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EBMG

Dyspepsia

Essentials

  • The cause of dyspeptic symptoms is either organic dyspepsia, where the symptoms originate from an organic cause, or functional dyspepsia, where symptoms originate from the upper part of the digestive tract without an organic, systemic or metabolic disease explaining the symptoms.
  • Gastroscopy is the investigation of choice in patients with alarming symptoms (table T1).
  • In the absence of alarming symptoms, the evaluation of dyspeptic symptoms may in patients less than 55 years of age be started with a therapeutic trial of a proton pump inhibitor (PPI) drug or with a H. pylori screening test. H. pylori-positive patients are treated with triple therapy Peptic Ulcer Disease, Helicobacter Pylori Infection and Chronic Gastritis.
  • Upper abdominal ultrasonography is not useful as a primary investigation.
  • The possibility of ischaemic heart disease as the cause of upper abdominal symptoms should be borne in mind with patients in risk groups.

Definitions and aetiology

  • Dyspepsia is accompanied by (Rome IV Criteria) at least one of the following symptoms for longer than 3 months:
    • excessive postprandial fullness
    • early satiety
    • epigastric pain or burning sensation.
  • In functional dyspepsia, no organic, systemic or metabolic disease explains the symptoms.
    • Dyspepsia is functional in about half of the cases.
    • The aetiology of functional dyspepsia is unknown. Suggested causes include visceral hypersensitivity, delayed gastric emptying and impaired fundic accommodation.
  • The causes of organic dyspepsia include peptic ulcer, gastro-oesophageal reflux disease (GORD), lactose intolerance, coeliac disease, malignant tumour, pancreatic or biliary tract disease, and endocrine or metabolic disease.
  • In GORD Gastro-Oesophageal Reflux Disease, the return of the gastric contents back to the oesophagus causes typical symptoms (heartburn and/or regurgitation of the gastric contents) or changes in the oesophageal mucosa.
    • The cause of epigastric symptoms in about 30% of patients
    • GORD can be diagnosed based on history alone, provided that no alarming symptoms are present (table T1).
    • Divided into two categories: erosive and non-erosive
    • The most important aetiological factor is the weakening of the lower oesophageal sphincter (90% of cases).
    • Dyspepsia and GORD can occur simultaneously.
  • Smoking increases dyspepsia; the association of coffee and alcohol with the symptoms is less clear.
  • Epigastric symptoms can also be caused by certain medicines, including anti-inflammatory drugs and bisphosphonates.
  • More rare causes include eosinophilic oesophagitis, diaphragmatic hernia and gastroparesis in diabetes.

Epidemiology

  • In the industrialised countries the incidence in the adult population is about 14-26%.
  • Epigastric complaints account for approximately 3% of all consultations in primary care.

Clinical presentation

  • The main symptoms of dyspepsia are
    • postprandial fullness
    • early satiety
    • epigastric pain or
    • burning sensation.
  • Moreover, the patient often complains of upper abdominal distension, nausea and heartburn.
  • Alarming symptoms (table T1) are an indication for urgent endoscopic examination.
Alarming symptoms in dyspepsia
The occurrence of symptoms (other than typical symptoms of GORD) for the first time at the age of 55 years or older
Dysphagia or pain on swallowing
Unintentional weight loss (more than 3 kg in 6 months)
Recurring vomiting or nausea
Anaemia or bleeding, such as haematemesis or melaena
Palpable mass on the upper abdomen or enlarged lymph nodes
Pain radiating from the abdomen to the back or continuous abdominal pain

Diagnosis

  • History
    • Principal symptoms
    • Does the patient present with symptoms that have not been investigated before?
    • Has the patient got alarming symptoms: weight loss, haematemesis or malaena, repeated vomiting, feeling of food becoming stuck when swallowing, dysphagia, upper abdominal pain radiating to the back or anaemia?
    • Previous investigations and procedures due to abdominal symptoms and their findings?
  • Physical examination
    • General health (weight, height, BMI)
    • A thorough physical examination
    • Inspection and palpation of the abdomen (and rectal examination and observation of the colour and consistency of the stools if the history is suggestive of bleeding)
  • Laboratory tests as dictated by the symptoms, findings of the physical examination, age and the provisional diagnosis (inflammatory aetiology, bleeding, possible malabsorption or a suspicion of a malignancy)
    • ESR, basic blood count with platelet count, CRP, anti-tissue transglutaminase IgA antibodies, genetic test for lactose intolerance
    • Endoscopic examinations if bleeding is suspected (instead of testing for occult blood in stool)
  • Imaging studies are usually of no benefit.
    • Upper abdominal ultrasonography is the initial investigation if symptomatic cholelithiasis is suspected.

