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Home | Articles | Gastrointestinal | Dyspepsia

Dyspepsia

Last updated 14th January 2025

The Size of the Problem

  1. 40% of UK population suffer from dyspepsia. 5% of all GP consults & 30% of all gastro referrals are for dyspepsia
  2. 50% of patients investigated for dyspepsia have normal endoscopy – many of these will have GORD which is a clinical diagnosis, not excluded by normal endoscopy.

When to Refer for Endoscopy

  1. Any dyspeptic patient with alarm features eg dysphagia, evidence of GI blood loss, persistent vomiting, unexplained weight loss, upper abdominal mass
  2. Dyspeptic taking NSAIDs/Warfarin or past history of PU
  3. New onset dyspepsia above the age of 55

Uncomplicated Dyspepsia

  1. H. pylori testing if persistent or recurrent symptoms (discontinue PPI for 2 week prior to test)
  2. If HP positive, Rx eradication therapy
  3. If HP negative, manage as functional dyspepsia with lifestyle measures and/or acid suppression

Eradication Therapy

  1. One week of triple therapy will eradicate HP in 80% of cases.  Double dose PPI eg 20mg Omeprazole plus Amoxicillin 1g and Clarithromycin 500mg all 3 given twice a day for one week: OR if penicillin allergy – Double dose PPI eg 20mg Omeprazole plus Metronidazole 400mg and Clarithromycin 500mg, all three given twice a day.
  2. Risk of diarrhoea and avoid alcohol if using Metronidazole
  3. No need to continue PPI if eradicating H. pylori in duodenitis or gastritis, but should give Omeprazole 20mg od for further 3 weeks for duodenal ulcer or gastric ulcer
  4. Usually no need to continue PPI long term unless NSAID user

Which Patients?

  1. DU, GU and gastric lymphoma – YES
  2. Strong family history – PROBABLY APPROPRIATE
  3. NSAID related ulcer, HP +ve dyspeptics who haven’t been investigated, oesophagitis and non-ulcer dyspepsia – CONTROVERSIAL

Follow Up After Eradication Therapy

  1. Uncomplicated DU or Bleeding peptic ulcer – H. pylori faecal antigen test only if symptoms persist
  2. Gastric ulcer – plus endoscopy to confirm healing in 8 weeks

Gastro-Oesophageal Reflux

  1. Gastro-oeosphageal reflux disease results in a retrosternal burning pain. It can also be associated with upper abdominal pain and an acid taste in the mouth. It can be worse both with eating and on lying flat.
  2. Reflux is a common long term condition that results in a high number of referrals to the Gastroenterology Service. Traditionally patients are either seen in Gastroenterology clinics as a new patient or referred directly for endoscopy. The detection rate from these investigations for patients with reflux who don’t present with ‘red flag’ Urgent Suspicion of Cancer (USoC) warning symptoms is very low
  3. Click this link to the Reflux Pathway from the NHS Scotland Centre for Sustainable Delivery which aims to help patients self-manage their condition and highlight to primary care the more complex cases that should be referred to secondary care for investigation. It also provides an opt-in mechanism so that patients who continue to have problems can still access secondary care services through Reflux clinics.

 

Dyspepsia Algorithm 1 – New Onset Dyspepsia

1Immediate referral is indicated for significant acute gastrointestinal bleeding.  Consider the possibility of cardiac or biliary disease as part of the differential diagnosis.  Urgent specialist referral* for endoscopic investigation 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 with unexplained** and persistent** recent-onset dyspepsia alone, an urgent referral for endoscopy should be made.  Consider managing previously investigated patients without new alarm signs according to previous endoscopy findings.
2Review medications for possible causes of dyspepsia, for example, calcium antagonists, nitrates, theophyllines, bisphosphonates, steroids and NSAIDs. Patients undergoing endoscopy should be free from medication with either a proton pump inhibitor (PPI) or an H2 receptor (H2RA) for a minimum of 2 weeks.
* The Guideline Development Group considered that ‘urgent’ meant being seen within 2 weeks.
** In the referral guidelines for suspected cancer (NICE Clinical Guideline no. 27), ‘unexplained’ is defined as ‘a symptom(s) and/or sign(s) that has not led to a diagnosis being made by the primary care professional after initial assessment of the history, examination and primary care investigations (if any)’. In the context of this recommendation, the primary care professional should confirm that the dyspepsia is new rather than a recurrent episode and exclude common precipitants of dyspepsia such as ingestion of NSAIDs. ‘Persistent’ as used in the recommendations in the referral guidelines refers to the continuation of specified symptoms and/or signs beyond a period that would normally be associated with self-limiting problems. The precise period will vary depending on the severity of symptoms and associated features, as assessed by then healthcare professional. In many cases, the upper limit the professional will permit symptoms and/or signs to persist before initiating referral will be 4-6 weeks.

