Dyspepsia with or without Helicobacter pylori infection - Clinical Approach in Adults

Effective Date: December 1, 2009
Revised Date: March 5, 2010

Recommendations and Topics

Scope

This guideline applies to non-pregnant adult patients with Dyspepsia. Dyspepsia is defined in this guideline as persistent or recurring symptoms consisting of upper abdominal pain, discomfort, nausea or bloating. Alarm features that require prompt investigation include: gastrointestinal blood loss, weight loss, early satiety, dysphagia, persistent vomiting, or symptom onset after the age of 55 years.1 The search for and eradication of Helicobacter pylori (H. pylori) is also discussed.

For patients presenting predominantly with reflux symptoms, please refer to the Gastroesophageal Reflux Disease guideline (GERD).

Diagnostic Codes: 536-Dyspepsia; 535 or 537-Gastritis and Duodenitis

Prevention and Risk Factors

Many medications have been associated with dyspepsia, particularly acetylsalicylic acid (ASA) and non-steroidal anti-inflammatory drugs (NSAIDs).2 If such medications are identified, then dose reduction or discontinuation should be considered as a first step. Emotional stress is not considered a risk factor for peptic ulcer disease, but may frequently be associated with functional (non-ulcer) dyspepsia.3 Lifestyle factors such as the use of alcohol and tobacco are potential triggers. Risk factors for being infected with H. pylori include immigration from a developing country, poor socioeconomic conditions, and family overcrowding.4

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Management

Management of Dyspepsia with alarm features:

Alarm features consist of: gastrointestinal blood loss, weight loss, early satiety, dysphagia, persistent vomiting, or symptom onset after the age of 55 years.1 Referral for upper gastrointestinal endoscopy is recommended.1,5

Management of Dyspepsia without alarm features:

Patients with mild or infrequent symptoms can be managed without further investigation using non-prescription acid reducing agents.1 Many medications can cause dyspeptic symptoms. A drug history including non-prescription medications is recommended.

For patients with more persistent symptoms, one of two approaches may be used:

  1. Test and treat for H. pylori infection – see below: Management of H. pylori infection.

This approach is most appropriate for patients who have not been previously screened and is especially applicable in individuals who have an increased risk for H. pylori infection.

Individuals with dyspepsia who currently have an endoscopically or radiographically confirmed duodenal or gastric ulcer,6 or have had one within the past five years, should be tested for H. pylori infection (refer to Table 1). This does not apply to patients in whom successful eradication has been previously confirmed.

  1. Empiric Therapy

This approach is most appropriate for patients who are unlikely to have H. pylori infection or who have previously tested negative for H. pylori. A 4-8 week course of treatment with a proton pump inhibitor (PPI) or H2-receptor antagonist (H2RA) may be prescribed. Refer to Appendix A (PDF, 115KB).

Management of Chronic Dyspepsia:

Patients with chronic non-progressive symptoms previously investigated with negative results and no alarm symptoms, almost certainly have functional dyspepsia. This is a benign but chronic relapsing condition and does not require further investigation. It has not been established that long term pharmacotherapy improves outcomes for dyspepsia and its use should be reassessed periodically. Education, reassurance and support are the foundations of care.7

Management of H. pylori Infection:

  1. Test as per Table 1Serology is recommended as an initial test to detect H. pylori. If the patient has had previously positive serology or other testing, then a urea breath test (UBT) is the recommended test. It is not necessary to order both serology and UBT for initial testing.
  2. Offer eradication treatment if the test is positive (see Table 2). Emphasize the importance of adherence to therapy.
  3. Confirmation of eradication is recommended in patients who have had a complicated duodenal ulcer (perforation or hemorrhage), gastric ulcer or mucosa associated lymphoid tissue (MALT) lymphoma. Persisting symptoms after eradication treatment should be followed by retesting or endoscopy. Retesting is otherwise not routinely required.
  4. An initial attempt to eradicate H. pylori may fail in as many as 20% of patients.8 Refractory H. pylori infection is seldom treated successfully by repeating the same regimen.6 A "rescue" or second line treatment is recommended (see Table 3).

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Rationale

Dyspepsia is a common clinical problem that seldom represents life-threatening disease. A description of the symptoms does not reliably differentiate ulcers from non ulcer disease. Functional dyspepsia is ultimately the most common diagnosis, but other possible diagnoses to consider include ulcer disease, gastroesophageal reflux disease and gastric cancer. Malignancy is an unlikely diagnosis in the absence of any alarm features, especially in patients under the age of 55 years.7

Alarm features suggest a higher risk of significant disease and require prompt investigation. Endoscopy is recommended to identify gastric and duodenal ulcers as well as esophageal and gastric cancers.7,11 Gastric ulcers are potentially malignant and require endoscopic biopsy.

Patients whose symptoms persist after an initial negative investigation are considered to have functional dyspepsia. The association between H. pylori and functional dyspepsia is unclear, although a minority of patients (from 1% to 15%) may improve after eradication treatment.6,12 Dyspepsia continuing after treatment of H. pylori is more likely the result of GERD or functional dyspepsia.

Infection with H. pylori is a chronic indolent process that in the majority of patients causes asymptomatic gastritis. New infection or re-infection with H. pylori is an uncommon event (less than 2% per year); therefore, repeated screening is generally unnecessary.13 General population or family screening is not strongly supported by the literature.

