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Referral and warning signs
When to refer
Urgent referral for Endoscopy if ALARM FEATURES present: Dysphagia, Odynophagia (in HIV negative), Weight loss, Abdominal mass, GI bleeding (haematemesis/melaena), Iron deficiency anaemia, Recurrent vomiting, New onset dyspepsia age >40-45. Refer if symptoms persist despite appropriate empirical treatment / H. pylori eradication.
Red flags
- Dysphagia (difficulty swallowing)
- Odynophagia (painful swallowing)
- Unintentional weight loss
- Palpable abdominal mass or lymphadenopathy
- Signs of GI bleeding (melaena, haematemesis)
- Iron deficiency anaemia
- Persistent/recurrent vomiting
- New onset symptoms in older age (>40-55)
Signs and symptoms
- Epigastric pain or burning
- Postprandial fullness (uncomfortable persistence of food after starting a meal)
- Early satiety (feeling full quickly after starting a meal)
- Bloating in upper abdomen
- Nausea
- Belching / Burping
- Heartburn (retrosternal burning sensation - key symptom of GERD, but can overlap with dyspepsia)
Risk factors
- Helicobacter pylori infection
- NSAID use (including Aspirin)
- Gastroesophageal Reflux Disease (GERD)
- Peptic Ulcer Disease (PUD)
- Gastritis / Duodenitis
- Gastric or oesophageal cancer (less common, but important to exclude)
- Gastroparesis (delayed gastric emptying)
- Pancreatic disease (chronic pancreatitis)
- Biliary disease (gallstones)
- Certain medications (e.g., iron, potassium supplements, some antibiotics)
- Functional dyspepsia (no identifiable organic cause)
Diagnosis
Clinical assessment
Diagnosis based on characteristic symptoms. History taking crucial to elicit predominant symptom type (ulcer-like, reflux-like, dysmotility-like), chronicity, relation to meals, associated symptoms, medication use (esp. NSAIDs), and ALARM FEATURES. Alarm features warrant urgent investigation (endoscopy) to rule out malignancy/serious pathology.
Investigations
- Initial approach often empirical treatment or 'Test-and-Treat' for H. pylori.
- Endoscopy (OGD): Indicated if ALARM FEATURES present, age >40-55 (age threshold varies), or failure of empirical therapy.
- Helicobacter pylori testing:
- - Urea Breath Test (UBT) or Stool Antigen Test (preferred non-invasive tests for initial diagnosis and confirming eradication).
- - Serology (Antibody test): Indicates exposure but not active infection, less useful for diagnosis/monitoring.
- - Endoscopic Biopsy (Rapid Urease Test - RUT, histology): For diagnosis during endoscopy.
- Abdominal Ultrasound: If biliary or pancreatic cause suspected.
- Other tests based on clinical suspicion (e.g., gastric emptying study for gastroparesis).
Diagnostic criteria
Presence of one or more dyspeptic symptoms. Further defined by presence/absence of organic cause (functional vs organic dyspepsia) and presence of alarm features.
Management
Non-pharmacological management
- Lifestyle modification: Identify and avoid trigger foods (fatty, spicy, caffeine, alcohol), eat smaller meals, avoid eating late at night, smoking cessation, weight loss if overweight.
- Reassurance if functional dyspepsia suspected after appropriate workup.
Pharmacological treatment
- Management depends on suspected cause and presence of alarm features:
- 1. No Alarm Features, Age <40-55:
- - Option 1: Empirical PPI trial. Omeprazole 20mg OD (or equivalent PPI) for 4-8 weeks. If symptoms resolve, stop. If recur, may need longer term/on-demand therapy or investigation.
- - Option 2: Test-and-Treat for H. pylori. Perform non-invasive H. pylori test (UBT/Stool Antigen). If positive, give eradication therapy (see PUD section GI013). If negative, consider PPI trial.
- 2. Alarm Features Present OR Age >40-55 OR Failure of Empirical Therapy:
- - URGENT Endoscopy (OGD) is required.
- - Management guided by endoscopic findings (e.g., treat PUD, oesophagitis, rule out malignancy).
- 3. Functional Dyspepsia (Symptoms persist despite negative investigations and H. pylori eradication):
- - Reassurance.
- - May try PPIs, H2 Receptor Antagonists (H2RAs - e.g., Ranitidine, Cimetidine), Prokinetics (e.g., Metoclopramide, Domperidone - use with caution), or low-dose Tricyclic Antidepressants (TCAs - e.g., Amitriptyline) for symptom control (often specialist guided).
- Antacids / Alginates (e.g., Magnesium Trisilicate compound): Can provide temporary symptomatic relief.
Monitoring
- Monitor symptom response to treatment.
- Monitor for development of alarm features.
- Confirm H. pylori eradication with UBT or Stool Antigen test ≥4 weeks after completing eradication therapy (and off PPIs for 1-2 weeks).
Complications
- Related to underlying organic cause if present (e.g., PUD complications - bleeding, perforation; oesophageal cancer).
- Reduced quality of life (functional dyspepsia).
Prevention
- Avoid NSAIDs where possible, or use with PPI protection if needed.
- Treat H. pylori infection.
- Lifestyle modifications (diet, smoking, alcohol).
Patient education
- Explain dyspepsia and potential causes.
- Lifestyle and dietary advice.
- Explain treatment approach (empirical PPI vs test-and-treat vs endoscopy).
- Importance of H. pylori eradication if positive.
- When to seek further help (alarm features, persistent symptoms).
- Reassurance if functional dyspepsia diagnosed.
Uganda-specific notes
H. pylori prevalence is high. Test-and-treat strategy often employed where testing available. Endoscopy access is limited. Alarm features are critical for identifying patients needing urgent referral. Consider empirical treatment carefully.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 6, Section 6.3.2