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

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

• Epigastric discomfort
• Fullness or bloating
• Excessive flatus
• Nausea
• Fatty food intolerance

Always ask about family history and medication use.

• 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.

• Always check for abdominal mass
• Consider taking FBC to demonstrate another alarm feature e.g. iron deficiency anaemia
• Testing for Helicobacter pylori is worthwhile. Patients taking NSAIDs have 2 to 4 times the risk of ulceration if H. pylori is positive.¹⁰ Testing patients for H. pylori and eradication before starting NSAIDs reduces the incidence of ulcers.¹¹

• Peptic ulcer
• Functional (non ulcer) dyspepsia
• Irritable Bowel syndrome
• Atypical GORD / GERD
• Biliary pain e.g. gallstones
• Achalasia
• Medication Induced
• Aerophagia
• Oesophageal spasm
• Carcinoma of oesophagus or stomach

Exclude abdominal mass and other causes of abdominal pain.

Urgent specialist referral - 2 week rule

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.

For the uninvestigated patient without alarm features

The NICE guideline suggests the following steps:

H. pylori eradication

If the infection is suspected or demonstrated eradication is the logical course of action. NICE suggests that eradication should be offered if a test is positive.

There are several regimes that are available. They usually consist of high dose acid suppression with a PPI and two antibiotics, also at quite high dose. The usual recommended duration of treatment is 7 days and it is said to give eradication in about 90% of cases. A 14 days course may produce a higher rate of eradication but the incidence of adverse effects may make compliance poor. Diarrhoea is common with two antibiotics at high dose.

The following is based on the recommendations of NICE:⁴

• If there was poor compliance, a more tolerable regimen may be required.
• Resistance can even develop during treatment, especially with a single antibiotic. A further attempt at eradication may be made. The regimen should be adjusted according to the nature of the problem. The organism may have been cultured after endoscopy so it may be possible to obtain sensitivities.

It is common practice to use 4 drugs for a repeated attempt. The antibiotics can be changed and chelated bismuth may be used. A typical quadruple therapy would be:

• PPI twice a day
• Bismuth 120 mg four times a day
• Metronidazole 400 mg three times a day
• Oxytetracycline 500 mg four times a day

All regimes are taken for 7 days.
Reinforce the importance of compliance as it is not easy to take so many tablets so many times a day, even for just a week. Chelated bismuth is rather unpleasant to take but it is effective at helping to eradicate H pylori.

Pharmacological issues

• During H. pylori eradication, abdominal discomfort and diarrhoea are very common but the patient should be encouraged to persist to achieve eradication and to heal the ulcer permanently. Lactobacilli, usually ingested in the form of natural unpasteurised yoghurt, may be of value in replacing the natural flora of the gut and they may also have a suppressive effect on H. pylori.¹⁸
• Adverse reactions to PPIs and H₂ blockers 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, angioedema, bronchospasm, anaphylaxis), depression, interstitial nephritis, blood disorders (including leucopenia, leucocytosis, 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.
If simple acid suppression is given, the patient should be reviewed after 1 or 2 months to ascertain that the end is being achieved and there are no warning signs such as weight loss to suggest malignancy.

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.¹⁹