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Treatment
of Dyspepsia
Sinister
Features
Patients
with continuing dyspepsia need to be referred for endoscopy if they are over 50
years old at first presentation (some would say over 45 years old), or they have
unintentional weight loss, dysphagia, haematemesis, melaena, anaemia, vomiting,
or previous gastric surgery.
Other
patients can initially be managed in the community.
Reflux:
patients have symptoms of heartburn/regurgitation. Stepped care is reasonable:
Advice
on life-style, especially on weight-loss, smoking and drinking.
Add
alginate/antacid mixture in adequate dosage: e.g. up to 20 ml four times daily
as 'Algicon' suspension ( low sodium) or 'Gaviscon' liquid.
If
symptoms are uncontrolled, or relapse, then give cimetidineH 800 mg twice daily
for two weeks, and reassess symptoms.
If
symptoms are still uncontrolled, then refer. Referred patients may be treated
with a proton pump inhibitor for up to 1 month, and their symptoms re-assessed.
Other
Dyspeptic Symptoms:
Patients
with "ulcer" symptoms often do not have ulcers. If there are no
sinister features, they can be treated empirically with cimetidine (note) 800 mg
at night for 2 to 4 weeks.
If
symptoms persist or recur, then patients under 50 years old, who have negative
non-invasive tests for H.pylori can be treated symptomatically, because an ulcer
is unlikely.
patients
aged 50 or more, and patients whose tests are not known to be negative, should
be referred for endoscopy.
patients
who have peptic ulcers diagnosed at endoscopy should have eradication therapy,
patients without obvious pathology can be treated symptomatically.
Suggested
treatment regimes for patients with ulcers and H. pylori are given overleaf. A
1-week course of three drugs is thought to be satisfactory, and may make
pseudomembranous colitis less likely; some would prefer to give a 2-week course.
Cimetidine
(800mg twice daily = ,20/month) should not be given to patients with renal
failure, or those receiving warfarin, theophylline or anti-convulsants.
Nizatidine (300 mg twice daily = ,43/month) or ranitidine (300 mg twice daily =
,55/month)
are
suitable alternatives.
Written
after consultation with the following experts: Dr R Cockel (SOH), Dr B Cooper
(City Hosital), Prof M Langman (QEH), Dr M Skander (GHH), and Dr R Walt (BHH).
The
suggested elimination regime for patients with proven ulcer disease (April 1995)
is:
Metronidazole
- 400 mg three times daily for 7 days
Amoxycillin
- 500 mg three times daily for 7 days (EXCEPT in penicillin allergy)
Omeprazole
- 40 mg daily for 7 days
OR
Bismuth
chelate - 120 mg four times daily for 7 days
Metronidazole
- 400 mg three times daily for 7 days
Oxytetracycline
- 500 mg four times daily for 7 days
OR
Omeprazole
- 20 mg daily for 7-10 days
and,
after 3 days' treatment,
Bismuth
chelate - 120 mg four times daily for 7 days
Metronidazole
- 400 mg three times daily for 7 days
Oxytetracycline
- 500 mg four times daily for 7 days
NOTE:
Metronidazole
can induce nausea, and patient should avoid alcohol. Bismuth causes black, loose
motions and a metallic taste in the mouth. Omeprazole occasionally causes
headaches; it can only be dispensed in an original pack.
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