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Dyspepsia

Dyspepsia

Definition:

Dyspepsia refers to persistent or recurrent abdominal discomfort / pain located in the upper abdomen i.e. below the diaphragm present for at least 4 weeks 

General points

  • Routine endoscopy is not indicated for dyspepsia without alarm symptoms or risk factors for cancer (see below) [1]
  • The incidence of upper GI cancer in those under 55y without alarm features is 1 per million population per year [2]
  • The majority of cases of dyspepsia can be treated in primary care
  • Risk factors for cancer: have a lower threshold for referral in those with Barrett's oesophagus, pernicious anaemia, peptic ulcer surgery or a family history of upper GI cancer [2]

Primary care treatment– in summary:

  • Review medications particularly
    • NSAIDs
    • Aspirin
    • SSRIs
    • corticosteroids
    • Calcium antagonists
    • Nitrates
    • Theophylline
    • Bisphosphonates should be stopped immediately
  • Lifestyle advice
    • Weight optimisation / exercise / minimise alcohol / stop smoking / certain foodstuffs as a trigger / over the counter alginate or ranitidine therapy
    • Patient education and reassurance – information leaflet here
      • CBT is a recognised treatment option
    • USS if history suggests pancreatic or biliary abnormality
    • Consider whether symptoms might be cardiac ischaemia

Pharmacotherapy - if one doesn't work try the other

·         Test (serological) and treat for H Pylori or

·         4week trial full dose PPI 30 minutes before food then stop

H Pylorieradication therapy

  • In functional dyspepsia – is only effective in  a minority (8%) of patients benefit
  • Triple therapy attains >85% eradication
  • Do not use clarithromycin or metronidazole if used in the past year for any infection.
  • 1st line: twice daily omeprazole PLUS amoxicillinPLUS clarithromycin or metronidazole. All for 7 days
  • If penicillin allergic: twice daily omeprazole PLUS clarithromycinPLUS metronidazole. All for 7 days
  • If penicillin allergic and clarithromycin exposure in the last year: twice daily omeprazole PLUS bismuthPLUS metronidazole PLUS tetracycline. All for 7 days

Stress the importance of medication adherence

Only if still symptomatic- re-test for helicobacter with a breath test – see BNF here. This test should not be performed within 4 weeks of treatment with an antibacterial or within 2 weeks of treatment with a PPI

If breath test positive then re-treat – discuss with microbiologist

If symptoms persist…

Treat as functional dyspepsia, in summary:

  • patient education that
    • the condition is poorly understood
    • some treatments help some people – use a trial and error approach
    • the aetiology is multifactorial and a complex interaction between upper GI motility and the brain-gut nervous system including gut hypersensitivity, hyperacidity and CNS processing dysfunction
    • it is often not cureable and runs a fluctuating course which may be worse under times of stress
  • excellent patient information leaflet available here
  • dietary manipulation: try excluding the following:
    • dairy products
    • wheat containing foodstuffs
    • spicy and acidic foods
    • citrus fruits
    • resistant starch
  • antacid medication
    • Step up / step down approach
      • Step 0- lifestyle advice as described above +/- over the counter treatments (alginates / ranitidine)
      • Step 1– maintenance PPI using lowest dose which controls symptoms or use when required
      • Step 2- maximise PPI dose or try different PPI
      • Step 3 - add ranitidine (max 300mg per day) +/- alginates
    • antispasm drugs e.g buscopan / colpermin
    • psychotherapeutic techniques e.g. CBT/ hypnotherapy

·         a secondary care opinion in challenging cases however because it is predominantly a neuromuscular disorder endoscopy rarely alters management

·         safety net by asking the patient to re-consult immediately if they develop any alarm features

NB – DOMPERIDONE has a safety warning from the MHRA issued in April 2014. The only indication now is for relief of nausea and vomiting and for a week maximum and at a dose not exceeding 30mg per day. This is because of concerns of cardiac side effects. It is contraindicated in those with a cardiac history. 

Note:

Perform 6-12 month medication reviews to try to step down

Possible risks of long term PPI use:

·         Epidemiological evidence of modest increase in fracture predominantly in the elderly (consider other risks for osteoporosis and treat accordingly) [3]

·         Controversial observational evidence of increased risk of c-difficile diarrhoea and pneumonia

Referral criteria

·         Primary care treatment fails

·         H Pylori has not responded to second line therapy

·         Have a lower threshold for referral if the patient has a history of Barrett’s oesophagus, pernicious anaemia, peptic ulcer surgery or a family history of upper GI cancer [2]

Referral is most appropriate to the upper GI medical clinic or direct to OGD

Information to include in the referral

  • Please detail which of the above primary care treatments have failed

Investigations prior to referral

  • FBC LFT HP serology
  • USS if history suggests pancreatic or biliary abnormality

Upper GI red flags/2ww criteria:

Refer for direct access gastroscopy:   

  • Dysphagia
  • Aged 55 or over with weight loss AND any of the following:
    • Reflux
    • Abdominal pain
    • Dyspepsia

Refer to the upper GI 2ww service:

  • Ultrasound indicates gall bladder cancer
  • CT indicates pancreatic cancer
  • Ultrasound indicates pancreatic cancer
  • Upper abdominal mass consistent with gastric cancer
  • Any patient with jaundice
  • Aged 60 or over with weight loss AND any of the following:
    • Diarrhoea
    • Back pain
    • Abdominal pain
    • Nausea
    • Vomiting
    • Constipation
    • New onset diabetes

Reference

[1] NICE clinical guideline 184 (September 2014) here

[2] BMJ 10 minute consultation - Dyspepsia - 2011;343:d6234 available here

[3] MHRA Drug Safety Update April 2012, vol 5 issue 9: A2 here

[4] Gastroenterology consultant working group, Royal Cornwall Hospital