Guideline 68: Dyspepsia

Dyspepsia
Section 3: Management of uncomplicated dyspepsia

Uncomplicated dyspepsia refers to patients whose dyspepsia is not accompanied by alarm features or associated with NSAID usage. The traditional management of patients in primary care has been to consider the role of lifestyle, antacids and H2RAs. There are a number of possible approaches to the management of patients with persisting or recurrent symptoms (see Figure 1). Some of these approaches incorporate the role of H. pylori infection in the aetiology of ulcer disease. Most studies of these approaches have involved patients of less than 55 years of age.

3.1 Patients less than 55 years of age

Acid suppression therapy

This has the disadvantage of depriving those with underlying ulcer disease from being cured by eradication of H. pylori infection.^{35,
36, 37} Evidence level 1+

Early endoscopy

Studies show that early upper GI endoscopy may be more effective than empirical prescribing but the benefit is small, not significant and unlikely to be cost-effective.^{38,
39, 40} Evidence level 1+

H. pylori “test and endoscope”

This strategy involves performing a non-invasive H. pylori test and performing endoscopies only on those patients with a positive result. This approach is no more effective, or less costly, than selective endoscopy at the general practitioner’s discretion.^{38,
40} Evidence level 1++

H. pylori “test and treat”

This strategy involves performing a non-invasive H. pylori test, eradicating the infection in all those testing positive and providing symptomatic treatment for those who test negative. Five randomised trials have compared the non-invasive H. pylori test and treat strategy with upper GI endoscopy. One of the trials randomised those with a positive non-invasive H. pylori test to endoscopy versus H. pylori eradication therapy without further investigation⁴¹ and another trial randomised patients with a negative non-invasive H. pylori test to endoscopy versus symptomatic treatment.⁴² A further three trials randomised patients at the point of presentation to endoscopy versus non-invasive H. pylori testing.^{43,
44, 45} Each of the five trials came to the same general conclusion, that non-invasive H. pylori testing was as effective as endoscopy in determining the management of dyspepsia.^{41,
42, 43,
44, 45} Evidence level 1++

The above strategy involves eradicating H. pylori infection in dyspeptic patients without underlying ulcer disease. There may be advantages and disadvantages related to this.^{46,
47} Evidence level 1++

Advantages include: ^{46,
47}

symptomatic benefit from eradicating the infection in a small subgroup of patients with functional dyspepsia
reducing the risk of subsequent ulcer disease
removing a risk factor for gastric cancer
removing concerns about potential adverse interactions between the infection and the subsequent long term use of proton pump inhibitors. Evidence level 1++

Disadvantages include:⁴⁸

potential risks from wider use of antibacterial therapy (eg resistance and complications)
possibility of inducing reflux oesophagitis following eradication of strains of H. pylori. Evidence level 1++

One recent cross sectional study proposed that the H. pylori test and treat strategy should be limited to dyspeptic patients whose history and symptoms indicated a high risk of underlying ulcer disease.⁴⁹ This strategy reduces the number of patients receiving H. pylori eradication therapy without underlying ulcer disease but has the disadvantage of depriving a substantial proportion of ulcer patients of curative therapy. Evidence level 1++

It is recognised that the balance of advantages over disadvantages for the H. pylori test and treat strategy will be less in populations with a low prevalence of H. pylori infection and related ulcer disease. The prevalence of H. pylori infection in the Scottish population with dyspepsia is approximately 40% at present and more than 20% of these patients have underlying ulcers.⁴⁵ The prevalence of H. pylori infection within any population increases with age and with lower socio-economic status.⁵⁰ Evidence level 1++

The H. pylori test and treat strategy is as effective and safe as endoscopy in determining the management of patients less than 55 years old with uncomplicated dyspepsia. In view of the fact that the H. pylori test and treat strategy is both non-invasive and cheaper than upper GI endoscopy,^{38,
39, 41,
42, 43,
44, 45,
46, 47,
48, 49} it is considered to be the preferred strategy. Facilities for non-invasive H. pylori testing should therefore be widely available. Evidence level 1++

A non-invasive H. pylori test and treat strategy is as effective as endoscopy in the initial management of patients with uncomplicated dyspepsia who are less than 55 years old.

3.2 Patients over 55 years old

Current guidelines advise that older patients (age ranges used in studies vary between over 45 to over 55 years) with uncomplicated dyspepsia should be investigated using early upper GI endoscopy.^{18,
19, 28,
51, 52} The phrase “recent onset” is also frequently used to indicate a need for more urgent investigation of dyspepsia. An examination of the literature does not produce evidence to support these claims.

3.2.1 MANAGEMENT

This guideline has cited substantial evidence supporting the use of non-invasive H. pylori testing in place of upper GI endoscopy in determining the management of patients less than 55 years old presenting with uncomplicated dyspepsia (see section 3.1). The question as to whether this recommendation can be extrapolated to include patients presenting with uncomplicated dyspepsia who are more than 55 years old has not yet been directly addressed by an RCT. There are, however, recent studies comparing the outcome of non-invasive management versus early upper GI endoscopy for this group of patients where no upper age limit was defined for inclusion in the study.

An RCT studied 500 Danish patients between the age of 18 and 88 years with recent onset uncomplicated dyspepsia with or without concomitant reflux symptoms. The patients were randomised to either H. pylori test and treat policy or early endoscopy and followed up for one year. The test and treat policy was as efficient and as safe as prompt endoscopy.⁴³ Evidence level 1+

A Canadian general practice controlled trial randomised 294 H. pylori positive patients with at least three months of uninvestigated dyspepsia (age range 18 to 82 years) to either H. pylori eradication therapy or omeprazole 20 mg for seven days.⁵³ The test and treat strategy showed significant symptomatic benefit after 12 months follow-up. Two patients died of cancer during the study, one from a brain tumour and one from inoperable oesophageal cancer that presented with dysphagia three months into follow-up. Evidence level 1+

A small Dutch study of 80 patients with recent onset uncomplicated dyspepsia (35 were more than 45 years of age) randomised to empirical omeprazole therapy followed by H. pylori test and eradicate for symptom relapse versus early endoscopy concluded that after one year the empirical strategy was just as effective as the prompt endoscopy strategy.⁵⁴ Evidence level 1-

The available evidence does not justify an age limit for a different management of patients with uncomplicated dyspepsia. Evidence level 2++

A non-invasive H. pylori test and treat policy may be as appropriate as early endoscopy for the initial investigation and management of patients over the age of 55 years presenting with uncomplicated dyspepsia.

Referral for assessment should be considered for patients over 55 years old with uncomplicated dyspepsia whose symptoms persist after initial management with the H.pylori test and treat strategy.