Dyspepsia and GORD

Quick Overview

Dyspepsia (epigastric pain/discomfort) affects ~25% of the population annually. GORD (gastro-oesophageal reflux disease) results from lower oesophageal sphincter dysfunction causing acid reflux. NICE CG184 provides evidence-based guidance on PPI prescribing, H. pylori management, and when to refer urgently. Key focus: distinguishing uncomplicated dyspepsia from alarm features requiring endoscopy within 2 weeks.

Core Facts & Concepts

Definitions & Epidemiology

• Dyspepsia: Epigastric pain/burning, postprandial fullness, early satiety for ≥4 weeks
• GORD: Symptoms (heartburn, regurgitation) ± oesophageal mucosal injury from reflux
• Prevalence: 10-30% adults; only 10-15% have erosive oesophagitis on endoscopy

🚩 Red Flag Symptoms (Urgent Endoscopy <2 weeks)

• Age ≥55 years with unexplained persistent dyspepsia
• Dysphagia (any age)
• Progressive unintentional weight loss
• Persistent vomiting
• Upper abdominal mass
• Iron-deficiency anaemia
• Gastrointestinal bleeding (melaena/haematemesis)

H. pylori Testing Strategies

• Test-and-treat: For uninvestigated dyspepsia without red flags, age <55
• Methods: Urea breath test (UBT) or stool antigen test (NOT serology)
• Stop PPI 2 weeks before testing (false negatives)
• Eradication therapy: 7-day triple therapy (PPI + amoxicillin + clarithromycin/metronidazole)
• Confirm eradication: UBT ≥4 weeks post-treatment

PPI Prescribing (NICE CG184)

• Initial: Full-dose PPI (e.g., omeprazole 20mg) for 4 weeks
• Maintenance: Lowest effective dose, on-demand therapy preferred
• Review annually: Attempt dose reduction or stopping

Problem-Solving Approach

Step-by-Step Management

1. Assess for red flags → Urgent endoscopy if present (age ≥55 + new dyspepsia = red flag)
2. Review medications: NSAIDs, calcium antagonists, nitrates, bisphosphonates (cause/worsen symptoms)
3. Lifestyle modifications (offer to all):
   • Weight loss if BMI >25
   • Avoid late-night meals (≥3 hours before bed)
   • Reduce alcohol, caffeine, fatty foods
   • Smoking cessation
   • Elevate bed head (not extra pillows)
4. H. pylori test-and-treat (age <55, no red flags):
   • Stop PPI 2 weeks before test
   • Eradicate if positive
   • Confirm eradication ≥4 weeks post-treatment
5. Empirical PPI trial: Full-dose × 4 weeks if H. pylori negative or eradication confirmed
6. Step-up therapy: Double-dose PPI or add H2-receptor antagonist (e.g., ranitidine) if inadequate response
7. Refer for endoscopy: Persistent symptoms after treatment, recurrent relapse, or patient preference

⚠️ Warning: Do NOT use serology for H. pylori testing-remains positive after eradication, cannot confirm current infection.

Analysis Framework

Differential Diagnosis of Dyspepsia

When to Step Down/Stop PPI

• Symptom-free for 4-8 weeks → Trial dose reduction
• Attempt on-demand therapy (take when symptomatic)
• Review annually-long-term PPI risks: C. difficile, osteoporosis, hypomagnesaemia

Visual Aid

Key Points Summary

✓ Red flags (age ≥55 + new dyspepsia, dysphagia, weight loss, anaemia, GI bleeding) → urgent endoscopy <2 weeks

✓ Test-and-treat H. pylori in age <55 without red flags using UBT or stool antigen (stop PPI 2 weeks before)

✓ PPI therapy: Full-dose × 4 weeks initially, then step down to lowest effective dose or on-demand (NICE CG184)

✓ Lifestyle modifications: Weight loss, avoid late meals, reduce alcohol/caffeine, smoking cessation, elevate bed head

✓ Confirm H. pylori eradication with UBT ≥4 weeks post-treatment (NOT serology-stays positive)

✓ Review PPI annually: Attempt dose reduction/stopping-long-term risks include C. difficile, osteoporosis, hypomagnesaemia

✓ Refer for endoscopy: Persistent symptoms despite treatment, recurrent relapse, patient preference for investigation