{"id":20521,"date":"2024-08-21T09:23:18","date_gmt":"2024-08-21T08:23:18","guid":{"rendered":"https:\/\/apps.nhslothian.scot\/refhelp\/?page_id=20521"},"modified":"2026-04-02T15:47:41","modified_gmt":"2026-04-02T14:47:41","slug":"dyspepsia","status":"publish","type":"page","link":"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/gastrointestinal\/dyspepsia\/","title":{"rendered":"Dyspepsia"},"content":{"rendered":"\n<p>There is helpful, patient-friendly information and advice to be found on the GI section of the NHS Lothian Internet pages.\u00a0 There are also some videos by our very own GI team which patients have been responding very positively to.\u00a0 Consider sharing the link with patients and\/or carers.<\/p>\n\n\n\n<p><a href=\"https:\/\/services.nhslothian.scot\/GI\/Dyspepsia\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/services.nhslothian.scot\/GI\/Dyspepsia<\/a><\/p>\n\n\n\n<p><strong>Definition<\/strong><\/p>\n\n\n\n<p>Dyspepsia or \u201cindigestion\u201d is very broadly defined as recurrent upper abdominal pain, with or without bloating, nausea and vomiting. Symptoms are often exacerbated by eating and early satiety is a recognised feature.<\/p>\n\n\n\n<p>Referral for endoscopy is seldom necessary in younger patients \u2013 cancer is exceptionally rare in patients under 55 with dyspepsia, in the absence of <a href=\"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/gastrointestinal\/urgent-suspected-upper-gi-cancer\/\" target=\"_blank\" rel=\"noreferrer noopener\">alarm symptoms<\/a>. Some will respond to <em>H. pylori<\/em> eradication, some will benefit from acid suppression, but the majority will have functional dyspepsia (FD), a disorder of gut-brain interaction (DGBI), similar to IBS.<\/p>\n\n\n\n<p>A test and treat strategy for H pylori should be adopted in the first instance if age &lt;55 years<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>See Primary Care Management for those aged &lt;55 years<\/li>\n\n\n\n<li>However, age&gt;55 years is an important determinant of more serious<strong> <\/strong>pathology<\/li>\n<\/ul>\n\n\n\n<p><strong><em>Updated Oct 25 IA, CN, LP &amp; JB<\/em><\/strong><\/p>\n\n\n\n<div class=\"wp-block-getwid-tabs\" data-active-tab=\"0\"><ul class=\"wp-block-getwid-tabs__nav-links\"><\/ul>\n<div class=\"wp-block-getwid-tabs__nav-link\"><span class=\"wp-block-getwid-tabs__title-wrapper\"><a href=\"#\"><span class=\"wp-block-getwid-tabs__title\">Referral  Guidelines<\/span><\/a><\/span><\/div><div class=\"wp-block-getwid-tabs__tab-content-wrapper\"><div class=\"wp-block-getwid-tabs__tab-content\">\n<p><strong>Before considering referral for endoscopy<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Consider the age of the patient<\/strong>\n<ul class=\"wp-block-list\">\n<li><strong>Serious pathology is&nbsp;rare&nbsp;in those &lt;55 years with no alarm symptoms<\/strong><\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>Undertake <strong>medication review<\/strong> to look for drugs which make cause or exacerbate symptoms<ul><li>NSAIDs<\/li><\/ul><ul><li>Corticosteroids<\/li><\/ul><ul><li>Opioids including codeine-based analgesia<\/li><\/ul><ul><li>Calcium channel antagonists<\/li><\/ul><ul><li>Nitrates<\/li><\/ul><ul><li>Theophyllines<\/li><\/ul>\n<ul class=\"wp-block-list\">\n<li>Bisphosphonates<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li><strong>Consider other diagnoses<\/strong><ul><li>Gallstone or biliary disease (especially if severe, episodic pain)<\/li><\/ul>\n<ul class=\"wp-block-list\">\n<li>Cardiac disease<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li><strong>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<\/strong><ul><li>Normal endoscopy &amp; USS- treat as&nbsp;<strong>Functional dyspepsia (FD)<\/strong><\/li><\/ul>\n<ul class=\"wp-block-list\">\n<li>Previous oesophagitis-treat as GORD<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>A test and treat strategy for H pylori should be adopted in the first instance if age &lt;55 