Dyspepsia

1. Dyspepsia

2. Dyspepsia • We will look at symptoms of dyspepsia and management of adult patients in primary care. • We will not cover dyspepsia in pregnant women or dyspepsia associated with the use of non-steroidal anti-inflammatory drugs (NSAIDs). • We will not cover management of gastric or duodenal ulcers or Barrett’s oesophagus.

3. What is Dyspepsia?NICE Clinical Guideline 17, Aug 2004 • Dyspepsia is a complex of symptoms of the upper gastrointestinal (GI) tract. • Symptoms are usually intermittent and may include upper abdominal pain or discomfort, acid reflux and heartburn, with or without nausea, vomiting or bloating. • Symptoms are a poor predictor of significant disease or underlying pathology.

4. What Could it Be?NICE Clinical Guideline 17, Aug 2004 • Patients presenting with symptoms of dyspepsia, who have not been investigated by endoscopy, are said to have uninvestigated dyspepsia. • Gastro-oesophageal reflux disease (GORD). This is endoscopically-determined oesophagitis or endoscopically-negative reflux disease (ENRD). • Peptic ulcer disease (PUD) refers to duodenal or gastric ulcers. • Non-ulcer dyspepsia (NUD) – no ulcer, oesophagitis or malignancy found on endoscopy and reflux symptoms are not predominant. • Zollinger-Ellison syndrome. (rare) • Malignancy. (rare)

5. Referral and EndoscopyNICE Clinical Guideline 17, Aug 2004 • Urgent specialist referral for endoscopy for patients of any age with: • chronic GI bleeding, progressive unintentional weight loss, progressive difficulty swallowing, persistent vomiting, iron deficiency anaemia, epigastric mass or suspicious barium meal. • Urgent referral for endoscopy for patients 55 years and over with unexplained and persistent recent-onset dyspepsia. • No routine endoscopy for patients without alarm signs.

6. Initial Management of Dyspepsia in Primary CareNICE Clinical Guideline 17, Aug 2004 • Management starts with lifestyle advice and the community pharmacist. • Lifestyle advice: • reduce weight • healthy diet • stop smoking • avoid known precipitants e.g. smoking, alcohol, coffee, chocolate, fatty foods. • raise head of bed • eat main meal well before bedtime

7. Initial management of dyspepsia in primary careNICE Clinical Guideline 17, Aug 2004 • Review the patient’s medication for possible causes of dyspepsia e.g. corticosteroids, NSAIDs. • Over-the-counter medicines include antacids and alginates, omeprazole and H2-receptor antagonists. • As required antacid and/or alginate therapy is appropriate for immediate relief of symptoms.

8. Uninvestigated Dyspepsia • Treat: • either empirically with a PPI (e.g. omeprazole 20mg daily). • or test for Helicobacter pylori using a carbon-13 urea breath test or stool antigen test, and treat if positive. • Offer an annual review to patients requiring long-term management of dyspepsia symptoms. • Encourage patients to step down or stop treatment. • A return to self-treatment with an antacid and/or alginate may be appropriate.

9. Trends in Prescribing of Proton Pump Inhibitorsin General Practice in England “Newer PPIs offer no advantage in terms of clinical efficacy over established PPIs, are usually more expensive and have less evidence for long-term safety.” MeReC Bulletin 2006;16:9-12

10. Primary Care Costs of PPIsDrug Tariff (March 2007)

11. Summary • Dyspepsia is very common. • Symptoms are a poor predictor of significant disease. • Routine endoscopy is not necessary for patients without alarm signs. • Self-management through community pharmacy. • Empirical treatment of uninvestigated dyspepsia with PPI (e.g. omeprazole 20mg) or test for Helicobacter pylori and treat if positive. • Titrate treatment up and down, and use medicines as required.