Most people experience a degree of dyspepsia at some time in their lives, and for some it may be a lifelong, relapsing and remitting problem. It causes a heavy financial burden on the NHS.
The clinical features of dyspepsia include epigastric pain associated with symptoms such as early satiety, bloating, belching, nausea and vomiting.
The pain is often retrosternal and commonly termed heartburn, which may or may not radiate upwards into the throat.
Symptoms tend to be episodic and precipitated by eating late in the day, eating spicy or acidic foods, consuming alcohol or smoking. They tend to be worse in the overweight and more common when lying flat.
A classic example is onset of pain when in bed after a late meal. The symptoms may only occur intermittently and cause little concern, but in some patients symptoms are recurrent and cause serious morbidity.
In a minority of cases there may be serious underlying pathology, so the clinician must be aware of red flags that require further investigation (see box).
Red flags in dyspepsia include:
Causes of dyspepsia
Non-ulcer dyspepsia, also termed functional dyspepsia, describes symptoms in the absence of any pathology. It is possible that Helicobacter pylori infection is implicated in the symptoms of many people falling into this group.
Excessive acid production or reduced mucosal protection may lead to erosions of the gastric or duodenal mucosa. These erosions can deepen to form a peptic ulcer with a risk of bleeding. There is a risk of malignant change in gastric ulcers.
Gastro-oesophageal reflux disease refers to the situation where acidic stomach contents pass up into the distal oesophagus. This may be due to motility dysfunction or lower oesophageal sphincter dysfunction.
This happens occasionally in normal individuals, but frequent episodes lead to symptomatic erosion of the lower third of the oesophageal mucosa.
If untreated, dysplasia of the mucosal cells can occur (Barrett's oesophagus) and may herald more sinister changes.
Mild dyspepsia is often self-managed and many patients admit to OTC antacid use without GP consultation.
On presentation to a GP, an initial screen must include checking for the red flags previously mentioned. It is important to establish if the dyspeptic symptoms are new or chronic, and if they are persistent.
Medication use, whether prescribed or OTC, is relevant. Steroids, NSAIDs, bisphosphonates, calcium antagonists and theophyllines can all cause reflux symptoms, and their use can be adjusted or stopped.
Anyone over 55 with persistent unexplained symptoms of new onset or anyone with any of the red flags should be referred for urgent endoscopy under the two-week rule.
If medication is implicated, it would be reasonable to stop it and review the situation before making the referral. NICE recommends that the time frame is up to six weeks, depending on severity of symptoms and degree of suspicion of malignancy.
The key issue for those who do not meet urgent referral criteria is patient education. Risk factors should be discussed and healthy eating advice, weight loss and smoking cessation support should be provided.
A medication review including possible aggravating OTC medication is mandatory. Antacid and alginate use should be encouraged.
If symptoms persist despite initial measures a proton pump inhibitor (PPI) can be tried.
Testing for H Pylori
Some centres will screen for H pylori before initiating a PPI, others tend to treat first for one month and then review symptoms and then test for H pylori if symptoms continue.
Both pathways are recommended by NICE.
Patients should be managed on the lowest dose of PPI that will control their symptoms, stopping treatment at regular intervals to see if it is still required. Referral for endoscopy is appropriate if the response is poor despite maximal therapy.
After endoscopy, management depends on findings. H pylori testing may reveal a need for eradication therapy. Patients who have evidence of erosion are recommended to have full strength PPI treatment with a review at one month.
If symptoms are poorly controlled, the dose should be doubled with review after a month. An H2-receptor antagonist or prokinetics could then be added if symptoms persist; however, cisapride is no longer licensed in the UK and evidence is sparse for other prokinetics.
Beyond this, review by a specialist is indicated. With a gastric ulcer, and where H pylori has been eradicated, full dose PPI should be given for one or two months followed by repeat endoscopy.
In cases of H pylori-associated ulceration, a repeat H pylori test should also be performed to ensure eradication. If healing is achieved, low dose PPI should be continued.
If there is ongoing ulceration, specialist referral is required.
All patients on regular dyspeptic medication should have regular review with symptoms managed on the lowest possible dose.
Although many patients remain on long-term dyspeptic medication, a significant proportion will have their symptoms controlled and PPIs are usually well tolerated.
- Dr Cumisky is a locum GP in Bath