Managing dyspepsia in primary care.

NICE recommends immediate referral for patients with dyspepsia and significant acute GI bleeding and urgent specialist referral for investigation if any of the following alarm symptoms are present: progressive difficulty swallowing; chronic GI bleeding; unintentional weight loss; persistent vomiting; abdominal mass; iron deficiency anaemia; suspicious findings on barium meal. Patients aged > 55 with unexplained and persistent dyspepsia, despite H. pylori testing and acid suppression therapy, should also be considered for endoscopy, as should those with previous gastric ulcer or surgery, continuing need for NSAIDs or raised risk of gastric cancer. Patients with uninvestigated dyspepsia should be managed by empirical treatment with a PPI or testing for and treating H. pylori if present. Testing by urea breath test, stool antigen test, or locally validated lab-based serology is suggested. H. pylori eradication is usually given as triple therapy, for seven days, involving a PPI, clarithromycin and either amoxicillin or metronidazole. It is important to take a thorough history and to enquire about any medication the patient is taking. Drugs that are common culprits for dyspepsia include: NSAIDs; calcium antagonists; bisphosphonates; steroids; theophyllines; nitrates. NSAIDs can also cause GI bleeding. Absence of dyspepsia in patients taking NSAIDs does not indicate a reduced risk of bleeding. Peptic ulcers fall into three categories: H. pylori associated ulcers; drug-induced ulcers (particularly NSAIDs); and ulcers in H. pylori-negative patients not taking causative medication. H. pylori is associated with both gastric and duodenal ulcer disease but it is in the duodenum where the closest relationship exists. In any 6-12 month period, 20-40% of healthy people, more commonly men, will experience symptoms of heartburn. Oesophageal reflux can progress to more serious disease such as erosive oesophagitis, stricture or Barrett's oesophagus.