JANUARY 2014
DYSPEPSIA
D
yspepsia is pain or discomfort, including fullness,
early satiety, bloating or nausea, centred in the upper
abdomen. The most common cause is functional
dyspepsia.
Functional or non-ulcer dyspepsia is defined as dyspepsia
without evidence of an organic disease that is likely to explain
the symptoms. It is estimated that up to 20% of the population
complains of functional dyspepsia at some time in their lives.
Functional dyspepsia is divided into two separate syndromes –
epigastric pain syndrome and postprandial distress syndrome.
Functional dyspepsia can impact considerably on quality of life.
Symptoms
Epigastric pain or discomfort is the most common symptom in
people with functional dyspepsia. However, some people will
not complain of pain, but will experience burning, pressure or
fullness after ordinary sized meals and often cannot finish a
normal sized meal (early satiety).
People with epigastric pain syndrome report intermittent
pain or burning in the upper middle region of the abdomen
or epigastric region at least once a week. It is not relieved by
defaecation or passing of wind.
Postprandial distress syndrome presents as bothersome
postprandial fullness after an ordinary sized meal, at least
several times a week. Early satiation that prevents a meal being
finished occurs at least several times a week. Upper abdominal
bloating or postprandial nausea or excessive belching can be
present.
In summary, symptoms of dyspepsia include:
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Postprandial fullness
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Early satiety
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Epigastric burning
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Postprandial nausea
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Belching
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Abdominal bloating
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Weight loss
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Nausea and vomiting
Symptoms often worsen with eating, and can wax and wane
over time.
‘Alarm symptoms’ require immediate assessment by a
medical practitioner. These include age >55 years with new
onset dyspepsia, chronic gastrointestinal bleeding, dysphagia
(difficulty swallowing), progressive unintentional weight loss,
persistent vomiting, iron deficiency anaemia, and epigastric
mass.
Gastro-oesophageal reflux disease (GORD) should be
considered if predominant heartburn or regurgitation exists.
Comorbid conditions
Comorbid conditions are major determinants of the quality
of life impact of functional dyspepsia. Dyspepsia may coexist with reflux disease, irritable bowel syndrome (IBS), or
gastroparesis.
Causes
Dyspepsia may develop due to genetic predisposition, a viral
infection, anxiety and stress, inflammation, surgery, trauma or
Helicobacter pylori infection. Hormonal influences may play a
role in some people.
Medication causes
Medicines known to cause or exacerbate dyspepsia include
NSAIDs, aspirin, bisphosphonates (alendronate, risedronate),
tetracycline and erythromycin antibiotics, theophylline,
nitrates and calcium channel blockers.
Diet
Dietary modifications include eating smaller meals with
reduced fat intake. Fullness and bloating are directly related to
the amount of fat ingested. Foods that precipitate symptoms
should be avoided, and the time of the main meal of the day
can be changed. Stopping smoking and reduction in alcohol
intake may have some benefit.
Treatment
Treatment options for dyspepsia are limited, but should
be based on the predominant symptom. The following
medications are used for treatment of dyspepsia; however
evidence of efficacy is limited:
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Proton pump inhibitors (PPIs)
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Histamine2 antagonists
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Prokinetic agents
DYSPEPSIA
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Tricyclic antidepressants (TCAs)
Serotonin reuptake inhibitors (SSRIs)
Eradication of Helicobacter pylori improves symptoms of
dyspepsia in only 7% of people treated.
Treatment should not be prolonged as functional dyspepsia is
generally a relapsing and remitting condition.
Proton pump inhibitors
Proton pump inhibitors are one of the most popularly
prescribed drugs in Australia for functional dyspepsia as well
as GORD and peptic ulcer disease. PPIs are more effective
than antacids and H2 antagonists at reducing symptoms of
dyspepsia.
For functional dyspepsia, PPIs have limited effectiveness and
there is no evidence of a difference in outcomes between
H2 antagonists and PPIs. Benefits of PPIs may be confined to
those people who have co-existing reflux symptoms, but are
ineffective with dysmotility-like symptoms such as fullness or
bloating.
A trial of PPIs for four to eight weeks is worthwhile, but
treatment should be ceased if symptoms are not controlled.
If effective, the dose of the PPI should be reduced or ‘stepped
down’ to find the lowest effective dose. Intermittent or on
demand use is reasonable to manage symptoms.
(Motilium) and metoclopramide (Maxolon) can be trialled.
These agents are dopamine antagonists with antiemetic
properties, usually used for diabetic gastroparesis. They
may improve gastric emptying by stimulating gastric smooth
muscle contractions.
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domperidone 10 to 20 mg orally, 3 to 4 times daily
before meals
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metoclopramide 5mg orally, 4 times daily
Domperidone should be started at the low dose due to
concerns of an increased risk of serious ventricular arrhythmias
or sudden cardiac death, particularly in patients taking daily
doses greater than 30 mg, and in patients older than 60 years
of age. If dizziness, palpitations, syncope or seizures occur, the
medication should be stopped immediately. Domperidone
also can cause a number of serious drug interactions.
Risk of extrapyramidal side effects limits the use of
metoclopramide in older people.
Other medications
If the predominant symptom is epigastric pain, tricyclic
antidepressants, tramadol, gabapentin and duloxetine are
suggested. There is no evidence for SSRI antidepressants in
treating functional dyspepsia.
There is some evidence that the herbal preparation (STW5
[Iberogast]) may be of value in treating functional dyspepsia.
Long-term use of higher dose PPIs are associated with an
increased risk of hip fracture, community acquired pneumonia,
and Clostridium difficile infections.
Other approaches include referral to a clinical psychologist
for assessment and cognitive behavioural therapy or
hypnotherapy.
Proton pump inhibitors include:
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Esomeprazole (Nexium)
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Omeprazole (Losec)
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Pantoprazole (Somac)
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Lansoprazole (Zoton)
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Rabeprazole (Pariet)
Summary
Histamine H2-receptor antagonists
References
Aliment Pharmacol Ther 2012;36:3-15.
Am J Gastroenterol 2012;107:1615-20.
BMJ 2013;347:f5059.
Aust Prescr 2012;35(6):199.
AMH Drug Choice Companion: Aged Care, 2010.
Histamine H2-receptor antagonists reduce acid production
and may be effective in relieving symptoms of dyspepsia.
Cimetidine is rarely used as it has many drug interactions and
needs to be taken up to 4 times daily. Famotidine, nizatidine
and ranitidine are all prescribed once or twice daily. Dose
reductions are needed in people with poor renal function.
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Cimetidine (Magicul)
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Famotidine (Ausfam, Pamacid, Pepzan)
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Nizatidine (Tazac, Tacidine)
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Ranitidine (Zantac, Rani2, Ranoxyl, Ulcaid)
Prokinetic agents
If the patient’s main symptom is a feeling of discomfort,
fullness and bloating, prokinetic agents such as domperidone
Functional dyspepsia is associated with a major impact on
quality of life and treatment options are limited. Therapy
should initially be based on the predominant symptom.
Pharmacist-conducted medication reviews (RMMRs) can
identify medications that can cause or exacerbate dyspepsia.