Dyspepsia
Summary
Dyspepsia refers to upper abdominal pain or discomfort, often associated with heartburn, early satiety, bloating, or nausea. It can be caused by organic pathology (Peptic Ulcer Disease, GORD, Gastric Cancer, H. pylori infection) or be Functional Dyspepsia (No identifiable structural cause). The key priority is to identify ALARM ("Red Flag") symptoms that require urgent investigation (OGD) to exclude malignancy. In the absence of alarm features, initial management follows a "Test and Treat" strategy for Helicobacter pylori or an empirical PPI trial. H. pylori is a common underlying cause and should be tested for using Urea Breath Test or Stool Antigen. Eradication regimens involve a PPI + two antibiotics.
Key Facts
- Definition: Upper abdominal pain/discomfort +/- Heartburn, Bloating, Nausea, Early Satiety.
- Causes: Functional Dyspepsia (Most common), Peptic Ulcer Disease (PUD), H. pylori, GORD, Gastric Cancer, Drugs (NSAIDs), Bile reflux.
- H. pylori: Common cause of PUD. Test (Urea Breath Test / Stool Antigen) and Treat.
- ALARM Symptoms: Anaemia, Loss of weight, Anorexia, Recent onset progressive symptoms, Melaena/Haematemesis, Swallowing difficulty (Dysphagia).
- Management: Test-and-Treat H. pylori OR PPI trial. Urgent OGD if alarm symptoms.
Clinical Pearls
"ALARM = OGD": Any alarm symptom warrants upper GI endoscopy to exclude malignancy or ulcer.
"Stop PPIs Before H. pylori Testing": PPIs reduce sensitivity of UBT and stool antigen. Stop for 2 weeks before testing.
"Age >55 with New Dyspepsia = Consider OGD": Higher risk of malignancy. Lower threshold for investigation.
"Functional Dyspepsia is a Diagnosis of Exclusion": Exclude organic causes first.
Why This Matters Clinically
Dyspepsia is extremely common. Early recognition of alarm features allows detection of gastric cancer at a treatable stage. H. pylori eradication prevents ulcer recurrence and reduces cancer risk.
Incidence
- Prevalence: ~25-40% of the population experience dyspepsia at some point.
- Consultations: ~2-5% of GP consultations.
- Functional Dyspepsia: Most common cause (~60% of dyspepsia).
Risk Factors
| Factor | Notes |
|---|---|
| H. pylori Infection | Major risk factor for PUD. |
| NSAIDs / Aspirin | Gastric irritation. Ulcer risk. |
| Smoking | Delays ulcer healing. |
| Alcohol | |
| Stress | (Psychological factors in functional dyspepsia). |
| Obesity | Increases GORD. |
| Cause | Frequency | Notes |
|---|---|---|
| Functional Dyspepsia | ~60% | No structural cause on investigation. Diagnosis of exclusion. |
| Peptic Ulcer Disease (PUD) | ~15% | Gastric or Duodenal. Often H. pylori or NSAID-related. |
| GORD (Gastro-Oesophageal Reflux Disease) | ~20% | Heartburn predominant. |
| Gastric Cancer | ~1-2% | Alarm symptoms. Older patients. |
| Oesophagitis / Oesophageal Cancer | <1% | Dysphagia. |
| Helicobacter pylori Gastritis | Variable | May cause symptoms without ulcer. |
| Drugs | NSAIDs, Aspirin, Iron, Bisphosphonates, Steroids. | |
| Biliary Disease | Gallstones (Usually RUQ/Colic, but may overlap). | |
| Gastroparesis | Diabetes. Early satiety. Bloating. Vomiting. |
Symptoms
| Symptom | Notes |
|---|---|
| Epigastric Pain / Discomfort | Burning, Gnawing, Aching. |
| Heartburn (Pyrosis) | Retrosternal burning. GORD predominant. |
| Early Satiety | Fullness after small meal (Functional, Gastroparesis). |
| Bloating / Distension | |
| Nausea +/- Vomiting | |
| Belching | |
| Regurgitation | GORD. |
ALARM Symptoms (Red Flags)
ALARM Mnemonic | Letter | Symptom | |--------|---------| | A | Anaemia (Iron deficiency). | | L | Loss of weight (Unintentional). | | A | Anorexia (Loss of appetite). | | R | Recent onset / Rapidly progressive. | | M | Melaena / Haematemesis (GI Bleeding). | | S | Swallowing difficulty (Dysphagia). |
Also consider: Palpable mass, Previous gastric surgery, Age >55 with new-onset dyspepsia (NICE threshold for 2WW).
