Dyspepsia
Define dyspepsia?
Dyspepsia is defined broadly to include patients with recurrent epigastric pain, heartburn, or acid regurgitation, with or without bloating, nausea or vomiting.
A pragmatic definition of “dyspepsia” is when the clinician suspects that symptoms are coming from the upper GI tract.
Discuss the common patterns of dyspepsia?
Dyspepsia occurs in three common patterns:
- Ulcer-like or acid dyspepsia -e.g. burning, epigastric hunger pain with food, antacid, and antisecretory agent relief
- Functional dyspepsia or dysmotility-like dyspepsia- with postprandial belching, bloating, epigastric fullness, anorexia, early satiety, nausea, and occasional vomiting;
- Reflux-like dyspepsia
These patterns overlap considerably. Although the clinical assessment is critical for overall management, it has poor predictive value for the specific diagnosis found upon the endoscopy
Discuss the management of dyspepsia?
- Offer simple lifestyle advice, including advice on healthy eating, weight reduction and smoking cessation.
- Review medications for possible causes of dyspepsia (for example, calcium antagonists, nitrates, theophyllines, bisphosphonates, corticosteroids and NSAIDs).
- Initial therapeutic strategies for dyspepsia are empirical treatment with a proton pump inhibitor (PPI) or testing for and treating H. pylori. There is currently insufficient evidence to guide which should be offered first.
- Offer empirical full-dose PPI therapy for 1 month to patients with dyspepsia. Offer H2RA or prokinetic therapy if there is an inadequate response to a PPI. PPIs are more effective than H2RAs at reducing dyspeptic symptoms in trials of patients with uninvestigated dyspepsia. However, individual patients may respond to H2RA therapy.
- Offer H. pylori ‘test and treat’ to patients with dyspepsia. H. pylori testing and treatment is more effective than empirical acid suppression at reducing dyspeptic symptoms after 1 year in trials of selected patients testing positive for H. pylori. The average response rate receiving empirical acid suppression was 47% and H. pylori eradication increased this to 60%: a number needed to treat for one additional responder of seven. Re-testing after eradication should not be offered routinely, although the information it provides may be valued by individual patients.
- If symptoms return after initial care strategies, step down PPI therapy to the lowest dose required to control symptoms. Discuss using the treatment on an as-required basis with patients to manage their own symptoms.
Discuss the role of endoscopy?
- Urgent OGD is indicated for patients of any age with dyspepsia when presenting with any of the following: chronic gastrointestinal bleeding, progressive unintentional weight loss, progressive difficulty swallowing, persistent vomiting, iron deficiency anaemia, epigastric mass or suspicious barium meal.
- Routine endoscopic investigation of patients of any age, presenting with dyspepsia and without alarm signs, is not necessary. However, in patients aged 55 years and older, if symptoms persist (4-6 weeks) despite HP treatment and acid suppression therapy, an urgent endoscopy should be requested.
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