Dyspepsia describes pain or discomfort in the upper abdomen. It has been defined variously by a number of expert groups:
- Prior to 1991, dyspepsia included patients with symptoms of heartburn and acid reflux.
- The Rome I definition defined patients with sole reflux symptoms as having gastro-oesophageal reflux disease (GORD) - also seen as 'GERD'.
- More recently, these criteria have been extended to exclude patients with predominant reflux symptoms and symptoms suggestive of irritable bowel syndrome (IBS).
Prescribing on ulcer healing drugs varies from year to year but there is a general increasing trend.
- A Belgian population study reported a prevalence of 20.6%.
- Approximately 25% of people with dyspepsia will consult their GP.
- There is evidence of inappropriate (not per guidelines) proton pump inhibitor (PPI) prescribing by GPs and hospital doctors.
- Epigastric discomfort
- Fullness or bloating
- Excessive flatus
- Fatty food intolerance
Always ask about family history and medication use.
- Unintentional weight loss.
- Recurrent vomiting.
- Evidence of gastrointestinal (GI) bleeding.
If investigated, patients with dyspeptic symptoms will prove to have either:
- Peptic ulcer disease (10%).
- Oesophagitis (15%).
- No significant abnormality (non-ulcer dyspepsia or functional dyspepsia - 75%).
Older patients are more likely to have serious disease.
- Always check for abdominal mass.
- Consider taking FBC to demonstrate another alarm feature - eg, iron-deficiency anaemia.
- Testing for Helicobacter pylori may be worthwhile. The evidence is equivocal but there seems to be a subset of H. pylori-related dyspepsia patients who do improve on eradication therapy.Eradication of H. pylori in patients who are about to start non-steroidal anti-inflammatory drugs (NSAIDs) substantially reduces the risk of endoscopic and complicated ulcers.
- Peptic ulcer.
- Functional (non-ulcer) dyspepsia.
- Atypical GORD.
- Biliary pain - eg, gallstones.
- Medication-induced dyspepsia.
- Oesophageal spasm.
- Oesophageal cancer or stomach cancer.
Exclude abdominal mass and other causes of abdominal pain.
Urgent specialist referral - two-week ruleIf the patient has dyspepsia at any age with any of the following alarm symptoms:
- Chronic GI bleeding.
- Progressive unintentional weight loss.
- Progressive dysphagia.
- Persistent vomiting.
- Iron-deficiency anaemia.
- Epigastric mass.
- Suspicious barium meal.
For patients without alarm features and with previous investigations for dyspepsia
It is possible to treat on the basis that a similar pathology has recurred, although refer to a specialist if the patient is unresponsive to treatment or the diagnosis is in doubt.
- If there has been a peptic ulcer previously and no evidence of H. pylori eradication, prescribe H. pylori eradication therapy if the test is positive. See separate article Helicobacter Pylori for details.
- If peptic ulcer has been excluded (functional or non-ulcer dyspepsia), H. pylori eradication (after a positive test) may relieve symptoms.
- For people with GORD, offer a full-dose PPI, as detailed in the National Institute for Health and Care Excellence (NICE) guidance, for four to eight weeks.
- Where there is no initial response to a PPI (and recent endoscopy has shown GORD), offer H2-receptor antagonist (H2RA).
- Prokinetic agents are no longer recommended. However, several new-generation prokinetics such as acotiamide are emerging. Acotiamide has received approval for use in Japan and is currently being evaluated in Europe.
- Some patients may require prolonged high doses of PPI and may ultimately be candidates for anti-reflux surgery. This is often carried out laparoscopically.
- If there has been oesophagitis previously, prescribe a PPI.
- If symptoms recur after initial treatment, offer the lowest-dose PPI that will control symptoms.
- If severe oesophagitis has been diagnosed on endoscopy:
- A full-dose PPI should be given for eight weeks (taking into account preference and clinical circumstances - eg, tolerability to PPIs, underlying health conditions and possible interactions with other drugs).
