Dyspepsia
Dyspepsia refers to persistent or recurrent abdominal discomfort / pain located in the upper abdomen i.e. below the diaphragm present for at least 4 weeks
General points
- Routine endoscopy is not indicated for dyspepsia without alarm symptoms or risk factors for cancer (see below) [1]
- The incidence of upper GI cancer in those under 55y without alarm features is 1 per million population per year [2]
- The majority of cases of dyspepsia can be treated in primary care
- Risk factors for cancer: have a lower threshold for referral in those with Barrett's oesophagus, pernicious anaemia, peptic ulcer surgery or a family history of upper GI cancer [2]
Primary care management:
- Asses for alarm symptoms and refer via 2ww if necessary
-
Review medications particularly
- NSAIDs
- Aspirin
- SSRIs
- corticosteroids
- Calcium antagonists
- Nitrates
- Theophylline
- Bisphosphonates should be stopped immediately
-
Lifestyle advice
- Weight optimisation / exercise / minimise alcohol / stop smoking / certain foodstuffs as a trigger / over the counter alginate or ranitidine therapy
-
Patient education and reassurance – information leaflet here
- CBT is a recognised treatment option
- USS if history suggests pancreatic or biliary abnormality
- Consider whether symptoms might be cardiac ischaemia
Pharmacotherapy - if one doesn't work try the other:
· Test (serological) and treat for H Pylori or
· 4week trial full dose PPI 30 minutes before food then stop
H Pylori eradication therapy:
- In functional dyspepsia – is only effective in a minority (8%) of patients benefit
- Triple therapy attains >85% eradication
- Do not use clarithromycin or metronidazole if used in the past year for any infection.
- 1st line: twice daily omeprazole PLUS amoxicillin PLUS clarithromycin or metronidazole. All for 7 days
- If penicillin allergic: twice daily omeprazole PLUS clarithromycin PLUS metronidazole. All for 7 days
- If penicillin allergic and clarithromycin exposure in the last year: twice daily omeprazole PLUS metronidazole PLUS levofloxacin 250mg bd. All for 7 – 10 days
Stress the importance of medication adherence
Only if still symptomatic- re-test for helicobacter with a breath test – see BNF here. This test should not be performed within 4 weeks of treatment with an antibacterial or within 2 weeks of treatment with a PPI
If breath test positive then re-treat – discuss with microbiologist
If symptoms persist and no new alarm symptoms:
Treat as functional dyspepsia, in summary:
-
patient education that
- the condition is poorly understood
- some treatments help some people – use a trial and error approach
- the aetiology is multifactorial and a complex interaction between upper GI motility and the brain-gut nervous system including gut hypersensitivity, hyperacidity and CNS processing dysfunction
- it is often not cureable and runs a fluctuating course which may be worse under times of stress
- excellent patient information leaflet available here
-
dietary manipulation: try excluding the following:
- dairy products
- wheat containing foodstuffs
- spicy and acidic foods
- citrus fruits
- resistant starch
-
antacid medication
-
Step up / step down approach
- Step 0- lifestyle advice as described above +/- over the counter treatments (alginates / ranitidine)
- Step 1– maintenance PPI using lowest dose which controls symptoms or use when required
- Step 2- maximise PPI dose or try different PPI
- Step 3 - add ranitidine (max 300mg per day) +/- alginates
- antispasm drugs e.g buscopan / colpermin
- psychotherapeutic techniques e.g. CBT/ hypnotherapy
-
Step up / step down approach
· a secondary care opinion in challenging cases however because it is predominantly a neuromuscular disorder endoscopy rarely alters management
· safety net by asking the patient to re-consult immediately if they develop any alarm features
NB – DOMPERIDONE has a safety warning from the MHRA issued in April 2014. The only indication now is for relief of nausea and vomiting and for a week maximum and at a dose not exceeding 30mg per day. This is because of concerns of cardiac side effects. It is contraindicated in those with a cardiac history.
Note:
Perform 6-12 month medication reviews to try to step down
Possible risks of long term PPI use:
· Epidemiological evidence of modest increase in fracture predominantly in the elderly (consider other risks for osteoporosis and treat accordingly) [3]
· Controversial observational evidence of increased risk of c-difficile diarrhoea and pneumonia
Referral criteria:
· Primary care treatment fails
· H Pylori has not responded to second line therapy
· Have a lower threshold for referral if the patient has a history of Barrett’s oesophagus, pernicious anaemia, peptic ulcer surgery or a family history of upper GI cancer [2]
Referral is most appropriate to the upper GI medical clinic or direct to OGD
Information to include in the referral:
- Please detail which of the above primary care treatments have failed
Investigations prior to referral:
- FBC LFT HP serology
- USS if history suggests pancreatic or biliary abnormality
Upper GI red flags/2ww criteria:
Refer for direct access gastroscopy:
- Dysphagia
-
Aged 55 or over with weight loss AND any of the following:
- Reflux
- Abdominal pain
- Dyspepsia
Refer to the upper GI 2ww service:
- Ultrasound indicates gall bladder cancer
- Ultrasound indicates liver cancer
- CT/USS indicates pancreatic cancer
- Upper abdominal mass consistent with gastric cancer
- Any patient with jaundice
-
Aged 60 or over with weight loss AND any of the following:
- Diarrhoea
- Back pain
- Abdominal pain
- Nausea
- Vomiting
- Constipation
- New onset diabetes
Reference
[1] NICE Clinical Knowledge Summary Dyspepsia – unidentified cause, revised Oct 2018 https://cks.nice.org.uk/dyspepsia-unidentified-cause#!scenario here
[2] BMJ 10 minute consultation - Dyspepsia - 2011;343:d6234 available here
[3] MHRA Drug Safety Update April 2012, vol 5 issue 9: A2 here
[4] Gastroenterology consultant working group, Royal Cornwall Hospital
5 RCHT Microbiology Department, November 2019
Date reviewed 13/11/2019
Next review due 13/11/2020
Sifter name Dr Rebecca Harling
Contributor Gastroenterology consultant working group, Royal Cornwall Hospital
Version No. 2.1