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Dyspepsia not requiring investigation 1 Dyspepsia not requiring investigation Quick info: Routine endoscopy is not indicated in patients under age 55 years if there are none of the following alarm symptoms: - chronic gastrointestinal bleeding - progressive weight loss (unintentional) - progressive difficulty swallowing - persistent vomiting - iron deficiency anaemia - mass in epigastrium - suspicious barium meal - any patient over age 55 years with unexplained and persistent recent onset dyspepsia Excludes patients with predominant reflux symptoms Some guidelines advise endoscopy for patients over 55 years of age who present with new onset dyspepsia without alarm symptoms but the evidence for this recommendation is weak 2 Lifestyle advice, medication review and symptomatic treatment Quick info: Advise patient to avoid triggers that may be associated with dyspepsia such as: smoking alcohol coffee chocolates fatty foods Advise patient on weight reduction being overweight may cause dyspepsia Raising the head of the bed and not eating close to bedtime may reduce dyspepsia symptoms in some people Consider antacid and/or alginate therapy for immediate symptom relief Review medications that may cause dyspepsia Consider whether the following may be reduced or stopped: NSAIDs Calcium antagonists Nitrates Theophyllines Bisphoshonates Steroids 3 Review Quick info: Review upper gastrointestinal tract symptoms: upper abdominal pain or discomfort heartburn acid reflux nausea vomiting reconsider differential diagnosis 6 Advise continuing self care Quick info: Advise patient to avoid triggers that may be associated with dyspepsia such as: smoking alcohol coffee chocolates fatty foods advise patient on weight reduction, as being overweight may cause dyspepsia raising the head of the bed and not eating close to bedtime may reduce dyspepsia symptoms in some people Consider antacid and/or alginate therapy for immediate symptom relief Review medications that may cause dyspepsia Consider whether the following may be reduced or stopped: NSAIDs Calcium antagonists Nitrates Theophyllines Bisphoshonates Steroids Advise patient to consult again if symptoms return despite these measures 7 Helicobacter pylori test Quick info: Helicobacter pylori is associated with peptic ulcer disease and non ulcer dyspepsia H. pylori can be detected using: Stool antigen test : now available at NWLHT Carbon-13 urea breath test - If proton pump inhibitor (PPI) used, perform H. pylori test at least 2 weeks after finishing treatment Serology: a positive result cannot differentiate between active or past infection 10 Give eradication therapy for one week Quick info: Eradication regimens: - 11 Proton pump inhibitor (PPI) plus amoxicillin and clarithromycin PPI plus metronidazole and clarithromycin Consider proton pump inhibitor (PPI) Quick info: The benefit from proton pump inhibitor (PPI) in patients with functional dyspepsia is small – only 1 in 10 show a therapeutic gain over placebo 12 Review at 6 weeks Quick info: Review upper gastrointestinal tract symptoms: upper abdominal pain or discomfort heartburn acid reflux Nausea Vomiting 13 If symptoms persist, manage as functional dyspepsia Quick info: 16 Majority of patients will have functional dyspepsia often associated with irritable bowel symptoms and/or psychosocial factors they do not usually respond to medication aimed at the gastrointestinal track for most patients, management is based on explanation and reassurance Advise continuing self care Quick info: Advise patient to avoid triggers that may be associated with dyspepsia such as: smoking alcohol coffee chocolates fatty foods advise patient on weight reduction, as being overweight may cause dyspepsia raising the head of the bed and not eating close to bedtime may reduce dyspepsia symptoms in some people Consider antacid and/or alginate therapy for immediate symptom relief Review medications that may cause dyspepsia Consider whether the following may be reduced or stopped: NSAIDs Calcium antagonists Nitrates Theophyllines Bisphoshonates Steroids Advise patient to consult again if symptoms return despite these measures 20 Review management plan Quick info: Re-treat Refer for specialist advice Refer for endoscopy 21 If symptoms persist, manage as functional dyspepsia Quick info: Majority of patients will have functional dyspepsia often associated with irritably bowel symptoms and/or psychosocial factors they do not usually respond to medication aimed at the gastrointestinal tract for most patients, management is based on explanation and reassurance