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ACG and CAG Clinical Guideline: Management of …

Clinical guidelines 1. ACG and CAG Clinical Guideline: Management of Dyspepsia Paul M. Moayyedi, MB, ChB, PhD, MPH, FACG1, Brian E. Lacy, MD, PhD, FACG2, Christopher N. Andrews, MD3, Robert A. Enns, MD4, Colin W. Howden, MD, FACG5 and Nimish Vakil, MD, FACG6. We have updated both the american College of Gastroenterology (ACG) and the Canadian Association of Gastroenterology (CAG) guidelines on dyspepsia in a joint ACG/CAG dyspepsia guideline. We suggest that patients 60 years of age presenting with dyspepsia are investigated with upper gastrointestinal endoscopy to exclude organic pathology. This is a conditional recommendation and patients at higher risk of malignancy (such as spending their childhood in a high risk gastric cancer country or having a positive family history) could be offered an endoscopy at a younger age.

Moayyedi et al. The American Journal of GASTROENTEROLOGY VOLUME XXX | XXX 2017 www.nature.com/ajg 2 lasting at least 1 month. Th is can be associated with any other upper gastroin testinal symptom su ch as epigastric fullness, nausea,

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Transcription of ACG and CAG Clinical Guideline: Management of …

1 Clinical guidelines 1. ACG and CAG Clinical Guideline: Management of Dyspepsia Paul M. Moayyedi, MB, ChB, PhD, MPH, FACG1, Brian E. Lacy, MD, PhD, FACG2, Christopher N. Andrews, MD3, Robert A. Enns, MD4, Colin W. Howden, MD, FACG5 and Nimish Vakil, MD, FACG6. We have updated both the american College of Gastroenterology (ACG) and the Canadian Association of Gastroenterology (CAG) guidelines on dyspepsia in a joint ACG/CAG dyspepsia guideline. We suggest that patients 60 years of age presenting with dyspepsia are investigated with upper gastrointestinal endoscopy to exclude organic pathology. This is a conditional recommendation and patients at higher risk of malignancy (such as spending their childhood in a high risk gastric cancer country or having a positive family history) could be offered an endoscopy at a younger age.

2 Alarm features should not automatically precipitate endoscopy in younger patients but this should be considered on a case-by-case basis. We recommend patients <60 years of age have a non-invasive test Helicobacter pylori and treatment if positive. Those that are negative or do not respond to this approach should be given a trial of proton pump inhibitor (PPI) therapy. If these are ineffective tricyclic antidepressants (TCA) or prokinetic therapies can be tried. Patients that have an endoscopy where no pathology is found are de ned as having functional dyspepsia (FD). H. pylori eradication should be offered in these patients if they are infected.

3 We recommend PPI, TCA and prokinetic therapy (in that order) in those that fail therapy or are H. pylori negative. We do not recommend routine upper gastrointestinal (GI) motility testing but it may be useful in selected patients. Am J Gastroenterol advance online publication, 20 June 2017; INTRODUCTION review data (12) for a joint ACG and CAG guideline on dyspepsia Descriptions of upper gastrointestinal symptoms date back thou- Management . sands of years (1). Stomach disorders became an obsession of developed countries in the eighteenth century (2) when the term dyspepsia was first coined (3). A systematic review (4) reported DEFINITION OF DYSPEPSIA AND SCOPE OF THE.

4 That ~20% of the population has symptoms of dyspepsia glob- GUIDELINE. ally. Dyspepsia is more common in women, smokers, and those Dyspepsia was originally defined as any symptoms referable to taking non-steroidal anti-inflammatory drugs (4). Patients with the upper gastrointestinal tract (13). The Rome committee has dyspepsia have a normal life expectancy (5), however, symptoms developed iterative definitions of dyspepsia that have become negatively impact on quality of life (6,7) and there is a significant more specific culminating in Rome IV (ref. 14). These definitions economic impact to the health service and society (8). Dyspepsia have attempted to minimize the inclusion of gastro-esophageal is estimated to cost the US health care service over $18 billion reflux disease in those with dyspepsia by excluding patients with per annum (8) and societal costs are likely to be double this (9) heartburn and acid regurgitation (15).