Abdominal Examination
| Finding | Significance |
|---|---|
| Epigastric Tenderness | Non-specific. PUD, Gastritis. |
| Palpable Mass | Gastric cancer (Advanced). Urgent. |
| Succussion Splash | Gastric outlet obstruction. |
Systemic Signs
| Finding | Significance |
|---|---|
| Pallor | Anaemia (Chronic blood loss). |
| Lymphadenopathy | Virchow's Node (Left Supraclavicular) – Gastric cancer metastasis. |
| Jaundice | Biliary/Pancreatic pathology. |
| Cachexia | Malignancy. |
When to Investigate (OGD) – Urgently
| Indication | Pathway |
|---|---|
| Alarm Symptoms | Urgent OGD (2WW if cancer suspected). |
| Age >5 with New-Onset Dyspepsia | Consider OGD (Per NICE NG12). |
| Treatment Failure | OGD if symptoms persist despite therapy. |
Helicobacter pylori Testing
| Test | Notes |
|---|---|
| Urea Breath Test (UBT) | Non-invasive. High sensitivity/specificity. Stop PPI 2 weeks, Antibiotics 4 weeks before. |
| Stool Antigen Test | Non-invasive. Good accuracy. Same PPI/Antibiotic washout. |
| Serology (Anti-H. pylori IgG) | Not for active diagnosis (Remains positive after eradication). |
| Biopsy (CLO Test / Histology) | At OGD. Direct detection. |
Bloods
| Test | Purpose |
|---|---|
| FBC | Anaemia? |
| Iron Studies | Iron deficiency? GI blood loss? |
| LFTs | Exclude biliary/hepatic causes. |
Principles
- Identify and Exclude Alarm Symptoms -> OGD.
- Lifestyle Modifications.
- Test and Treat H. pylori (If positive).
- Empirical PPI Trial (If H. pylori negative or after eradication).
- Review Medications (Stop NSAIDs if possible).
Lifestyle Advice
| Advice | Benefit |
|---|---|
| Reduce Caffeine, Alcohol | Reduce gastric acid stimulation. |
| Stop Smoking | Impairs ulcer healing. |
| Weight Loss | Reduces GORD. |
| Small Frequent Meals | Reduces distension. |
| Avoid Late Evening Meals | Reduces nocturnal reflux. |
| Raise Head of Bed | GORD. |
Medication Review
- Stop NSAIDs if possible. If essential, co-prescribe PPI.
- Review other gastric irritants (Iron, Bisphosphonates).
H. pylori Test and Treat
If H. pylori Positive:
First-Line Eradication (Triple Therapy) – 7 days
| Drug | Dose |
|---|---|
| PPI (e.g., Omeprazole) | 20mg BD |
| Amoxicillin | 1g BD |
| Clarithromycin | 500mg BD |
Alternative if Penicillin Allergy: PPI + Clarithromycin + Metronidazole.
Second-Line (If First Fails)
| Drug | Dose |
|---|---|
| PPI | Standard dose BD |
| Bismuth Subcitrate | 120mg QDS |
| Metronidazole | 400mg TDS |
| Tetracycline | 500mg QDS |
Quadruple therapy.
Confirm Eradication: Repeat UBT or Stool Antigen 4+ weeks after treatment (Off PPI for 2 weeks).
PPI Trial (If H. pylori Negative or Post-Eradication Symptoms Persist)
| Drug | Dose | Duration |
|---|---|---|
| Omeprazole | 20mg OD | 4-8 weeks |
| Lansoprazole | 30mg OD | Alternative |
If symptoms resolve, step down/stop PPI.
Functional Dyspepsia
- Diagnosis of exclusion.
- Low-dose Tricyclic Antidepressants (Amitriptyline 10-25mg ON) may help.
- Prokinetics (Metoclopramide, Domperidone) for early satiety/bloating.
