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Dyspepsia: a common but highly treatable condition

Elaine Cockram
RGN BSc(Hons)
Nurse Practitioner
Lead Nurse
Edgware Walk-in Centre and Urgent Treatment Centre
E:elaine.cockram@ ntlworld.com

Dyspepsia is a very common ailment within the general population. It has a prevalence of between 23% and 41%, yet only about a quarter of sufferers will consult their GP.(1) This means that a large proportion of symptomatic individuals in the community are either putting up with their symptoms or probably treating themselves with simple antacids and other remedies purchased over the counter from chemists and shops. Nurses can expect to encounter these symptomatic patients within their clinical settings and must be prepared to give necessary treatment and advice.

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What is dyspepsia?
Dyspepsia, indigestion and heartburn are broad terms often used by patients to describe pain or discomfort that arises in the upper gastrointestinal tract. The pain may be located anywhere from the epigastrium to the throat, and it characteristically worsens with stooping, lying down and food intake. The pain is often described as a "burning sensation" and is relieved by antacids. Other symptoms include waterbrash (mouth fills with saliva), nocturnal cough or wheeze, nausea, vomiting or regurgitation. It is important to determine the severity of the symptoms and to what extent they are affecting daily life.
Most dyspeptic symptoms emanate from their oesophagus, stomach or duodenum. The symptoms may be due to oesophagitis, gastritis, a duodenal ulcer, duodenitis, bile reflux, a hiatus hernia, gastric ulcer or gastric cancer.(2) Dyspepsia can be classified as:(3,4)
Ulcer-like dyspepsia - pain related to the stomach area. Characteristics include:

  • Pain relieved by antacids.
  • Pain experienced before meals or when hungry.
  • Pain is periodic (pain-free intervals of weeks).
  • Nighttime pain (disturbs sleep).

Reflux-like dyspepsia - symptoms tend to be retrosternal and may be accompanied by regurgitation of acid. Characteristics include:

  • Discomfort on stooping.
  • Pain after large meals.
  • Pain when lying flat.
  • Nonspecific nausea or excessive belching.
  • Waterbrash (oesophageal inflammation may cause sudden brisk salivation).

Dysmotility-like dyspepsia - will have symptoms of bloating and bowel dysfunction due to delayed gastric emptying. Characteristics include:

  • Nausea or vomiting.
  • Hunger followed by early satiety.
  • Epigastric heaviness aggravated by food or milk.
  • Discomfort often relieved by belching.
  • Abdominal fullness, bloatedness and distension.
  • Diffuse, often severe pain.

Idiopathic dyspepsia - encompasses conditions that do not fit well into any of the other three categories.
 
What to consider when taking a history
The challenge in taking a history is to distinguish those few patients with potentially serious problems from the majority who have no specific treatable problem or diagnosis. To make a competent assessment for patients with dyspepsia it is important to glean information about the site and character of the pain and any aggravating or relieving factors. Anxieties the person may have about the significance of symptoms should also be addressed
Epigastric pain is likely to be of a gastroduodenal or biliary origin, whereas central abdominal pain is probably due to involvement of the small intestine.(2)
In the case study, my patient did not have acid reflux, where stomach contents are regurgitated into the oesophagus. Acid reflux may occur alone or be associated with a hiatus hernia; in each case the cause is an incompetent cardiac sphincter. Reflux of gastric acid into the oesophagus causes inflammation of the lower oesophagus. Pain when bending or stooping would indicate a hiatus hernia.
The occurrence of epigastric pain after meals suggests peptic ulceration; the occurrence of pain before a meal when the patient is hungry is suggestive of duodenal ulceration rather than gastric ulceration (although this is not always the case). As the patient in the case study was fairly young, the likelihood that no specific pathological condition would be discovered (ie, the diagnosis will be nonulcer dyspepsia) was relatively high. With increasing age, however, especially after the age 50, the diagnosis of specific conditions, such as gastric cancer and peptic ulcer disease, becomes more common.(5)
Patients with dyspeptic symptoms should always be asked about their use of NSAIDs (nonsteroidal anti-inflammatory drugs), since these medications are a common cause of peptic ulceration.
If the patient has a history of or a strong family history of cardiac disease and/or smokes it is important to consider ischaemic heart disease as a reason for the pain. Oesophageal spasm may have similar symptoms to cardiac-related pain, so an electrocardiogram (ECG) will be required; however, ECG will not exclude myocardial infarction. A trial of antacids and observation may be helpful, but if in doubt, refer.

Red flags
Patients who have the following symptoms need to be referred to the GP, as they will require further investigation:(1,6)

  • Dysphagia - food sticking on swallowing.
  • Persistent, continuous vomiting.
  • Unexplained iron-deficiency anaemia or pernicious anaemia.
  • A palpable epigastric mass.
  • Gastrointestinal bleeding - vomiting "coffee grounds" or fresh blood, stools that look like black tar or fresh blood in stools.
  • Unintentional weight loss (Ž3kg).
  • Previous history of gastric ulceration.
  • Previous gastric surgery.
  • Family history of gastrointestinal cancer in more than two first-degree relatives.
  • Severe pain.
  • Any patient over 55 with recent (
  • Suspected mesenteric ischaemia (typically symptoms of colicky periumbilical pain 15-30 minutes after eating, associated with diarrhoea).

Other symptoms that require referral are:

  • Change in bowel habit.
  • Jaundice.
  • Suspected myocardial infarction.

