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PatientPlus articles are written for doctors and so the language can be technical. However, some people find that they add depth to the articles found in the other sections of this website which are written for non-medical people.

Dyspepsia

Dyspepsia describes pain or discomfort in the upper abdomen, and has been defined in a variety of different ways by a number of expert groups.

  • Prior to 1991 dyspepsia included patients with symptoms of heartburn and acid reflux.1
  • The Rome I definition defined patients with sole reflux symptoms as having gastro-oesophageal reflux disease (GERD or GORD).2
  • More recently the these criteria have been extended to exclude patients with predominant reflux symptoms and symptoms suggestive of irritable bowel syndrome.3
Incidence

The costs of managing dyspepsia outstrip all other conditions in the NHS. Expenditure on ulcer healing drugs and endoscopies cost the NHS in excess of ££600 Million.4 Dyspepsia is common, with an incidence of 2 per 1000 population per year.5 Dyspepsia is also a lifelong, intermittent and relapsing disorder.

  • As many as 3% of the population may be taking long term prescribed medication for dyspepsia.6
  • In any 6 month period 41% of the population will suffer an episode of dyspepsia, and a quarter will have consulted their GP about their symptoms.7
Presentation
  • Epigastric discomfort
  • Fullness or bloating
  • Excessive flatus
  • Nausea
  • Fatty food intolerance

Always ask about family history and medication use.

Also ask about "red flag symptoms" such as:

  • Unintentional weight loss
  • Recurrent vomiting
  • Dysphagia
  • Evidence of GI bleeding

The separation of dyspeptic patients into subgroups on the basis of symptoms has not been shown to be reliable in primary care.8,9
If investigated, patients with dyspeptic symptoms will prove to have either:

Older patients are more likely to have serious disease.

Investigation
  • Always check for abdominal mass
  • Also consider taking blood for FBC, so as to demonstrate another alarm feature i.e. iron deficiency anaemia.
Differential diagnosis

Exclude abdominal mass and other causes of abdominal pain.

Evidence based management4

Urgent specialist referral - 2 week rule

If 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
  • Patients aged 55 years or older with unexplained and persistent recent-onset dyspepsia should be referred urgently for endoscopy.10

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 specialist if unresponsive to treatment or the diagnosis is in doubt.

  • If peptic ulcer previously and no evidence of H.pylori eradication, prescribe H.pylori eradication therapy. If previous eradication therapy, use breath test to determine if successful and re-eradicate if necessary.
  • If oesophagitis previously prescribe PPI.11
    • NICE4 suggests full dose PPI for 1-2 months, and then titrating down to 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 GORD), a further month of double dose may be tried, followed by a month of H2RA or prokinetic if there is still no response forthcoming.
    • 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 or prokinetic if still no response.
  • If none of the above (non-ulcer dyspepsia) H.pylori eradication (after a positive test) may relieve symptoms in one in 20 patients (NNT = 20)12
  • If none of the above and predominant heartburn symptoms (endoscopy negative reflux disease) prescribe H2 blocker, or PPI if not controlled.13
  • If none of the above and predominant epigastric pain, neither acid suppression therapy or prokinetics are particularly effective, but an H2 blocker is the least costly.14

For the uninvestigated patient without alarm features

The NICE guideline suggests the following steps:

  • Review medications; possible drug causes of dyspepsia include NSAID's, steroids, calcium antagonists, nitrates, theophyllines, biphosphonates. Reduce or stop if possible.
  • Lifestyle advice i.e. healthy eating, weight reduction, stop smoking, promote use of antacids/alginates.
  • Try the 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 lab serology) and eradicate if positive.
    • Empirical acid suppression (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 e.g. metoclopramide or H2RA e.g. ranitidine for 1 month.
Where patients show an inadequate response to treatment consider other diagnoses e.g. gallstones and/or referral to a specialist.

See Also: Drugs used in Dyspepsia and Peptic Ulcer Disease.

