Dyspepsia and how to avoid them

One of the major challenges in the proper management of patients with dyspepsia is to correctly identify when an upper gastrointestinal endoscopy is indicated. Alarm features include: dysphagia, weight loss, an abdominal mass or lymphadenopathy, evidence of gastrointestinal blood loss or iron deficiency anaemia, recurrent vomiting, and the recent onset of dyspeptic symptoms (or a change in bowel habit) in patients who are over 45 or 50 years old (depending on local guidelines). Prospective trials and meta-analyses indicate that the presence of alarm symptoms is associated with a 5–10% risk of serious disease, compared with the 1–2% risk in patients who have no alarm symptoms.^2,15

At least 20% of patients with functional dyspepsia report clinically relevant weight loss (>5% body weight) at initial assessment. Early endoscopy is indicated to exclude a life-threatening pathology in this group. Endoscopy should also be performed in patients who have severe symptoms that fail to respond to therapy and if alarm features develop during follow up.^3,4 If endoscopy is performed, then gastric body and duodenal biopsies should be acquired to test for Helicobacter pylori infection and to exclude coeliac disease, respectively. This is reasonable even if appearances are normal.

Symptoms of chronic abdominal pain, early satiety, bloating and nausea in younger patients are characteristic of functional dyspepsia, but are not alarm symptoms and do not normally require extensive investigation. At presentation, guidelines recommend standard laboratory tests be performed, including a full blood count, clinical chemistry for renal and liver function, calcium, thyroid function and coeliac serology (these may not be indicated routinely in patients of non-European ethnicity). Stool antigen tests or a urea breath test should also be performed to allow a ‘test and treat’ approach to be adopted for those who have a Helicobacter pylori infection. ^3,4

Abdominal ultrasound to exclude gallbladder stones and other abdominal pathology is part of the routine evaluation in many European countries; however, the diagnostic yield is low unless there is a clinical suspicion of specific disorders.^16,17 Computed tomography should not be performed routinely, especially in young females, to avoid unnecessary exposure to radiation.

In patients who have ongoing symptoms, it is not appropriate to repeat endoscopic or other investigations without a clear indication. The reassurance provided by repeated tests in patients with functional gastrointestinal symptoms is minimal, as is the impact they have on treatment.¹⁸

Dyspeptic symptoms are common in the community; however, many individuals who have these symptoms do not seek medical attention. Psychiatric co-morbidity (e.g. anxiety, somatization disorder)^19,20 and external factors, such as work and social pressures, increase consultation rates for dyspeptic symptoms.^8,9 Furthermore, psychosocial co-morbidity increases negative perceptions of the condition (e.g. fear of cancer), subjective symptom severity, time off work and the likelihood that the patient will not respond to standard treatment.²⁰

The possibility of an eating disorder must also be considered. Dyspeptic symptoms are reported by up to 90% of patients with anorexia nervosa and can be used to excuse food refusal and distract attention from the eating disorder.²¹ A related condition in which patients are not focused on body image is Avoidant/Restrictive Food Intake Disorder (ARFID). Patients with this eating disorder are pathologically anxious that eating a wide range of foods will lead to severe abdominal (or other) symptoms.²² This can lead to malnutrition and is associated with a very poor quality of life. The risk factors for eating disorders include: female sex, young adult age group, a family history of an eating disorder, fear of being or becoming fat even when underweight, repeated dieting, unusual dietary beliefs or behaviours, excessive physical activity, and psychosocial stress.

Publicly available, short questionnaires completed ahead of a consultation facilitate collection of this information (e.g. Hospital Anxiety and Depression Score [HADS], Patient Health Questionnaire [PHQ15; Somatization Score]). Awareness of these factors can clarify the causes of disease and guide the clinician towards a more holistic and effective management strategy. In general, psychiatric treatment such as cognitive behavioural therapy (CBT) should be directed at those patients who have specific issues.¹⁹

Many patients will label any return of food to the mouth as vomiting, but direct questioning can clarify the issue. Vomiting is often preceded by nausea and waterbrash (rush of saliva into mouth), and involves the forceful evacuation of large volumes (>100 ml) of digested gastric contents. Regurgitation is the return of small volumes (<100 ml) of fresh or semi-digested food from the oesophagus or stomach. Regurgitation can occur in dyspeptic patients due to reflux or rumination. In those with reflux disease ‘volume regurgitation’ rarely occurs more than once or twice after meals, but may also occur in bed at night. In rumination syndrome, regurgitation usually occurs multiple times after meals due to repeated voluntary, albeit subconscious, contractions of the abdominal wall muscles in response to dyspeptic symptoms.²³ The distinction between these conditions is important because each requires very different management. If the clinical assessment is unclear then a definitive diagnosis can be established by observation during high-resolution manometry with a test meal.²³

Clinical guidelines recommend initial treatment of dyspepsia with a trial of proton pump inhibitor (PPI) therapy.^3,4 This is supported by meta-analyses of published trials as summarized by a Cochrane review.²⁴ At the same time a test and treat approach to H. pylori infection is recommended.²⁵ Note that, although effective in well-designed trials, the absolute benefit of H. pylori eradication is modest, being not more than 10% above placebo for dyspeptic symptoms at 3 month follow-up.²⁶

