Effectiveness of Management Strategies for Uninvestigated Dyspepsia

Dyspepsia is defined as having one or more symptoms of epigastric pain, burning, postprandial fullness, or early satiation.

Bloating and nausea often coexist with dyspepsia but are nonspecific and are thus not included in its definition. Heartburn is also excluded from diagnostic symptom criteria for dyspepsia since it is thought to primarily arise from the esophagus and it is suggestive of gastroesophageal reflux disease (GERD) although it too may occur concomitantly.

TAKE-HOME MESSAGE

The author’s review of the meta-analysis of 15 studies of management approaches for patients with dyspepsia found “test and treat” was ranked the best management strategy, although it performed similarly to prompt endoscopy and was not superior to any of the other strategies.

The “test and treat” resulted in a lower rate of endoscopy compared with all other strategies except symptom-based management. Participants preferred prompt endoscopy to the other management strategies.

Wider application of a “test and treat” strategy for dyspepsia at the primary care level, which is recommended in recent national guidelines, should be encouraged.

Available Brand

Test and treat for dyspepsia with unknown cause

Physicians can do harm if they put someone on chronic acid suppression for dyspepsia according to the evidence-based guideline without inquiring into the root cause. There is generally a cause can be found 80% of the time. So if they don’t find the cause at first and prescribing empirical treatment then, they will do more things that often add cost, harm, and poor outcomes. This study can help us avoid the dangers of prescribing more medicines.

This meta-analysis was designed to investigate the effectiveness of patients remaining asymptomatic from dyspepsia after 12 months of the following four regimens (Most effective to least effective).

Test and treat: Test for pylori with stool antigen or urea breath test and then treat if positive
Prompt endoscopy: Immediate endoscopy
Test and scope: Test for pylori and then do endoscopy if positive
Empirical acid suppression: Acid suppression for 8 weeks

Doctors Liked to Read More

Summary of Recommendations:

A reason to order endoscopy early is if there are red flags, including age >60 years, weight loss, dysphagia, anemia, or blood in stool or emesis.

“Test and Treat” was ranked first; although it performed similarly to prompt endoscopy. Symptom based management was ranked the lowest of all the strategies when considering effectiveness. Management of dyspepsia with drug treatments is unsatisfactory and often lacks an adequate evidence base because the underlying causes of symptoms are poorly understood.

This not only does nothing to get at the root of the problem, it also puts patients at risk of chronic PPI use. Only 6 weeks of a PPI can result in rebound hyperacidity, which makes it really hard to get patients off this drug.

If you use this method after doing your history, consider just 2 to 4 weeks of a PPI so discontinuation is more likely to be successful with less rebound dyspepsia.

Patients liked “prompt endoscopy” the best

Don’t underestimate the patient's satisfaction with a negative endoscopy. Knowing you don’t have something bad, such as cancer, can be therapeutic.

Prescribing a medication is easy, but getting to know the context of a human being is hard. This is the art of medicine and is more effective, less harmful, and less expensive than just prescribing a pill for every ill.

Taking History is Important:

Many times, physicians won’t even have to get to this decision if they take a good history and find one of the following:

Nutrition: Is the person drinking two pots of coffee a day, eating processed or large meals before bedtime?
Medications/supplements: Rule out excessive mint consumption, such as peppermint, which relaxes the lower esophageal sphincter. Regular use of NSAIDs or oral steroids? Are opioids delaying gastric emptying?
Increased pressure: Is the person obese or pregnant?
Emotional stress: The extreme form of reflux is vomiting, which can happen with acute emotional stress. Chronic low-grade stress inhibits digestion and slows gastric motility.