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The treatment - dyspepsia and GORD

Dr Adam Haycock, consultant gastroenterologist, discusses treatment and referral options for primary care in patients with dyspepsia and GORD

Typical symptoms of dyspepsia and GORD can include abdominal pain, early satiety, postprandial fullness, bloating, indigestion, heartburn, regurgitation and cough. The following assumes there are no associated alarm symptoms such as:

• Weight loss.

• GI bleeding.

• Dysphagia.

• Odynophagia.

• Persistent vomiting.

• Jaundice.

• A palpable mass or lymphadenopathy.

The above should prompt urgent referral and investigation with an upper GI endoscopy.

Standard current treatment

Management can be divided into patients with uninvestigated symptoms, endoscopically or radiologically confirmed reflux, confirmed peptic ulcer disease or investigation-negative (functional) dyspepsia or reflux.

Uninvestigated symptoms

Uninvestigated reflux symptoms should be managed the same as dyspepsia. Often patients will already have tried OTC preparations such as alginates, which can be continued.

Test and treat for Helicobacter pylori using first-line treatment regimes, although be aware that successful eradication in patients testing positive does not improve symptoms in the majority of patients. If symptoms do continue post-eradication treatment, then re-test for H. pylori with a 13C urea breath test (stool and serum tests are not as reliable) to check for eradication failure.

Patients who are still positive should be offered second-line eradication with clarithromycin or metronidazole, whichever was not used previously.

Patients testing negative for H. pylori should be offered empirical full-dose PPI for four weeks and then adjust the medications according to response. Those who respond to full dose should be encouraged to step down to the lowest dose that will control their symptoms. Self-management using PPI on a prn basis is reasonable, but should be reviewed annually. Patients with a partial response can be given an H2 antagonist in addition, to be taken last thing at night to prevent breakthrough symptoms.

Confirmed oesophagitis or reflux

Initial treatment with full-dose first-line PPI, such as omeprazole, for eight weeks may be enough to heal moderate to severe reflux oesophagitis, but in non-responders a swap to an alternative full-dose PPI, such as esomeprazole or pantoprazole, may be effective. PPIs may need to be continued long term, but again, patients should be encouraged to reduce the dose to a level sufficient to control their symptoms. Patients who fail to respond should be considered for formal pH testing to confirm the diagnosis and to assess suitability for an anti-reflux procedure.

Peptic ulcer disease

In endoscopically confirmed NSAID-associated peptic ulcer disease, the NSAIDs should be stopped where possible. Those continuing NSAIDs should be counselled about potential harm and reviewed every six months, with encouragement to use only as needed and with ongoing gastric protection. Patients with helicobacter-associated ulcers should be offered eradication therapy. Full-dose PPIs are recommended for four to eight weeks initially, and patients with a gastric ulcer need a re-scope within three months to confirm healing.

Functional dyspepsia

Management is controversial and often unsuccessful. Patients will often modify their dietary habits to prevent symptoms, but a formal food diary may be helpful in identifying specific triggers.

PPIs may help a proportion of patients in the short term, but long-term continuous therapy should be avoided. Low-dose antidepressants, such as amitriptyline 10-25mg at night, can be trialled for 12 weeks, and continued for six months if there is symptomatic response, with repeat prescriptions if symptoms recur.

A large trial evaluating amitriptyline, escitalopram and placebo has been completed and is due to report later this year.1

What treatments have become newly available

Laparoscopic insertion of a magnetic bead band (LINX) for management of reflux symptoms is not yet available on the NHS, but may be a safe and efficacious alternative to traditional laparoscopic anti-reflux procedures, although further evidence is required.

Cognitive behavioural therapy (CBT) and psychotherapy can reduce dyspeptic symptoms in the short term and have been recognised by NICE as cost-effective for specific individuals.

What has fallen out of fashion and why

Domperidone has been used as a prokinetic in functional dyspepsia and has been shown to improve symptoms in up to a third of patients in placebo-controlled trials. However, it is associated with small but significant cardiac side-effects, including arrhythmias and prolonged QT interval. A recent drug safety update now restricts its use to nausea and vomiting in patients without cardiac risk factors, and it should no longer be used for treatment of bloating and heartburn. Metoclopramide 10mg taken 30 minutes before meals can be used as an alternative.

The recent NICE update is more relaxed about the long-term use of PPIs because of improved cost-benefit ratios as a result of general price reduction on this class of drugs.2

Special cases – Barrett’s oesophagus

Management of endoscopically confirmed Barrett’s is usually symptomatic control with acid suppression using PPIs. Although the data are not yet sufficient to recommend PPIs as chemoprotective agents, it has been common practice for years to try to prevent progression of disease. Endoscopic surveillance should be offered to individuals with endoscopically and histologically proven Barrett’s, although the risks may outweigh the benefits in patients with low-risk (stable, non-dysplastic) disease. New guidelines for the management of patients with dysplasia have moved away from surgical intervention and now recommend endoscopic resection of visible lesions within a Barrett’s segment, followed by radiofrequency ablation.3

Non-drug options and the evidence

The current recommendations are to offer lifestyle advice, including avoidance of precipitants and not eating late in the evening, although targeted interventions for dietary restriction have not been proven to be of benefit. Weight loss in obese patients, raising the head of the bed, and mild routine physical activity have been shown to help, although the effect is modest at best. Smoking cessation is recommended, but there is no evidence it reduces dyspepsia or reflux symptoms. CBT or hypnotherapy may help reduce symptoms in the short term in functional dyspepsia. There is no evidence to support natural or homeopathic remedies for dyspepsia or reflux.

Dr Adam Haycock is a consultant gastroenterologist at St Mark’s Hospital and the London Clinic

References

  1. Bouras EP, DiBaise J, Howden CP et al. Functional Dyspepsia Treatment Trial (FDTT). clinicaltrials.gov, identifier NCT00248651
  2. NICE. CG184: Dyspepsia and gastro-oesophageal reflux disease. London: NICE; 2014
  3. Fitzgerald RC, Di Pietro M, Ragunath K et al. British Society of Gastroenterology guidelines on the diagnosis and management of Barrett’s oesophagus. Gut, 2014;63:7-42

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Readers' comments (3)

  • Dear dr Haycock. Metoclopramide Also affects the qt interval and is now for restricted use like domperidone. In addition, there is no mention of age as a risk factor where early endoscopy for new onset symptoms rather than hp eradication is the preferred management.

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  • I take all GERD and Barretts and hiatus hernia patients and gastritis patient off all cereal grains, and have done for the past few years since reading a book called 'Fast Tract Digestion' by Norman Robillard PhD. I have had very very good response so far, a good 95% total cessation of symptoms. This makes me think that all of these pathologies are, in fact, closely related to coeliac disease, as is IBS and IBD. Patients get off all their PPIs, zantac, and even find that they can eat late at night without being punished, as long as they eat zero grains (a term which includes oats, corn, rice of course and all those 'gluten free' processed foods that are being promoted so hard). They also need to bring their other carbs down low as these do just feed the rogue microbes that have increased in their gut due to the raising of pH that we have brought about by using acid blocking drugs. I now admit that I was wrong, and patients don't mind as long as they feel better within a month, and they do!

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  • good article,I would have liked to see clarification on the use of double doses of PPI

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