Examination and clinical observations
In all cases of abdominal pain, a full abdominal examination is necessary. It is also advisable to undertake baseline clinical observations such as blood pressure, temperature and pulse.
Initial attention during the physical examination should be focused on detecting signs of serious or systemic conditions. These signs include fever, jaundice, anaemia, abdominal mass and blood in the stool. Blood tests may be required to eliminate complications, such as pancreatitis, liver disease or anaemia.

Management and treatment
The nurse should be able to suggest over-the-counter medication or administer medication by patient group direction for those patients that have uncomplicated ulcer-like dyspepsia. The aim of treatment is to:

  • Relieve symptoms.
  • Prevent complications such as ulceration.
  • Prevent recurrence.

The majority of patients with a recent onset of dyspepsia will settle quickly with antacids, such as magnesium trisilicate mixture or antacid alginates (Gaviscon; Britannia), which coats the oesophagus and forms a floating raft on gastric contents.
A short course of an oral H(2)-receptor antagonist - cimetidine or ranitidine - can be given if antacids have failed. If over-the-counter medication fails it is worth trying prescription doses as these are higher and may be more effective.
Proton pump inhibitors are also recommended but should usually be reserved for people with a definite diagnosis and should not be used routinely for mild symptoms of dyspepsia.(6,7)

Known causative factors of dyspepsia
These include: drugs (aspirin and other anti-inflammatory drugs), smoking, alcohol, coffee, pregnancy, obesity, tight clothes and large meals.
The following health advice can be given to avoid the unpleasant symptoms of dyspepsia:

  • Eat frequent small meals.
  • Avoid fried foods, spices, acidic foods - coffee, tea, cocoa, tomato products, citrus fruits and milk are all potent stimulators of acid secretion.(8)
  • Avoid gastric irritant drugs.
  • Smoking cessation can accelerate the healing of a gastric ulcer.
  • Curb caffeine and alcohol intake.
  • Avoid eating before bedtime.
  • Reduce weight if required.
  • Wear loose, nonrestrictive clothing.

Reviewing the patient
The patient must be reviewed to determine whether the initial treatment is working. If symptoms persist the patient will require investigations to determine the cause.
Helicobacter pylori is a bacterium linked with duodenal and gastric ulcers and is associated with an increased incidence of gastric cancers. Ingestion of the bacteria can cause acute gastritis with associated nausea and vomiting and eventually chronic ulceration.(9) Elimination of the infection with a combination of the proton pump inhibitor omeprazole and clarithromycin, a macrolide antibiotic, can achieve a 70-80% cure rate and alters the course of the disease from a chronic, relapsing condition to a cure.(10) The best test for identification of H pylori and for confirmation of eradication is the (13)C breath test - this is a carbon-tagged breath test that depends on urease degradation of urea to produce tagged carbon, which then appears in exhaled breath. This test can be performed in the treatment room and is available on prescription.(1)
 
Conclusion
To conclude, patients under the age of 55 with dyspepsia can be assessed and treated by nurses providing they do not have symptoms of complications. Nurses need to be aware of the causes of dyspepsia. Commonly, no specific cause can be identified; however, the nurse needs to be aware of the relevant disease processes within this area, so that they are confident when offering treatment and advice. The patient may require referral to their GP for further investigations such as a barium meal or endoscopy.

References

  1. British Society of Gastroenterology. Dyspepsia management guidelines. London: British Society of Gastroenterology; 2002. Available from URL: http:/www.bsg.org.uk/ clinical_prac/guidelines.htm
  2. Hope RA, Longmore JM, McManus SK, Wood-Allum CA. Oxford handbook of clinical medicine. 4th ed. Oxford: Oxford University Press; 1998.
  3. Jamison JR. Differential diagnosis for primary practice. London: Churchill Livingstone; 1999.
  4. Jones R, Murfin D. Gastrointestinal problems in the community and in general practice. In: Jones R, editor. Gastrointestinal problems in general practice. Oxford: Oxford University Press; 1993.
  5. Adelman AM. Abdominal pain: dyspepsia. In: Weiss D, editor. 20 common problems in primary care. New York: McGraw-Hill; 1998.
  6. Department of Health. Upper gastrointestinal cancers. Referral guidelines for suspected cancer. London: Department of Health; 2000. Available from URL: http://www.doh.gov.uk/ cancer/referral.htm
  7. National Institute for Clinical Excellence. Guidance on the use of proton pump inhibitors in the treatment of dyspepsia. NICE Technology Appraisal Guidance Number 7. London: NICE; 2000.
  8. Ingram Tagg P. Heartburn. Nurse Practitioner 1996;21 Suppl:9.
  9. Cottrill RB. Helicobacter pylori (update). Professional Nurse 1996;12(1):46-8.
  10. Logan RP, Gummet PA, Hegarty BT, et al. Clarithromycin and omeprazole for H. pylori (letter). Lancet 1992;340(239).

Resources
British Society of Gastroenterology
W:www.bsg.org.uk

Digestive Disorders Foundation
W:www.digestive disorders.org.uk

Medinfo®
Provides free and easy-to-understand medical information and advice to the public, written by a GP
W:www.medinfo.co.uk

Pharmiweb
A health information website designed for healthcare professionals
W:www.pharmiweb.net

Prodigy
W:www.prodigy.nhs.uk