Clinical focus: Dealing with dyspepsia

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Key facts

• Dyspepsia (indigestion) and heartburn are common conditions that affect the upper GI tract
• Symptoms are usually minor and treatable in primary care, taking a stepwise approach
• Some symptoms can lead to longer-term problems; others have more serious underlying causes that require referral.

Learning objectives

After reading this educational feature you should:

• Understand the possible causes of heartburn and dyspepsia
• Be able to recommend appropriate self-care measures and treatments for minor symptoms
• Be familiar with red flags and know when to refer patients to their GP.

It is estimated that around 40 per cent of people in the UK experience dyspepsia (indigestion) every year, while 25 per cent experience heartburn.

Symptoms are usually more of a minor inconvenience than anything to worry about. Sometimes, however, they may lead to a long-term health problem, such as inflammation and narrowing of the oesophagus. In other cases, there may be a more serious underlying cause, such as a peptic ulcer or Barrett’s oesophagus.

One in 20 people with acid reflux, which can cause heartburn, have Barrett’s oesophagus, in which some cells grow abnormally. This may be an early sign of oesophageal cancer, which is often diagnosed in its latter stages once it has spread to other parts of the body and is then difficult to treat.

NHS screening

A clinical trial (BEST4 Screening) is now aiming to determine whether a quick ‘pill-on-a-thread’ capsule sponge test can be used to screen people with chronic heartburn for Barrett’s oesophagus. Currently, patients with chronic heartburn are diagnosed mainly using endoscopy, but availability is limited through the NHS.

A previous clinical trial has shown that the capsule sponge test picks up 10-times more cases of Barrett’s oesophagus in people with chronic heartburn than routine GP care.

“The capsule sponge is changing how we detect Barrett’s oesophagus and oesophageal cancer,” says Professor Rebecca Fitzgerald, chief investigator for Heartburn Health (see below), professor of cancer prevention at the University of Cambridge and director of the Early Cancer Institute. “Catching it earlier can save lives and reduce the need for chemotherapy and surgery to remove the oesophagus.”

Elsewhere, the University of Cambridge and Queen Mary University of London have announced that they are working with the NHS on the establishment of Heartburn Health, which is a platform for research into chronic heartburn and its associated health conditions. Men over 55 years of age and women over 65 who are taking medication for chronic heartburn are being invited by text message to join the initiative.

NICE guidelines

According to NICE guidance, community pharmacists should offer initial and ongoing advice for people with dyspepsia symptoms. This includes lifestyle changes, using OTC medicines, support with prescribed medicines and signposting to a GP if necessary.

Identifying symptoms

Dyspepsia is a non-specific term used to describe upper gastrointestinal tract (GI) discomfort that lasts for four weeks or more. The symptoms occur after eating or drinking and may include bloating, stomach cramps, nausea and/or vomiting, a feeling of fullness as well as heartburn.

Many people with these symptoms have functional dyspepsia, which has no identifiable underlying cause.

• Functional dyspepsia
The British Society of Gastroenterology describes functional dyspepsia as a common disorder of the gut-brain interaction that affects around 7 per cent of the UK population. The nerves in the stomach become over-sensitive, causing pain – this may be associated with stress, anxiety and depression. Functional dyspepsia may also be linked to increased levels of Helicobacter pylori (H. pylori) bacteria in the stomach and may occur with irritable bowel syndrome.

• Heartburn
The main symptom of heartburn is a burning pain in the chest, caused by stomach acid rising up the oesophagus. The acid may reach as far up as the mouth, leading to a sour taste, nausea and a sore throat. Some people have a hoarse voice or are constantly clearing their throat, coughing or choking. Heartburn may be worse at night (nocturnal heartburn) or after eating, bending over or lying down (postprandial heartburn).

• GORD
If acid reflux occurs regularly, this is usually a sign of gastroesophageal reflux disease (GORD). Risk factors include being overweight, smoking, drinking excess alcohol, pregnancy and having a hiatus hernia. The underlying cause of GORD is a weakened sphincter muscle at the bottom of the oesophagus. This muscle usually opens so that food can pass into the stomach and then closes to stop acid leaking back up into the oesophagus. If the sphincter muscle becomes weakened and doesn’t close fully, acid reflux can occur.

• Peptic ulcer disease
Around 80 per cent of people with dyspepsia have underlying peptic ulcer disease. This is usually caused by an H. pylori infection. Peptic ulcers often run in families but can also be common in people who smoke or take non-steroidal anti-inflammatory drugs (NSAIDs) regularly.

Seeking a diagnosis

According to the British Society of Gastroenterology, dyspepsia is generally diagnosed by assessing a patient’s symptoms while screening for red flags. Patients should also be asked about regular use of medicines that can trigger dyspepsia, such as calcium antagonists, nitrates, bisphosphonates, corticosteroids and NSAIDs.

