-needed' basis with
people to manage their own symptoms.
 Avoid long-term, frequent-dose, continuous antacid therapy
(it only relieves symptoms in the short term rather than
preventing them).
NON PHARMACOLOGIC TREATMENT
Foods need to avoid/limit intake:
 Spicy food
 Fatty foods
 Tomato-based foods
 Salads with mayonnaise
 Coffee, softdrinks, tea, chocolate
 Fruit juices
 Milk, milk-based products
 Alcoholic beverages
 Vegetables like (onion, garlic, cucumber, broccoli, brussels sprout.
cabbage, cauliflower, green pepper, turnip, and mung sprout.
NON PHARMACOLOGIC TREATMENT

Lifestyle Modifications
 Increasing oral fluid intake
 Avoid skipping meals and eat on time
 Avoid smoking
 Encourage to lose weight
 Proper posture
 Avoid lying down after eating
THANK YOU