Instagram Threads

Bay Four

          Patterns, pearls and practical medicine

Dyspepsia, peptic ulcer disease and GORD

Terminology and symptoms

  • Dyspepsia is a complex of symptoms present for > 4 weeks, including upper abdominal pain, heartburn, reflux, nausea/vomiting
      • Common, effects 40% of us each year
  • GORD (gastro-oesophageal reflux disease) is a common cause of dyspepsia
      • GORD is due to reduced tone of lower oesophageal sphincter, increased intra-gastric pressure, delayed gastric emptying, impaired oesophageal clearance of acid
      • May also cause hoarseness, cough, asthma, dental erosions
      • Can be proven by endoscopy ie oesophagitis, or not (NERD = non-erosive reflux disease)
  • Symptoms are a poor predictor of underlying pathology (but if it’s mostly heartburn and reflux – it’s probably GORD)
  • Dysphagia is not very common overall, but occurs in around 30% of erosive oesophagitis (investigation of dysphagia is covered separately in oesophageal disorders)

Causes of dyspepsia 

  • GORD
  • Barrett’s oesophagus – more common if long duration of GORD / previous oesophagitis, stricture or ulcer
  • Peptic ulceration – gastric and duodenal ulcers
  • Malignancy
  • H pylori infection
  • Pancreatobiliary disease
  • Medications – alpha blockers, anticholinergics, aspirin and NSAIDs, benzodiazepines, betablockers, bisphosphonates, CCBs, steroids, nitrates, theophylline, tricyclics
  • Gastroparesis – associated with diabetes, scleroderma, Parkinson’s and other neurological disease, post-fundoplication. Vomiting common
  • Functional – one of the most common causes
      • Postprandial distress syndrome
      • Epigastric pain syndrome
      • It is very difficult to distinguish organic from functional causes based on symptoms, demographics or risk factors
  • Zollinger-Ellison syndrome (rare) – PU disease, diarrhoea, weight loss, hypercalcaemia

Key differentials of dyspepsia

  • Cardiac disease / angina pain can radiate to the epigastrum
  • Hepatobiliary disease
  • Pancreatic disease
  • Cancer
  • Gastroenteritis
  • Coeliac disease
  • Lactose intolerance
  • IBD
  • IBS
  • Bacterial overgrowth
  • Abdominal aortic aneurysm

Risk factors for GORD

  • Smoking and ETOH
  • Stress
  • A diet high in caffeine/coffee, chocolate, fatty foods, spicy food, tomatoes
  • Obesity
  • Certain medications (see above)
  • Pregnancy
  • Hiatus hernia
  • Family history

Points in the history and exam

  • Diet (and timing of meals) and ETOH
  • Alarm symptoms – see below
  • Antacid use
  • Triggers – may include smoking, certain foods, medications, stress
  • Food restriction – this can make the symptoms worse by causing weight loss and changing gut transit time (and also strong correlation between number of foods restricted and psychomorbidity
  • Family history of upper GI cancer
  • Examine for abdominal masses
  • Document weight

Assess for ALARM symptoms

  • Loss of appetite
  • Unexplained weight loss
  • Dysphagia
  • Odynophagia
  • Haematemesis or malaena
  • Persistent vomiting
  • Early satiety
  • Persistent, severe abdominal pain

Investigations

  • OGD for some
      • Often not required initially, especially if no trial of PPI, or previous scope ok and no new alarm signs
      • Typical findings if no red flags/alarm symptoms
          • Normal in around 70% (non-erosive reflux disease or NERD)
          • Ulcers in 6%
          • Cancer in 0.5%
          • Barretts in 3%
          • Erosive oesophagitis in 20%
      • Overall (for those with and without ALARM symptoms) – 13% of those scoped for dyspepsia have PUD
      • Risk of cancer rises sharply at age 50 (but more so in men) – so often scope those aged >55 (or >40 if patient comes from area of high upper GI cancer prevalence) or in younger patients who have ALARM symptoms
      • Some advise stopping PPIs for 2 weeks beforehand and self-medicating with antacids if required
      • Can test for H pylori at the same time – A CLO test (Campylobacter-like organism test) is a rapid urease test used on a stomach tissue sample
      • Reflux oesophagitis can be graded
          • The LA classification (A-D)
          • C or D will need a follow up OGD on high dose PPI 8-12 weeks later (check for Barret’s oesophagus)
  • Gastric emptying study
      • The incidence of gastroparesis is very small compared to functional dyspepsia, so not routinely recommended
      • However 90% of patients with gastroparesis fulfil functional dyspepsia diagnostic criteria
  • Bloods
      • Include lipase/amylase, LFTs
      • Unexplained anaemia or high platelets are red flags for cancer
      • Consider coeliac screen
  • H Pylori testing
      • Not routine in dyspepsia or GORD (consider on case by case basis), but advised in PUD, persistent symptoms despite PPI, before starting NSAIDs if history of ulcers
      • Either carbon-13 breath test (first line if available) or stool
      • Ensure no PPI for 2 weeks or antibiotics for last 4 weeks
      • Don’t routinely retest if previously treated (unless concern about adherence, aspirin/NSAID indicated, family history of GI cancer, symptoms severe/persistent, person requests retesting)
      • If retesting, use the breath test. This should be done > 8 weeks after eradication
  • Other investigations to consider
      • Oesophageal manometry if dysmotility suspected (eg achalasia, scleroderma-like oesophagus)
      • Ambulatory oesophageal pH monitoring to quantify reflux and correlate to symptoms
      • Barium swallow can help diagnose hiatus hernias and achalasia

