CCFP Topic: Dyspepsia

To paraphrase the CAG definitions, dyspepsia describes the broad category of upper GI syndromes accompanied by symptoms of gnawing or burning epigastric pain, and may or may not include bloating, nausea or vomiting, burping, or regurgitation of food or stomach acid. Essentially it sounds like an undifferentiated upper GI complaint.

Unfortunately, there is overlap in symptoms with other conditions that are not gastrointestinal in nature.

Our goal is to rule out the potentially serious causes, and to hopefully determine a diagnosis so we can treat it. The AAFP has an article on dyspepsia that outlines the possible GI causes. We will use this to guide our differential and go over how we might rule them in or out on history and physical.

Also, we will assume that for every patient we’re going to get a reasonable history that includes OPQRSTAAA, and focus on some of the more specific points to inquire about.

ACS

First, as the objectives indicate, we cannot miss ACS. Whether you’re in a clinic or the ED, this is the big one.

Although we talked about acute coronary syndrome extensively in the chest pain episodes, we will include a couple of the highlights to ask about when taking your history for an epigastric or thoracic pain. Keep in mind the symptoms of ACS are quite variable between patients, including the location and nature of the pain, and the associated symptoms like nausea.

The following points on history all have likelihood ratios of approximately 2, in favour of ACS as the diagnosis.

• Ask about cardiac history and risk factors including abnormal stress test or peripheral artery disease
• Ask if their symptoms are associated with exertion
• Ask about radiation to bilateral jaw or arms
• Ask about a change in symptoms within the last 24 hours

Your physical should include a cardiac exam, but we’re not likely to find much in either a GI syndrome or an ACS. Instead getting an ECG and troponin should be top priority if there is any concern this may be cardiac.

Of course, if you’re in clinic and there’s any concern this is ACS you should immediately call 911

Pulmonary/Other Cardiac

I couldn’t find a lot of information pointing to pulmonary or other cardiac causes as part of the differential for dyspepsia, but it’s worth thinking about since the main symptom of dyspepsia is epigastric discomfort.

Be sure to rule out pneumonia or pulmonary empyema, as well as pericarditis, all of which can have similar low chest pain. Ask about fever, cough, shortness of breath and positional changes.

Physical exam, including auscultation of the lungs and heart, is more relevant as you may hear changes in breath sounds, or a classic rub. Getting a CXR or ECG can of course be useful.

GI

Moving onto the GI causes…

Here the majority of patients will fall into the category of functional dyspepsia. This means that no definite structural or biochemical cause can be identified. However, that implies that a thorough work-up has been completed. In practice, we will treat patients empirically if there are no red flags, thus a cause may not be identified. We’ll go through an algorithm for management a little later.

Of those with a discernible cause, peptic ulcers make up the largest portion. Here ask about:

• A personal or strong family history of ulcers?
• Melena
• Smoking
• Alcohol

Also inquire about medications and herbals, which we’ll go over shortly.

Physical exam may reveal epigastric tenderness or melena on a DRE, and there may be anemia on bloodwork.

Investigations can include tests for H pylori or endoscopy, depending on the presentation and level of concern. We’ll go over this a bit later.

The next most common cause is gastroesophageal reflux disease.

• Does the patient complain of heartburn or sour belches?
• Are symptoms worse when the patient is lying down?
• Does the patient have a chronic cough or hoarseness?

Physical and lab work should be pretty normal here.

Gastric or esophageal cancer makes up 1-2% of dyspepsia complaints, especially in the over 50 population. Ask about:

• Recent significant weight loss?
• Trouble swallowing?
• Recent protracted vomiting?
• History of melena?
• Smoking
• Alcohol
• Hot beverages or pickled vegetables (more common causes in Asia)

A change in weight, painless jaundice, or a mass in the abdomen may be noted.

Somewhat less commonly presenting with just dyspepsia is biliary tract disease. Here we want to ask about:

• Any history of jaundice?
• Dark urine?
• Pain occurring after meals or associated with meals or belching?

In this case, there can be RUQ or epigastric tenderness and maybe a positive murphy sign. You may also notice some jaundice. Investigations may reveal altered liver enzymes and bilirubin, or indications of an infection.

Going down our list into the less common causes of dyspepsia, we get to pancreatitis. Ask:

• Is the pain stabbing, and does it radiate to the back?
• Is the pain abrupt, is it unbearable in severity and does it last for many hours without relief?
• Is there a history of heavy alcohol use? Or any of the other 11 causes of pancreatitis (triglycerides, biliary disease, and scorpion stings are obviously the important ones to rule out)

Irritable bowel syndrome

• Is dyspepsia associated with an increase in stool frequency?
• Is pain relieved by defecation?