Dyspepsia Algorithm 2 – Uninvestigated Dyspepsia

1Review medications for possible causes of dyspepsia, for example, calcium antagonists, nitrates, theophyllines, bisphosphonates, steroids and NSAIDs.
2Offer lifestyle advice, including advice on healthy eating (cut down on caffeinated & fizzy drinks), weight reduction and smoking cessation, promoting continued use of antacid/alginates.
3There is currently inadequate evidence to guide whether full-dose PPI for one month or H. pylori test and treat should be offered first. Either treatment may be tried first with the other being offered where symptoms persist or return.
4Detection: use stool antigen test or, when performance has been validated, laboratory-based serology.  Eradication: use a PPI, amoxicillin, clarithromycin 500mg  regimen or, if penicillin allergy, a PPI, metronidazole, clarithromycin 500mg regimen.  Do not re-test even if dyspepsia remains unless there is a strong clinical need.
5Offer low-dose treatment with a limited number of repeat prescriptions. Discuss the use of treatment on an as-required basis to help patients manage their own symptoms.
6In some patients with an inadequate response to therapy it may become appropriate to refer to a specialist for a second opinion. Emphasise the benign nature of dyspepsia. Review long-term patient care at least annually to discuss medication and symptoms.

Dyspepsia Algorithm 3 – Gastro-oesophageal Reflux Disease

1GORD refers to endoscopically determined oesophagitis or endoscopy-negative reflux disease. Patients with uninvestigated ‘reflux-like’ symptoms should be managed as patients with uninvestigated dyspepsia. There is currently no evidence that H. pylori should be investigated in patients with GORD.
2Offer low-dose treatment, possibly on an as-required basis, with a limited number of repeat prescriptions.
3Review long-term patient care at least annually to discuss medication and symptoms.

In some patients with an inadequate response to therapy or new emergent symptoms it may become appropriate to refer to a specialist for a second opinion.  Review long-term patient care at least annually to discuss medication and symptoms.  A minority of patients have persistent symptoms despite PPI therapy and this group remain a challenge to treat.  Therapeutic options include doubling the dose of PPI therapy, adding an H2RA at bedtime and extending the length of treatment.

Dyspepsia Algorithm 4 – Gastric Ulcer

1If NSAID continuation is necessary, after ulcer healing offer long-term gastric protection or consider substitution to a newer Cox-2-selective NSAID.
2Use stool antigen test or, when performance has been validated, laboratory-based serology.
3Use a PPI, amoxicillin, clarithromycin 500mg regimen or a PPI, metronidazole, clarithromycin 500mg regimen.  Follow guidance found in the British National Formulary for selecting second-line therapies.  After two attempts at eradication manage as H. pylori negative.
4Perform endoscopy 6-8 weeks after treatment. If re-testing for H. pylori use a stool antigen test.
5Offer low-dose treatment, possibly on an as-required basis, with a limited number of repeat prescriptions.
6Review care annually, to discuss symptoms, promote stepwise withdrawal of therapy when appropriate and provide lifestyle advice. In some patients with an inadequate response to therapy it may become appropriate to refer to a specialist.

Dyspepsia Algorithm 5 – Duodenal Ulcer 

1If NSAID continuation is necessary, after ulcer healing offer long-term gastric protection or consider substitution to a newer Cox-2-selective NSAID.
2Use a stool antigen test or, when performance has been validated, laboratory-based serology.
3Use a PPI, amoxicillin, clarithromycin 500mg regimen or a PPI, metronidazole, clarithromycin 500mg regimen.
4Use a stool antigen test.
5Follow guidance found in the British National Formulary for selecting second-line therapies.
6Offer low-dose treatment, possibly on an as-required basis, with a limited number of repeat prescriptions.
7Consider: non-adherence with treatment, possible malignancy, failure to detect H. pylori infection due to recent PPI or antibiotic ingestion, inadequate testing or simple mis-classification; surreptitious or inadvertent NSAID or aspirin use; ulceration due to ingestion of other drugs; Zollinger Ellinson syndrome, Crohn’s disease.
8Review care annually, to discuss symptoms, promote stepwise withdrawal of therapy when appropriate and provide lifestyle advice.

Dyspepsia Algorithm 6 – Non-ulcer Dyspepsia

1Use a PPI, amoxicillin, clarithromycin 500mg regimen or a PPI, metronidazole, clarithromycin 500mg regimen. Do not re-test unless there is a strong clinical need.
2Offer low-dose treatment, possibly on an as-required basis, with a limited number of repeat prescriptions.
3In some patients with an inadequate response to therapy or new emergent symptoms it may become appropriate to refer to a specialist for a second opinion.  Emphasise the benign nature of dyspepsia. Review long-term patient care at least annually to discuss medication and symptoms.

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Content updated by Dr Zahra Bayaty