Dyspepsia

Before considering referral for endoscopy

• Consider the age of the patient
  • Serious pathology is rare in those <55 years with no alarm symptoms
• Undertake medication review to look for drugs which make cause or exacerbate symptoms
  • NSAIDs
  • Corticosteroids
  • Opioids including codeine-based analgesia
  • Calcium channel antagonists
  • Nitrates
  • Theophyllines
  • Bisphosphonates
• Consider other diagnoses
  • Gallstone or biliary disease (especially if severe, episodic pain)
  • Cardiac disease
• In those who have had a previous endoscopy in last 3 years, but no new alarm symptoms, consider treatment in line with the results of that that previous endoscopy
  • Normal endoscopy & USS- treat as Functional dyspepsia (FD)
  • Previous oesophagitis-treat as GORD
• A test and treat strategy for H pylori should be adopted in the first instance if age <55 years

However, age>55 years is an important determinant of more serious pathology

Guidelines for referral for Urgent Suspected GI Cancer

Patients with the following:

• Dysphagia (interference of the swallowing mechanism at any age OR
• Unexplained Odynophagia (pain on swallowing at any age)

PLEASE SEE DYSPHAGIA PAGE FOR FULL GUIDANCE

• Unexplained weight loss, particularly >55 years, combined with one or more of the following features:
  • new or worsening upper abdominal pain or discomfort
  • unexplained iron deficiency anaemia
  • reflux symptoms
  • dyspepsia resistant to treatment
  • vomiting
• New vomiting persisting for more than two weeks

Refer as USOC via: Sci Gateway – Gastroenterology Medical – GI Upper

Summary of Upper GI Referral Pathways in NHS Lothian

In the absence of alarm symptoms in those aged <55 years:

Consider lifestyle measures

• Achieve and maintain healthy weight, take regular aerobic exercise, avoid food triggers, avoid smoking, reduce caffeine intake, modify alcohol intake. No evidence to support diet therapy e.g. low FODMAP.

Trial of alginates as required

Offer trial of an H2RA (Famotidine 20-40mg OD)

If no response to simple measures, then either:

• Test and treat Helicobacter pylori
  • Check H pylori stool antigen and treat if positive
  • Stop PPI for at least 2 weeks prior to test
  • See LJF for H pylori treatment regimens

or

• Treat with full dose PPI (omeprazole 20mg-40mg od or equivalent) for 4 weeks

• If symptoms recur offer ongoing PPI therapy but step-down treatment to lowest effective dose as there is no real dose-response effect in dyspepsia
• Discuss use of “as required” treatment to encourage self- management of symptoms
• Offer annual review to assess symptom control and reduce or withdraw treatment if possible

Further information

Management of those with normal investigations (Functional dyspepsia)

• Secondary Care would consider using the following measures:
  • If still symptomatic despite above measures, offer low-dose tricyclic agent (TCA) as a gut-brain neuromodulator e.g. nortriptyline or amitriptyline 10-20mg at night, titrated slowly up to 30-50mg nocte, as required and tolerated. Careful explanation of the rationale is required as is counselling about side-effects
  • Mirtazapine 15mg OD can be effective in FD when there is early satiation and weight loss
• These are unlicensed uses and not listed on the formulary for these indications. Referrers can use SCI Gateway to seek Specialist advice however, if they think this would be an option that would be helpful for a patient.
  • Gut-brain directed behavioural therapies including stress management, CBT, hypnotherapy can be useful in some patients. There is currently no facility for this in NHS Lothian in primary or secondary care.
  • No evidence to support the use of either SSRI or SNRI drugs in FD

Dyspepsia and Gastro Oesophageal Reflux Disease (NICE 2014, update 2019)

BSG guidelines (2023) on management of functional dyspepsia:
www.bsg.org.uk/clinical-resource/bsg-guidelines-on-the-management-of-functional-dys

Functional dyspepsia advice leaflet.pdf