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Recent NICE guidelines provide fresh scope for the management of dyspepsia in primary care Dr Owen Epstein takes a closer look
of dyspepsia in primary care Dr Owen Epstein
takes a closer look
Think of the term 'dyspepsia' and the first words most likely to spring to mind are 'acid' and 'ulcer'.
In fact, almost two-thirds of dyspepsia confronting GPs is now likely to be due to non-ulcer dyspepsia, a disorder most often unrelated to those instant recalls.
Barry Marshall's discovery of Helicobacter pylori 20 years ago adds further confusion as generations of medical students brought up on the refrain 'no acid, no ulcer' have abruptly been forced to switch paradigms to 'no Helicobacter, no ulcer'. There is scope for confusion but NICE help is at hand.
It is important to disentangle dyspepsia and heartburn. Dyspepsia refers to an epigastric pain or discomfort, which may be associated with early satiety, nausea and upper abdominal bloating. Heartburn is heartburn.
The diagnosis is usually readily obvious from the history alone. If a patient fails to instantly recognise the term as a searing retrosternal sensation, which responds rapidly to simple antacids, it is unlikely that the symptom is heartburn.
Dyspeptic symptoms may arise from acid and pepsin-related gastric and duodenal inflammation and ulceration, but the same symptoms are caused by impaired gastric compliance, gastric dysrhythmias and abnormalities of the gastric pump.
These latter abnormalities underlie much of the dyspepsia presenting in general practice and cannot be diagnosed by endoscopy.
Heartburn results from an increased frequency of spontaneous relaxation of the lower oesophageal sphincter. This results in pathological exposure of the gullet mucosa to gastric contents, including acid and pepsin, causing a pain with a particular quality.
New methods of investigating the stomach and oesophagus
The fundus of the stomach has an impressive capacity to relax during eating (known as receptive relaxation). Loss of this elasticity can cause dyspepsia and can be demonstrated by use of a barostat.
Gastric rhythm is dictated by the gastric pacemaker, embedded in the greater curve of the stomach. The impulse generated by this pacemaker is called the 'slow wave'. The normal three cycles/minute frequency can be replaced by brady- and tachygastrias which can be detected by electrogastrography. The gastric pump is readily assessed by an isotope-labelled test meal, which measures emptying time. These investigations are not routinely available but in five to 10 years, electrophysiological studies will be as widely used as endoscopy in diagnosis.
A 24-hour oesophageal pH study is the gold standard for confirming pathological acid reflux. However, there is evidence that a response to a proton pump inhibitor (PPI) is equally reliable as a test for acid reflux.
NICE, ageism and re-engineering the management of dyspepsia
Until three years ago, most guidelines recommended referring all patients over 45 for endoscopy. The age limit was then raised to 55 and over until, in August 2004, NICE deemed that ageism should no longer prevail.
Gastric cancer is a disease of the over-50s and the age-determined recommendations were driven by a fear of delaying cancer diagnosis.
However, more than 99 per cent of patients presenting with gastric cancer have alarm features at first presentation (see table 1, below). NICE has distilled the evidence and recommends that dyspeptic patients should be managed according to symptoms and signs rather than age.
Irrespective of age, patients presenting with alarm features should be referred for endoscopy with treatment dictated by endoscopic findings.
However, the new guidance offers considerable scope for treating uncomplicated dyspepsia in primary care without prior endoscopy.
Treating uncomplicated dyspepsia in general practice
The empirical approach to treatment recommended by both NICE (figure 1, page 48) and SIGN recognises the value of therapeutic trials as a simple mechanism for teasing out the various subgroups.
Most patients with peptic ulcer disease will harbour H. pylori and a policy of 'test and treat' will cure most peptic ulcers. Numerous analyses have indicated this approach is cost-effective. Testing in primary care can be performed using a validated laboratory-based serology test, a 13 C-urea breath test or a stool antigen test.
A week's triple therapy using a PPI, clarithromycin and amoxicillin is recommended, with metronidazole replacing amoxicillin where penicillins are contraindicated.
However, anticipate that only about 20 per cent of H. pylori-positive dyspeptic patients will be cured. Responders are probably the patients with peptic ulcer disease and in the remainder, the organism is an innocent bystander.
For patients who are H. pylori negative at the outset, or those with H. pylori who fail to respond to the triple therapy, the use of an antisecretory drug (eg H2 receptor antagonist or low-dose PPI) for four weeks will tease out a further group of antacid-responsive dyspeptics.
For those remaining symptomatic following H. pylori eradication and/or antisecretory treatment, it is reasonable to offer three to four weeks of a prokinetic agent (eg metoclopramide or domperidone). This selects a group where dysmotility might be playing a role.
Once an effective treatment has been revealed, patients can be educated to adjust lifestyle, and titrate treatment to the minimum regimen, which maintains quality of life.
Which dyspeptic patients
should be referred?
Patients with uncomplicated dyspepsia unresponsive to the sequential treatments outlined above should be referred for further investigation including endoscopy and ultrasound.
All patients with alarm symptoms or signs should be referred for rapid hospital investigation. It is also advisable to refer patients with troublesome dyspepsia on NSAIDs as endoscopic findings and
H. pylori status might dictate long-term NSAID management.
What about those who return to primary care with a negative ultrasound and endoscopy?
This group probably represents patients with abnormal gastric compliance or pump failure. For those already treated for H. pylori, and given a trial of a PPI and prokinetic, it might be worth prescribing low-dose amitriptyline (eg 10-25mg at night) and recommending small frequent meals.
There is evidence that psychotherapy and hypnotherapy are also of value in refractory non-ulcer dyspepsia and these options should be explored.
NICE and the management of heartburn
While heartburn is a discrete disorder, the principles of treatment are similar to those outlined for dyspepsia. One distinguishing exception is the role of
H. pylori, which plays no part in the pathogenesis of heartburn and need not be tested for.
NICE guidance offers a simple approach to the management of heartburn in primary care (figure 2, page 51).
If there are alarm symptoms (table 1), patients should be urgently referred for specialist care.
If heartburn is uncomplicated, it is reasonable to prescribe a standard dose of PPI. Most patients will respond briskly and dramatically to treatment.
After four to eight weeks of treatment, educate the patient on lifestyle and titrate the dose down to the lowest regimen that maintains the patient symptom-free.
Some patients find 'on demand' treatment satisfactory, while others are best treated with daily maintenance therapy.
The predictability, safety and efficacy of antisecretory treatment makes a strong case for avoiding anti-reflux surgery.
Go on, try it
The new guidelines encourage a change in the practice of referring older patients with foregut syndromes for endoscopy and challenge our fear of missing foregut cancer. Changing these beliefs and practices is difficult for both hospital doctors and GPs.
Take comfort from the thoroughness and thoughtfulness given to preparation of these pathways. Following the guidance will be both interesting and rewarding and you should be able to manage most of your dyspeptic and reflux patients without resorting to a specialist referral or open-access endoscopy.
Owen Epstein is lead consultant gastroenterologist at the Royal Free Hospital, London
·NICE dyspepsia guideline (August 2004)
·SIGN guideline (Scottish guidelines)
Table 1 Alarm features in dyspepsia and heartburn
dyspepsia and heartburn
·Unintentional weight loss (>3kg)
·Haematemesis or melena
·Failure to respond to H. pylori eradication, PPIs and prokinetics