Dyspepsia Radcliffe Publishing Oxford

Document Sample
Dyspepsia Radcliffe Publishing Oxford Powered By Docstoc

                  Advice on children written by Susie Lapwood

                Clinical decision and action checklist

      1   Are any alarm symptoms present?
      2   Could this be acid-related dyspepsia?
      3   Could this be dysmotility dyspepsia?
      4   Could this be gastro-oesophageal re¯ux disease (GORD)?
      5   Is the dyspepsia persisting?

                                 Key points
.   Dyspepsia can be caused by acid-induced damage, abnormal motility or
    oesophageal re¯ux.
.   Adults and children with severe neurological impairment are particularly
    prone to dyspepsia.
.   `Alarm' symptoms should usually prompt urgent admission to hospital.
.   Prokinetic agents and proton pump inhibitors are important treatments in


Dyspepsia is a common problem which includes a range of upper gastrointestinal
symptoms of which upper abdominal pain is the commonest.1,2 In adults and
children with communication diculties the only symptoms may be food refusal,
weight loss or failure to thrive.
86 Dyspepsia

                                                            Acid-related dyspepsia: First line treatment is a proton
         Types of dyspepsia                                 pump inhibitor (PPI).17 If the patient is vomiting or
                                                            has swallowing problems, omeprazole can be given
                                                            intravenously or through a feeding tube (see Drug
Acid-related (organic) dyspepsia is due to acid-related     information (p. 265) ). If gastric bleeding is occurring,
damage of the stomach or duodenum, e.g. gastric ulcer.      sucralfate is an e€ective haemostatic agent.18±20 Infec-
NSAIDs and H pylori infection are common causes.3±5         tion with H pylori is common and should be treated if
A common symptom is epigastric pain that is worse at        present.21 NSAIDs are another common cause of
night and relieved by antacids.2                            mucosal damage and should be stopped or changed
                                                            to an NSAID less likely to cause damage (see Managing
Dysmotility (non-ulcer) dyspepsia is due to abnormal        the adverse e€ects of analgesics (p. 53) ).
motility of the oesophagus or of the stomach and
duodenum. Gastric stasis and cancer-associated dys-         Dysmotility dyspepsia: This often needs a prokinetic
pepsia syndrome (CADS) are part of this type of             agent, which will have to be given by a non-oral route if
dyspepsia.6±8 It is more common in neurologically           vomiting is present.22±24 In standard doses metoclo-
impaired children and often associated with GORD            pramide is as e€ective as domperidone, but in children
(see next type).9 Pain is relieved by vomiting in gastro-   domperidone is safer.25,26 In persistent cases erythro-
duodenal dysmotility, but in oesophageal dysmotility,       mycin can help, but can cause nausea and tolerance
pain develops after meals.2                                 may develop.27±29 Taking meals as frequent snacks
                                                            rather than large meals may also help. In a patient on
Gastro-oesophageal re¯ux disease (GORD) is caused           tube feeding smaller, more frequent boluses may help.
by re¯ux of gastric contents into the oesophagus            Activated dimeticone is a defoaming agent which
sucient to cause local damage and symptoms.10 It           reduces gastric distension.30,31
occurs in up to 75% of neurologically impaired
children.9,11 Other causes include hiatus hernia, adop-     GORD: If dysphagia is a predominant symptom this
tion of a prolonged supine position, and increased          should be investigated, especially as aspiration occurs
intra-abdominal pressure secondary to spasticity, sco-      silently in up to 40% of patients (see Dysphagia
liosis or seizures.12 GORD symptoms can be worsened         (p. 91) ). In patients unable to position themselves,
by overfeeding, especially through a gastrostomy in         repositioning them in a semi-prone position can help.
neurologically impaired adults and children, whose          Alginates ¯oat on the stomach contents and reduce
energy needs are less than active patients. Symptoms        re¯ux symptoms.32 As with dysmotility dyspepsia,
are intermittent and often non-speci®c. They may            prokinetics are an important treatment and altering
include heartburn (especially on bending and lying          the size and frequency of meals and feeds can also help.
¯at), dysphagia, epigastric pain, with atypical symp-
toms of vomiting, dental enamel erosion, respiratory
symptoms (e.g. nocturnal post-prandial asthma,
aspiration, chest infections), eating-related problems
(e.g. irritability, hyperextensive posture, choking, dys-
                                                                    Persistent dyspepsia
phagia) and ear, nose and throat problems (e.g. cough,
hoarseness).12±16 Sandifer's syndrome (neck extension       Bile re¯ux: This can be eased by substances that bind
and head rotation during or after meals) can occur in       bile acids such as hydrotalcite.33
infants or young children and is associated with iron
de®ciency anaemia and severe oesophagitis.                  Infection: In addition to H pylori, infections such as
                                                            candida, CMV and herpes (zoster or simplex) can cause
                                                            the same symptoms as dyspepsia. Treatment will
                                                            resolve the symptoms.
                                                            Referral for investigation and treatment: The opinion
                                                            of a gastroenterologist can be invaluable. In children
Alarm symptoms: These symptoms would normally               with persistent GORD, fundoplication ‡aÀ pyloro-
require prompt admission to hospital for investigation      plasty is e€ective in over 80% but surgery has a high
and treatment. Some patients will be too ill for transfer   morbidity with 26±59% having post-operative com-
or will have made clear their wish to remain at home or     plications, 60±75% getting recurrence of GORD (the
hospice. These patients need adequate analgesia, anti-      higher ®gure in neurological impairment) and 5±15%
emetics, comfort and company for their last days and        needing repeat surgery.11,34 An e€ective alternative is to
hours.                                                      consider a jejunal feeding tube.35,36
                                                                                                    Dyspepsia 87

Clinical decision            If YES A Action

1 Are any alarm              Any of the following would usually prompt urgent admission to hospital for
  symptoms present?          endoscopy and treatment. Alternative options are:
                             .  Rapid clinical deterioration: see Emergencies (p. 199).
                             .  Persistent vomiting causing dehydration or electrolyte disturbance: see Nausea
                                and vomiting (p. 109).
                             .  Haematemesis (from bleeding ulcer or severe gastritis): see cd-5 in Bleeding
                                (p. 69).
                             .  Malaena (upper gastrointestinal haemorrhage): see cd-5 in Bleeding (p. 69).
                             .  Persistent and worsening pain (perforation or other intra-abdominal crisis): see
                                cd-5d in Emergencies (p. 207).
                             .  Severe dysphagia (oesophageal obstruction): see Dysphagia (p. 91).

