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Dyspepsia

 

Differential diagnosis of dyspepsia

  • Peptic ulcer disease (PUD)
  • Oesophagitis/Gastritis
    • Alcohol; NSAIDs; stress
    • Hiatus hernia
    • Barrett’s oesophagus
  • GORD (Gastro-Oesophageal Reflux Disease)
  • Malignancy
  • Oesophageal spasm
  • Biliary causes
  • Other causes of upper abdominal pain
    • Angina; AAA; musculoskeletal; pancreatitis

 

 History of dyspepsia

  • Presenting complaint
    • Upper abdominal pain/discomfort
    • Bloating
    • Nausea/vomiting
    • Association with eating/opening bowels
    • Early satiety
    • Positional element
  • ALARMS symptoms: think malignancy
    • Anaemia
    • Loss of weight
    • Anorexia
    • Recent progression
    • Malaena or haematemesis
    • Swallowing difficulty (dysphagia)
  • Past medical history
    • Previous gastric/GI malignancy
    • Previous gastric surgery
  • Medications
    • NSAIDS
    • Corticosteroids
    • Bisphosphonates
    • PPIs and compliance/length of treatment
    • Antacids
  • Family history
    • Gastric or other GI malignancy
    • Iron deficiency anaemia
  • Social history
    • Smoking
    • Alcohol

 

 Examination of dyspepsia

  • Signs of anaemia
  • Cachexia
  • Lymphadenopathy (check for Virchow’s node)
  • Abdominal tenderness in epigastrium/right upper quadrant
  • Abdominal mass

 


Lecture on the investigation and treatment of dyspepsia

 

 Initial management of dyspepsia

See NICE guidance for full recommendations: NICE – Dyspepsia

  • Lifestyle advice
    • Weight loss; smoking cessation; avoid precipitants; raise the head of the bed; don’t eat late at night
    • Stop NSAIDs/Bisphosphonates/steroids
    • Use of antacids (eg. Gaviscon, Peptac) PRN.
  • Trial of full-dose proton pump inhibitor (PPI) for 4-8 weeks for patients with GORD symptoms.
  • Offer antihistamine therapy (e.g. Ranitidine 150mg once –twice daily) if inadequate response to PPI.
  • Test for Helicobacter pylori (H. pylori) if symptoms persist. Allow a 2 week washout period after stopping the PPI.
    • Treat H. pylori if positive or if endoscopic evidence of PUD
    • Eradication therapy with e.g. Amoxicillin 1g twice daily and Clarithromycin 500mg twice daily plus full-dose PPI for 7 days.
    • If allergic to penicillin then substitute Clarithromycin 250mg and Metronidazole 400mg both twice daily.
  • Upper GI endoscopy if symptoms persist despite above

 

 Further management of dyspepsia

  • Urgent (within 2 weeks) upper GI endoscopy if:
    • ALARMS symptoms present
    • Age > 55
    • High risk i.e. previous gastric surgery; FHx gastric malignancy

 

Click here for medical student OSCE and PACES questions about dyspepsia

Common dyspepsia exam questions for medical students, finals, OSCEs and MRCP PACES

 

Click here to download free teaching notes on dyspepsia: Presentation-Dyspepsia

Perfect revision for medical students, finals, OSCEs and MRCP PACES