years<\/li>\n<\/ul>\n\n\n\n<p class=\"has-alert-red-color has-text-color has-link-color wp-elements-dc7f873f48b15a59e8d1cf56630084b4\"><strong>However, age&gt;55 years is an important determinant of more serious pathology<\/strong> &#8211;<strong>PLEASE SEE BELOW<\/strong><\/p>\n\n\n\n<p><strong>Guidelines for referral for Urgent Suspected GI Cancer<\/strong><\/p>\n\n\n\n<p>Upper GI USOC Referrals are divided into two referral pathways:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><a href=\"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/gastrointestinal\/urgent-suspected-upper-gi-cancer\/\" target=\"_blank\" rel=\"noreferrer noopener\">Urgent Suspected Upper GI Cancer page<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/gastrointestinal\/dysphagia\/\" target=\"_blank\" rel=\"noreferrer noopener\">Dysphagia page<\/a><\/li>\n<\/ul>\n\n\n\n<p><strong>Summary of Upper GI Referral Pathways in NHS Lothian<\/strong><strong><\/strong><\/p>\n\n\n\n<figure class=\"wp-block-image size-large\"><img loading=\"lazy\" decoding=\"async\" width=\"1024\" height=\"465\" src=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/Upper-GI-Referral-Pathways-1024x465.png\" alt=\"Upper GI Referral Pathways\" class=\"wp-image-20524\" srcset=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/Upper-GI-Referral-Pathways-1024x465.png 1024w, https:\/\/apps.nhslothian.scot\/files\/sites\/2\/Upper-GI-Referral-Pathways-300x136.png 300w, https:\/\/apps.nhslothian.scot\/files\/sites\/2\/Upper-GI-Referral-Pathways-768x349.png 768w, https:\/\/apps.nhslothian.scot\/files\/sites\/2\/Upper-GI-Referral-Pathways.png 1126w\" sizes=\"auto, (max-width: 1024px) 100vw, 1024px\" \/><figcaption class=\"wp-element-caption\"><span class=\"media-credit\">NHS Lothian<\/span> Figure 1 NHS Lothian (JB for RH May 2024)<\/figcaption><\/figure>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-getwid-tabs__nav-link\"><span class=\"wp-block-getwid-tabs__title-wrapper\"><a href=\"#\"><span class=\"wp-block-getwid-tabs__title\">Primary Care Management<\/span><\/a><\/span><\/div><div class=\"wp-block-getwid-tabs__tab-content-wrapper\"><div class=\"wp-block-getwid-tabs__tab-content\">\n<p>In the absence of alarm symptoms in those aged &lt;55 years:<\/p>\n\n\n\n<p>Consider lifestyle measures<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>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.<\/li>\n<\/ul>\n\n\n\n<p>Trial of alginates as required<\/p>\n\n\n\n<p>Offer trial of an H2RA (Famotidine 20-40mg OD)<\/p>\n\n\n\n<p>If no response to simple measures, then&nbsp;<strong>either:<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Test and treat Helicobacter pylori\n<ul class=\"wp-block-list\">\n<li>Check H pylori stool antigen and treat if positive<\/li>\n\n\n\n<li>Stop PPI for at least 2 weeks prior to test<\/li>\n\n\n\n<li>See LJF for H pylori treatment regimens<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n\n\n\n<p><strong>or<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Treat with full dose PPI (omeprazole 20mg-40mg od or equivalent) for 4 weeks<\/li>\n<\/ul>\n\n\n\n<ul class=\"wp-block-list\">\n<li>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<\/li>\n\n\n\n<li>Discuss use of \u201cas required\u201d treatment to encourage self- management of symptoms<\/li>\n\n\n\n<li>Offer annual review to assess symptom control and reduce or withdraw treatment if possible<\/li>\n<\/ul>\n\n\n\n<p><strong>Further information<\/strong><\/p>\n\n\n\n<p><strong>Management of those with normal investigations (Functional dyspepsia)<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Secondary Care would consider using the following measures:\n<ul class=\"wp-block-list\">\n<li>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<\/li>\n\n\n\n<li>Mirtazapine 15mg OD can be effective in FD when there is early satiation and weight loss<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>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.