Metabolic disorders

• Does the patient have a medical history of diabetes mellitus, hypo or hyperthyroidism, or hyperparathyroidism?
• Do they have risk factors for hypercalcemia, like cancer or bone metastases?

Digestion and malabsorption issues, including celiac disease or lactose intolerance.

• Timing and association with types of foods?

Medication caused

• Have they used NSAIDs or COX inhibitors?
• How much alcohol or caffeine do they intake?
• Other possible medication causes include:
  • Acarbose (Precose)
  • Alendronate (Fosamax)
  • Cisapride (Propulsid)
  • Codeine
  • Iron
  • Metformin (Glucophage)
  • Oral antibiotics (e.g., erythromycin)
  • Orlistat (Xenical)
  • Potassium
  • Corticosteroids (e.g., prednisone)
  • Theophylline
• A number of herbs are also noted as causing dyspepsia:
  • Garlic – Stomach burning, nausea
  • Gingko – Mild gastrointestinal disturbances
  • Saw palmetto – Upset stomach
  • Feverfew – Gastrointestinal disturbances
  • Chaste tree berry – Gastrointestinal disturbances
  • White willow – Possibly adverse reactions similar to those of salicylates

https://www.aafp.org/afp/1999/1015/p1773.html

The red flags to watch out for when a patient complains of dyspepsia include:

• Clinically significant or unintentional weight loss (>5 percent body weight over 6 to 12 months).
• Overt gastrointestinal bleeding.
• Presence of alarm features, or a rapid progression from previous of any of:
  • Dysphagia 
  • Odynophagia
  • Unexplained iron deficiency anemia
  • Persistent vomiting
  • Palpable mass or lymphadenopathy
  • Family history of upper gastrointestinal cancer

Ok, we’ve covered the differential for dyspepsia, including ACS as a mimic, and the big GI causes, peptic ulcers, GERD and cancer. We also talked about the red flags that we need to watch out for, but what do we do once we have our history and physical?

Surprisingly, the objectives don’t cover this, but we’re going to include it anyway. The primary investigations we have in our tool box are endoscopy, testing for H pylori, and empiric therapy with a PPI.

To answer the questions of what investigations when, we’re going to look to the algorithm included in the CAG Guidelines for Dyspepsia, and screenshots of their pathway are included in the shownotes.

If the patient has any of those red flags we talked about, or if they are over 60, they should be referred for endoscopy. The timing for this is not specified and will likely depend on your specialist, or how concerned you are about this patient.

Based on the endoscopy, if there is a specific disease process or finding we will treat to that.

Otherwise if the endoscopy is relatively normal, or if there is no endoscopy performed, because they’re young or non-concerning, then testing for H pylori is suggested.

If H pylori is present, treat it with your four agents. Typically this is a PPI, bismuth, clarithromycin and metronidazole. We’ve attached a small table from the AHS pathway for H Pylori treatment based on CAG recommendations.

Then test for eradication of H Pylori at least 4 weeks after antibiotics are completed, and at least 3 days without PPI, but ideally hold PPIs for 2 weeks before testing for eradication.

If H pylori is not present, then a 4 to 8 week trial of a PPI is suggested.

If symptoms are present but improved, then continue for 6 months.

If symptoms persist and there are no new concerning features, the CAG and ACG suggests a trial of a tricyclic antidepressant or a prokinetic. If still no response to this, they actually recommend psychotherapy at this juncture.

If all that fails, or things get worse, refer for an endoscopy!

Let’s quickly talk about PPIs. The main one we use all the time is pantoprazole, but there are others, some of which are OTC including lansoprazole, esomeprazole, and omeprazole.

All the PPIs seem to be safe in pregnancy and breastfeeding, but pantoprazole has been fairly extensively studied and no dosing changes need to be made.

The typical dosing is 40mg PO once daily (ideally 30 minutes prior to breakfast – ensure your patient is timing their dose correctly before trying the next line of treatment). A dosing of 20mg per day is also an option. In practice, I haven’t seen the lower dose prescribed.

With suspected UGiBs, we go the IV route with a loading dose of 80mg followed by an infusion of 8mg per hour, though this may differ based on your site and your specialist preference. Of note, a systematic review/meta analysis from 2014 showed non inferiority when comparing PAntoprazole 40 mg IV BID to a pantoprazole infusion. That said, essentially every centre I’ve worked in is very attached to panto infusions.

• https://www.albertahealthservices.ca/assets/about/scn/ahs-scn-dh-pathway-hpylori.pdf

• https://www.cag-acg.org/images/publications/CAG_CPG_Dyspepsia_AJG_Aug2017.pdf

• https://www.uptodate.com/contents/approach-to-the-adult-with-dyspepsia

• https://www.aafp.org/afp/2010/1215/p1459.html