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The management of dyspepsia

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VOL: 99, ISSUE: 38, PAGE NO: 30

Anne Crozier, BN, RGN, is nurse specialist (GI/Endoscopy), Ninewells Hospital, Tayside University Hospitals NHS Trust.

Dyspepsia is a general term that describes pain or discomfort centred in the upper abdomen, often after meals (Talley et al, 1999). It can be associated with other symptoms such as nausea, vomiting, anorexia, bloating, belching and early satiety, among others. Patients with these symptoms frequently refer to them as indigestion.

Epidemiology

Dyspepsia is not a disease but a group of symptoms that alert the practitioner to disease of the upper gastrointestinal tract. It is reported to affect up to 40 per cent of adults in any one year (Penston and Pounder, 1996). Fifty per cent of people with dyspepsia self-medicate using antacids and low dose H2 receptor antagonists (H2RA), possibly with advice from a community pharmacist, but statistics show that as many as one in four people in Scotland with dyspepsia and one in 10 in England and Wales consult their general practitioner. This group of patients therefore creates a substantial financial burden on the UK health care system.

Background

In the past, young patients with dyspepsia were being over-investigated, despite suggestions that investigations such as endoscopy rarely influenced the management of their symptoms (Williams et al, 1998). In 1996 the British Society of Gastroenterology advised that patients under 45 years of age presenting with new dyspepsia symptoms could safely be treated with a short trial of an anti-secretory agent before gastroscopy should be necessary (BSG, 1996). At the same time, the society recommended that anyone who was over 45 years with recent onset of symptoms should have further investigations. Since then, evidence has shown that these precautions are unnecessary, and the recently published guidelines on dyspepsia (Scottish Intercollegiate Guidelines Network, 2003) recommend that the age limit before further investigations are necessary should be increased to 55 years, and propose that these patients should now also follow a strategy that is non-invasive.

Helicobacter pylori

Helicobacter pylori is a spiral shaped bacterium that can live in the stomach and duodenum. When H. pylori infects the stomach it causes gastritis, which is associated with gastric cancer and ulcer disease. Over 90 per cent of patients with duodenal ulcers are infected with H. pylori, although there are known to be other contributing factors such as smoking, family history and male gender.

It is also known that eradication of H. pylori leads to the cure of ulcer disease in the majority of patients (Tsai, 1997). The Scottish Intercollegiate Guidelines Network (1999) recommends that all patients with confirmed duodenal ulcers, gastric ulcers or low-grade gastric lymphomas should always receive H. pylori eradication treatment. This is achieved using three drugs: a proton pump inhibitor (PPI) and two antibiotics.

Differential diagnosis

General practitioners who are faced with patients complaining of dyspeptic symptoms will consider not only disease of the gastrointestinal tract but also cardiac, hepatobiliary, pancreatic or bowel problems. They will also check whether the patient is taking non-steroidal anti-inflammatory drugs (NSAIDs) or other drugs that can affect the digestive system.

Management strategies

There are three forms of dyspepsia:

- Dyspepsia with alarm features;

- Uncomplicated dyspepsia - no alarm features but patients are found to be positive for H. pylori;

- Functional dyspepsia - no causal organic disease has been identified.

Dyspepsia with alarm features

Early investigation by a hospital specialist is essential for those patients presenting with dyspepsia, regardless of age, who also have alarm features. These include dysphagia, unintentional weight loss, persistent or recurrent vomiting, upper abdominal mass, evidence of gastro-intestinal bleeding or anaemia from gastrointestinal bleeding (Box 1).

Uncomplicated dyspepsia

This refers to patients with dyspepsia who do not have any alarm features. Traditionally, these patients have been advised on lifestyle, diet and antacids. The main strategies of care for patients with uncomplicated dyspepsia have been a choice of acid suppression therapy, early endoscopy, test and endoscopy or test for H. pylori and treatment (Box 2).

- Acid suppression therapy: this may alleviate symptoms but will not cure ulcer disease by eradicating H. pylori. The National Institute for Clinical Excellence (2000) suggests that antacids may be used on a step up or step down basis but should not be used long-term without a confirmed diagnosis;

- Early endoscopy: This has been shown to be more effective than empirical drug therapy, but the benefits have been shown to be small, and cost-effectiveness has not been proven. However, gastroscopy should be the investigation of choice when further assessment of the gastrointestinal (GI) tract is necessary;

- Test and endoscopy: patients are given a non-invasive test to establish their H. pylori status, and those found to be positive have an endoscopy;

- H. pylori test and treat: patients are tested for H. pylori using non-invasive methods such as serology, a breath test or a faecal antigen test. Those with a positive result have eradication therapy. Those who test negative have symptomatic treatment.

