Dr. Brennan M. Spiegel joked that the title of his talk would probably give away the answer. However, he said it was reasonable to consider whether to should start empiric PPI therapy or refer the patient for prompt endoscopy.
“If you look at the ACG guidelines, the correct answer is to test for H pylori
, and treat if positive,” he said. We do not know if the patient has a peptic ulcer, so we need to consider whether to test and treat route for H pylori
first or treat with empiric PPI. “This might be underlying gastroesophageal reflux disease (GERD), though it is not reflux predominant, or this could be dysfunctional dyspepsia, which is the single most common cause of dyspepsia in a patient with uncomplicated symptoms,” said Spiegel.
He showed data which compared the cost-effectiveness of the H. pylori
"test and treat" strategy with that of empirical PPI therapy. The point at which they become equally effective was about 12% of the population with H. pylori
. “If the prevalence in your community is higher than 12% then this model suggested the “test and treat” strategy is more cost effective.
ACG Guidelines for the Management of Dyspepsia
Spiegel focused his discussion of the patient case to the ACG guidelines (Link to ACG guidelines: http://s3.gi.org/physicians/guidelines/dyspepsia.pdf
), describing the treatment algorithm for management of uninvestigated dyspepsia. Dyspepsia is a chronic pain or discomfort centered in the upper abdomen; patients with predominant or frequent (more than once a week) heartburn or acid regurgitation, should be considered to have GERD until proven otherwise.
“The first question you have to ask yourself is ‘how old is this patient,” said Spiegel. If the patient is over the age of 55, the guidelines state the patient may be at risk factor for gastric cancer, but no age threshold is absolute. “And the guidelines recommend endoscopy, though the risk for cancer is low.” If the patient has no other alarm features such as bleeding, anemia, unexplained weight loss, persistent vomiting, a family history of gastrointestinal cancer, previous documented peptic ulcer, among others, “the next question to consider is whether symptoms are reflux predominant—heartburn and regurgitation—or non-reflux predominant,” he said.
For reflux predominant, Spiegel recommended bypassing “test and treat” and offer empiric PPI therapy, adding “about 95% of gastroenterologists” will offer empiric PPI therapy in this situation. If the patient displays non-reflux predominant symptoms, the guidelines suggest determining the local prevalence of H. pylori
in the patient’s local community. “If you are in a large urban environment, the prevalence of H. pylori
in the community is most certainly over 10%,” said Spiegel, adding the prevalence is almost 40% in the metro Los Angeles region.
If the patient lives in a community with a high H. pylori
prevalence (greater than 10%), the guidelines suggest “test and treat” for H. pylori
. If H. pylori
treatment fails, and the patient’s symptoms continue, the guidelines recommend an empiric trial with a PPI. An endoscopy is recommended if the patient fails with PPI therapy. Spiegal noted the treatment algorithm is reversed for patients living in a community with low H. pylori
prevalence (less than 10%).
remain to be prevalent,” Spiegel concluded, adding gastroenterologists should remember to check the local prevalence of H. pylori
. “And remember that one size does not fit all when we are treating patients for H. pylori