Patients with persistent symptoms should be tested for H. pylori infection with a stool antigen test or breath test. Those considered to be at high risk of infection include older people, patients of North African ethnicity and those living in a known high-risk area. Some pharmacies sell H. pylori rapid testing kits directly to customers. If a person has a positive result, they should be referred to their GP.

Most people with dyspepsia but no alarm symptoms are not usually offered an endoscopy or any other tests. However, the British Society of Gastroenterology recommends an endoscopy for those aged 55 years and older with dyspepsia alongside weight loss, treatment-resistant symptoms, or nausea or vomiting, and in those aged 40 years or older with an increased risk of gastric cancer or upper gastrointestinal cancer.

Patients aged 60 years or older with dyspepsia, abdominal pain and weight loss should be referred for abdominal CT scanning to exclude pancreatic cancer. Ideally, people with functional dyspepsia should be referred to a secondary care clinic with access to a specialist doctor, diet and lifestyle support, effective medicines and gut-brain behavioural therapies.

Self-care

Many people find that simple lifestyle changes can ease mild to moderate dyspepsia symptoms. These changes include:

• Losing weight if appropriate
• Stopping smoking
• Avoiding common dietary triggers such as alcohol, coffee (and other caffeine-rich drinks), chocolate, citrus fruits or juices, tomatoes, mint and fatty foods
• Avoiding acidic or spicy foods or drinks that may irritate the oesophagus
• Not lying down immediately after eating – lying on the left side may be more comfortable
• Raising the head of the bed so a person is more upright when lying down
• Taking regular exercis
• Wearing comfortable clothes that are not restrictive or tight around the waist and chest
• Drinking ginger or chamomile tea
• Relaxation therapies, cognitive behavioural therapy and hypnotherapy – especially for functional dyspepsia

Certain eating habits can also worsen heartburn and dyspepsia symptoms. Management advice includes eating smaller meals during the day and avoiding eating large meals close to bedtime or before exercising.

“Making sure that patients are as relaxed as possible at mealtimes is really important,” says Debbie Grayson, a pharmacist and nutritional therapist who runs Digestion with Confidence (digestionwithconfidence.co.uk). “Most patients are extremely busy and often ‘inhale’ food without taking time to chew, which can be a huge issue to someone with compromised digestion. The chewing process reduces the burden on stomach acid and other digestion factors.”

Not everyone finds it easy to change their lifestyle on their own, so they may need specialist advice. “Pharmacy teams can signpost customers to alcohol liaison services, stopping smoking services or NHS weight management services,” says Julie Thompson, information manager at the charity Guts UK. “Anyone who is struggling to eat or manage limited food choices should be referred to a NHS dietitian.”

Stepwise treatment

Most people with dyspepsia and heartburn will be looking for OTC medicines to ease their symptoms, rather than making an appointment with their GP. According to NICE guidelines, it is important that symptoms are treated in a stepwise approach by using the most effective lowest dose of a proton pump inhibitor (PPI) as required, and returning to self-treatment ‘as needed’ with antacids and/or alginates.

• Antacids
Antacids are alkaline liquids or tablets that neutralise stomach acid. They usually work immediately and are best taken after meals and before going to bed. These products may be useful for short-term symptom control but should not be taken regularly for long periods.

• Alginates
Alginates form a thick coating over the stomach contents, acting as a protective barrier. These are often combined with antacids to treat acid reflux. Their effects only last for a few hours at a time and again these should not be used for long periods. Both alginates and antacids work best when taken with food or soon after eating.

• PPIs
PPIs decrease acid secretion. They can be recommended if antacids and alginates do not work or the symptoms keep coming back.

PPIs should be used at the lowest effective dose for the shortest time possible. A two-week course of omeprazole or esomeprazole can be sold OTC for adults over the age of 18 years for the short-term relief of dyspepsia-like symptoms. If customers require a longer PPI course, they will need to speak to their GP.

A GP may prescribe a PPI for four to eight weeks, depending on symptom severity. If reflux has caused severe oesophagitis, the dose can be doubled. If this approach isn’t working, or the symptoms continue or return at the end of the course, an endoscopy may be advised.

If patients are being tested for H. pylori infection with a breath test or a stool antigen test, they should not take PPIs for two weeks beforehand. If they test positive for H. pylori, they should be treated with eradication therapy. This involves a week-long course of two antibiotics (amoxicillin and either clarithromycin or metronidazole) alongside a PPI.

In most cases, one course of eradication therapy will treat the infection. If patients still have symptoms after the seven-day course, second-line eradication therapy should be prescribed and possibly a third-line course after that, if required.

If people with functional dyspepsia test negative for H. pylori, the GP may prescribe a low-dose PPI or standard dose H2-receptor antagonist for one month to see if their symptoms resolve.

If functional dyspepsia persists, a GP may refer the patient to specialised care or prescribe a low-dose tricyclic antidepressant to calm down the gut muscles and reduce pain sensations.

Dietary and lifestyle advice is the first-line management approach for GORD during pregnancy, and taking antacids with alginates if required. If these measures don’t work, omeprazole can be prescribed to help control symptoms.