Referral for endoscopy

Routine endoscopic investigation of dyspeptic patients is not necessary, but should be considered in patients over 55 where symptoms persist despite of H.pylori testing and acid suppression.4 However there has been some dissent over the NICE recommendations, citing the value of early detection of GI cancer and its improved survival rates.15

Patients with the following risk factors have a higher risk of malignancy and so lower your threshold for endoscopy referral:

NB: As the prevalence of H.pylori is falling in the UK, a 30 year old with dyspepsia may have a less than 20% chance of infection. For this reason, eradication of H.pylori without testing first is not recommended and likely to be very wasteful of resources, especially as this is likely to cause some dilemma when they return with symptoms.16,17

Document references
  1. No authors listed; Management of dyspepsia: report of a working party. Lancet. 1988 Mar 12;1(8585):576-9.
  2. Talley NJ, et al; Functional dyspepsia: A classification with guidelines for diagnosis and management. Gastroenterol. Int. 1991 4:145-160.
  3. Drossman DA, Corazziari E, Talley NJ, Thompson WG, Whitehead WE. Rome II: The functional gastrointestinal disorders. Allen Press: Lawrence KS USA, 2000.
  4. Dyspepsia: Managing dyspepsia in adults in primary care, NICE (2004)
  5. McCormick A, Fleming D, Charlton J. Morbidity statistics from General Practice. Fourth national morbidity study 1991-1992. London: Office of Population Censuses and Surveys., 1995;
  6. Ryder SD, O'Reilly S, Miller RJ, et al; Long term acid suppressing treatment in general practice. BMJ. 1994 Mar 26;308(6932):827-30. [abstract]
  7. Jones RH, Lydeard SE, Hobbs FD, et al; Dyspepsia in England and Scotland. Gut. 1990 Apr;31(4):401-5. [abstract]
  8. Hansen JM, Bytzer P, Schaffalitzky De Muckadell OB; Management of dyspeptic patients in primary care. Value of the unaided clinical diagnosis and of dyspepsia subgrouping. Scand J Gastroenterol. 1998 Aug;33(8):799-805. [abstract]
  9. Talley NJ, Weaver AL, Tesmer DL, et al; Lack of discriminant value of dyspepsia subgroups in patients referred for upper endoscopy. Gastroenterology. 1993 Nov;105(5):1378-86. [abstract]
  10. Referral guidelines for suspected cancer, NICE (2005)
  11. Chiba N, De Gara CJ, Wilkinson JM, et al; Speed of healing and symptom relief in grade II to IV gastroesophageal reflux disease: a meta-analysis. Gastroenterology. 1997 Jun;112(6):1798-810. [abstract]
  12. 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. [abstract]
  13. van Pinxteren B, Numans ME, Bonis PA, et al; Short-term treatment with proton pump inhibitors, H2-receptor antagonists and prokinetics for gastro-oesophageal reflux disease-like symptoms and endoscopy negative reflux disease. Cochrane Database Syst Rev. 2006 Jul 19;3:CD002095. [abstract]
  14. Moayyedi P, Soo S, Deeks J, et al; Pharmacological interventions for non-ulcer dyspepsia. Cochrane Database Syst Rev. 2006 Oct 18;(4):CD001960. [abstract]
  15. Griffin SM, Bowrey DJ, Allum WH. Upper gastrointestinal surgeons comment on NICE dyspepsia guidelines BMJ; February 5th, 2005
  16. Foy R, Parry JM, Murray L, et al; Testing for Helicobacter pylori in primary care: trouble in store? J Epidemiol Community Health. 1998 May;52(5):305-9. [abstract]
  17. Delaney BC, Moayyedi P, Forman D; Initial management strategies for dyspepsia. Cochrane Database Syst Rev. 2003;(2):CD001961. [abstract]
Internet and further reading Acknowledgements EMIS is grateful to Dr Hayley Willacy for writing this article. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2007.
DocID: 459
Document Version: 2
DocRef: bgp1656
Last Updated: 3 Jul 2007
Review Date: 2 Jul 2009

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