There are both advantages and disadvantages of the test and treat strategy (Box 3) but the reasons for adopting it are because of the apparent low incidence of gastric cancer in subjects under 55 years of age (Gilbert et al, 2002) and the fact that over 90 per cent of patients with ulcers have H. pylori infection and will therefore benefit from eradication therapy. This is now the strategy of choice in patients with uncomplicated dyspepsia (SIGN, 2003).

Functional dyspepsia

Patients are said to have functional dyspepsia when no pathology or disease can be found to be causing their symptoms. This diagnosis is one of exclusion and clinicians must use their clinical judgement in deciding when and how much investigation is required before this diagnosis can be made. It should be remembered that, in the majority of patients with dyspepsia who are under the age of 55 years, no underlying cause will be found and that most patients do not require invasive investigation before a diagnosis can be made. It is fruitless and counter-productive to repeat invasive procedures in pursuit of a diagnosis.

Once a diagnosis has been made, the clinician needs to consider treatment options. It has been shown that the patients with dyspepsia who are most likely to consult their GPs are those who are anxious, depressed, stressed, have severe symptoms or who worry that their symptoms are a sign of life-threatening illness. These concerns need to be addressed.

Although the causes and mechanisms responsible for functional dyspepsia symptoms are unknown, it is believed that abnormalities of upper gastrointestinal motor and sensory functions are involved. These patients will require individualised treatment for the alleviation of their symptoms. Some patients will need only advice and reassurance whereas others will require more active treatment. The clinician will need to give lifestyle advice as well as pharmacological treatments.

Lifestyle advice

There have been many studies carried out to determine the relationship between lifestyle, diet and dyspepsia. Alcohol, smoking, caffeine, irregular eating habits and stress have all been cited as factors that intensify symptoms in patients with functional dyspepsia. Eighty per cent of patients in one study felt their dyspeptic symptoms were relieved by the avoidance of certain foods (Mullan et al, 1994); other studies have found no association between these factors and dyspepsia (Woodward et al, 1999). Although at present there is no clear evidence that any of these elements are responsible for symptom exacerbation, patients with functional dyspepsia should be encouraged to stop smoking, reduce their intake of alcohol and caffeine and eat a healthy, balanced diet.

Drug treatment for functional dyspepsia

Not every patient will require pharmacological intervention. However, for those who do, it should be remembered that in functional gastrointestinal disorders there is a considerable placebo effect to drug treatment. None of the drug therapies used in the treatment of functional dyspepsia has a high success rate and drug treatment should be given either intermittently or for short periods only (SIGN, 2003). Drugs used in the management of functional dyspepsia include:

- Antacids;

- Prokinetics;

- Acid suppressives;

- Cytoprotectives;

- Antidepressants;

- H. pylori eradication agents.

Antacids

Although antacids are widely used by patients who have dyspepsia, there appears to be no evidence to support their use or their efficacy in the treatment of patients with functional dyspepsia.

Prokinetics

Domperidone (for relief of nausea and vomiting) or metoclopramide (a motility stimulant) are the drugs most widely used, although their value is uncertain in the management of patients with dyspepsia.

Acid suppressives

Acid suppressive drugs include H2 receptor antagonists (H2RAs) and proton pump inhibitors (PPIs). Treatment results for these drugs have been shown to be similar. In patients with functional dyspepsia there is a high placebo response to these drugs and it is therefore difficult to quantify the benefits of this therapy. It is suggested that those patients most likely to benefit from these drugs in the long term will have a recognised response after one week (Talley et al, 1998), therefore a short trial of acid suppression therapy could be considered in patients with functional dyspepsia. NICE (2000) recommends low-dose PPIs for patients whose symptoms appear to be acid-related but does not endorse routine PPIs for all patients with functional dyspepsia.

Cytoprotectives

Cytoprotective drugs include bismuth chelate, sucralfate and misoprostol. These work in different ways. Bismuth chelate stimulates prostaglandin or bicarbonate secretions, sucralfate protects the gastric mucosa from acid-pepsin attack and misoprostol has both antisecretory and protective properties. Studies evaluating these drugs for functional dyspepsia have shown conflicting data.

Antidepressants

Although there is evidence that antidepressants have a role in the management of functional bowel disorders, this has not been proven in functional dyspepsia (Jackson et al, 2000).

H. pylori eradication

About 50 per cent of patients with functional dyspepsia will be H. pylori positive. Eradication therapy is suggested for these patients (Moayyedi et al, 2001). Triple therapy is the recommended eradication treatment and consists of the administration of a PPI and two antibiotics for seven days. This gives consistently high eradication rates (SIGN, 1999).

Prognosis in functional dyspepsia

Statistics have shown that at 10-year follow-up two-thirds of patients with functional dyspepsia were still experiencing dyspepsia symptoms. Many of these patients also displayed symptoms that were connected with irritable bowel syndrome and some may change over time from one functional disorder to the other and back again (SIGN, 2003).

