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Hey whats going on guys and welcome to another video here.  Today were going to talk about dyspepsia.  Now, dyspepsia is very common, very high yield.  You have to know this for your boards; you have to know this for clinical practice.  Really, the main thing about dyspepsia, and the main thing that they want you to know is who gets scoped.  Who’s going to require that endoscopy?  Who’s not going to require that endoscopy?  Thats the main question, when it comes down to dyspepsia.  So, very quickly, depending on where you look, depending on the textbooks or the guidelines that your going to look at, they’re going to have varying definitions.  So, I made it a little bit simple for us.  Were going to define dyspepsia as having one of three symptoms: it can either be epigastric pain, it can be post prandial fullness, or it can be early satiety.  Now, usually the symptoms are going to be present for a couple of weeks and thats the general definition of dyspepsia.  So anyone presenting with one of these three symptoms for a couple of weeks, we can term that they have dyspepsia.

Now, some quick stats for you guys: 25% will have dyspepsia at one point in their life.  As you can see its very very common, which is why the boards want you to know.  They want to test you on common things.  70% are going to be termed functional dyspepsia.  Functional dyspepsia means we’ve ruled out other causes, we’ve ruled out medication, we’ve ruled out biliary causes, and everything is negative.  The workup is negative.  So, now we have idiopathic dyspepsia.  We have no idea why it is that we have this, so were going to term this functional dyspepsia.  70% are going to have functional dyspepsia.  That means only 30% of patients are going to have an identifiable cause as to why they are having these symptoms.

So, the first thing you need to do is rule out medications.  Is the patient taking alcohol?  Are the patients taking NSAIDs?  These are two very common things that lead to gastritis, that lead to dyspepsia.  So, alcohol and NSAIDS.  Both of these are going to destroy that gastric lining.  Both of these are going to lead to inflammation of the stomach.  So, very important first step.  Lets say the patient is a chronic alcoholic, lets say the patient is taking naproxen every day for their headaches.  They need to get off these medications, they need to get off the alcohol and we need to start them on a PPI.  Thats it, your done, you move on; very simple.  Alright, so lets go to other causes now.

We also need to rule out peptic ulcer disease.  Now, peptic ulcer disease encompasses duodenal ulcer and peptic ulcer.  Classically, and for your board review, duodenal ulcers are going to improve with meals, while peptic ulcers are going to worsen with meals.  Now, for clinical practice or in real life, it doesn’t really matter.  You know, who cares one way or the other and they don’t really present this way.  But, for your boards know that duodenal ulcers are going to improve while peptic ulcers are going to worsen.  Now, some signs that you might have an ulcer are bleeding, internal bleeding right?  So, if you have melena in your stools, if you have bloody emesis, these are signs of peptic ulcer disease.  Now, patients that present, or you think have peptic ulcer disease,we need to make sure that they don’t take NSAIDs and they’re not on alcohol as we stated earlier because those things can predispose.  We want to make sure that we don’t have Hpylori.  Hpylori is a bacterial infection that predisposes to ulcer formation.  Hpylori will also predispose to something called MALT lymphoma.  So, theres a high associate with MALT lymphoma and there is an association with gastric cancer.  So, we need to know those things for our boards.

Now, alarm symptoms, right?  As we stated earlier, the main thing with dyspepsia is who gets scoped.  Who needs an endoscopy?  Who doesn’t need an endoscopy?  Anybody that presents over the age of 55 with dyspepsia needs to have an endoscopy done.  We need to make sure we don’t have cancer.  Patients under 55 needs to get scoped if they have certain alarm symptoms.  What are these alarm symptoms?  Well, maybe they have a family history of cancer? Are they anemic, dysphagia, odynophagia?  These are things that are going to point to possible cancer or possible ulcer formation; melena and things like that as well.  So, if they have alarm symptoms, scope them.  If they don’t have these alarm symptoms then they don’t need a scope.  Those are indications for endoscopy.

Now, lets say that they are not on medications, they don’t drink alcohol, they don’t have signs of peptic ulcer disease, the next step is going to be Hpylori testing.  We’ve already talked a little bit about Hpylori.  There are three different ways you can go ahead and diagnose Hpylori.  You can do breath testing, you can do stool antigen testing, and you can do a serologic antibody testing.  Now, serologic antibody testing is no longer recommended and it should never be done.  But its still there and it will still be an option, right?  So, antibody testing is bad, for the reason that antibodies stay positive for life.  So, we don’t know if this is active infection or old infection.  So, for that reason, don’t do it.  The preferred test is a breath test.  You blow into a little bag and send the bag off to a lab, we get the results back; very clean, very easy, very good.  The alternative is to do stool antigen testing, and the reason why its not recommended is its not very clean, its more cumbersome, its more work.  They are both good, they are both good at detecting active infection, and they are both used to check for cure or to check for reinfection if symptoms are not resolving.  If you do have a positive Hpylori, then the preferred treatment is going to be triple therapy.  This is going to be a PPI, any PPI will do twice daily, clarithromycin twice daily, and metronidazole or amoxicillin twice daily.  The therapy is usually going to be for two weeks.

Lets say we have Hpylori negative, then we give them a PPI.  Were just going to empirically treat with a PPI.  If they are still not improving, then we need to rule out things like irritable bowel syndrome, we need to rule out things like biliary causes, psych can also do this.  Depression and anxiety can cause whats called dyspepsia.  Alright, so, that was it for today guys.  I hope you guys learned something.  Very quickly to go back and reiterate something, your going to do the empiric PPI therapy for a couple of months.  Your going to do this for two months and way PPIs should be given to patients; its something I forgot to add in there but I want to let you guys know because its not so much for boards, but very important when you see patients.  A lot of people don’t know this, but PPIs need to be taken on an empty stomach, you need to be fasting, you need to take it first thing in the morning.  Then, you have to eat 30 minutes later.  Very important to eat 30 minutes later because thats going to activate those proton pumps.  The more proton pumps you have right after doing the PPI, the better its going to work.  So, make sure the patients take it on an empty stomach, and after half an hour make sure they eat something to create more of those proton pumps so that the PPI can work at its maximum benefit.  Alright guys, lets just say, now this is for you guys not for boards, but lets say the PPI doesn’t work.  Whats the next step?  The next step is actually going to be a tricyclic antidepressant.  Were going to assume these patients are depressed and were going to give a trial, a one month-two month trial of a tricyclic.  Lets say that doesn’t work.  Then, were going to do reglan.  Were going to do reglan for about a month.  And if that doesn’t work, thats it, thats the end of the algorithm.  No real other suggestions.  A lot of these patients are going to have psych problems though, and a lot of these patients are going to be depressed and thats going to be the reason for their abdominal discomfort.  Alright guys, hope you guys learned something.  Very high yield.  The main point that we drive home is who gets scoped and who doesn’t get scoped right?  Thats what the boards want you to know.  Hope you have a great day and thanks so much for joining me today.