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Ten Top Tips - Non ulcer dyspepsia

GP and hospital endoscopist Dr Raghu Nath offers his hints on managing NUD

GP and hospital endoscopist Dr Raghu Nath offers his hints on managing NUD


The commonest cause of upper gastrointestinal symptoms is non-ulcer dyspepsia. Some 50 to 60% of patients presenting with dyspepsia have negative investigations and belong to the group labelled as having non-ulcer or functional dyspepsia. It is therefore an endoscopic diagnosis.


Patients with only reflux symptoms and negative endoscopy are not classed as having NUD. There is considerable overlap of symptoms in patients with dyspepsia. But when patients have negative endoscopic findings in the presence of isolated heartburn or acid reflux they are more likely to have endoscopic negative reflux disease (ENRD) rather than NUD.


Test and treat for H. pylori is an effective and cost-effective option. In those that are positive for H. pylori, eradication therapy offers a chance of cure in some. Meta-analysis has shown that for one patient to benefit 14 will have to receive eradication therapy (NNT 1 to 14, 7%).


Acid suppression therapy is appropriate in H. pylori negative patients. In more than a third of patients with NUD symptoms will naturally improve, 7% will benefit with eradication therapy and of the remaining more than half will continue to have symptoms. Intermittent, on-demand or long-term acid suppression therapy will be required for many NUD patients who are negative for H.pylori or fail to respond to successful eradication therapy.


H2 receptor antagonists (H2RAs) are effective in NUD. Evidence suggests seven patients need to be treated with H2RAs to improve one case of dyspepsia that would not have been improved by placebo, assuming a placebo response rate of 40%.


Proton pump inhibitor therapy is effective in NUD. Evidence suggests 10 participants need treatment with PPI to cure one case of NUD that would not have been cured by placebo, assuming a 25% placebo response rate.


Half-strength PPI is as effective as full-strength PPI in NUD. Six RCTs did not find any statistically significant difference between low and standard doses of PPIs.


There is no clear evidence for using prokinetics in NUD. Since the removal of cisapride from the market there have been no good-quality studies to conclusively evaluate the effect of domperidone or metoclopromide in NUD.


Antacids are no better than placebo in NUD. One trial did not find any difference (RR 1.02) between antacids and placebo in 109 patients with dyspepsia.


Psychological treatment in NUD. Studies have shown NUD patients have higher scores of anxiety, depression, neurotism, chronic tension, hostility, hypochondriasis and tendency to be more pessimistic when compared with the community controls. However, the role of psychological interventions in NUD remains uncertain and there is insufficient evidence for psychological approaches to treatment in NUD

Dr Raghu Nath is a GP trainer in County Durham, a hospital endoscopist and honorary clinical senior lecturer at the University of Durham

Competing interests: none declared

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