Tests

There are many tests that are used in the diagnosis and management of patients with dyspepsia, ranging from simple blood tests to gastroscopy:

- Enzyme-linked immunosuppressant assay (ELISA): This serological, hospital-based test is commonly used for the detection of H. pylori. Although the test is not as accurate as a C-urea breath test there is a place for it in determining the H. pylori status of a patient pre-treatment/eradication;

- Near patient test: This blood test provides a rapid diagnosis from only a drop of whole blood but the sensitivity and specificity are not as good as other tests;

- Faecal antigen test: This has been shown to be an accurate test for the diagnosis of H. pylori in patients who have had the infection for at least two weeks; however, its accuracy is reduced significantly if the patient has been taking PPIs;

- 13C- and 14C- urea breath tests (CUBTs): These are the tests of choice to determine H. pylori status before and after eradication therapy. They have been shown to be very accurate, although false negatives can occur if they are used within two weeks of using a PPI or four weeks of treatment with antibiotics;

- Barium meal: For the few patients who cannot tolerate an endoscopy or where there is no facility to perform the procedure, a barium meal is the test of choice.

- Gastroscopy: Endoscopy is the investigation of choice when further assessment of the upper gastrointestinal tract is necessary. It can detect mucosal abnormalities such as erosions of the stomach or duodenum or early gastric cancers. It is a more sensitive test than a barium meal and allows for lesions to be biopsied.

Managing dyspepsia in the community

Before treating patients complaining of dyspepsia, GPs will first need to consider the possibility of diseases of the lungs, heart, gall bladder, bowel and pancreas and whether the patients are taking NSAIDs or other drugs. Once it has been established that a patient’s symptoms are likely to be coming from the gastrointestinal tract it will be necessary to establish which are the predominant features. If it is heartburn, the patient should be managed as having gastro-oesophageal reflux disease (GORD). However, any patients who have alarm features (Box 1), regardless of their age, should be referred to a hospital specialist for further management.

Patients with uncomplicated dyspepsia who have already been counselled on lifestyle and dietary changes and have had no benefit from taking antacids or H2RAs, should be offered a non-invasive test for H. pylori. This would take the form of a simple breath, stool, or blood test that could be undertaken by the practice nurse at a dedicated clinic.

Patients testing positive for H. pylori should be given eradication therapy in the form of a PPI and two antibiotics for seven days (triple therapy). They should then be re-tested (the ‘gold standard’ here is a CUBT) to confirm that eradication has been achieved. If the therapy has been successful and the patient is asymptomatic than no further treatment is necessary.

In patients who remain H. pylori positive, further eradication therapy needs to be prescribed until the bacteria are eliminated. Patients testing negative for H. pylori and those still symptomatic after H. pylori eradication should be treated as having functional dyspepsia.

Lifestyle advice should be given to these patients:

- Cease smoking;

- Give up/reduce alcohol and caffeine intake;

- Eat a balanced diet;

Individuals who have adopted extreme dietary measures in an attempt to relieve symptoms should be encouraged to eat normally.

A short trial of acid suppression therapy may be considered but this should not necessarily be seen as a long-term solution. Many of these patients will need to be reassured that, although they are experiencing a high degree of discomfort, this is not a sign of their having a more serious condition.

It should be remembered that any patient who at any time develops an alarm feature should be referred to a specialist for further investigation.

Patient information

Patients will find many books and leaflets at chemists and bookshops around the country. The recently published SIGN guideline on dyspepsia (SIGN, 2003) has incorporated a patient information leaflet, which describes the condition and outlines what a doctor can do. It also offers diet and lifestyle advice.

Information from the leaflet can be incorporated into local information materials for use with patients who have dyspepsia (SIGN, 2003). The guideline can be accessed on SIGN’s website (www.sign.ac.uk).

Further information for patients is also available from the British Society of Gastroenterology’s website (www.bsg.org.uk).

Conclusion

Patients with dyspepsia can be categorised into three specific groups:

- Those with alarm features (including dysphagia, weight loss, persistent vomiting, upper abdominal mass and evidence of GI blood loss);

- Those with no alarm features but found to be positive for H. pylori (uncomplicated dyspepsia);

- Those in whom no causal organic disease has been identified (functional dyspepsia).

Recently published guidelines have provided much needed clarity on the most appropriate and effective methods of investigating and managing patients who have dyspepsia. These guidelines (SIGN, 2003) advise that patients presenting with new uncomplicated dyspepsia could safely follow a non-invasive test and treat strategy, and that those with a positive result should have eradication therapy.

Understanding the management of dyspepsia (Box 4) is important for nurses so that they are able to provide appropriate lifestyle advice and reassurance, identify alarm features and support patients through the test and treat process

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