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Dyspepsia - unidentified cause - Management
How do I manage dyspepsia in someone with alarm features?
- For people with dyspepsia and significant acute gastrointestinal bleeding, arrange immediate admission to hospital.
- For all other people with dyspepsia and alarm features:
- Arrange endoscopy within 14 days and do a full blood count.
- Suspend nonsteroidal anti-inflammatory drugs while awaiting referral. Offer alternative analgesics (e.g. paracetamol and/or opioids).
- The management of other drugs will depend on clinical judgement of the benefits and risks of continued treatment. When there is uncertainty seek specialist advice. Management options include:
- Stopping the drug.
- Reducing the frequency or dose of the drug.
- Substituting the drug for one less likely to cause bleeding or dyspepsia.
- Review and manage lifestyle factors known to exacerbate dyspepsia.
- Prescribe either an alginate or an antacid to relieve dyspepsia whilst awaiting endoscopy. Ensure that proton pump inhibitors or H2-receptor antagonists (including those obtained over-the-counter) are not used, for a minimum of 2 weeks, before endoscopy.
- Advise those people who deteriorate significantly to seek medical attention.
Clarification / Additional information
- Examples of common drugs known to cause gastrointestinal bleeding include:
- Nonsteroidal anti-inflammatory drugs (e.g. ibuprofen, diclofenac, naproxen, indometacin).
- Antiplatelet drugs (e.g. aspirin, clopidogrel).
- Anticoagulants (e.g. warfarin).
- Corticosteroids (e.g. prednisolone).
Basis for recommendation
These recommendations conform with those issued by the National Institute for Health and Clinical Excellence (NICE), covering the management of dyspepsia, and referral guidelines for suspected cancer [NICE, 2005; NICE, 2005].
- Basis for arranging endoscopy within 14 days for people with alarm features:
- These recommendations are based upon evidence summarized by NICE for the sensitivity of alarm features for identifying people at risk of having an upper gastrointestinal cancer [NICE, 2005; NICE, 2005].
- Basis for prescribing an alginate or an antacid to relieve the symptoms of dyspepsia while awaiting endoscopy:
- Experts recommend treatment with alginates or antacids for dyspepsia while awaiting endoscopy because they help to relieve symptoms but do not mask malignant ulceration [NICE, 2005]. However, although commonly prescribed, the evidence for antacids and alginates are poor and lacking. Evidence indicates alginate preparations are more effective than placebo in relieving symptoms of gastro-oesophageal reflux.
- Basis for managing drugs known to increase the risk of gastrointestinal (GI) bleeding or exacerbate dyspepsia: experts recommend reviewing all medications known to increase risk of GI bleeds or exacerbate dyspepsia [NICE, 2005]. Options for the management of drugs known to exacerbate dyspepsia and GI bleeds are provided by CKS. These are pragmatic recommendations based upon clinical experience.
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