\n<ul class=\"wp-block-list\">\n<li>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.<\/li>\n\n\n\n<li>No evidence to support the use of either SSRI or SNRI drugs in FD<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-getwid-tabs__nav-link\"><span class=\"wp-block-getwid-tabs__title-wrapper\"><a href=\"#\"><span class=\"wp-block-getwid-tabs__title\">Resources and Links<\/span><\/a><\/span><\/div><div class=\"wp-block-getwid-tabs__tab-content-wrapper\"><div class=\"wp-block-getwid-tabs__tab-content\">\n<p><a href=\"https:\/\/www.nice.org.uk\/guidance\/cg184?UID=2290628302024818102221\" data-type=\"link\" data-id=\"https:\/\/www.nice.org.uk\/guidance\/cg184?UID=2290628302024818102221\" target=\"_blank\" rel=\"noreferrer noopener\">Dyspepsia and Gastro Oesophageal Reflux Disease (NICE 2014, update 2019)<\/a><\/p>\n\n\n\n<p>BSG guidelines (2023) on management of functional dyspepsia:<br><a href=\"http:\/\/www.bsg.org.uk\/clinical-resource\/bsg-guidelines-on-the-management-of-functional-dys\" target=\"_blank\" rel=\"noreferrer noopener\">www.bsg.org.uk\/clinical-resource\/bsg-guidelines-on-the-management-of-functional-dys<\/a><\/p>\n\n\n\n<p><a href=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/gi-Functional-dyspepsia-advice-leaflet.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Functional dyspepsia advice leaflet.pdf<\/a><\/p>\n\n\n\n<p><a href=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/PPV-of-symptoms-for-UGI-Cancer.pdf\" data-type=\"link\" data-id=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/PPV-of-symptoms-for-UGI-Cancer.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">PPV of symptoms for UGI Cancer<\/a><\/p>\n<\/div><\/div>\n<\/div>\n\n\n\n<p><\/p>\n","protected":false},"excerpt":{"rendered":"<p>There is helpful, patient-friendly information and advice to be found on the GI section of the NHS Lothian Internet pages.&nbsp; There are also some videos by our very own GI team which patients have been responding very positively to.&nbsp; Consider sharing the link with patients and\/or carers. https:\/\/services.nhslothian.scot\/GI\/Dyspepsia Definition Dyspepsia or &ldquo;indigestion&rdquo; is very broadly<\/p>\n","protected":false},"author":6,"featured_media":0,"parent":3955,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"categories":[1125],"class_list":["post-20521","page","type-page","status-publish","hentry","category-https-apps-nhslothian-scot-refhelp-dyspepsia"],"publishpress_future_workflow_manual_trigger":{"enabledWorkflows":[]},"rttpg_featured_image_url":null,"rttpg_author":{"display_name":"heatherlevy","author_link":"https:\/\/apps.nhslothian.scot\/refhelp\/author\/heatherlevy\/"},"rttpg_comment":0,"rttpg_category":" <a href=\"https:\/\/apps.nhslothian.scot\/refhelp\/category\/gastrointestinal\/https-apps-nhslothian-scot-refhelp-dyspepsia\/\" rel=\"tag\">Dyspepsia<\/a>","rttpg_excerpt":"There is helpful, patient-friendly information and advice to be found on the GI section of the NHS Lothian Internet pages.&nbsp; There are also some videos by our very own GI team which patients have been responding very positively to.&nbsp; Consider sharing the link with patients and\/or carers. https:\/\/services.nhslothian.scot\/GI\/Dyspepsia Definition Dyspepsia or &ldquo;indigestion&rdquo; is very broadly","_links":{"self":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/20521","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/users\/6"}],"replies":[{"embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/comments?post=20521"}],"version-history":[{"count":11,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/20521\/revisions"}],"predecessor-version":[{"id":27501,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/20521\/revisions\/27501"}],"up":[{"embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/3955"}],"wp:attachment":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/media?parent=20521"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/categories?post=20521"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}