Dyspepsia - red flag symptoms

Red flag symptoms

• Iron deficiency anaemia
• Unintentional weight loss
• Dysphagia
• Persistent vomiting
• Epigastric mass
• Chronic GI bleeding
• Over 55 years with unexplained and persistent dyspepsia

Dyspepsia refers to epigastric pain or discomfort which may occur with early satiety, postprandial fullness, heartburn and regurgitation.¹  

Epigastric pain or discomfort may distinguish dyspepsia from gastro-oesophageal reflux disease (GORD); however pain may be a feature with GORD.¹ Heartburn or regurgitation more commonly occurs with GORD.

Up to 40% of adults in the general population have dyspepsia and dyspepsia may present in up to 5% of GP consultations.² The British Society of Gastroenterology (BSG) advises that dyspepsia is not a diagnosis and defines it as a group of symptoms that may represent disease affecting the upper GI tract.²

Clinical assessment

History-taking should assess the timing, frequency and reoccurrence of symptoms. The presentation may be acute or chronic. It is helpful to establish whether there is any relationship to eating and medication and whether there are any exacerbating or relieving factors.² The patient may have tried over the counter treatments.

Other relevant features in the history may include dysphagia, odynophagia, nausea, vomiting, anorexia, weight loss, haematemesis, change in bowel habit, shortness of breath and chest pain.³ It may be relevant to exclude pregnancy in women of child-bearing age².

A past medical history of Barrett’s oesophagus and peptic ulcer surgery are relevant.² A drug history including alcohol consumption and smoking status is helpful.

A single acute episode of dyspepsia associated with shortness of breath may be suggestive of cardiac ischaemia particularly in the presence of risk factors; moreover a history of exertional symptoms may be suggestive of angina. Progressive dysphagia with early satiety and other symptoms of dyspepsia may be indicative of achalasia.¹ Furthermore there may be regurgitation of undigested food especially at night. Diabetes may cause a delay in gastric emptying.

The use of NSAIDs, bisphosphonates, nitrates, theophyllines, corticosteroids and calcium-channel antagonists may be contributory.³ 

Peptic ulcer disease may present with pain that is relieved with eating and the use of antacids. Gastric and duodenal ulceration may be associated with Helicobacter pylori infection. Non-ulcer dyspepsia refers to patients with dyspepsia who have had a normal endoscopy. GORD may be exacerbated by lying down and patients may report an acid taste in the mouth.² 

Less likely causes of dyspepsia include pancreatic or hepatobiliary disease and irritable bowel syndrome.¹

Dyspepsia on a background of weight loss and dysphagia may be suggestive of oesophageal malignancy. Early satiety may be a feature of gastric malignancy.⁴ It is worth checking whether there is a family history of gastric cancer. Risk factors for malignancy include a history of Barrett’s oesophagus, peptic ulcer surgery more than 20 years ago, known dysplasia, atrophic gastritis or intestinal metaplasia.² In the presence of risk factors, referral for endoscopy may be considered.

Physical examination may include observations; the patient may be jaundiced or cachectic. The abdomen should be examined to assess for tenderness and organomegaly. There may be lymphadenopathy present. Rectal examination may indicate the presence of black stools or blood.

Causes of dyspepsia
Malignancy Cardiac ischaemia Achalasia Delayed gastric emptying Hiatus hernia Medication Peptic ulcer disease GORD Pregnancy

Management

If red flags are present an urgent referral for endoscopy is needed (2 week wait pathway).⁴ The new NICE guidance advises urgent referral for patients aged 55 and over with weight loss and any of the following: upper abdominal pain, reflux and dyspepsia.⁴

Routine upper GI endoscopy is recommended in patients aged 55 or over with: treatment-resistant dyspepsia or upper abdominal pain with low haemoglobin levels or a raised platelet count with any of the following: nausea, vomiting, weight loss, dyspepsia, upper abdominal pain.⁴

If there is heartburn with or without dyspepsia a PPI may be considered and then stepped down. In patients younger than 55 years without red flag symptoms a trial of acid suppression may be tried for one month. Helicobacter pylori testing as well as blood tests may be helpful.³ In patients with dyspepsia who have not responded to treatment referral may be considered.

In the case of referral for endoscopy, PPIs should be stopped 2 weeks prior to the procedure. Furthermore PPI therapy should be stopped for 2 weeks prior for testing for H pylori. It is recommended to stop NSAIDs prior to referral. An alginate or antacid may be used to alleviate symptoms prior to endoscopy.

Lifestyle advice includes weight loss if appropriate, smoking cessation and reducing alcohol consumption as well as stopping or reducing the intake of food that exacerbate symptoms.³ Those with reflux symptoms may find raising the head of the bed and avoiding meals within three hours of going to bed beneficial.³

• Dr Kochhar is a GP in Bexhill, East Sussex

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Photo: A Dowsett, Public Health England/Science Photo Library

References:

1. Zagari RM, Fuccio L, Bazzoli F. Investigating dyspepsia. BMJ 2008; 337:a1400
2. Cooke PA, Gormley GJ, Gilliland A, Cupples ME. Dyspepsia. BMJ 2011; 343;d6234
3. NICE. Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management. CG184. September 2014
4. NICE. Suspected cancer: recognition and referral. NICE clinical guideline NG12. 2015