Dyspepsia describes pain or discomfort in the upper abdomen. It has been defined variously by a number of expert groups:
- Prior to 1991, dyspepsia included patients with symptoms of heartburn and acid reflux.
- The Rome I definition defined patients with sole reflux symptoms as having gastro-oesophageal reflux disease (GORD) - also seen as 'GERD'.
- More recently, these criteria have been extended to exclude patients with predominant reflux symptoms and symptoms suggestive of irritable bowel syndrome (IBS).
The costs of managing dyspepsia outstrip all other conditions in the NHS. Expenditure on ulcer healing drugs increases year on year.
- The prevalence of dyspepsia is estimated to be 23-41% of the population. Approximately 25% will consult their GP.
- There is evidence of inappropriate (not per guidelines) proton pump inhibitor (PPI) prescribing in the community.
- Epigastric discomfort
- Fullness or bloating
- Excessive flatus
- Fatty food intolerance
Always ask about family history and medication use.
If investigated, patients with dyspeptic symptoms will prove to have either:
- Peptic ulcer disease (10%).
- Oesophagitis (15%).
- No significant abnormality (non-ulcer dyspepsia or functional dyspepsia - 75%).
Older patients are more likely to have serious disease.
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- Always check for abdominal mass.
- Consider taking FBC to demonstrate another alarm feature, eg iron-deficiency anaemia.
- Testing for Helicobacter pylori may be worthwhile. The evidence is equivocal but there seems to be a subset of H. pylori-related dyspepsia patients who do improve on eradication therapy. Eradication of H. pylori in patients who are about to start non-steroidal anti-inflammatory drugs (NSAIDs) substantially reduces the risk of endoscopic and complicated ulcers.
- Peptic ulcer.
- Functional (non-ulcer) dyspepsia.
- Atypical gastro-oesophageal reflux disease (GORD).
- Biliary pain, eg gallstones.
- Medication-induced dyspepsia.
- Oesophageal spasm.
- Carcinoma of oesophagus or stomach.
Exclude abdominal mass and other causes of abdominal pain.
Urgent specialist referral - two-week ruleIf the patient has dyspepsia at any age with any of the following alarm symptoms:
- Chronic GI bleeding
- Progressive unintentional weight loss
- Progressive dysphagia
- Persistent vomiting
- Iron-deficiency anaemia
- Epigastric mass
- Suspicious barium meal
For patients without alarm features and with previous investigations for dyspepsia
It is possible to treat on the basis that a similar pathology has recurred, although refer to a specialist if the patient is unresponsive to treatment or the diagnosis is in doubt.
- If there has been a peptic ulcer previously and no evidence of H. pylori eradication, prescribe H. pylori eradication therapy if the test is positive. See separate article Helicobacter Pylori for details.
- If there has been oesophagitis previously, prescribe a proton pump inhibitor (PPI):
- The National Institute for Health and Clinical Excellence (NICE) suggests full-dose PPI for 1-2 months and then titrating down to a low dose or as required dosage if symptoms allow (and there is no underlying condition or co-medication requiring ongoing treatment).
- Where there is no initial response (and recent endoscopy has shown gastro-oesophageal reflux disease (GORD)), a further month of double dose may be tried, followed by a month of H2-receptor antagonist (H2RA).
- Prokinetic agents are not recommended. NICE says that cisapride is no longer licensed, whilst the evidence for metoclopramide and domperidone is limited. However, several new-generation prokinetics such as acotiamide are emerging which look promising and are currently being evaluated.
- The H2RAs provide a swift and effective means of acid suppression and can be used intermittently to achieve control of symptoms. The PPIs are more prolonged in action, produce more profound acid suppression and are more expensive. Their greater efficacy may still provide value for money.
- Some patients may require prolonged high doses of PPI and may ultimately be candidates for anti-reflux surgery.
- Where patients have reflux, but endoscopy failed to show oesophagitis, try full-dose PPI for a month, followed by a month of H2RA.
- If none of the above (non-ulcer dyspepsia), H. pylori eradication (after a positive test) may relieve symptoms in 1 in 20 patients (NNT = 20).
- If none of the above and predominant heartburn symptoms (endoscopy-negative reflux disease), prescribe H2RA, or PPI if not controlled.
- If none of the above and predominantly epigastric pain, an H2RA is the least costly.
For the uninvestigated patient without alarm features
The NICE guideline suggests the following steps:
- Review medications: possible drug causes of dyspepsia include NSAIDs, steroids, calcium antagonists, nitrates, theophyllines and bisphosphonates. Reduce or stop if possible.
- Offer lifestyle advice, ie stopping smoking, more regular meals, ceasing excessive alcohol consumption.
- Antacids are cheap, simple and may be all that is required for relief of occasional symptoms. Most antacids contain a mixture of aluminium hydroxide that tends to cause constipation and magnesium hydroxide that tends to cause diarrhoea. The balance between the two cannot be assured and there may be disturbance of bowel function. If a large amount of antacid is being consumed, consider acid suppression.
- Try either of the following. The alternative choice can be tried if symptoms persist or return:
- Test for H. pylori (carbon-13 urea breath test, stool antigen or laboratory serology) and eradicate if positive.
- Empirical acid suppression (with PPI) - full dose for one month.
