Dyspepsia

Dyspepsia describes a range of upper gastro-intestinal symptoms, which are typically present for 4 or more weeks

Symptoms
  • Upper abdominal pain or discomfort
  • Fullness
  • Bloating
  • Nausea
  • Gastric reflux
Causes
  • Indigestion
  • GORD
  • Gastro-oesophageal malignancy
  • Duodenal ulcers
  • Gastritis
Aims of Treatment

The aim of treatment is to manage symptoms, and where possible, to treat the underlying cause of dyspepsia.

Urgent referral [ALARM Acronym):

  • Anaemia
  • Loss of weight
  • Anorexia
  • Recently changed, unexplained new dyspepsia in 55+ years unrespsonive to treatemtn
  • Malaena
Drugs Causing Dyspepsia
  • Alpha-blockers,
  • Antimuscarinics
  • Aspirin
  • Benzodiazepines
  • Beta-blockers
  • Bisphosphonates,
  • Calcium-channel blockers
  • Corticosteroids
  • Nitrates
  • Non-steroidal anti-inflammatory drugs (NSAIDs)
  • Theophylline
  • Tricyclic antidepressants, should be reviewed.

The lowest effective dose should be used and if possible, stopped.

Uninvestigated Dyspepsia
  • Antacids for symptomatic relief (not for longtern use)
  • PPI for 4 weeks
  • Public Health England recommends that patients who are at high risk for H. pylori infection should be tested for H. pylori first, or in parallel with a course of proton pump inhibitor.
Investigated (Functional) Dyspepsia 
  • H.Pylori testing and management
  • PPI or H2 antagonists treatment for 4 weeks

Pharmacological Treatment

Antacids – Neutralise stomach acids

Aluminium salt- Causes constipation

Magnesium salt Causes diarrhoea

Calcium salt

Potassium salt

Sodium salt

Sodium content:

High sodium content may cause hypertension, heart, liver or kidney failure

Low sodium content: Maalox and Mucogel, Altracite plus

Antacid interactions: Tetracyclin i.e. doxycycline, Quinolones, Bisphosphates (do not take antacids 2 hours before or 2 hours after). Damages enteric coating by increases gastric pH

Alignates- Forms viscous raft on top of stomach contents to prevent reflux

Sodium alignate

Alginic acid

H2 Antagonists 

Famotidine

Dose: 20-40mg once daily

Renal adjustment: Use normal dose every 48 hours or use half normal dose if
eGFR <50

Pregnancy: Avoid (benefit vs risk)

Breastfeeding: Present in breastmilk but not known to be harmful


Cimetidine

Dose: 400mg twice daily

Renal: See BNF

Pregnancy: Avoid

Breastfeeding: Avoid 


Ranitidine

Dose: 150mg-300mg twice daily

Renal: Use half normal dose if
eGFR <50

Pregnancy: Avoid unless essential

Breastfeeding: Not harmful

H2 antagonists side effects:
Constipation, diarrhoea, dizziness, fatigue, headache, myalgia and skin reactions

H2 antagonists caution: H2-receptor antagonists might mask symptoms of gastric cancer; particular care is required in patients presenting with ‘alarm features’ therefore gastric malignancy should be ruled out before treatment.


Proton Pump Inhibitors
Lansoprazole: 
Dose: 15-30mg Once Daily

Pregnancy: Avoid

Breastfeeding: Use in caution- present in breastmilk but unlikely to be harmful

Side effects specific to lansoprazole: Dry throat and fatigue

Dose adjustment:  Dose reduced by 50% in moderate to severe impairment.

Esomeprazole: 
Dose: 20-40mg once daily

Pregnancy: Caution

Breastfeeding: Caution

Dose adjustments: Max. 20 mg daily in severe impairment

Omeprazole
 Dose: 20-40mg once daily

Pregnancy: Not harmful 

Breastfeeding: Not harmful

Interaction: Clopidogrel (reduced anti-platlet effect, usually switched to lansoprazole)

Pantoprazole

Dose: 20-40mg once daily

Pregnancy: Avoid

Breastfeeding: Not known to be harmful

Side effects (specific to pantoprazole): Asthenia, gastrointestinal discomfort, sleep disorder

Rabeprazole

Dose: 20 once daily

Pregnancy: Not harmful

Breastfeeding: Not harmful

PPI common side effects:  
Abdominal pain, diarrhoea, constipation, dry mouth, headache, insomnia and nausea

PPI MHRA warning: 
Very low risk of subacute cutaneous lupus erythematosus (September 2015). If patient develops lesions and it is accompanied by arthralgia: advise them to avoid exposing the skin to sunlight and consider discontinuing PPI treatment with consideration to benefit v risk. 

PPI cautions: 

Risk of osteoporosis
Patients at risk of osteoporosis should take an adequate intake of calcium and vitamin D

Gastric Cancers:
Gastric malignancy should be ruled out before treatment.

GI infections: 
More prone to contracting C.Difficile

Longterm use:
-Risk of electrolyte imbalance (hypomagnesemia, hyponatremia). 
-Fractures
-Rebound acid reflux once discontinued