dyspepsia
DYSPEPSIA

Dyspepsia is having any one of the following: disturbing postprandial fullness, early satiation, epigastric pain and/or burning felt predominantly in the upper abdomen.

It is considered a symptom complex rather than a specific diagnosis.

Acid suppression is the recommended initial therapy.

Principles of Therapy

Clinical Decision

  • Patients <40 years old without alarm features and prior dyspepsia workup can be treated either by:
    • Empiric therapy with antisecretory agents if local H pylori prevalence is <5%
    • Testing and, if positive, treating for H pylori if local prevalence is >10%
    • If local prevalence rate is 5-10%, treatment choice will depend on length of symptoms, comorbidities, NSAID use, risk factors for gastric or esophageal malignancy, testing availability and cost, and patient preference
  • H pylori testing and treating are effective as initial therapeutic strategy at reducing dyspeptic symptoms in trials of patients with uninvestigated dyspepsia
    • Recommended as initial therapy by some experts
Therapeutic Principles for Empiric Therapy
  • Acid suppression, given for 4-8 weeks, is the recommended initial therapy
    • Patients should be treated with a 4-week trial of acid suppression before deciding whether or not therapy has been effective
  • It is not clear which class of drugs (PPIs, H2RAs or prokinetic agents) would be the most appropriate for all patients
    • May consider prescribing based on predominant symptom complaints
  • In areas where H pylori infection is prevalent, empiric therapy is not recommended in H pylori-positive patients with dyspepsia

Pharmacotherapy

Proton Pump Inhibitors (PPIs)

  • PPIs were shown to be more effective than other agents as initial therapeutic strategy at reducing dyspeptic symptoms in trials of patients with uninvestigated dyspepsia when patients were not adequately excluded for GERD
  • Patients with heartburn symptoms may be treated initially with PPI then step-down therapy with H2RAs once their symptoms improve
  • Low-dose PPI are used as step-down therapy

Histamine2-Receptor Antagonists (H2RAs)

  • Individual patients may respond to H2RA therapy
  • H2RAs have been shown to be significantly more effective than placebo
  • H2RAs may also be used as step-down therapy

Prokinetic Agents

  • Individual patients, often those with dysmotility-like symptoms, may respond to prokinetics
  • Treatment should be at the lowest effective dose for the shortest duration possible to reduce the risk of adverse effects
    • Studies show that Mosapride does not have any significant cardiovascular effects even with concomitant administration of Ketoconazole and Erythromycin; Mosapride does not block D2 receptor hence does not cause extrapyramidal effects   

Adjunctive Therapy

Antacids

  • Self-treatment with antacid with or without alginates may be continued for immediate symptom relief but additional therapy is appropriate to manage persistent or more severe symptoms
  • Antacids and alginates effectively reduce acid but evidence of healing effect has not been demonstrated
Antidepressants and Anxiolytics
  • Efficacy in the treatment of functional dyspepsia was shown in two meta-analyses
  • May be used as 2nd-line therapy if dyspeptic symptoms failed to improve with initial therapy

Non-Pharmacological Therapy

  • Specialist investigation is necessary for patients >55 years (>40 years in areas with high prevalence of gastric cancer), patients with alarm symptoms, patients who did not respond to empiric therapy and have persistent symptoms, and for further evaluation of an alternate diagnosis

Endoscopy

  • Upper GI endoscopy is the investigation of choice when further evaluation is warranted
  • Endoscopy allows a clinician to view the GIT and, if necessary, perform diagnostic and therapeutic procedures, eg biopsy
  • Routine endoscopic investigation of patients at any age, presenting with dyspepsia and without alarm signs, is not necessary
  • Should be reserved for patients who have little or no response to therapy after 7-10 days or for patients whose symptoms have not resolved after 4-8 weeks
    • If upper GI endoscopy is unremarkable, patients with persistent symptoms or alarm features should be evaluated further for other diagnosis
  • Depending on local protocol: For patients >55 years (>40 years in areas with high prevalence of gastric cancer), consider endoscopy when symptoms persist despite H pylori testing/treatment and acid suppression therapy, and when patient has one or more of:
    • Previous gastric ulcer or surgery
    • Continuing need for NSAID treatment
    • Raised risk of gastric cancer
    • Anxiety about cancer
  • Patients undergoing endoscopy should be free from medication with either a PPI or H2RA for a minimum of 2 weeks
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