Advice for all patients with dyspepsia (and consider providing written advice)

  • Avoid the following
      • Ultra-processed food
      • Fatty food
      • Spicy food, tomatoes, chocolate
      • Caffeinated coffee
      • ETOH
      • Smoking
      • Antacids long term
  • Alter daily routine
      • Eat a while (> 3 hours) before bed
      • Regular smaller meals, eat slowly
      • Raise head of bed if possible (not extra pillows)
  • Low fodmap diet if IBS present too
  • Small particle food if history of gastroparesis
  • Weight loss (check if any drugs or other conditions contributing to weight gain)
  • Stress management

Management

  • Over the years, various management strategies have been suggested and trialled, including
      • OGD for most / all
      • Scope those who are H pylori positive
      • Test for H pylori and treat if positive (‘test and treat’)
          • Eradication of H pylori improves symptoms (NNT 12)
          • This strategy also reduces use of endoscopy
      • PPI for all comers – usually trialled for 4 weeks and if PPIs fail test for H pylori (but must be off PPI for 2 weeks pre-test)
      • Symptom-based management
  • Proton Pump Inhibitors (PPIs)
      • Can either treat empirically with full dose PPI, or use as required
      • Treat for 4-8 weeks if either negative for H pylori, or patient remains symptomatic after it’s been eradicated
      • H2 receptor antagonist may also be used (for example if inadequate response to PPI)
      • Long term PPI may be required for
          • Barrett’s
          • Those taking NSAIDs or steroids long term
          • Severe oesophagitis
          • previous stricture
          • PUD with persistent H pylori
          • Refractory / recurrent symptoms
  • Stop contributing medications if possible
      • Might reduce dose of NSAID if can’t stop them
      • Might switch to another anti-platelet
      • Try to avoid CCBs, nitrates, sildenafil/tadalafil
      • Reconsider bisphosphonates, steroids, antibiotics, benzodiazepines, tricyclics, some contraceptives, iron and potassium supplements, theophylline
  • Consider scope
  • If no scope – trial PPI and reassess

Management based on scope results

  • If GORD on scope – treat with 4 weeks of a PPI
  • If severe oesophagitis on scope – treat with 8 weeks of a PPI and consider long term PPI
  • If previous stricture – long term PPI
  • If persistent symptoms and confirmed oesophagitis
      • Consider another 4 weeks of PPI
      • Consider double dose PPI for 4/52
      • Consider adding or switching to a histamine receptor antagonist (at bedtime)
  • If persistent symptoms and OGD negative (often known as functional dyspepsia)
      • Consider other diagnoses
      • Check adherence to treatment
      • Consider switching PPI to histamine receptor antagonist
      • H pylori eradication will only help 7% of those improve if present, but worth trying. Usually don’t retest.
      • Consider specialist referral +/- additional investigations
  • If Peptic Ulcer Disease on scope
      • PUD can cause upper GI bleeds, perforation, gastric outlet obstruction, and increases risk of malignancy (if H pylori associated)
      • Eradicate H Pylori if positive
          • 60% risk of recurrence if patient remains positive, 5% if eradicated
          • Usually do this after 8 weeks of PPI if patient was taking NSAIDs, immediately if not
      • Stop NSAIDs if possible
      • Full dose PPI for 8 weeks for everyone
      • Consider repeat scope in 6-8 weeks depending on size and location of the lesion (Gastric ulcers likely need follow up, duodenal ulcers not always)
      • An unhealed ulcer – consider non-adherence, cancer, false-negative H pylori test or persistent H pylori, NSAIDs, Zollinger-Ellison syndrome, Crohn’s. More below.

