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Dyspepsia: management of dyspepsia in adults in primary care

National Institute for Health and Clinical Excellence

Key priorities for implementation

  • The following have been identified as priorities for implementation
  • Referral for endoscopy
    • Review medications for possible causes of dyspepsia (for example, calcium antagonists, nitrates, theophyllines, bisphosphonates, corticosteroids and non-steroidal anti-inflammatory drugs (NSAIDs)). In patients requiring referral, suspend NSAID use
    • Urgent specialist referral for endoscopic investigation* is indicated for patients of any age with dyspepsia when presenting with any of the following: chronic gastrointestinal bleeding, progressive unintentional weight loss, progressive difficulty swallowing, persistent vomiting, iron deficiency anaemia, epigastric mass or suspicious barium meal
    • routine endoscopic investigation of patients of any age, presenting with dyspepsia and without alarm signs, is not necessary However, in patients aged 55 years and older with unexplained† and persistent† recent-onset dyspepsia alone, an urgent referral for endoscopy should be made
  • Interventions for uninvestigated dyspepsia
    • Initial therapeutic strategies for dyspepsia are empirical treatment with a proton pump inhibitor (PPI) or testing for and treating H. pylori. There is currently insufficient evidence to guide which should be offered first. A 2-week washout period following PPI use is necessary before testing for H. pylori with a breath test or a stool antigen test
  • Interventions for gastro-oesophageal reflux disease (GORD)
    • Offer patients who have GORD a full-dose PPI for 1 or 2 months
    • If symptoms recur following initial treatment, offer a PPI at the lowest dose possible to control symptoms, with a limited number of repeat prescriptions
  • Interventions for peptic ulcer disease
    • Offer H. pylori eradication therapy to H. pylori-positive patients who have peptic ulcer disease
    • For patients using NSAIDs with diagnosed peptic ulcer, stop the use of NSAIDs where possible. Offer full-dose PPI or H2 receptor antagonist (H2RA) therapy for 2 months to these patients and, if H .pylori is present, subsequently offer eradication therapy
  • Interventions for non-ulcer dyspepsia
    • Management of endoscopically determined non-ulcer dyspepsia involves initial treatment for H. pylori if present, followed by symptomatic management and periodic monitoring
    • Re-testing after eradication should not be offered routinely, although the information it provides may be valued by individual patients
  • Reviewing patient care
    • Offer patients requiring long-term management of dyspepsia symptoms an annual review of their condition, encouraging them to try stepping down or stopping treatment
    • A return to self-treatment with antacid and/or alginate therapy (either prescribed or purchased over-the-counter and taken as required) may be appropriate
  • H. pylori testing and eradication
    • H. pylori can be initially detected using either a carbon-13 urea breath test or a stool antigen test, or laboratory-based serology where its performance has been locally validated
    • Office-based serological tests for H. pylori cannot be recommended because of their inadequate performance
    • For patients who test positive, provide a 7-day, twice-daily course of treatment consisting of a full-dose PPI with either metronidazole 400 mg and clarithromycin 250 mg or amoxicillin 1 g and clarithromycin 500 mg

Presentation at GP and endoscopy
Flowchart of referral criteria and subsequent management
Presentation at GP and endoscopy Flowchart of referral criteria and subsequent management algorithm

Dyspepsia: management of dyspepsia in adults in primary care continued

Common elements of care

Recommendations

  • For many patients, self-treatment with antacid and/or alginate therapy (either prescribed or purchased over-the-counter and taken 'as required') may continue to be appropriate for immediate symptom relief. However, additional therapy is appropriate to manage symptoms that persistently affect patients' quality of life
  • Offer older patients (over 80 years of age) the same treatment as younger patients, taking account of any comorbidity and their existing use of medication
  • Offer simple lifestyle advice, including advice on healthy eating, weight reduction and smoking cessation
  • Advise patients to avoid known precipitants they associate with their dyspepsia where possible. These include smoking, alcohol, coffee, chocolate, fatty foods and being overweight. Raising the head of the bed and having a main meal well before going to bed may help some people
  • Provide patients with access to educational materials to support the care they receive
  • Psychological therapies, such as cognitive behavioural therapy and psychotherapy, may reduce dyspeptic symptoms in the short term in individual patients. Given the intensive and relatively costly nature of such interventions, routine provision by primary care teams is not currently recommended
  • Patients requiring long-term management of dyspepsia symptoms should be encouraged to reduce their dose of prescribed medication stepwise: by using the effective lowest dose, by trying as-required use when appropriate, and by returning to selftreatment with antacid or alginate therapy