The role of gastroscopy in diagnosis

  • Alarming symptoms (table T1) are an indication for gastroscopy in patients of all ages.
  • Without the presence of alarming symptoms, gastroscopy is indicated only if dyspeptic symptoms continue despite H. pylori eradication or symptomatic treatment.
  • If the patient is using anti-inflammatory medication gastroscopy is indicated where the medication cannot be withdrawn and the symptoms persist despite PPI therapy or the patient has a history of a peptic ulcer.

Differential diagnosis Value of Clinical History in Differentiating Organic and Functional Dyspepsia

  • The following conditions may result in symptoms that resemble dyspepsia
    • ischaemic heart disease Acute Coronary Syndrome
    • certain medicines (anti-inflammatory drugs, bisphosphonates, SSRIs, antimicrobials, metformin, drugs used in memory disorders, dipyridamole etc.)
    • psychiatric disorders (such as anxiety disorders Anxiety Disorder, somatoform disorders)
    • irritable bowel syndrome Functional Bowel Disorders and the Irritable Bowel Syndrome (IBS)
    • musculoskeletal disorders of the upper body
    • metabolic disorders (e.g. diabetes, porphyria, thyroid and parathyroid disorders, disorders of cortisol metabolism)
    • chronic kidney disease
    • pneumonia Pneumonia
    • prolonged gastroenteritis or a post-infectious motility disorder

Treatment Additional Bedtime H2-Receptor Antagonist for the Control of Nocturnal Gastric Acid Breakthrough

  • If it is considered that functional dyspepsia warrants treatment, PPIs are the first choice drugs (table T2).
  • The drug therapy is symptom oriented; the medicine should only be taken when required and in continuous use the lowest effective dose used.
    • PPI medication is associated with potential adverse effects, such as an increased infection risk and negative effects on bones particularly in elderly persons when the treatment is long-term.
  • In patients aged less than 55 years with symptoms not suggestive of an organic disease, a treatment trial with PPIs of 2-4 weeks' duration may be undertaken before further investigations are considered.
    • The placebo effect in the treatment of functional dyspepsia is as high as 30-60%.
    • If no improvement is evident after one month, the situation should be reassessed.
    • Scientific evidence is inconsistent as regards the efficacy of dietary measures in the treatment of dyspepsia.
  • Eradication treatment of confirmed H. pylori infection does not eliminate symptoms in all patients but does reduce the risk of peptic ulcer disease and stomach cancerPeptic Ulcer Disease, Helicobacter Pylori Infection and Chronic Gastritis.

Dosage of PPIs

Dyspepsia or mild oesophagitisInitial treatment of severe oesophagitis or H. pylori eradicationProphylaxis of oesophagitis
Esomeprazole20-40 mg once daily40 mg once daily (20 mg twice daily)20 mg once daily
Lansoprazole30 mg once daily30 mg once or twice daily15 mg once daily
Omeprazole20-40 mg once daily40 mg once daily (20 mg twice daily)10-20 mg once daily
Pantoprazole40 mg once daily40 mg once or twice daily20 mg once daily
Rabeprazole20 mg once daily20 mg once or twice daily10 mg once daily

Follow-up

  • Functional dyspepsia does not need routine follow-up.
  • If the patient has undergone endoscopy for the same symptoms within the last few years and the histological analysis has been normal, repeat gastroscopy is usually not indicated.
  • No follow-up is needed after H. pylori eradication provided that a positive treatment outcome was confirmed Peptic Ulcer Disease, Helicobacter Pylori Infection and Chronic Gastritis.
  • The follow-up of organic dyspepsia is arranged according to the underlying cause (gastric ulcer, chronic pancreatitis, specific intestinal inflammatory conditions and complicated GORD).

Arrangement of treatment

  • Upper abdominal complaints are primarily investigated and treated in the primary health care.
  • Specialist management or advice is indicated in some cases of organic dyspepsia, complicated GORD and treatment resistant H. pylori infection.

    References

    • Black CJ, Paine PA, Agrawal A, et al. British Society of Gastroenterology guidelines on the management of functional dyspepsia. Gut 2022;71(9):1697-1723. [PubMed]
    • Ford AC, Tsipotis E, Yuan Y, et al. Efficacy of Helicobacter pylori eradication therapy for functional dyspepsia: updated systematic review and meta-analysis. Gut 2022. [PubMed]
    • Eusebi LH, Black CJ, Howden CW et al. Effectiveness of management strategies for uninvestigated dyspepsia: systematic review and network meta-analysis. BMJ 2019;367:l6483. [PubMed]
    • Pittayanon R, Yuan Y, Bollegala NP et al. Prokinetics for functional dyspepsia. Cochrane Database Syst Rev 2018;(10):CD009431. [PubMed]
    • Pinto-Sanchez MI, Yuan Y, Hassan A et al. Proton pump inhibitors for functional dyspepsia. Cochrane Database Syst Rev 2017;(11):CD011194. [PubMed]