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The waiting game

Dyspepsia: disentangling the web of symptoms

Dyspepsia is a symptom complex where a definitive diagnosis is often not possible, as Dr Lindsay McLeman, Dr Alistair McKinlay and Professor Emad El-omar explain

Dyspepsia is a symptom complex where a definitive diagnosis is often not possible, as Dr Lindsay McLeman, Dr Alistair McKinlay and Professor Emad El-omar explain

Dyspepsia literally means maldigestion. This common complaint remains difficult to define and embraces a constellation of symptoms that include upper abdominal pain or discomfort, retro-sternal pain, heartburn, bloating, early satiety, nausea, vomiting and anorexia.

The first priority is to determine what the patient means by 'indigestion'. In more than 50 per cent of dyspeptic patients investigations are normal and functional causes, often grouped together as non-ulcer dyspepsia, are common.

·First assess the patient's symptoms in light of their age and drug therapy, and determine whether alarm symptoms are present.·Medical treatment: if there are no alarm symptoms or criteria for specialist referral, the patient should receive symptomatic treatment with H2 blockers, proton pump inhibitors (PPI) or prokinetics, and be reviewed. Those who respond do not require endoscopy and can be managed as appropriate for 'uninvestigated dyspepsia'.

Some PPIs are more powerful acid inhibitors than others. So if you suspect an acid-related problem that does not settle with one PPI, you could try the stronger PPI, or double the dose of the ordinary one. If neither strategy works, then it is unlikely that the patient is suffering from an acid-related problem and other functional diagnoses have to be considered. PPIs are stronger than H2 antagonists. So if acid is the problem in those with reflux-like symptoms, we try the PPI. If symptoms persist we add a prokinetic such as domperidone, with or without an alginate for breakthrough symptoms.

·Heartburn: if this predominates, manage the patient as gastro-oesophageal reflux disease, with alginates and PPIs.·Other patients with ulcer-like symptoms: these should be tested for Helicobacter pylori, and treated appropriately.·Non-responders: patients who fail to respond, particularly those over the age of 55 or those with recurrent symptoms, warrant consideration for endoscopy.

Who should be investigated?

In those aged over 55 a distinction should be drawn between those with new symptoms of dyspepsia and those presenting with an exacerbation of previous chronic symptoms.

A more useful strategy is to test for H. pylori, which is strongly associated with duodenal and gastric ulceration, and where successful eradication is curative. No study has yet shown harm from its eradication.Serological tests for H pylori are useful in patients who have never received eradication therapy, and are adequate for diagnosis in primary care. But serology post-eradication is unreliable, as reductions in antibody titres can take up to two years to become negative.In these circumstances, the 13C or 14C urea breath test should be carried out. Patients who have a positive urea breath test after treatment should receive second-line therapy and not a repeat of their first-line regime.

Gastro-oesophageal reflux disease

Though gastro-oesophageal reflux disease (GORD) is now classified separately from dyspepsia, in primary care it is often hard to make the distinction. GORD is defined as symptoms or mucosal damage resulting from exposure of the distal oesophagus to refluxed gastric contents.

Management can be difficult, as the degree of mucosal damage does not correlate with the degree of symptoms, and 50 per cent of patients with GORD symptoms have a normal endoscopy (non-erosive reflux disease).Investigation of GORD is warranted if the diagnosis is unclear, if symptoms persist or are refractory to treatment, if complications are suspected or if alarm symptoms are present. Upper gastrointestinal endoscopy is recommended for assessing mucosal injury or for alarm symptoms, while for assessing the correlation between degree of reflux and symptoms pH studies and oesophageal manometry are best ­ these are usually instigated by the specialist.

GORD management strategies

·Lifestyle modification: simple measures include elevating the bed head, avoiding large meals late in the evening, and not reclining immediately after eating. Certain dietary items exacerbate symptoms.

Excessive alcohol consumption has been shown to cause direct mucosal injury and is also thought to act directly on the lower oesophageal sphincter (LOS). Exacerbating medications should be avoided, or the dose reduced if possible. Obesity increases pressure on the LOS, while smoking aggravates reflux and raises the risk of oesophageal cancer.

·Medical therapy: NICE guidelines recommend initial treatment with full-dose PPI for one to two months; then if symptoms recur a PPI should be used at the lowest dose required to control symptoms. Subsequently, patients should be encouraged to use a PPI as required. The initial choice should be a PPI. ·H. pylori eradication in GORD patients: some studies have found eradication in GORD to offer symptom relief, while others have shown no benefit.

The Maastricht-2 consensus report recommends eradicating H. pylori in any patient who is likely to require long-term treatment with a PPI.·Surgery for GORD: surgery is not recommended for routine management except in patients with a significantly impaired quality of life. One review found medical therapy and surgery were similarly effective for control of oesophageal acid exposure and symptom relief, but 10-65 per cent of patients still required medical therapy postoperatively.·Barrett's oesophagus: Surveillance is controversial as there are no well-designed randomised controlled trials showing a benefit.

The present BSG guidelines say that doctors should discuss with patients the risks of adenocarcinoma developing, the benefits of surveillance and the risks of endoscopy. If surveillance is undertaken, patients should undergo upper gastrointestinal endoscopy every two years.Lindsay McLeman is specialist registrar in gastroenterologyAlastair McKinlay is consultant physicianEmad El-omar is professor of gastroenterology/honorary consultant physician, Aberdeen University and Aberdeen Royal Infirmary

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