Dyspepsia

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Dyspepsia
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Dyspepsia

• We will look at symptoms of dyspepsia and
  management of adult patients in primary care.
• We will not cover dyspepsia in pregnant women or
  dyspepsia associated with the use of
  non-steroidal anti-inflammatory drugs (NSAIDs).
• We will not cover management of gastric or
  duodenal ulcers or Barretts oesophagus.

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What is Dyspepsia?NICE Clinical Guideline 17,
Aug 2004

• Dyspepsia is a complex of symptoms of the upper
  gastrointestinal (GI) tract.
• Symptoms are usually intermittent and may include
  upper abdominal pain or discomfort, acid reflux
  and heartburn, with or without nausea, vomiting
  or bloating.
• Symptoms are a poor predictor of significant
  disease or underlying pathology.

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What Could it Be? NICE Clinical Guideline 17,
Aug 2004

• Patients presenting with symptoms of dyspepsia,
  who have not been investigated by endoscopy, are
  said to have uninvestigated dyspepsia.
• Gastro-oesophageal reflux disease (GORD). This
  is endoscopically-determined oesophagitis or
  endoscopically-negative reflux disease (ENRD).
• Peptic ulcer disease (PUD) refers to duodenal or
  gastric ulcers.
• Non-ulcer dyspepsia (NUD) no ulcer,
  oesophagitis or malignancy found on endoscopy and
  reflux symptoms are not predominant.
• Zollinger-Ellison syndrome. (rare)
• Malignancy. (rare)

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Referral and EndoscopyNICE Clinical Guideline
17, Aug 2004

• Urgent specialist referral for endoscopy for
  patients of any age with
• chronic GI bleeding, progressive unintentional
  weight loss, progressive difficulty swallowing,
  persistent vomiting, iron deficiency anaemia,
  epigastric mass or suspicious barium meal.
• Urgent referral for endoscopy for patients 55
  years and over with unexplained and persistent
  recent-onset dyspepsia.
• No routine endoscopy for patients without alarm
  signs.

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Initial Management of Dyspepsia in Primary Care
NICE Clinical Guideline 17, Aug 2004

• Management starts with lifestyle advice and the
  community pharmacist.
• Lifestyle advice
• reduce weight
• healthy diet
• stop smoking
• avoid known precipitants
• e.g. smoking, alcohol, coffee, chocolate, fatty
  foods.
• raise head of bed
• eat main meal well before bedtime

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Initial management of dyspepsia in primary care
NICE Clinical Guideline 17, Aug 2004

• Review the patients medication for possible
  causes of dyspepsia e.g. corticosteroids, NSAIDs.
• Over-the-counter medicines include antacids and
  alginates, omeprazole and H2-receptor
  antagonists.
• As required antacid and/or alginate therapy is
  appropriate for immediate relief of symptoms.

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Uninvestigated Dyspepsia

• Treat
• either empirically with a PPI (e.g. omeprazole
  20mg daily).
• or test for Helicobacter pylori using a carbon-13
  urea breath test or stool antigen test, and treat
  if positive.
• Offer an annual review to patients requiring
  long-term management of dyspepsia symptoms.
• Encourage patients to step down or stop
  treatment.
• A return to self-treatment with an antacid and/or
  alginate may be appropriate.

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Trends in Prescribing of Proton Pump
Inhibitorsin General Practice in England
Newer PPIs offer no advantage in terms of
clinical efficacy over established PPIs, are
usually more expensive and have less evidence for
long-term safety. MeReC Bulletin 2006169-12
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Primary Care Costs of PPIsDrug Tariff (March
2007)
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Summary

• Dyspepsia is very common.
• Symptoms are a poor predictor of significant
  disease.
• Routine endoscopy is not necessary for patients
  without alarm signs.
• Self-management through community pharmacy.
• Empirical treatment of uninvestigated dyspepsia
  with PPI (e.g. omeprazole 20mg) or test for
  Helicobacter pylori and treat if positive.
• Titrate treatment up and down, and use medicines
• as required.