Dyspepsia
Dyspepsia covers a range of symptoms of the upper gastrointestinal tract including upper abdominal pain or discomfort, heartburn, acid reflux and nausea or vomiting. They are all important and common symptoms in primary care. Up to 40% of adults have symptoms of dyspepsia; 5% of the population consults their GP about it, and 1% of the population is referred for endoscopy each year. Of those who do have an endoscopy, 40% have non-ulcer (functional) dyspepsia, 40% have gastro-oesophageal reflux disease (GORD) and 13% have some form of ulcer detected. Gastric and oesophageal cancers only account for 3% of patients who have endoscopy.
History
- Find out exactly what symptoms the patient has. Patients often say they have ‘indigestion’ or ‘heartburn’, but the terms can mean different things to different people.
- Ask the usual questions about the nature of any pain, including site, onset and character. Establish whether the symptoms are intermittent or persistent.
- Ask about any worries or ideas the patient has (those who seek medical help for dyspepsia are often worried about significant disease such as cancer).
- Bear in mind other common causes of upper abdominal pain or discomfort such as gallstones or cardiac pain (see Figure 44).
- Ask about influencing factors too: the gnawing pain of a peptic ulcer may be improved by food if it’s a duodenal ulcer, or worsened if it is a gastric ulcer. Typically, ulcer pain is worse at night. Gastritis or GORD will often be relieved by antacids bought over the counter. GORD is often worse on bending or lying down.
- Ask about the patient’s diet and other lifestyle factors. Spicy or fatty foods can make dyspepsia worse. Smoking, obesity, alcohol, coffee and chocolate can all worsen symptoms of reflux by lowering lower oesophageal sphincter pressure. Don’t forget pregnancy.
- Find out what medications the patient is taking: NSAIDs, corticosteroids, aspirin, calcium channel blockers, nitrates, theophyllines, bisphosphonates and SSRIs can all precipitate dyspepsia symptoms.
Alarm Features
Enquire specifically about alarm features, which should prompt an urgent referral for further investigations to exclude malignant disease:
Chronic gastrointestinal bleeding (e.g. vomiting small amounts of blood, blood in stools including melaena)
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