DYSPEPSIA Dr.Vishal Rathore

Dyspepsia popularly known as indigestion meaning hard or difficult digestion, is a medical condition characterized by chronic or recurrent pain in the upper abdomen, upper abdominal fullness and feeling full earlier than expected when eating.

Prevalence %, of which 50% self medicate 25% consult their G.P. 5% of G.P. consultations are for dyspepsia Prescribed drugs and endoscopies cost £600M in 2000 OTC indigestion remedies sold for £100M in 2002

Causes Reflux oesophagitis 12% Duodenal ulcer 10% Gastric ulcer 6% Gastric carcinoma 1% Oesophageal carcinoma 0.5% Non-erosive GORD Functional (non-ulcer) dyspepsia

Alarm Symptoms/ Signs* GI bleeding (same day referral) Persistent vomiting Weight loss (progressive unintentional) Dysphagia Epigastric mass Anaemia due to possible GI blood loss Thus all patients with new-onset dyspepsia should have abdominal examination and FBC

First Approach to Dyspepsia Consider possible causes outside upper GI tract -Heart, lung, liver, gall bladder, pancreas, bowel Consider drugs and stop if possible - Aspirin / NSAIDs, calcium antagonists, nitrates, theophyllines, etidronate, steroids

Refer if dyspepsia in 55+* year old Alarm symptoms/signs (2 week referral) Unexplained and persistent recent-onset dyspepsia without alarm symptoms – Unexplained means no cause known – Persistent implies present for a length of time (NICE suggest 4-6 weeks) – Recent-onset implies new-not a recurrent episode.

Referral for Endoscopy Review medications for possible causes of dyspepsia (calcium antagonists, nitrates, theophyllines, bisphosphonates, corticosteroids and non-steroidal anti-inflammatory drugs [NSAIDs]). In patients requiring referral, suspend NSAID use.

Urgent specialist referral Endoscopic investigation is indicated for patients of any age with dyspepsia when presenting with any of the following: chronic gastrointestinal bleeding, progressive unintentional weight loss, progressive difficulty swallowing, persistent vomiting, Iron deficiency anaemia, epigastric mass suspicious barium meal

Routine Endoscopic Investigation Patients of any age, presenting with dyspepsia and without alarm signs, is not necessary. However, in patients aged 55 years and older with unexplained and persistent recent-onset dyspepsia alone, an urgent referral for endoscopy should be made.

Management of simple dyspepsia in those aged < 55 years Stress benign nature of dyspepsia Lifestyle advice – Healthy eating – Weight reduction – Stop smoking – Use of antacids

Interventions for uninvestigated dyspepsia Initial therapeutic strategies for dyspepsia are empirical treatment with a proton pump inhibitor (PPI) or testing for and treating H. pylori. There is currently insufficient evidence to guide which should be offered first. A 2-week washout period following PPI use is necessary before testing for H. pylori with a breath test or a stool antigen test

Nice Guideline Summary Refer if “alarm symptoms” at any stage Test and treat (Test for H. pylori and treat positives) THEN, IF STILL SYMPTOMATIC PPI for one month THEN Manage recurrent symptoms as functional dyspepsia

Rx of H. Pylori One week triple therapy *  PPI (full dose) e.g. omeprazole 20mg bd  Clarithromycin 500mg bd  Amoxycillin 1g bd (or Metronidazole 400mg bd) Use a carbon-13 urea breath test, stool antigen test or, when performance has been validated, laboratory based serology. If re-testing for H. pylori use a carbon-13 urea breath test.*

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