Dyspepsia
NICE Clinical guideline [CG184] Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management. Last updated: Oct 2019.
Background Information
Definition
Dyspepsia: a group of symptoms arising from the upper GI tract
- Dyspepsia is not a diagnosis
- Possible symptoms include: upper abdominal pain / discomfort, heartburn, nausea, vomiting, reflux
- The ACG defines dyspepsia in clinical practice as predominant epigastric pain lasting at least 1 month [Ref]
There are 2 main types of dyspepsia:
- Uninvestigated dyspepsia: patients with dyspepsia but have NOT had an endoscopy
- Functional dyspepsia (also known as non-ulcer dyspepsia): patients with dyspepsia who have normal findings on endoscopy (no ulcer, no malignancy, no oesophagitis)
Aetiology
The most common cause is functional dyspepsia (normal endoscopy) (up to 80%)
Organic causes of dyspepsia:
| GI tract causes |
|
| Other GI causes (non-GI tract) |
|
| Extra-GI causes |
|
Guidelines
Red Flags for Upper GI Malignancy
Offer urgent upper gastrointestinal endoscopy if:
- Dysphagia alone, or
- ≥55 y/o with weight loss and any of the following:
- Upper abdominal pain
- Reflux
- Dyspepsia
Other less commonly examined red flags:
- Consider a suspected cancer pathway referral for people with an upper abdominal mass consistent with stomach cancer
- Consider non-urgent direct access upper gastrointestinal endoscopy in people with haematemesis
- Consider non-urgent direct access upper gastrointestinal endoscopy in ≥55 y/o with:
- Treatment-resistant dyspepsia, or
- Upper abdominal pain with low haemoglobin levels, or
- Raised platelet count with any of the following:
- Nausea
- Vomiting
- Weight loss
- Reflux
- Dyspepsia
- Upper abdominal pain, or
- Nausea or vomiting with any of the following:
- Weight loss
- Reflux
- Dyspepsia
- Upper abdominal pain
Management
General / Conservative Management
For all patients:
| Medication review | Important drugs to look out for:
|
| General lifestyle advice |
|
| Prevent triggers / attacks |
|
Uninvestigated Dyspepsia Management
Step up if symptoms persist:
| Step 1 | Offer one of the following approaches
|
| Step 2 | Attempt the alternative approach (as listed in step 1) |
| Step 3 | Consider H2-receptor antagonist (e.g. ranitidine, famotidine, nizatidine) |
Precautions regarding H. Pylori testing (stool antigen or urea breath test):
- If the patient takes a PPI → delay until after 2 weeks of not taking it
- If the patient takes an antibiotic → delay until after 4 weeks of not taking it
Regarding long-term treatment with PPI, advise:
- Long-term PPI is not routinely recommended
- Use the lowest effective dose to control symptoms
- If possible, step down or stop treatment
- Consider self-treatment with antacid and/or alginate therapy, although not recommended for long-term or continuous use
Key long-term complications of PPI use:
- Risk of infections – C. difficile infection, pneumonia
- Electrolyte deficiencies – hyponatraemia, hypomagnesaemia
- Malabsorption – iron deficiency, risk of osteoporosis (from impaired calcium absorption)
- GI effects – rebound acid hypersecretion when stopped suddenly, hypergastrinaemia → fundic gland polyps
Functional Dyspepsia Management
1st line: H. pylori test and treat – see the Helicobacter Pylori Infection article for more information
If the patient is H. pylori -ve and dyspepsia persists: offer a PPI or H2-receptor antagonist (e.g. ranitidine, famotidine, nizatidine) to be taken at the lowest dose possible to control symptoms
Regarding long-term treatment with PPI, advise:
- Long-term PPI is not routinely recommended
- Use the lowest effective dose to control symptoms
- If possible, step down or stop treatment
- Consider self-treatment with antacid and/or alginate therapy, although not recommended for long-term or continuous use
Key long-term complications of PPI use:
- Risk of infections – C. difficile infection, pneumonia
- Electrolyte deficiencies – hyponatraemia, hypomagnesaemia
- Malabsorption – iron deficiency, risk of osteoporosis (from impaired calcium absorption)
- GI effects – rebound acid hypersecretion when stopped suddenly, hypergastrinaemia → fundic gland polyps
References