Uninvestigated dyspepsia

  • See management flowchart for patients with uninvestigated dyspepsia

 

Management flowchart for patients with uninvestigated dyspepsia

Dyspepsia: management of dyspepsia in adults in primary care continued

Gastro-oesophageal reflux disease, peptic ulcer and non-ulcer dyspepsia

  • See management flowcharts for patients with GORD, gastric ulcer and duodenal ulcer

 

Management flow chart for patients with GORD

Management flow chart for patients with gastric ulcer

Management flow chart for patients with duodenal ulcer

Management flow chart for patients with non-ulcer dyspepsia

Dyspepsia: management of dyspepsia in adults in primary care continued

Reviewing patient care

Recommendations

  • Offer patients requiring long-term management of dyspepsia symptoms an annual review of their condition, encouraging them to try stepping down or stopping treatment (unless there is an underlying condition or comedication requiring continuing treatment)
  • A return to self-treatment with antacid and/or alginate therapy (either prescribed or purchased over the counter and taken as required) may be appropriate
  • Offer simple lifestyle advice, including healthy eating, weight reduction and smoking cessation
  • Advise patients to avoid known precipitants they associate with their dyspepsia where possible. These include smoking, alcohol, coffee, chocolate, fatty foods and being overweight. Raising the head of the bed and having a main meal well before going to bed may help some people
  • Routine endoscopic investigation of patients of any age, presenting with dyspepsia and without alarm signs, is not necessary. However, in patients aged 55 years and older with unexplained† and persistent† recent-onset dyspepsia alone, an urgent referral for endoscopy should be made

Helicobacter pylori: testing and eradication

Recommendations

  • H. pylori can be initially detected using a carbon-13 urea breath test or a stool antigen test, or laboratory-based serology where its performance has been locally validated
  • Re-testing for H. pylori should be performed using a carbon-13 urea breath test. (There is currently insufficient evidence to recommend the stool antigen test as a test of eradication)
  • Office-based serological tests for H. pylori cannot be recommended because of their inadequate performance
  • For patients who test positive, provide a 7-day twice-daily course of treatment consisting of a full-dose PPI, with either metronidazole 400 mg and clarithromycin 250 mg or amoxicillin 1 g and clarithromycin 500 mg
  • For patients requiring a second course of eradication therapy, a regimen should be chosen that does not include antibiotics given previously (see the British National Formulary for guidance)

* The Guideline Development Group considered that 'urgent' meant being seen within 2 weeks

† In the referral guidelines for suspected cancer (NICE Clinical Guideline no. 27), 'unexplained' is defined as 'a symptom(s) and/or sign(s) that has not led to a diagnosis being made by the primary care professional after initial assessment of the history, examination and primary care investigations (if any)'. In the context of this recommendation, the primary care professional should confirm that the dyspepsia is new rather than a recurrent episode and exclude common precipitants of dyspepsia such as ingestion of NSAIDs. 'Persistent' as used in the recommendations in the referral guidelines refers to the continuation of specified symptoms and/or signs beyond a period that would normally be associated with self-limiting problems. The precise period will vary depending on the severity of symptoms and associated features, as assessed by the healthcare professional. In many cases, the upper limit the professional will permit symptoms and/or signs to persist before initiating referral will be 4–6 weeks

 

full guideline available from…
National Institute for Health and Clinical Excellence, MidCity Place, 71 High Holborn, London WC1V 6NA
guidance.nice.org.uk/CG17

National Institute for Health and Clinical Excellence. Dyspepsia: management of dyspepsia in adults in primary care. August 2004

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eGuidelines.co.uk (22 May 2012)
© 2012 MGP Ltd
First included: Oct 04.
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