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Thursday, January 12, 2006

New dyspepsia guidelines from American College of Gastroenterology

Upated guidelines for management of patients with dyspepsia have been published by the American College of Gastroenterology (AGA). The AGA publishes its guidelines on line free for everybody. The panel defines dyspepsia as "chronic or recurrent pain or discomfort centered in the upper abdomen" and discomfort as a" subjective negative feeling that is nonpainful". Dyspepsia is distinguished from GERD by the symptoms of heartburn and acid regurgitation.For patients with dyspepsia greater than age 55 or those with alarm symptoms
(GI bleeding,jaundice,odynophagia,palpable mass or enlarged lymph nodes,progressive dysphagia,unexplained iron deficiency anemia or unintended weight loss) early endoscopy is recommended. For those younger patients several approaches are acceptable. These include a trial of proton pump inhibitors (PPIs), testing for H. pylori (with the stool antigen or urea breath test) and then treating if positive with triple therapy and several variations of those themes.They do not recommend h, pylori treatment without a positive test.The entire paper is worth reading as it offers the latest party line thinking and specific treatment details for a very common complaint.The issue of non-gerd dyspepsia continues to be vexing for patients and physicians and in this regard they talk about "fundic dysaccomodation" and visceral hypersensitivity for neither of which is there clear cut advice.
The panel presents data that indicate that only a minority of patients with dyspepsia are shown to have reflux esophagitis (though they may have reflux symptoms),peptic ulcer or gastric cancer. Further although h. pylori may be diagnosed and treated the presenting symptoms may remain. Even so the treatment algorithm for dyspepsia relies on PPI trials and treatment for h.pylori. Those tools work well for those two specific conditions but many patients' symptoms are not due to those conditions. We are left with many patients labeled as functional dyspepsia and for them we have nothing as effective as PPIs are for acid reflux symptoms.

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