- Switch to another full-dose PPI or high-dose PPI if initial treatment fails.
- Offer a full-dose PPI long-term as maintenance treatment.
For the uninvestigated patient without alarm features
The NICE guideline suggests the following steps:
- Review medications: possible drug causes of dyspepsia include NSAIDs, steroids, calcium antagonists, nitrates, theophyllines and bisphosphonates. Reduce or stop if possible.
- Offer lifestyle advice, ie stopping smoking, more regular meals, ceasing excessive alcohol consumption.
- Antacids are cheap, simple and may be all that is required for relief of occasional symptoms. Most antacids contain a mixture of aluminium hydroxide that tends to cause constipation and magnesium hydroxide that tends to cause diarrhoea. The balance between the two cannot be assured and there may be disturbance of bowel function. If a large amount of antacid is being consumed, consider acid suppression.
- Try either of the following. The alternative choice can be tried if symptoms persist or return:
- Test for H. pylori (carbon-13 urea breath test, stool antigen or laboratory serology) and eradicate if positive.
- Empirical acid suppression (with PPI) - full dose for one month.
Where there has been a satisfactory response at any of the steps above, reassure and return to self-care.
If the patient responds to a PPI but then relapses, consider low-dose or intermittent treatment.
Where patients show an inadequate response to treatment, consider other diagnoses (eg, gallstones) and/or referral to a specialist.
- Adverse reactions to PPIs and H2RAs are usually rare and mild but severe problems can arise:
- Rare but not serious problems may include taste disturbance, peripheral oedema, photosensitivity, fever, arthralgia, myalgia and sweating.
- Serious problems include liver dysfunction, hypersensitivity reactions (including urticaria, angio-oedema, bronchospasm, anaphylaxis), depression, interstitial nephritis, blood disorders (including leukopenia, leukocytosis, pancytopenia, thrombocytopenia) and skin reactions (including Stevens-Johnson syndrome, toxic epidermal necrolysis, bullous eruption).
- Many of the drugs used in the management of peptic ulcer disease carry a warning that they should not be used in pregnancy or whilst breast-feeding:
- This is usually because of lack of information about safety in pregnancy rather than evidence of adverse effects in pregnancy.
- However, misoprostol - a prostaglandin analogue - should be avoided in pregnancy as it may cause abortion.
- PPIs are metabolised mostly in the liver. In liver disease, dose adjustment may be required for omeprazole, pantoprazole and esomeprazole. There are no data on the use of rabeprazole in people with severe hepatic impairment, so the manufacturer advises caution.
- Omeprazole and esomeprazole may interfere with warfarin monitoring.
Dr Hayley Willacy would recommend this study which asks if it is time to limit the use of proton pump inhibitors (PPIs). The study found that, when compared to H2-blockers, PPI use was associated with a 25 per cent increased risk of all-cause mortality. The authors state that this should not deter prescription and use of PPIs where medically indicated, but should encourage and promote pharmacovigilance and emphasise the need to exercise judicious use of PPIs, and limit use and duration of therapy to instances where there is a clear medical indication and where benefit outweighs potential risk.
Patients should be reviewed at the end of a course of treatment, especially H. pylori eradication, to confirm a satisfactory outcome. The criteria to be used to measure satisfactory patient outcome are subject to controversy, and instruments to determine clinical endpoints are evolving.
If simple acid suppression is given, the patient should be reviewed after one or two months to ascertain that the end is being achieved and there are no warning signs such as weight loss to suggest malignancy.
Referral for endoscopy
Routine endoscopic investigation of dyspeptic patients is not necessary but should be considered in patients over the age of 55 where symptoms persist despite H. pylori testing and acid suppression.
- Family history of upper GI cancer in more than two first-degree relatives.
- Barrett's oesophagitis.
- Pernicious anaemia.
- Peptic ulcer surgery over 20 years ago.
- Known dysplasia, atrophic gastritis, intestinal metaplasia.
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