Red flag symptoms - Dyspepsia

How to rule out the sinister causes, such as ulceration and malignancy. By Dr Pipin Singh

Ask the patient about a history with gastric ulcer
Ask the patient about a history with gastric ulcer
Red flag symptoms
  • New-onset indigestion in a patient aged >55 years
  • Unexplained persistent vomiting
  • Haematemesis
  • Unintentional weight loss
  • Progressively worsening dysphagia
  • Odynophagia
  • Exertional epigastric pain

Dyspepsia is a common presentation in primary care and often presents in non-specific ways.

A detailed history of the problem is essential to decipher the cause.

Common descriptions a patient may use include 'indigestion', 'burning sensation', 'chest pain', 'sensation of acid in the throat' and 'nausea'.

Ask how long the patient has had the symptom. Find out what brings it on and if it is worse after food or at night. Check if there has been any vomiting. If so, explore this in detail and establish if there has been any haematemesis. Ask about any odynophagia or dysphagia.

Explore the patient's medication history, in particular the use of aspirin and NSAIDs, or any history of PPI use.

Questions to ask

1. Has the patient ever had an endoscopy? If so, how long ago and what were the results?

2. Has the patient ever had a test for Helicobacter pylori infection? What was the result? If positive, did they undergo eradication?

3. Is there any history of Barrett's oesophagus?

4. Has the patient lost any weight without intending to do so?

5. Does the patient smoke or drink alcohol?

6. Is there any history of gastric bypass surgery?

7. If a female of reproductive age, when was her last period?

8. Is there any family history of upper GI malignancy, duodenal or gastric ulceration, or Barrett's oesophagus?

9. What does the patient believe is the cause of the problem?

Patients will often have their own thoughts as to the aetiology of the problem and challenging health beliefs may be an important part of the consultation.

What does the patient fear most about the symptom and what did they think might be the outcome of the consultation? Recent media campaigns have focused on oesophageal cancer and dyspepsia, so this may be a concern. Addressing these matters will allow for appropriate management to be devised.

Possible causes
  • Upper GI malignancy
  • Posterior duodenal ulcer
  • Gastric ulceration
  • Hiatus hernia
  • Barrett's oesophagus
  • Gastritis
  • Duodenitis
  • Pancreatic cancer
  • Pregnancy
  • Iatrogenic, for example, aspirin, NSAIDs, calcium-channel blockers, bisphosphonates

Examination, investigations

It may be necessary to check BP and pulse. Pale conjunctiva may signify anaemia. It may be relevant to examine the oropharynx.

Check for supraclavicular lymph nodes. Palpate the abdomen. Note any epigastric mass or tenderness. Is there any rebound or guarding?

Investigations may include:

  • Blood work to include FBC (U&Es, ferritin and glucose may be necessary for some patients). It may be necessary to check an amylase level if there is a history of pain.
  • Pregnancy test if necessary.
  • Test for H pylori.

When to refer

The presence of any of the red flags may warrant referral under the two-week wait for endoscopy.

Most GPs will have direct access to endoscopy if the patient fails to respond to a PPI and there is a negative H pylori test and symptoms persist.

An outpatient appointment may be necessary if there are multiple comorbidities and the patient takes warfarin.

If the patient is taking a PPI, they usually need to stop it two weeks before having endoscopy.

A history of bypass surgery may require referral back to the upper GI surgeon who performed the operation.

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