If the initial trial of PPI therapy (e.g. 2 weeks omeprazole 20 mg twice daily or equivalent) is not effective, then a second trial with a different preparation or a higher dose can be tried. However, if this is not effective, then the PPI should be stopped because of the increased risk of gastrointestinal infection, and other side effects, plus the costs related to long-term therapy. In functional dyspepsia patients who have heightened visceral sensitivity, PPI withdrawal can be complicated by rebound hyperacidity leading to reflux symptoms.²⁷ The same issue can arise after eradication therapy for H. pylori infection (note: successful H. pylori eradication itself does not increase the short to mid-term risk of reflux symptoms²⁸). In both cases, patients should be informed in advance of the possibility of rebound reflux symptoms, reassured that this is temporary and advised to take antacid or alginate (e.g. Gaviscon) to suppress symptoms.²⁹

Pharmaceutical management in patients with functional dyspepsia is complicated by a high rate of patient-reported ‘medication allergies’. These reports should be questioned because true allergic reactions are rare. Many adverse reactions are actually nocebo effects (i.e. incorrect attribution of symptoms to medication) or due to medication intolerance in patients who have heightened sensitivity to a range of stimuli. Although not dangerous, these issues can limit the use of potentially beneficial medications in patients with functional dyspepsia (e.g. antiemetics, antidepressants). Patients should be reassured that, unlike true allergies, intolerance is not dangerous and can be mitigated by commencing treatment at low doses. This is often necessary when prescribing antidepressant medications. To avoid drowsiness and anticholinergic effects, the starting dose of any antidepressant should be very low (e.g. 10–20 mg amitriptyline) and increased every 1–2 weeks by small increments. The most appropriate dose is the maximum dose tolerated by the patient (often well below that used in psychiatric medicine). The efficacy of these medications does not appear to be related to the dose.

In patients that fail to respond to lifestyle advice and empirical therapy, physiological investigations can be performed to identify abnormal gastrointestinal function. A ‘drink test’ that reproduces typical symptoms after ingestion of low volumes of a nutrient drink (e.g. less than 400 mL, 1.5kcal/ml liquid) supports the diagnosis of functional dyspepsia. Scintigraphy or ¹³C-breath tests document abnormal gastric emptying - slow (gastroparesis’) or rapid (dumping) - in up to 40% of patients with dyspepsia.³⁰ Combining the two in a single procedure can provide a comprehensive assessment of gastric motor and sensory function, both of which are important in functional dyspepsia and related conditions.³¹

The impact of these findings on treatment decisions has been demonstrated in recent studies. Patients with a clinically relevant delay in gastric emptying on well validated tests (i.e. >2 times the upper limit of normal) often respond to prokinetic therapy³², especially if constipation is also present. If pharmacological treatment fails, then referral for gastric electrical stimulation with the Enterra device can be effective in up to 70% of cases³³, independent of effects on gastric emptying. Similarly, in pilot studies treatment directed at the pylorus (e.g. pneumatic dilatation, gastric per-oral endoscopic myotomy (G-POEM)) has been shown to relieve dyspeptic symptoms.³⁴ By contrast, in a large randomized controlled trial, patients without gastroparesis responded significantly better to antidepressant therapy, than those with objective evidence of gastric dysfunction on scintigraphy.³⁵

The presence of gallstones in an otherwise normal gallbladder should not be considered a routine indication for surgical cholecystectomy.^36–38 Similarly, as for patients without functional dyspepsia, a clear indication for appendectomy and other abdominal procedures (e.g. ovarian cystectomy) is required. If surgery is performed without definitive evidence of surgical pathology, then the success of any operation is very low and severe, postsurgical exacerbation of functional gastrointestinal symptoms is common.³⁹

The causes of dyspepsia are many and patient responses to dyspeptic symptoms are varied, including dietary change and physical and alternative therapies (e.g. yoga, acupuncture).⁴⁰ If the resources are available, then a multidisciplinary approach that can address an individual patient’s needs and wants has many advantages. Dieticians are required to introduce an effective exclusion diet (e.g. FODMAP diet) that maintains nutritional requirements. This is necessary because many patients find it difficult to identify foods that trigger their symptoms.⁴¹ Similarly, physiotherapists can teach abdominal breathing exercises and relaxation techniques that are effective for the treatment of functional bloating and of rumination syndrome.^23,42 The support of psychiatric services is appropriate for patients with major depression, an anxiety disorder or eating disorders who can present with dyspeptic symptoms.^19,20

An effective and trusting doctor–patient relationship is the basis for successful management of functional gastrointestinal disease. If such a relationship is in place, then presenting the patient with a clear diagnosis, an explanation of what causes symptoms and simple advice about how to self manage the condition may be all that is required. For the related condition of functional noncardiac chest pain, it has been shown that well-informed patients are more satisfied, cope with symptoms better and seek medical attention less frequently.⁴³ These findings were independent of the final diagnosis and disease severity.⁴³ By contrast, there is very little evidence that comprehensive investigation provides lasting reassurance in this patient group. Good communication is an essential part of any treatment plan!