Where there has been a satisfactory response at any of the steps above, reassure and return to self-care.
If the patient responds to PPI but then relapses, consider low-dose or intermittent treatment.
If there is no response, consider a prokinetic, eg metoclopramide or H2RA, eg ranitidine for one month.
Where patients show an inadequate response to treatment, consider other diagnoses, eg gallstones and/or referral to a specialist.
- Adverse reactions to PPIs and H2RAs are usually rare and mild but severe problems can arise:
- Rare but not serious problems may include taste disturbance, peripheral oedema, photosensitivity, fever, arthralgia, myalgia and sweating.
- Serious problems include liver dysfunction, hypersensitivity reactions (including urticaria, angio-oedema, bronchospasm, anaphylaxis), depression, interstitial nephritis, blood disorders (including leukopenia, leukocytosis, pancytopenia, thrombocytopenia) and skin reactions (including Stevens-Johnson syndrome, toxic epidermal necrolysis, bullous eruption).
- Many of the drugs used in the management of peptic ulcer disease carry a warning that they should not be used in pregnancy or whilst breast-feeding:
- This is usually because of lack of information about safety in pregnancy rather than evidence of adverse effects in pregnancy.
- However, misoprostol - a prostaglandin analogue - should be avoided in pregnancy as it may cause abortion.
- PPIs are metabolised mostly in the liver. In liver disease, dose adjustment may be required for omeprazole, pantoprazole and esomeprazole. There are no data on the use of rabeprazole in people with severe hepatic impairment, so the manufacturer advises caution.
- Omeprazole and esomeprazole may interfere with warfarin monitoring.
Patients should be reviewed at the end of a course of treatment, especially H. pylori eradication, to confirm a satisfactory outcome. The criteria to be used to measure satisfactory patient outcome are subject to controversy and instruments to determine clinical endpoints are evolving.
If simple acid suppression is given, the patient should be reviewed after one or two months to ascertain that the end is being achieved and there are no warning signs such as weight loss to suggest malignancy.
Referral for endoscopy
Routine endoscopic investigation of dyspeptic patients is not necessary but should be considered in patients over the age of 55 where symptoms persist despite H. pylori testing and acid suppression.
Further reading & references
- Dyspepsia - proven non-ulcer, Prodigy (July 2008)
- Dyspepsia - pregnancy-associated, Prodigy (May 2008)
- Endoscopy. A surgeon describes what an endoscopy is, what happens during the procedure, and how you can prepare yourself for it. A short video from NHS Choices. (June 2008)
- No authors listed; Management of dyspepsia: report of a working party. Lancet. 1988 Mar 12;1(8585):576-9.
- Drossman DA, Dumitrascu DL; Rome III: New standard for functional gastrointestinal disorders. J Gastrointestin Liver Dis. 2006 Sep;15(3):237-41.
- Dyspepsia - Data Focused Commentary, National Prescribing Centre, 2007
- Dyspepsia - unidentified cause, Prodigy (June 2008)
- Batuwitage BT, Kingham JG, Morgan NE, et al; Inappropriate prescribing of proton pump inhibitors in primary care. Postgrad Med J. 2007 Jan;83(975):66-8.
- Hughes JD, Tanpurekul W, Keen NC, et al; Reducing the cost of proton pump inhibitors by adopting best practice. Qual Prim Care. 2009;17(1):15-21.
- Dyspepsia, Gastro Training, 2011
- Talley NJ et al; American Gastroenterological Association Technical Review on the Evaluation of Dyspepsia, Gastroenterology, 2005;129:1756–1780.
- Suzuki H, Nishizawa T, Hibi T; Can Helicobacter pylori-associated dyspepsia be categorized as functional J Gastroenterol Hepatol. 2011 Apr;26 Suppl 3:42-5. doi:
- Should You Eradicate Helicobacter Pylori Prior to Chronic NSAID Treatment? - Smith J; Clinical Correlations, 2011
- Dyspepsia: Managing dyspepsia in adults in primary care, NICE Clinical Guideline (2004)
- Referral for suspected cancer, NICE Clinical Guideline (2005)
- Tack J, Janssen P; Emerging drugs for functional dyspepsia. Expert Opin Emerg Drugs. 2011 Jun;16(2):283-92. Epub 2011 Mar 17.
- Moayyedi P, Soo S, Deeks J, et al; Eradication of Helicobacter pylori for non-ulcer dyspepsia. Cochrane Database Syst Rev. 2005 Jan 25;(1):CD002096.
- Dyspepsia - proven gastro-oesophageal reflux disease, Prodigy (June 2008)
- Moayyedi P, Soo S, Deeks J, et al; Pharmacological interventions for non-ulcer dyspepsia. Cochrane Database Syst Rev. 2006 Oct 18;(4):CD001960.
- British National Formulary
- Ang D, Talley NJ, Simren M, et al; Review article: endpoints used in functional dyspepsia drug therapy trials. Aliment Pharmacol Ther. 2011 Mar;33(6):634-49. doi:
|Original Author: Dr Hayley Willacy||Current Version: Dr Laurence Knott||Peer Reviewer: Dr Hannah Gronow|
|Last Checked: 14/12/2011||Document ID: 459 Version: 6||© EMIS|
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