CKS Clinical solutions - Dyspepsia

A 53-year-old man presents with a two-month history of upper abdominal pain. It is relieved by food and antacids.

Barium test showing dyspepsia (Photograph: SPL)
Barium test showing dyspepsia (Photograph: SPL)

Is this dyspepsia?
Dyspepsia is identified by the presence of characteristic features and by exclusion of other causes of epigastric pain. Features of dyspepsia are upper abdominal discomfort and epigastric tenderness as well as nausea, fullness in the upper abdomen, or belching.

How should I assess him?
Examine for red flags, such as gastrointestinal bleeding, weight loss, difficulty swallowing, vomiting, iron deficiency anaemia or epigastric mass.1 Ask about any medication, in particular NSAIDs.

Managing the patient?
For gastrointestinal bleeding, arrange immediate admission to hospital. For other red flags, arrange endoscopy within 14 days and take a FBC. Stop any NSAIDs, and stop or reduce other drugs known to cause gastrointestinal bleeding.

Ensure PPIs or H2-receptor antagonists (including those obtained OTC) are not used for a minimum of two weeks before endoscopy.

If the patient has no red flags and is taking NSAIDs, stop NSAIDs and offer alternative analgesia. Prescribe a PPI for one month and test and treat for Helicobacter pylori infection if symptoms recur.

For patients without red flags and not taking NSAIDs, treat with a PPI for one month or test and treat for H pylori. If symptoms recur, use alternative strategy.

What lifestyle advice should I give?
Recommend losing weight, stopping or reducing smoking and alcohol consumption, and avoiding food or drink that worsen symptoms.

How do I test for and treat Helicobacter pylori
The urea breath test, stool antigen test and laboratory serology testing are recommended. For urea breath test and stool antigen test, PPIs should be stopped two weeks before the test, and delay testing until 28 days after treatment with an antibiotic.

Prescribe triple-therapy regimen, twice daily for seven days:

  • Amoxicillin 1g and clarithromycin 500mg and either lansoprazole 30mg or omeprazole 20mg, or
  • Clarithromycin 250mg and metronidazole 400mg and either lansoprazole 30mg or omeprazole 20mg.

Evidence
Recommendations are based on guidelines from NICE;1,2 the Health Protection Agency;3 and a European Helicobacter Study Group report.4 In patients without red flags, RCTs showed no difference between empirical treatment and endoscopically-guided treatment.5 H pylori eradication and acid suppression is equally cost-effective in the initial management.6

The sensitivity of stool antigen testing, urea breath testing, and some serological tests to detect H pylori appears to be more than 90 per cent.5

Reliable, evidence-based answers to real-life clinical questions, from the NHS Clinical Knowledge Summaries in association with GP.

See www.cks.nhs.uk

References
1. NICE (2005) Dyspepsia: management of dyspepsia in adults in primary care (amended NICE guideline). www.nice.org.uk

2. NICE (2005) Referral for suspected cancer (NICE guideline). Clinical guideline 27. www.nice.org.uk

3. HPA (2008) Diagnosis of Helicobacter pylori (HP) in dyspepsia: quick reference guide for primary care for consultation and local adaptation. www.hpa.org.uk

4. Malfertheiner, P., Megraud, F., O'Morain, C. et al. (2007) Gut 56(6), 772-81.

5. North of England Dyspepsia Guideline Development Group (2004) Dyspepsia: managing dyspepsia in adults in primary care (full NICE guideline). www.nice.org.uk

6. Delaney, B.C., Qume, M., Moayyedi, P. et al. (2008) BMJ 336(7645), 651-4.

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