Dr Sophie Nelson Provides 10 Top Tips for the Assessment and Management of Dyspepsia in Adults in Primary Care
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Dyspepsia is a condition associated with a group of symptoms that alert doctors to consider disease of the upper gastrointestinal (GI) tract. These symptoms will usually have been present for more than 4 weeks and may include heartburn, epigastric pain, acid reflux, nausea, and vomiting.1 Dyspepsia may affect as many as 40% of adults per year, yet only one in five people will consult their GP;2 the rest will either put up with their symptoms or will self-medicate. The following tips focus on the diagnosis and management of dyspepsia in primary care and are based on recommendations from NICE Clinical Guideline (CG) 184 on Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management. A review of the guideline is due in 2018.
1. Diagnose Alternative Causes
Some dyspepsia will be down to organic disease such as gastric or duodenal ulcers. If no organic disease can be found then the term ‘functional dyspepsia’ may be used.
It is important to consider alternative diagnoses, such as cardiac or biliary disease—especially if standard treatments for dyspepsia do not seem to be effective, and to order investigations to rule out these diagnoses if appropriate. For example, pain which is worse on exertion or which radiates to the jaw or left arm may raise suspicions about a cardiac cause. It is worth considering if the patient is at high risk of cardiac disease and to order an electrocardiogram and/or cardiology assessment if appropriate. Pain which is colicky and around the right upper quadrant could still be dyspepsia, but an ultrasound may help to rule out gallstones.
2. Test for Helicobacter Pylori
Helicobacter pylori (H. pylori) is a common bacterium found in the stomachs of a third of the UK’s population.3 It can cause dyspeptic symptoms and is also implicated in about one in three stomach cancers.4 Detection via breath or stool testing is recommended in the investigation of dyspepsia and is usually done before prescribing a proton pump inhibitor (PPI)—referred to by NICE CG184 as ‘test and treat’. If a PPI has already been initiated, then a 2-week washout is required to avoid false negatives.1
If a re-test is needed after H. pylori eradication therapy, then stool antigen testing should not be used because false positives are likely.1 If a positive result is reported then triple therapy should be commenced in the form of two antibiotics and a PPI for 1 week.1 Local antibiotic guidance should be followed.
3. Know Who to Refer for Endoscopy
Upper GI endoscopy is the procedure of choice if there is a need to investigate a patient’s symptoms further. However, if there are no alarm symptoms, then it is not always necessary to arrange a gastroscopy in order to diagnose and treat dyspepsia.
NICE CG184 does not make recommendations as to whether PPIs/H2 receptor antagonists (H2 RAs) should be stopped before endoscopy (NICE CG17—which was superseded by CG184—suggested stopping H2 RAs 2 weeks ahead of the procedure, unless the patient was having surveillance for Barrett’s oesophagus or follow up to ensure a gastric ulcer has healed).1 It is, therefore, recommended that clinicians check their local endoscopy unit’s policy.
Table 1 summarises the indications for, and urgency of, an endoscopy referral for suspected oesophageal or stomach cancer.5
Table 1: When to Refer Patients with Dyspepsia Symptoms for Endoscopy1,5
|When to Refer||Dyspepsia Symptoms|
|Urgent (same-day)||Dyspepsia and upper GI bleeding|
Aged ≥55 with weight loss and one of the following:
upper abdominal pain
People aged ≥55 years with:
Upper abdominal pain with low haemoglobin levels
Raised platelet count with any of the following:
upper abdominal pain.
Nausea and vomiting with any of the following:
upper abdominal pain.
|Adapted from © NICE 2015 Suspected cancer: recognition and referral. Available from www.nice.org.uk/ng12 All rights reserved. Subject to Notice of rights. NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. See www.nice.org.uk/re-using-our-content/uk-open-content-licence for further details.|
4. Recommend Lifestyle Adjustments to Improve Symptoms
The first-line management of a patient with dyspepsia is a discussion about lifestyle changes. It is possible for a patient to cure the condition without any medical intervention simply by identifying and avoiding any triggering factors. Common triggering foods include chocolate, coffee, alcohol, and fatty foods, therefore, avoiding these foods and eating a healthy balanced diet can improve symptoms significantly.1 People who are overweight have a higher intra-abdominal pressure and are therefore more prone to dyspepsia, so in the author’s opinion, aiming for a body mass index of 20–25 kg/m2 is a good start.
