Dyspepsia - red flag symptoms

By Dr Suneeta Kochhar on the 3 November 2020

The red flag symptoms and possible causes of dyspepsia, with advice on management.

H pylori may be associated with gastric and duodenal ulceration (Photo:MedicalRF.com/Getty Images)

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Red flag symptoms and features

Iron deficiency anaemia
Unintentional weight loss
Dysphagia
Persistent vomiting
Epigastric mass
Chronic GI bleeding
Over 55 years with unexplained and persistent dyspepsia
Low Hb, ferritin and/or mean corpuscular volume (MCV)

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

Taking a history

History-taking should assess the timing, frequency and recurrence 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 - ask how the symptoms responded.

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 age.²

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. Ask specifically about over the counter NSAID and aspirin use.

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.

Further points on assessment

Other drugs to consider include bisphosphonates, nitrates, theophyllines, corticosteroids and calcium-channel antagonists.³ Certain diabetic medications can also lead to upper GI symptoms such as metformin and GLP-1 analogues.

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 Review any previous gastro assessments, scan reports and endoscopy reports if relevant.

When assessing patients by video, check for cachexia and assess skin colour.

For face-to-face assessment, appropriate PPE should be worn.

When examining during face-to-face assessment, palpate the abdomen and check for masses and organomegaly. Are there any supraclavicular nodes? Does the patient appear cachectic or jaundiced?

Possible causes

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 or oesophageal 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. Assess the throat and palpate for lymph nodes. Virchow’s node (supraclavicular node) may be a manifestation of metastatic gastric cancer.

The abdomen should be examined to assess for tenderness, masses and organomegaly. There may be lymphadenopathy present. Rectal examination may indicate the presence of black stools or blood.

Gastrointestional causes

Malignancy including pancreatic cancer
Achalasia
Delayed gastric emptying
Hiatus hernia
Peptic ulcer disease
GORD
Barrett’s oesophagus
Helicobacter pylori

Non-gastrointestinal causes

Cardiac ischaemia
Medication
Pregnancy
Lifestyle causes
Excess alcohol intake
Smoking
Excess fatty foods

Primary care investigations to consider depending on local availability would include:

FBC
UEs
LFTs
Amylase
Calcium
TTG (coeliac screen)
Helicobacter stool test
USS abdomen
CT abdomen with pancreas views

Management

If red flags are present an urgent referral for endoscopy is needed (two-week wait pathway).4 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 by NICE 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, or upper abdominal pain.⁴

Your clinical judgment may prompt you to make a more urgent referral if you feel that a raised platelet count, abdominal pain or iron deficiency are a cause of concern.

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 Ensure patients submit a stool sample prior to commencing the PPI. 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

Alternatives to PPIs

If patients are intolerant of PPIs or have had previous adverse reactions such as bloating, symptomatic low magnesium, or high risk of C difficile, then consider H2 receptor antagonists such as ranitidine. If ranitidine is unavailable, consider alternatives such as famotidine.