Quick guide of dyspepsia

This is a quick and complete guide of dyspepsia for specialists and professional pharmacists.
Abdelwahab Ward, BS Pharm, PharmD

Overview ã…¡ Dyspepsia is a predominant epigastric pain. It may be associated with epigastric fullness, nausea, heartburn, or vomiting. Endoscopy is warranted in all patients aged 60 years or older and selected younger patients with "alarm" features. 

     In all other patients, testing for Helicobacter pylori is recommended; if positive, empiric treatment is started. Patients who are H. pylori-negative or who do not improve after H. pylori eradication should be prescribed a trial of empiric proton pump inhibitor therapy. Patients with refractory symptoms should be offered a trial of a tricyclic antidepressant, a prokinetic agent, or psychological therapy.

ASSESSMENT

Symptoms and signs. History entails chronicity, location, and quality of the epigastric pain but has limited diagnostic utility. Postprandial fullness. Heartburn and nausea or vomiting. Concomitant weight loss, persistent vomiting, constant or severe pain, progressive dysphagia, hematemesis, or melena warrants endoscopy or abdominal CT imaging.

DIAGNOSIS

Investigations and imaging. Obtain complete blood count, serum electrolytes, liver enzymes, calcium, and thyroid function tests. Fecal antigen test and urea breath test for H. pylori. Abdominal ultrasonography or CT scanning is indicated if pancreatic or biliary tract disease is suspected.

Diagnostic procedures. In patients younger than 60 years with uncomplicated dyspepsia, initial noninvasive strategies should be pursued. Upper endoscopy can be used to diagnose gastroduodenal ulcers, erosive esophagitis, and upper gastrointestinal malignancy. However, it is mainly indicated to look for upper gastric or esophageal malignancy in patients over age 60 years with new-onset dyspepsia (in whom there is increased malignancy risk) and in selected younger patients with "alarm" features (1) In patients under age 60, the risk of malignancy is < 1%, even among patients with reported "alarm" features, such as Progressive weight loss, (2) Rapidly progressive dysphagia, (3) Severe vomiting, (4) Evidence of bleeding or anemia, (5) Jaundice.

     In patients with refractory symptoms or progressive weight loss, consider obtaining antibodies for celiac disease (IgA tissue transglutaminase [tTG] antibody) or stool testing for ova and parasites or Giardia antigen, fat, or elastase.

MANAGEMENT

MEDICATIONS
  • Proton pump inhibitors: Omeprazole, esomeprazole, or rabeprazole 20 mg once daily orally, pantoprazole 40 mg once daily orally or dexlansoprazole or lansoprazole, 30 mg once daily orally.
  • Antidepressants: (e.g., desipramine or nortriptyline, 25–50 mg) each night at bedtime orally.
  • Buspirone: Dosage 10 mg three times daily 15 minutes before meals orally. It promotes gastric accommodation and reduces postprandial bloating and fullness in some patients.
  • Metoclopramide: Dosage 5–10 mg three times daily orally. It may improve symptoms. However, cannot be recommended for long-term use due to the risk of tardive dyskinesia.
  • IPrucalopride: Dosage 2 mg once daily orally. It has demonstrated improvement in gastric emptying and symptoms in patients with gastroparesis. However, its efficacy has not been studied in functional dyspepsia (in patients with no demonstrable organic cause). It is approved for treatment of chronic constipation.
  • H. pylori eradication therapy benefits 5–10% (see Helicobacter pylori Gastritis). For further information, see notes "Appropriate drug regimens for Helicobacter pylori eradication" and Approach to gastritis".

REFERENCES

Abdelwahab Ward, BS Pharm, PharmD