- Psychological therapies.
| Complication | Notes |
|---|---|
| Peptic Ulcer Bleeding | Haematemesis, Melaena. |
| Perforation | Sudden severe pain. Peritonitis. Free air on imaging. |
| Gastric Cancer | Detected late if alarm symptoms missed. |
| Stricture / Obstruction | Pyloric stenosis from chronic ulceration. |
| Barrett's Oesophagus | From chronic GORD. Pre-malignant. |
| Scenario | Outcome |
|---|---|
| Functional Dyspepsia | Chronic relapsing. Benign. |
| H. pylori Eradication | Cures PUD in most. Reduces recurrence. Reduces cancer risk. |
| NSAID-Related | Resolves with cessation + PPI. |
| Gastric Cancer (Early) | Curable with surgery. |
| Gastric Cancer (Late) | Poor prognosis. |
Key Guidelines
| Guideline | Organisation | Notes |
|---|---|---|
| NICE CG184 | NICE | Dyspepsia and GORD. Test-and-Treat. PPI trial. |
| NICE NG12 | NICE | Suspected Cancer Referral. Alarm symptoms. |
| Maastricht VI Consensus | European H. pylori Study Group | H. pylori management. |
Scenario 1:
- Stem: A 40-year-old man presents with 3 months of epigastric pain and bloating. No weight loss, dysphagia, or vomiting. What is the initial management?
- Answer: H. pylori Test (UBT or Stool Antigen). If positive, Eradication Therapy. If negative, PPI Trial.
Scenario 2:
- Stem: A 62-year-old woman presents with 4 weeks of dyspepsia and unintentional 4kg weight loss. What is the next step?
- Answer: Urgent OGD (2WW Referral). ALARM symptom (Weight loss + Age >55).
Scenario 3:
- Stem: What is the first-line H. pylori eradication regimen?
- Answer: Triple Therapy for 7 days: PPI (Omeprazole 20mg BD) + Amoxicillin 1g BD + Clarithromycin 500mg BD.
| Scenario | Urgency | Action |
|---|---|---|
| Dyspepsia without ALARM symptoms (<55) | Routine | Test-and-Treat H. pylori or PPI trial. |
| New Dyspepsia Age >5 | Urgent | Consider OGD. |
| ALARM Symptoms | 2WW (Urgent OGD) | Exclude cancer. |
| Treatment Failure | Routine | Gastroenterology. OGD. |
What is Dyspepsia?
Dyspepsia (or "indigestion") is pain or discomfort in your upper tummy. It may come with heartburn, bloating, feeling full quickly, or nausea.
What causes it?
- Sometimes there's no clear cause (Functional Dyspepsia).
- A stomach bug called Helicobacter pylori.
- Stomach ulcers.
- Acid reflux (GORD).
- Medications (like painkillers).
How is it treated?
- Testing for and treating H. pylori (A course of antibiotics + acid-reducing medicine).
- A trial of acid-reducing medicine (PPI) like Omeprazole.
- Lifestyle changes (Reduce alcohol, caffeine, stop smoking).
When should I worry?
- Difficulty swallowing.
- Unintentional weight loss.
- Vomiting blood or dark stools.
- Severe pain. Seek medical help immediately if you have these symptoms.
Key Counselling Points
- Report Alarm Symptoms: "Come back urgently if you have trouble swallowing, weight loss, or blood in vomit/stool."
- Complete Antibiotic Course: "If you have H. pylori, finishing the full course is essential to clear the infection."
- Lifestyle Matters: "Reducing alcohol, caffeine, and quitting smoking can help symptoms."
| Standard | Target |
|---|---|
| H. pylori test offered for uninvestigated dyspepsia | >0% |
| OGD performed for alarm symptoms within 2 weeks | 95% |
| PPI stopped 2 weeks before H. pylori testing | >0% |
| Eradication confirmed after H. pylori treatment | >0% |
- H. pylori Discovery (1982): Barry Marshall and Robin Warren discovered the bacterium. Marshall famously drank a Petri dish of H. pylori to prove it caused gastritis. Nobel Prize 2005.
- Triple Therapy: Revolutionised ulcer treatment. Previously, ulcers were treated surgically.
- PPI Era (1989): Omeprazole introduced. Transformed acid suppression.
- NICE CG184. Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management. 2014. nice.org.uk
- NICE NG12. Suspected cancer: recognition and referral. nice.org.uk
- Malfertheiner P, et al. Management of Helicobacter pylori infection: the Maastricht VI Consensus Report. Gut. 2022. PMID: 35944925
Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. If you have persistent dyspepsia or alarm symptoms, please consult a healthcare professional.