People with dyspepsia may choose several routes for the initial management of the condition. Some people purchase antacids or H2RA medicines over the counter, some consult with a community pharmacist and others will consult their general practitioner. Figure 1 describes an evidence-based approach to investigation and management.
Figure 1: Dyspepsia an evidence-based approach to investigation and management
2.1 The role of the community pharmacist
The UK market for over the counter indigestion remedies was £88.5m in 1999 and £93.7m in 2000.11 In the UK, antacids are categorised under the Medicines Act, Section 3 1978, as general sales list (GSL) items and may be bought at a variety of sales outlets such as supermarkets, petrol stations and corner shops without the supervision of a pharmacist. Antacids may also be purchased from pharmacies. H2RAs are categorised as either GSL for 6 to 12 tablets of ranitidine or as pharmacy supervised sale (P), for larger quantities of ranitidine or other H2RAs. The dose of over the counter H2RA is usually 50% of the standard prescribed maintenance dose and the quantity is limited to 24 tablets in a pack. Users are advised they should not be taken for prolonged periods without seeking medical advice.
Pharmacists are well placed to provide an early intervention for people suffering from symptoms of dyspepsia. It has been demonstrated that advice on self-medication and counselling by pharmacists has a measurable impact on health-related quality of life and that patients value the information that pharmacists provide.12 Patients advised to visit their general practitioner (GP) by their pharmacist may not present to their GP. This could be important if their symptoms include alarm features that may be suggestive of a more serious pathology.13 Evidence level 2+
|Community pharmacists should advise patients suffering from dyspepsia associated with alarm symptoms to consult their general practitioner (see section 2.4). Extrapolated from studies rated 2+|
The general practitioner, faced with the patient complaining of “indigestion” will consider all possible sources including the oesophagus, stomach, heart, liver, gall bladder, pancreas, bowel, NSAIDs and other drugs.
Alarm features such as dysphagia, evidence of GI blood loss, persistent vomiting, unexplained significant weight loss or an upper abdominal mass should be identified (see section 2.4). Patients with these findings merit early referral to a hospital specialist. The management strategy for uncomplicated dyspepsia given in this guideline should only be used if pathology outwith the stomach and proximal duodenum is thought unlikely and alarm features are not present. It should again be emphasised that this guideline does not address dyspepsia associated with NSAID use.
2.3 Symptoms of dyspepsia
Dyspepsia refers to pain or discomfort centred in the upper abdomen.10
The presence of pain or discomfort in the upper abdomen is often accompanied by a combination of several symptoms including bloating, early satiety, heartburn, and nausea or vomiting. It is helpful to inquire about the predominant symptom, such as upper abdominal discomfort, pain, heartburn or reflux in order to distinguish dyspepsia from GORD.
The value of dyspepsia symptom subgroups to reflect underlying pathophysiology is limited.14, 15 Unaided clinical diagnosis in dyspeptic patients in primary care is unreliable and the specificity of individual symptoms have been shown to be low.14 A clinical diagnosis of peptic ulcer will miss approximately half of all ulcer cases and a provisional diagnosis of ulcer will be confirmed in only one-third. Symptom assessment cannot be used to make a reliable diagnosis in patients with dyspepsia. Evidence level 2+
Computerised models have been developed using multiple clinical and demographic criteria to try to identify patients at low risk of organic dyspepsia and hence improve the likelihood of an accurate diagnosis.16, 17 Computerised models are rarely validated and cannot therefore be generally recommended.16 Evidence level 2-
Symptom assessment cannot be relied upon to make a diagnosis of the cause of dyspepsia.
Many guidelines recommend that alarm features such as dysphagia, recurrent vomiting, significant unintentional weight loss, anaemia from gastrointestinal haemorrhage or upper abdominal mass, are used as predictors for major pathology (eg ulcer with complications or oesophageal cancer) in patients with dyspepsia. 18, 19 They further recommend that patients of any age with these features should have early investigation.18, 19 These recommendations tend to be based on expert opinion rather than published evidence.18, 19 Evidence level 4
The evidence concerning alarm features such as dysphagia, recurrent vomiting, significant unintentional weight loss, anaemia from gastrointestinal haemorrhage or upper abdominal mass does not allow clear conclusions. In some studies 20, 21, 22, 23 alarm features are seen to be predictive of major pathology, but in others this association is not found.24 A recent American multicentre database study of 3815 patients having first endoscopy for dyspepsia, showed that male sex, age over 45 years and anaemia were significant but weak predictors for major upper GI pathology.25 In this study, weight loss and dysphagia were not found to be significant predictors. It was demonstrated that age and alarm features are not effective predictors of endoscopic findings among patients with dyspepsia and that better clinical prediction strategies are required. Evidence level 2++
Several cohort studies show that up to 95% of younger patients (age ranges used in studies vary between under 45 years to under 55 years) with upper GI cancer have more than one alarm feature. 20, 21, 25, 26 The Scottish Audit of Gastric and Oesophageal Cancer (SAGOC) data show that 9% of patients with upper GI cancer in Scotland are under 55 years of age and 93% of them have an alarm feature at the time of presentation.27 Evidence level 2++
In the dyspeptic population, some alarm features (age over 45 years, anaemia, male sex) are weak predictors for upper GI cancer.25 However, in populations of patients with dyspepsia and upper GI cancer, alarm features are almost always present.20, 21
Patients with dyspepsia and alarm features should be referred to a hospital specialist for assessment.
2.4.1 AGE AND GASTRIC CANCER
In 1998 both the American Gastroenterological Association18 and a working party for the World Congress of Gastroenterology advised that patients over 45 and 50 years of age respectively presenting with new onset uncomplicated dyspepsia should undergo early upper GI endoscopy.28 This recommendation was not evidence-based but arose from a perception that non-invasive investigation or empirical therapy for uncomplicated dyspepsia in this group of patients would delay the diagnosis of gastric cancer and may adversely affect survival. Evidence level 4
A recent systematic review however found no evidence to suggest that an initial course of empirical therapy, rather than endoscopy, adversely affects outcome in patients with underlying gastric cancer.29 Some patients with uncomplicated dyspepsia will also have gastric cancer but there is no evidence that early, potentially curable gastric cancer found via endoscopy to investigate uncomplicated dyspepsia is other than a chance finding. Despite the belief of many clinicians that uncomplicated dyspepsia may be a symptom of cancer, upper GI cancer may in fact be no more prevalent than in an age matched non dyspeptic population. Evidence level 1+
There is no evidence to support the mandatory use of early upper GI endoscopy to investigate patients over 55 years old who present with new onset uncomplicated dyspepsia. Evidence level 1+
2.4.2 ENDOSCOPY VERSUS BARIUM MEAL FOR PATIENTS WITH ALARM FEATURES
Endoscopy is more sensitive than barium meal at detecting early curable gastric cancer and is also more likely to detect gastric and duodenal erosions.30, 31 Any lesions seen can also be biopsied immediately. A well conducted barium meal is a useful investigation which will detect most serious disease in the upper GI tract32 but it does involve a radiation dose (typical effective dose 2mSv equivalent to 11 months of background radiation).33 This is particularly relevant now that the European Union regulations governing the exposure of patients to medical radiation are in force.34 Evidence level 2+,4
Upper GI endoscopy is the investigation of choice when further evaluation is warranted and should be widely available.
Barium meal studies are appropriate where the local endoscopy services are unavailable or for patients who cannot tolerate endoscopy.