Please enable JavaScript.
Coggle requires JavaScript to display documents.
Dyspepsia (Proven GORD) - Coggle Diagram
Dyspepsia (Proven GORD)
The term dyspepsia is used to describe a complex upper gastrointestinal tract symptoms which are typically present for four or more weeks, including upper abdominal pain or discomfort, heartburn, acid reflux, nausea and/or vomitting.
Gastro-oesophageal reflux disease (GORD) is usually a chronic condition where there is reflux of gastric contents (particularly acid, bile, and pepsin) back into the oesophagus causing predominant symptoms of heartburn and regurgitation. Atypical symptoms include hoarseness, cough, asthma, and dental erosions in some people.
'Proven GORD' - endoscopically-determined reflux disease.
Risk Factors for GORD
Obesity
Drugs with decrease LOS tone eg alpha-blockers, anticholinergics, benzodiazepines, beta-blockers, bisphosphonates, CCB, corticosteroids, NSAIDs, nitrates, theophyllines and tricyclic antidepressants.
Trigger foods, such as coffee and chocolate which may reduce lower oesophageal sphincter tone and fatty foods which delay gastric emptying.
Pregnancy
Smoking and alcohol
Hiatus hernia
Stress and anxiety
Family history
Risk factors for Barrett's oesophagus
Long duration and/or increased frequency of GORD
Previous oesophagitis or hiatus hernia
Male
Previous oesophageal stricture or ulcers
Initial Management Proven GORD
Access for stress and anxiety
Ask about any over-the-counter medication such as antacids and/or alginates
Sleep with the head of bed raised (bed raiser, wood, bricks, not with pillows as this may increase intra-abdominal pressure and worsen symptoms)
Review the person's medication and consider reducing/stopping drugs which may cause or exacerbate symptoms.
Offer advise on lifestyle measures: Weight loss, avoid trigger foods, eat smaller meals, eat 3-4 hours before going to bed, stop smoking and reduce alcohol intake.
Proven GORD - offer a full dose PPI for 4 weeks to aid healing
Offer written information and advice on symptoms, self care and management options.
Assess for any red flag symptoms
Severe oesophagitis - offer full dose PPI for 8 weeks to aid healing, and offer full dose PPI for maintenance treatment
Do not arrange testing for Helicobacter pylori infection
Advise to arrange follow up appointment for refractory symptoms following initial management .
Refractory Symptoms
Endoscope-negative reflux disease: consider switching to H2RA for 1 month.
Recurrent symptoms after initial management consider need for long-term treatment: use PPI at lowest effective dose to control symptoms and consider self-treatment with antacid/alginate
Confirmed oesophagitis - consider further course of the initial PP1 for one month or double dose for 1 month, add Histamine H2-receptor antagonist at bedtime (two weeks course intermittently)
Severe oesophagitis - Consider 8 week treatment dependant on clinical judgement of high dose PPI or alternative full-dose/high dose PPI
Persistent GORD despite management consider alternative diagnosis eg cardiac or hepatobiliary disease
Severe oesphagitis has controlled symptoms offer a full-dose PPI long-term as maintenance treatment.
Assess for any new red flag symptoms
Offer people on long-term treatment an annual review of their symptoms and treatment
Consider if referral to gastroenterologist or upper gastrointestinal surgeon required for specialist investigations and management.
Medication: PPI
Pantoprazole
Full dose 40mg once a day
Low dose 20mg once daily
Double dose 40mg twice daily
Rabeprazole
Full dose 20mg once daily
Low dose 10mg once daily
Double dose 20mg twice daily
Lansoprazole
Full dose 30mg once daily
Low dose 15mg once daily
Double dose 30mg twice daily
Esomeprazole
20mg once a day (40mg once daily for severe oesophagitis)
Low dose 20mg for server oesophagitis
Double dose 40mg once daily (40mg twice daily for severe oesophagitis)
Omeprazole
Full dose 20mg once a day (40mg once daily if sever oesophagitis
Low dose 10mg once a day (20mg once a daily severe oesophagitis)
Double dose 40mg one a day (40mg twice daily for severe oesphagitits)
Medication: H2HA
Famotidine
20-40mg twice a day
Nizatidine
150-300mg twice daily
Ranitidine
Usual treatment 150mg twice daily
150mg at night (Nocturnal dose in addition to PPI)
Red flags
Change in bowel habit
Jaundice
New onset diabetes
Nausea or vomiting
Back pain
Abdominal pain
Upper abdominal mass
Unexplained weight loss
Loss of appetite
Dyspepsia
Haematemesis