5 Rome definitions have with 2 5% (refs 7,9) having time off work because of symptoms. been helpful in better-standardizing patients that are included Cost-effective Management of dyspepsia can reduce its health in studies of dyspepsia but are less relevant to Clinical practice as and economic burdens, but it is over 10 years since either the there is considerable overlap in symptom presentation (16) mak- american College of Gastroenterology (ACG) (10) or Canadian ing classification difficult in many patients presenting in primary Association of Gastroenterology (CAG) (11) published guidelines and secondary care. For this reason, we have used a clinically on dyspepsia.

6 We have therefore updated previous systematic relevant definition of dyspepsia as predominant epigastric pain 1. Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada; 2 Division of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA; 3 Department of Medicine, University of Calgary, Calgary, Alberta, Canada; 4 Division of Gastroenterology, St Paul's Hospital, University of British Columbia, Paci c Gastroenterology Associates, Vancouver, British Columbia, Canada; 5 Division of Gastroenterology, University of Tennessee Health Science Center, Memphis, Tennessee, USA; 6 University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.

7 Correspondence: Dr Paul M. Moayyedi, MB, ChB, PhD, MPH, FACG, Division of Gastroenterology, McMaster University Medical Centre, 1200 Main Street West, Hamilton, Ontario, HSC 4W8B, Canada. E-mail: Received 31 May 2016; accepted 28 March 2017. 2017 by the american College of Gastroenterology The american Journal of GASTROENTEROLOGY. 2 Moayyedi et al. lasting at least 1 month. This can be associated with any other Table 1. Summary and strength of recommendations upper gastrointestinal symptom such as epigastric fullness, nausea, vomiting, or heartburn, provided epigastric pain is the patient's 1. We suggest dyspepsia patients aged 60 or over have an endoscopy to primary concern.

8 Although this definition may differ slightly from exclude upper gastrointestinal neoplasia. Conditional recommendation, very low quality evidence. those used in specific trials, we feel it best represents the Clinical problem and the breadth of trial definitions used across time, 2. We do not suggest endoscopy to investigate alarm features for dys- pepsia patients under the age of 60 to exclude upper GI neoplasia. location, and patient populations. Functional dyspepsia refers Conditional recommendation, moderate quality evidence. to patients with dyspepsia where endoscopy (and other tests 3. We recommend dyspepsia patients under the age of 60 should have where relevant) has ruled out organic pathology that explains the a non-invasive test for H.

9 Pylori, and therapy for H. pylori infection if patient's symptoms. positive. Strong recommendation, high quality evidence. This guideline will focus on initial investigations for dyspep- 4. We recommend dyspepsia patients under the age of 60 should have sia such as Helicobacter pylori (H. pylori) testing and endoscopy empirical PPI therapy if they are H. pylori-negative or who remain symptomatic after H. pylori eradication therapy. Strong recommenda- as well as pharmacological therapies such as H. pylori treatment, tion, high quality evidence. PPIs, and prokinetic therapy. We do not address the Management 5. We suggest dyspepsia patients under the age of 60 not responding of organic pathology that may present with dyspepsia identified to PPI or H.

10 Pylori eradication therapy should be offered prokinetic at endoscopy, such as esophagitis or peptic ulcer disease as there therapy. Conditional recommendation very low quality evidence. are other ACG guidelines for these specific diseases (17). Further, 6. We suggest dyspepsia patients under the age of 60 not responding to when H. pylori testing or treatment is recommended we do not PPI or H. pylori eradication therapy should be offered TCA therapy. specify which investigation or which therapy to use, as this will Conditional recommendation low quality evidence. be addressed in an ACG guideline on H. pylori and other recent 7. We recommend FD patients that are H.


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