AJG AUTHOR INSIGHTS

MANAGEMENT OF DYSPEPSIA

Paul Moayyedi, MB ChB, PhD, MPH, FACG; Brian E. Lacy, MD, PhD, FACG; Christopher N. Andrews, MD; Robert A. Enns, MD; Colin W. Howden, MD, FACG; and Nimish Vakil, MD, FACG.

IN THE FIRST UPDATE IN MORE

THAN 10 YEARS, the American College of Gastroenterology and the Canadian Association of Gastroenterology joined forces on an updated systematic review and clinical guideline on dyspepsia management.

The focus of the guideline is on initial investigations for dyspepsia, such as Helicobacter pylori testing and endoscopy, as well as pharmacological therapies such as H. pylori treatment, PPIs and prokinetic therapy. The authors do not address the management of organic pathology that may present with dyspepsia identified at endoscopy, such as esophagitis or peptic ulcer disease, as there are other ACG guidelines for these specific diseases. Further, when H. pylori testing or treatment is recommended, we do not specify which investigation or which therapy to use, as this will be addressed in an ACG Guideline on H. pylori and other recent guidelines that have been published.

Figure 1. Algorithm for the management of undiagnosed dyspepsia.

Listen to the AJG Podcast

Paul Moayyedi, MB ChB, PhD, MPH, FACG, discusses the evolving definition and diagnosis of dyspepsia, when and when not to use endoscopy, and how H. pylori factors into dyspepsia treatment in a conversation with AJG Co-Editorin-Chief, Brennan M.R. Spiegel MD, MSHS, FACG.

 LISTEN Here: goo.gl/9gd835

Figure 2. Algorithm for the treatment of functional dyspepsia.

TABLE 1 . SUMMARY AND STRENGTH OF RECOMMENDATIONS

1. We suggest dyspepsia patients aged 60 or over have an endoscopy to exclude upper gastrointestinal neoplasia. Conditional recommendation, very low quality evidence. 2. We do not suggest endoscopy to investigate alarm features for dyspepsia patients under the age of 60 to exclude upper GI neoplasia. Conditional recommendation, moderate quality evidence. 3. We recommend dyspepsia patients under the age of 60 should have a non-invasive test for H. pylori, and therapy for H. pylori infection if positive. Strong recommendation, high quality evidence. 4. We recommend dyspepsia patients under the age of 60 should have empirical PPI therapy if they are H. pylori negative or who remain symptomatic after H. pylori eradication therapy. Strong recommendation, high quality evidence. 5. We suggest dyspepsia patients under the age of 60 not responding to PPI or H. pylori eradication therapy should be offered prokinetic therapy. Conditional recommendation, very low quality evidence. 6. We suggest dyspepsia patients under the age of 60 not responding to PPI or H. pylori eradication therapy should be offered TCA therapy. Conditional recommendation, low quality evidence. 7. We recommend FD patients that are H. pylori positive should be prescribed therapy to treat the infection. Strong recommendation, high quality evidence. 8. We recommend FD patients who are H. pylori negative or who remain symptomatic despite eradication of the infection should be treated with PPI therapy. Strong recommendation, moderate quality evidence. 9. We recommend FD patients not responding to PPI or H. pylori eradication therapy (if appropriate) should be offered TCA therapy. Conditional recommendation, moderate quality evidence. 10. We suggest FD patients not responding to PPI, H. pylori eradication therapy or tricyclic antidepressant therapy should be offered prokinetic therapy. Conditional recommendation, very low quality evidence. 11. We suggest FD patients not responding to drug therapy should be offered psychological therapies. Conditional recommendation, very low quality evidence. 12. We do not recommend the routine use of complementary and alternative medicines for FD. Conditional Recommendation, very low quality evidence. 13. We recommend against routine motility studies for patients with FD. Conditional recommendation, very low quality evidence. 14. We suggest motility studies for selected patients with FD where gastroparesis is strongly suspected. Conditional recommendation, very low quality evidence.

FD, functional dyspepsia; H. pylori, Helicobacter pylori; PPI, proton pump inhibitor; TCA, tricyclic antidepressant.

Finding Freedom from Fecal Incontinence with my Orange Tote

Sigrid LaFata and Stacy B. Menees, MD, MS

A former beauty pageant contestant and registered nurse, Sigrid LaFata shares her experience of living with fecal incontinence after the removal of her sigmoid colon following colon cancer. In a personal and heartfelt reflection published in the Red Section of The American Journal of Gastroenterology, Ms. LaFata describes how bowel incontinence made her lose her freedom. She writes, “I felt like I had to stop living. It was exhausting and isolating. I could never leave the house.”

Faced with frequent episodes of stool leakage, she took to carrying around a large orange tote with extra clothes and supplies to handle emergencies. After consulting with Dr. Stacy Menees at the University of Michigan, Ms. LaFata’s symptoms improved with changes in diet, including a low FODMAP approach, as well as physical therapy for her pelvic floor. She reports, “Things were coming under control, and I was back to work, slowly getting my life back.”

Dr. Menees encouraged Ms. LaFata to tell her story in the pages of the Red Section where the editors, Dr. Sameer Saini and Dr. Hetal Karsan, have created a special feature for patient voices. Thanks to Ms. LaFata’s courage and candor, and her partnership with Dr. Menees, other patients can benefit from her experience.

 READ the full piece in the Red Journal: rdcu.be/uEUM

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My Approach to Fecal Incontinence: It’s all about Consistency (Stool, that is)

Stacy B. Menees MD, MS, University of Michigan

DR. STACY MENEES RECOMMENDS that fecal incontinence “needs to be sought out as patients suffer in silence.” She notes that, “Patients are embarrassed to discuss this problem and are unlikely to volunteer this complaint freely.”

In a clinical overview to accompany the testimonial by her patient Sigrid LaFata in AJG’s Red Section, Dr. Menees offers a concise definition of fecal incontinence (FI), and an overview of evaluation and treatment, including an algorithm. She distinguishes between fecal soiling and FI, and notes the importance of subtyping the disorder as active or passive, and working with patients to identify consistency using the Bristol Stool Scale.

 READ about Dr. Menees’ approach to Fecal Incontinence, and view the Algorithm for Evaluation and Treatment of FI: rdcu.be/uFrF