Historically, there has been enormous confusion over the definition of dyspepsia. SIGN, in its recently published guideline, has used the Rome II recommendation of “pain or discomfort centred in the upper abdomen”. Previous terms such as ‘non-ulcer dyspepsia’, ‘motility-like dyspepsia’ or ‘reflux-like dyspepsia’ are confusing and unhelpful.
All dyspepsia guidelines agree that patients with alarm symptoms should be referred for investigation. So far so good. The SIGN guideline also covers two other groups of patients: those with uncomplicated dyspepsia where no investigation has been undertaken and functional dyspepsia where investigations do not demonstrate any abnormality.
I feel that SIGN relies too heavily on the presence or absence of Helicobacter pylori as an initial investigation. The infection may play only a small role in functional dyspepsia, especially when discomfort (as opposed to pain) is the predominant symptom. Discomfort may be characterised by feelings of fullness, satiety, bloating, belching or nausea and probably relates to factors such as gastric sensitivity, problems with accommodation and delayed gastric emptying.
SIGN relies on conclusions from two studies – that there is no evidence of the benefit of early investigation in patients over the age of 55 years with new dyspepsia symptoms and that ‘test and treat’ is an acceptable strategy for initial management.
The guideline therefore recommends that ‘test and treat’ is the best management for patients at any age. I believe this is flawed.
I agree that there is little study evidence that early investigation in elderly patients is beneficial, but older patients are more likely to have pathology. Moreover, because of a cohort effect, elderly patients are more likely to have H. pylori infection and, logically, infection is less likely to be the cause of their new onset dyspepsia. Missing early cancers in this group could be a significant risk.
The guideline has many positive points. The advice to use breath testing (or stool antigen testing) rather than serology for H. pylori infection is to be applauded, and the concept of re-testing even in asymptomatic patients is in line with the recommendations of the European Helicobacter Study Group, contained in The Maastricht 2-2000 Consensus Report.
Patient information is also good and includes advice regarding diet and lifestyle. I would also advocate counselling patients if H. pylori eradication therapy is contemplated, because most will not benefit symptomatically. Finally, there are many excellent suggestions for areas of future research.
However, contrary to the recommendation from SIGN, I will continue to investigate my older patients with new onset symptoms. I do not disagree with the advice to test for H. pylori in the younger patient, but prefer to offer my patients the choice of treatment (‘test and treat’) or investigation (‘test and investigate’).
The management of functional dyspepsia is closely related to that of irritable bowel syndrome. Medication has a limited place but it is the general practitioner’s duty to educate, reassure and set reasonable goals. Patients should be encouraged to take some responsibility and to adopt dietary and lifestyle changes.