People who smoke should be encouraged to quit, not only to improve dyspeptic symptoms, but also to reduce their risk of oesophageal cancer: it is estimated that 66% of oesophageal cancers are linked to tobacco smoking.6
Raising the head of their bed (for example, on books or bricks) can help patients experiencing night-time dyspepsia.1
5. Involve the Practice or Community Pharmacist
Initial management can be commenced under guidance of a practice or community pharmacist. First, it is important to review a patient’s current medications to see if there are any that could be contributing to their dyspepsia. Common culprits include calcium antagonists, nitrates, theophyllines, bisphosphonates, steroids, and non-steroidal anti-inflammatories.1 If a patient is taking any of these medications it may help to stop them and find an alternative if possible, or if not possible then to reduce the dose to the lowest effective.
It may be that mild symptoms can be controlled with an over-the-counter remedy such as an alginate. Low doses of H2 RAs or PPIs can also be bought over the counter and used as required.
6. Offer Treatment With a PPI
If initial treatments fail then it would be appropriate to offer a 4-week course of a full-dose PPI, remembering to test for H. pylori before commencing the course. If symptoms recur after this, then NICE CG184 recommends recommencing at the lowest possible dose that adequately controls the patient’s symptoms, or trialling taking the medication only when symptoms occur. If there is an inadequate response to the PPI then an H2 RA should be offered next. Suggested doses for individual PPIs are outlined in Table 2.1
Table 2: Suggested Doses for Individual Proton–Pump Inhibitors1
|PPI Doses Relating to Evidence Synthesis and Recommendations in the Original Guideline (CG17; 2004)|
|PPI||Full/standard dose||Low dose (on-demand dose)||Double dose|
|Esomeprazole||20 mg* once a day||Not available||40 mg‡ once a day|
|Lansoprazole||30 mg once a day||15 mg once a day||30 mg† twice a day|
|Omeprazole||20 mg once a day||10 mg† once a day||40 mg once a day|
|Pantoprazole||40 mg once a day||20 mg once a day||40 mg† twice a day|
|Rabeprazole||20 mg once a day||10 mg once a day||20 mg† twice a day|
*Lower than the licensed starting dose for esomeprazole in GORD, which is 40 mg, but considered to be dose-equivalent to other PPIs. When undertaking meta-analysis of dose-related effects, NICE classed esomeprazole 20 mg as a full-dose equivalent to omeprazole 20 mg.
NICE CG184 also recommends that psychological therapies, such as cognitive behavioural therapy, can be effective in reducing dyspeptic symptoms in the short term in some individuals.1 This approach may be beneficial in individuals with troublesome symptoms and coexistent anxiety or depression.7
7. Treat Organic Causes of Dyspepsia
A patient diagnosed with oesophagitis should be given at least 8 weeks of PPI therapy. If this fails they may need a high-dose PPI or trial of an alternative PPI. They may also need to continue the full dose in the long term as maintenance therapy.
If peptic ulcer disease is discovered on endoscopy, then 8 weeks of full-dose PPI/H2 RA is also recommended. Helicobacter pylori eradication treatment is required if testing is positive, with a repeat endoscopy and consideration of repeat H. pylori testing 6–8 weeks afterwards.1 If symptoms recur after completing the course then PPI therapy may need to be long term (at the lowest dose to control the patient’s symptoms).
Patients who have had dilatation of an oesophageal stricture secondary to acid reflux are advised to remain on long-term full-dose PPI medication.
8. Look Out for Barrett’s Oesophagus
Around 1 in 10 people with acid reflux go on to develop Barrett’s oesophagus.8 It is not necessary to screen for Barrett’s oesophagus routinely, but it is a diagnosis to consider in patients with dyspepsia. The frequency of endoscopic surveillance will depend on the degree of dysplasia found on histology and the length of the Barrett’s oesophagus segment. It may be that the harms of repeated endoscopies outweigh the benefits, especially in people with a low risk of progression to cancer. It is worth considering an individual’s risk factors (such as male sex, increasing age, and length of Barrett’s oesophagus segment), as well as their personal preference, before deciding on the surveillance regimen.1 Treatment for Barrett’s oesophagus will depend on the severity; options include long-term PPI therapy, radiofrequency ablation, endoscopic mucosal resection, and surgery.9
9. Know When to Refer to Secondary Care
Consider referral to secondary care when a patient has dyspeptic symptoms that are unexplained or resistant to treatment. It would also be appropriate to refer a patient with H. pylori and persistent symptoms that have not responded to second-line eradication therapy.1
10. Consider Surgical Options
There are now many surgical options available for the treatment of dyspepsia. These may be offered to people who have responded to medical management but who are unable to tolerate PPIs, or to those who do not wish to be on medication in the long term.1 A laparoscopic fundoplication is the traditional option in these situations, but there are newer, less invasive options, including interventional endoscopic procedures or the insertion of devices to tighten the sphincter muscle at the gastro-oesophageal junction.10 These can all be discussed with an upper GI surgeon.
Dr Sophie Nelson
GPwSI gastroenterology, Wilmslow
|Take-home Messages on Dyspepsia|