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Dyspepsia

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Overview

Dyspepsia describes upper abdominal symptoms that are consistent with indigestion, which are discussed below. The symptoms of dyspepsia poorly correlate with underlying pathophysiology, therefore NICE has set out guidelines regarding its management, including which patients require urgent investigation.

Epidemiology

  • Dyspepsia symptoms are very common and occur in around 40% of the population each year

Causes

The most common causes are:

Other causes include:

Presentation

Overview

Features that suggest dyspepsia are:

  • Epigastric pain or discomfort
  • Bloating
  • Heartburn
  • Feeling full earlier when eating
  • Nausea and vomiting
  • Loss of appetite

Red flags

Alarm symptoms are features that are associated with underlying malignancy and warrant an urgent referral via a suspected cancer pathway to gastroenterology. These features can be remembered using VBAD:

  • Recurrent vomiting
  • Bleeding, such as melaena (black, tarry stools)
  • Anaemia, abdominal mass, or unintended weight loss
  • Dysphagia

Referral

Urgent referral (suspected cancer pathway) criteria

The following patients should urgently be referred to secondary care via a suspected cancer (2-week wait) pathway:

  • All patients with dysphagia
  • All patients with an upper abdominal suggestive of stomach cancer
  • Any patient ≥55 years with weight loss and any of the following:
    • Upper abdominal pain
    • Reflux
    • Dyspepsia

Non-urgent direct-access referral criteria 

The following patients should be referred to secondary care via a non-urgent pathway:

  • Patients with dyspepsia and haematemesis
  • Any patient ≥55 years with any of the following:
    • Treatment-resistant dyspepsia
    • Upper abdominal pain and anaemia
    • Nausea or vomiting with weight loss, reflux, dyspepsia, upper abdominal pain
    • Raised platelet count and nausea, vomiting, weight loss, reflux, dyspepsia, upper abdominal pain

Management

Dyspepsia due to an unidentified cause

Patients that do not meet the referral criteria are treated as follows:

  • 1st-line: review medications and give lifestyle advice
    • Some drugs may be causing dyspepsia such as NSAIDs, steroids, nitrates, and bisphosphonates and should have their doses adjusted or stopped if possible
    • This avoids unnecessary over-prescribing of treatment
  • 2nd-line: trial full-dose proton pump inhibitor (PPI) for one month or test and treat for H. pylori which involves:
    • Testing for H. pylori: carbon-13 urea breath test is the test of choice
    • Treating H. pylori: see Helicobacter pylori
    • There is no need to check for H. pylori eradication, however, if necessary, a repeat carbon-13 urea breath test is done

Patient Advice

Some advice that may help with dyspepsia includes:

  • Losing weight if patients are overweight or obese
  • Avoid trigger foods if possible, typically fatty foods as they slow gastric emptying
  • Eat smaller regular meals, with the last meal 3-4 hours before going to bed
  • Stop smoking
  • Reduce alcohol consumption

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