Although H. pylori is the major cause of duodenal ulcer, gastric ulcer, gastric carcinoma and MALT lymphoma, these complications arise in a minority of infected patients.6 For patients with peptic ulcer disease, eradication of H. pylorireduces the rate of ulcer recurrence from 67 to 6% in duodenal ulcers and from 59 to 4% in gastric ulcers.11 H. pyloritesting (other than serology) will reliably confirm eradication.

The duration of treatment for H. pylori is somewhat controversial. While a seven day treatment is most often recommended, a fourteen day treatment is thought to yield a 5% increase in eradication success rates.16 This increase must be weighed against added cost and risk of adverse events which include Clostridium difficile colitis, allergic reactions, and increased antibiotic resistance.6

NSAIDs are the second leading cause of gastric and duodenal ulcer and may be co-pathogenic with H. pylori.14

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References

  1. Musana AK, Yale SH, Lang KA. Managing Dyspepsia in a Primary Care Setting. Clin Med and Research 2006;4(4):337-342.
  2. Leong R, Chan F. Drug-induced side effects affecting the gastrointestinal tract. Expert Opin Drug Saf 2006;5(4):585-591.
  3. Levy R, Olden K, Naliboff B, et al. Psychosocial Aspects of the Functional Gastrointestinal Disorders. Gastroenterology 2006;130:1447-1458.
  4. Ables AZ, Simon I, Melton E. Update on Helicobacter pylori Treatment. Am Fam Physician 2007;75:351-358.
  5. The Royal College of Radiologists. Making the best use of clinical radiology services: referral guidelines. London: The Royal College of Radiologists; 2007.
  6. Chey WD, Wong BC and the Practice Parameter Committee of the American College of Gastroenterology. Am. J. of Gastroent 2007;102:1808-1825.
  7. Mason JM, Delaney B, Moayyedi P, et al. Managing dyspepsia without alarm signs in primary care: new national guidance for England and Wales. Aliment Pharmacol Ther 2005;21:1135-1143.
  8. Peura D. Treatment regimens for Helicobacter pylori. UpToDate 2008; Available from: www.uptodate.com April 30th, 2008.
  9. Hunt R, Thomson A. Canadian Helicobacter pylori Consensus Conference. Can J Gastroentero 1998;12(1):31-40.
  10. Hunt R, Gallone C, Veldhuyzan S, et al. Canadian Helicobacter Study Group Consensus Conference: Update on the Management of Helicobacter pylori - An evidence-based evaluation of six topics relevant to clinical outcomes in patients evaluated for H. pyloriinfection. Can J Gastroenterol 2004;18(9):547-554.
  11. Ramakrishnan K, Salinas R. Peptic Ulcer Disease. Am Fam Physic 2007;76(7):1006-1012.
  12. Moayyedi P, Deeks S, Delaney B, et al. Eradication of Helicobacter pylori for non-ulcer dyspepsia (Review) Cochrane Database of Systematic Reviews. The Cochrane Collaboration 2006 Feb;Art No: CD002096.
  13. Niv Y, Hazazi R. Helicobacter pylori Recurrence in Developed and Developing Countries: Meta-Analysis of 13C-Urea Breath Test Follow-up after eradication. Helicobacter 2008;13(1):56-61.
  14. Huang J, Sridhar S, Hunt R. Role of Helicobacter pylori infection and non-steroidal anti-inflammatory drugs in peptic ulcer disease: a meta-analysis The Lancet 2002;359:14-22.
  15. McNulty C, Tear L, Owen R, et al. Test and treat for dyspepsia-but which test? British Medical Journal 2005;330:105-106.
  16. Fuccio L, Minardi M, Zagari R, et al. Meta-analysis: Duration of First-Line Proton-pump Inhibitor-based Triple Therapy for Helicobacter pylori Eradication. Ann Of Int Med 2007;147(8):553-563.

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List of Abbreviations

ASA

Acetylsalicylic acid

GERD

Gastroesophageal reflux disease

H2RA

Histamine2-receptor antagonist

MALT

Mucosa associated lymphoid tissue

NSAID

Non steroidal anti-inflammatory drugs

PPI

Proton pump inhibitor

UBT

Urea breath test

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Appendices

Appendix A - Prescription Medication Table for Oral Acid Suppression (PDF, 115KB)

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This guideline was developed by the Guidelines and Protocols Advisory Committee, approved by the British Columbia Medical Association and adopted by the Medical Services Commission.

This guideline is based on scientific evidence current as of the effective date.

The principles of the Guidelines and Protocols Advisory Committee are to:

  • encourage appropriate responses to common medical situations
  • recommend actions that are sufficient and efficient, neither excessive nor deficient
  • permit exceptions when justified by clinical circumstances.
Contact Information
Guidelines and Protocols Advisory Committee
PO Box 9642 STN PROV GOVT
Victoria BC V8W 9P1
E-mail: hlth.guidelines@gov.bc.ca
Web site:
Clinical Practice Guidelines

 

Disclaimer The Clinical Practice Guidelines (the "Guidelines") have been developed by the Guidelines and Protocols Advisory Committee on behalf of the Medical Services Commission. The Guidelines are intended to give an understanding of a clinical problem and outline one or more preferred approaches to the investigation and management of the problem. The Guidelines are not intended as a substitute for the advice or professional judgment of a health care professional, nor are they intended to be the only approach to the management of clinical problems.  We cannot respond to patients or patient advocates requesting advice on issues related to medical conditions. If you need medical advice, please contact a health care professional.

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