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Council of Cooperative Health Insurance Dyspepsia : Clinical Practice Guidelines Approach to the evaluation and management of dyspepsia in adults age ≥60 years OR patients <60 years with any of the following : - Clinically significant weight loss (>5 percent usual body weight over 6 to 12 months). • Overt gastrointestinal bleeding. - >1 other alarm feature or Rapidly progressive alarm features: • Unintentional weight loss • Dysphagia - Odynophagia • Unexplained iron deficiency anemia - Persistent vomiting • Palpable mass or lymphadenopathy • Family history of upper gastrointestinal cancer Upper endoscopy with gastric biopsy Organic disease Yes ↓ Treat under underlying cause No ↓ Functional Dyspepsia Evaluate for active H. pylori infection Present ↓ Eradicate H. pylori Persistent symptoms Trial of PPI 4-8 w Persistent symptoms Continue 6 months, Resume if symptoms recur Improved Trial of PPI 4-8 weeks Persistent symptoms Trial of TCA 8-12 weeks Consider discontinuation of PPI, unless partial improvement Review symptoms in 8-12 weeks Persistent Trial of prokinetic for 4 weeks. Discontinue TCA Improved Persistent Reevaluate symptoms OGD if not already performed GI referral Work up of uninvestigated Dyspepsia Box 1 No Work up indicates Organic disease No Yes Treat underlying cause Description of condition Dyspepsia describes a range of upper GI symptoms, typically present for \( \geq \) 4 weeks. Heartburn, gastric reflux, bloating, nausea and/or vomiting, postprandial fullness, early satiation, epigastric pain, or burning. Magnitude of the condition It occurs in at least 20 % of the population. Up to 75 % have functional dyspepsia. Approximately 25 % of patients with dyspepsia have an underlying organic cause Underlying cause functional dyspepsia, Gastro-esophageal reflux disease, Peptic ulcer disease, gastro-esophageal malignancy, cardiac, gallbladder disease, pancreatic disease, Medications (potassium supplements, digoxin, iron, theophylline, oral antibiotics, NSAIDs, steroids, niacin, gemfibrozil, narcotics, colchicine, quinidine, estrogens, levodopa). Workup of uninvestigated dyspepsia Box1 History: detailed history is necessary to determine the underlying cause and to identify patients with alarm. Physical examination: usually normal, except for epigastric tenderness. Signs of dyspepsia secondary to organic disease may be evident. Laboratory tests — Routine blood counts and blood chemistry including liver function tests, serum lipase, and amylase, should be performed to identify patients with alarm features (eg, iron deficiency anemia) and underlying metabolic diseases that can cause dyspepsia (eg, diabetes, hypercalcemia) <table><tr><td>How to test for H Pylori</td><td>•urea (13C) breath test OR Stool Antigen test (SAT) be used for evaluation of active infection•Tests should not be performed within 2 weeks of treatment with a proton pump inhibitor or within 4 weeks of antibacterial treatment, as this can lead to false negatives.</td></tr><tr><td>When to repeat test to confirm eradication?</td><td>ROUTINE check for eradication is NOT recommended.Confirm eradication if: stomach cancer, MALT lymphoma, Hx of PUD specially if bleeding and persistent symptoms after treatment.</td></tr><tr><td>Non-drug treatment</td><td>Lifestyle measures, such as healthy eating, weight loss , avoiding trigger foods, eating smaller meals, eating the evening meal 3–4 hours before going to bed, raising the head of the bed, Smoking cessation, and reducing alcohol consumption Assess the patient for stress and anxiety as these conditions may exacerbate symptoms</td></tr></table> <table><tr><td>Treatment Regimens for H pylori</td><td>1stLineStandard triple therapy: PPI, amoxicillin 1 g, and clarithromycin 500 mg (Biaxin) twice daily 7-10 day up to 14 days ORPPI, clarithromycin 500 mg, and metronidazole 500 mg (Flagyl) twice daily 10-14 daysSequential therapy: PPI and amoxicillin 1 g twice daily, followed by PPI, clarithromycin 500 mg, and tinidazole 500 mg (Tindamax) or metronidazole 500 mg twice daily. 10 days (5 days each)2ndlineNon-bismuth-based quadruple therapy (concomitant therapy):PPI, amoxicillin 1 g, clarithromycin 500 mg, and tinidazole 500 mg or metronidazole 500 mg twice daily for 10 daysBismuth-based quadruple therapy: Bismuth subsalicylate 525 mg or subcitrate 300 mg, metronidazole 250 mg, and tetracycline 500 mg, four times daily; and PPI twice daily 10-14 daysLevofloxacin-based triple therapy: PPI and amoxicillin 1 g twice daily, and levofloxacin 500 mg (Levaquin) once daily 10 days</td></tr><tr><td>Proton Pump Inhibitor (PPI)</td><td colspan="3">Examples: esomeprazole , omeprazole , lansoprazole , PantoprazoleIndications: for H pylori eradication use higher dose twice daily , prophylaxis of NSAIDs associated ulcer, PUD, dyspepsiaSide effects : Common: Abdominal pain; constipation; diarrhea; dizziness; dry mouth;; headache; insomnia; nausea; skin reactions; vomiting. Uncommon Arthralgia; bone fractures; confusion; depression; drowsiness; leucopenia; malaise; myalgia; paranesthesia; peripheral edema; thrombocytopenia; vertigo; vision disorders. Gynecomastia, taste alterationSafety Information: Hypomagnesaemia (more common after 1 year of treatment, but sometimes after 3 months of treatment, monitor especially if on digoxin); subacute cutaneous lupus erythematosus., risk of osteoporosis. Hepatic & Renal impairment: Use with caution. Pregnancy & breast feeding : can use omeprazole .</td></tr></table> <table><tr><td></td><td>Omeprazole</td><td>Lansoprazole</td><td>Pantoprazole</td><td>Esomeprazole</td></tr><tr><td>H pylori Eradication</td><td>20-40mg BID 10-14 days</td><td>30 mg bid 10-14 days</td><td>40 mg bid 10-14 days</td><td>20 mg bid for 10-14 days</td></tr><tr><td>Gastric ulcer</td><td>20-40 mg OD 8 weeks</td><td>30 mg od 8 weeks</td><td>40-80 mg od 8 weeks</td><td>20 mg od 4-8 weeks</td></tr><tr><td>Duodenal ulcer</td><td>20-40mg OD 4 weeks</td><td>30 mg od 4 weeks</td><td>40-80 mg od 4 weeks</td><td></td></tr><tr><td>Prophylaxis with NSAIDs</td><td>20 mg od</td><td>15-30mg od</td><td>20 mg daily</td><td>20 mg daily</td></tr><tr><td>GERD</td><td>20 mg od 4 week10-40 mg od for long term only if symptoms return</td><td>30mg od 4 weeks15-30mg od for long term only if symptoms return</td><td>40 mg 4-8 weeks</td><td>20 mg daily 4-8 weeks for long term only if symptoms return</td></tr><tr><td>Functional dyspepsia</td><td>10 mg od 4 weeks</td><td>15 mg od 4 weeks</td><td>20 mg od 4 weeks</td><td>20 mg od 4 weeks</td></tr><tr><td>Esophagitis</td><td>40 mg od 8 weeks, longer if appropriate</td><td>30 mg od 8 weeks longer if appropriate</td><td>40mg od 8 weeks longer if appropriate</td><td>40mg od 8 weeks longer if appropriate</td></tr></table>