Dyspepsia

Differential diagnosis

  • Stomach/oesophageal Ca – weight loss, dysphagia
  • Ulcer – melena
  • MI – chest pain, SOB, palpitations
  • GORD/dyspepsia – belching, fatty foods, flatulence, heartburn
  • Medications – NSAIDs, bisphosphonates, calcium channel blockers, nitrates
  • Liver/gallbladder/pancreas

 

Data gathering

  • Red flags – weight loss, anorexia, recent onset, progressive, vomiting, melena,  swallowing difficulties, chest pain/shortness of breath
  • Examine – Abdominal examination

 

Clinical management

  • Investigations
    • Bloods – FBC, ferritin, LFTs, coeliac
    • H.pylori stool test (after stopping PPI for 2 weeks)
  • Explanation
    • problem with digestion in upper gut, abdominal pain and bloating are common symptoms, certain triggers should be avoided (NSAIDs, alcohol)
  • Treatment
    • Lifestyle – stop smoking, reduce alcohol and caffeine, weight loss, foods, stop meds causing it
    • Gaviscon – neutralises stomach acid
    • PPI
    • H.pylori eradication
      • 1st line: Omeprazole 40mg BD + Amoxicillin 1g BD + Clarithromycin 500mg BD for 7 days
      • 2nd line: Omeprazole 40mg BD + tripotassium dicitratobismuthate 120mg QDS + tetracycline 500mg QDS + metronidazole 400mg TDS for 14 days
  • Follow up / Safety-net
    • review in 6 weeks
    • sooner if deterioration e.g. melaena, dysphagia
    • 2ww if:
      • >55yo and unexplained and persistent recent onset dyspepsia (avoid PPIs 2 weeks beforehand)

Reference