The Institute for Clinical regular...

The Institute for Clinical regularitys Improvement (ICSI) recently published a guideline forward the evaluation and management of dyspepsia and gastroesophageal ebb disease (GERD). The guideline, available online at www.icsi.org, applies to the treatment of adult male patients and nonpregnant adult female patients who have had epigastric discomfort forward more than 25 percent of days during the previous four weeks. The information does not apply to patients with symptoms that are characteristic of irritable bowel syndrome pancreatic disease, or biliary tract disease.

The ICSI notes that the intent of its health care guideline series is to provide an analytic framework for evaluation and treatment, not to establish a protocol for approaching all patients who have a particular condition. The ICSI further notes that its guidelines rarely establish the solely approach to a medical condition.

Dyspepsia

The action of choice for the evaluation of dyspepsia is endoscopy. If a radiologist with special training in gastrointestinal radiology is available, multiphase barium upper gastrointestinal studies are an acceptable alternative.

When a patient quick in emergenciess with dyspepsia, the physician should be alert for "alarm features" that may signal the nearness of an underlying disease that requires imperative endoscopic evaluation and treatment (Figure 1) The ICSI prompts performance of endoscopy within single in kind day if a patient with dyspepsia has melena, hematemesis, or acute-onset dysphagia, and within seven to 10 days if the patient has anemia, persistent vomiting, or involuntary los of more than 5 percent of dead body weight.

The ICSI notes that referral to a gastroenterologist is appropriate when a patient has a documented history of sore When a patient presents with dyspepsia and a documented history of sore (endoscopy or barium upper gastrointestinal studies) unless has no alarm features or ebb symptoms, case management begins with serologic testing for Helicobacter pylori. The ICSI remarks that urea breath testing for H pylori is as sensitive as and more specific than serologic testing. Thus, if an H pylori breath proof is available and has a similar preciousness it is preferable to a serologic test

If H pylori testing is positive, the ICSI make acceptables eradicative therapy (Table 1). If H pylori testing is negative, the patient should be given full-dose histamine-[H.sub.2] receptor agonist ([H.sub.2]RA) therapy (Table 2); in addition, consideration should be given to stopping smoking, if indicated, and, if possible, discontinuing the use of nonsteroidal anti-inflammatory put drugs intos (NSAIDs).

If the patient with dyspepsia has no documented fester the likelihood of GERD is extremely high when the primary symptom is heartburn (89 percent probability) or acid regurgitation (95 percent probability). An algorithm for the management of GERD is not absented in Figure 2.

If a patient with dyspepsia still no GERD or documented imposthume is 50 years or older the ICSI notes that it is appropriate to perform nonurgent esophagogastroduodenoscopy (within four to eight weeks) to mastership out gastric cancer. Patients younger than 50 years should be exampleed for H. pylori. If the serologic exhibition is positive, eradicative therapy should be given (Table 1) If the proof is negative, the ICSI commends empiric [H.sub.2]RA therapy (Table 2); in addition, smoking cessation and stopping NSAID use should be considered. If NSAID use cannot be discontinued, a 12-week duration of therapy is recommended

With treatment, symptoms of gastric and duodenal sore s generally improve after four weeks. Data glance at that antiulcer treatment should be continued for eight weeks. In chiefly patients, [H.sub.2]RA therapy is greatest in quantity effective. [H.sub.2]RA therapy should be continued for a total of 12 weeks in the patient who be in want ofs NSAID therapy for the treatment of peptic pustules especially gastric ulcers. If the patient does not relapse within 12 month the dyspepsia has resolv If relapse appears endoscopy should be performed.

If symptoms do not improve after four weeks despite treatment, the ICSI attract favor tos endoscopy. If the endoscopic examination reveals an pustule biopsy for H. pylori or a urea breath ordeal should be performed. If the experiment is positive, case management includes eradicative therapy. If the patient was previously treated for H pylori infection, a different remedy should be used, and treatment should be continued for 14 days. If H pylori testing is negative, smoking status and NSAID use should be reviewed. In the patient who does not use NSAIDs, a fasting serum gastrin measurement should be obtained to control out Zollinger-Ellison syndrome.

If endoscopy does not reveal an fester the diagnosis is nonulcer or functional dyspepsia. While the ICSI reports that no treatment has been shown to be clearly effective, benefit may be derived from the elimination of certain medications (eg NSAIDs) or victualss (e.g., alcohol, caffeine, fats); eradication of H pylori (if not done previously); proton cross-examine inhibitor (PPI) or tricyclic antidepressant therapy; or psychotherapy.