H Pylori eradication

  • 35% of people in the UK are colonised (more in other countries eg Russia, Brazil, Pakistan, Turkey)
  • If not taking NSAIDs, H pylori is present in 90% of those with duodenal ulcers and 75% of those with gastric ulcers
  • Treatment is for 7 days
  • Usually with PPI twice daily + amoxicillin 1g BD + either clarithromycin 500mg BD or metronidazole 400mg BD (consider clarithromycin and metronidazole if penicillin allergic)
  • Retreatment protocols slightly different – check local guidance

Other measures

  • Prokinetics
      • Superior to placebo in meta-analysis
      • But avoid metoclopramide if history of Parkinson’s
      • Ensure no long QT if giving metoclopramide or domperidone
  • Surgery / procedures
      • Laproscopic fundoplication is the gold standard
      • Can be complicated by gas-bloat syndrome, dysphagia/strictures. May be unsuccessful.
      • Occasionally other endoscopic procedures performed in specialist centres (ablation, injection of bulking agents)
  • Occasionally amitriptyline used in epigastric pain subtype, or mirtazapine if low weight
  • Psychological treatments have shown some benefit in functional dyspepsia
  • Refer to gastroenterology if there are refractory symptoms or complications

GORD in pregnancy

  • Investigations usually not required (but always do if ALARM symptoms as usual)
  • H pylori testing and treatment usually delayed until after delivery if required
  • Treat with calcium containing antacids first line (after lifestyle addressed) in the short term. Don’t take at same time as folic acid or iron
  • Avoid bicarbonate or magnesium trisilicate
  • Omeprazole or famotidine are 2nd line

Complications of GORD

  • Oesophageal ulcers and oesophagitis (+/- anaemia). Risk of severe oesophagitis in NERD is 10%
  • Upper GI bleeds
  • Strictures
  • Aspiration pneumonia
  • Barrett’s – which increases risk of cancer to around 5% over the next 15 years
  • Oral problems – dental erosions, gingivitis

Refractory peptic ulcer disease

  • A duodenal ulcer persisting despite 8 weeks of therapy, or a gastric ulcer after 12 weeks
  • Requires sufficient acid suppression and compliance, H pylori eradicated, and cessation of NSAIDs
  • Ask whether this is a non-healing ulcer, or something else
  • Most (90%) due to
      • Ongoing mucosal injury – NSAIDS, steroids, bisphosphonates, smoking + vaping, ETOH, cocaine, cytotoxics, olemesartan
      • Poor adherence
      • Persistent H pylori
          • Restest using stool antigen (off PPI for 2 weeks)
          • Twice daily PPI dosing better than once dailt (take 30 minutes before meal)
          • 2 week course instead of one week may be required
          • 86% achieve eradication when adherent (only 44% if not fully adherent)
          • Consider Pylera for 10 days (contains bismuth, metronidazole and tetracycline and omeprazole). May be better than standard eradication therapy. Can cause darkening of tongue and stool
          • Rifabutin is also very effective (resistance <1%), but not 1st or 2nd line (partly due to cost and concerns about overuse given it’s used in TB)
          • 10% of patients are ultrafast metabolisers of PPIs (due to polymorphisms in CYP2C19) and can develop apparent refractory PUD. Can trial esomeprazole in this scenario (or vonoprazan – extremely effective, but not available in UK currently, and very expensive)
  • Consider cancer in persistent gastric ulcers
      • Red flags include
          • Large (>1cm)
          • Irregular margins or rolled edges
          • Weight loss, IDA
          • Failure to heal
      • Do 8 biopsies per ulcer (edge and base) and always repeat OGD for Gus
  • Consider hypersecretion / Zollinger-Ellison syndrome
      • Rare than most people assume
      • Multiple ulcers. Can be distal in duodenum, or jejunal (almost pathognomonic).
      • May be diarrhoea. May be family history (MEN 1 in 40%)
      • Do fasting gastrin off PPI for 2 weeks. If >10 x upper limit of normal – highly specific for ZES
      • Additional tests include gastric acid secretion test, secretin stimulation, PET CT, EUS
  • Rare causes
      • Crohn’s, CMV (eg in immunosuppressed), TB, vasculitis, Bechet’s, mastocytosis, ischaemia

 

Scroll to Top

Comments and corrections

Help us improve by reporting your comments and corrections.

Thank you!

Your comment has been sent. We review all submissions carefully.