2 Could this be acid-        .   If bleeding (haematemesis or malaena): start sucralfate suspension 10 ml
  related dyspepsia?             6-hourly.
  (e.g. epigastric pain or   .   Start PPI, e.g. omeprazole 20 mg or lansoprazole 30 mg daily.
  heartburn worse at night   .   Stop any drugs causing upper GI mucosal irritation such as iron or a NSAID.
  and eased by antacids)     .   Take blood for serum H pylori immunoassay. If positive, use one week triple
                                 therapy of amoxycillin, clarithromycin and a PPI.

3 Could this be a            .   Consider stopping or reducing the dose of antimuscarinic drugs.
  dysmotility                .   Start a prokinetic, e.g. metoclopramide or domperidone 10 mg 6-hourly. Use
  dyspepsia? (e.g. pain          domperidone for children (see Drugs in palliative care for children: starting
  eased by vomiting or           doses (p. 253) ).
  occurring after meals)         If vomiting is present, start metoclopramide SC infusion 40 mg/24 hours (or
                                 domperidone PR 30 mg 6-hourly) and change to oral once vomiting is
                             .   Consider activated dimeticone liquid 20±40 mg before meals or feeds to help
                                 trapped gastric air to be brought up.
                             .   Reduce the size of meals or feeds and give more frequently.

4 Could this be GORD?        .   Start alginate 250±500 mg, e.g. Gaviscon after each meal or feed (see Drugs in
  (e.g. heartburn or             palliative care for children: starting doses (p. 253) ).
  epigastric pain worse on   .   Start a prokinetic, e.g. metoclopramide or domperidone 10 mg 6-hourly. Use
  bending or lying ¯at)          domperidone for children (see Drugs in palliative care for children: starting
                                 doses (p. 253) ).
                             .   Also consider:
                                 If dysphagia and/or aspiration are present: see Dysphagia (p. 91).
                                 If the patient is unable to move: lie on front or left side, head elevated to 30
                                 If NG/gastrostomy-fed: alter feeding regime from large bolus to frequent small
                                 volume feeds. Continuous feeding can be tried but this sometimes aggravates

5 Is the dyspepsia           .   If infection is present (H pylori, candida, CMV, herpes): treat the infection.
  persisting?                .   If mucosal ulceration is causing pain: start a mucosal protecting agent (e.g.
                                 sucralfate suspension 10 ml 6±8 hourly)
                             .   If not on PPI: start omeprazole 20 mg (PO or through feeding tube) or
                                 lansoprazole 30 mg PO daily. Ranitidine is an alternative, but is less e€ective
                                 and can cause problematic rebound nocturnal acid secretion.
                             .   If bile re¯ux is the problem: use hydrotalcite suspension 5±10 ml between
                                 meals and bedtime. If this is insucient, consider cholestyramine 1±2 g after
                             .   If dysphagia or NG tube is present: consider gastrostomy. See Dysphagia
                                 (p. 91) and Nutrition and hydration problems (p. 115).
                             .   If dysmotility persists: consider erythromycin 100±250 mg (10 mg/kg in children)
                             .   If GORD is present: consider referral for gastroenterological opinion for
                                 consideration of a jejunal feeding tube or surgery.
                             .   If symptoms persist: refer for investigation.

cd ˆ clinical decision
88 Dyspepsia

B ˆ book; C ˆ comment; Ch ˆ chapter; CS-n ˆ case study-number of cases; CT-n ˆ controlled trial-number
of cases; E ˆ editorial; GC ˆ group consensus; I ˆ interviews; Let ˆ letter; LS ˆ laboratory study; MC ˆ multi-
centre; OS-n ˆ open study-number of cases; R ˆ review; RCT-n ˆ randomised controlled trial-number of
cases; RS-n ˆ retrospective survey-number of cases; SA ˆ systematic or meta analysis.

 1 Meinechie-Schmidt V, Christensen E (1998)              11 Martinez DA, Ginn-Pease ME, Caniano DA
   Classi®cation of dyspepsia. Scandinavian Journal          (1992) Recognition of recurrent gastroeso-
   of Gastroenterology. 33: 1262±72. (CT-7270)               phageal re¯ux following antire¯ux surgery in
 2 Grainger SL, Klass HJ, Rake MO, Williams JG               the neurologically disabled child: high index of
   (1994) Prevalence of dyspepsia: the epidemiol-            suspicion and de®nitive evaluation. Journal of
   ogy of overlapping symptoms. Postgraduate                 Pediatric Surgery. 27(8): 983±8. (OS-240)
   Medical Journal. 70: 154±61. (R, 25 refs)              12 Bagwell CE (1995) Gastro-oesophageal re¯ux in
 3 Childs S, Roberts A, Meineche-Scmidt V, de Wit            children. Surgery Annual. 27: 133±63. (R)
   N, Rubin G (2000) The management of                    13 de Caestecker J (2001) ABC of the upper gastro-
   Helicobacter pylori infection in primary care: a          intestinal tract. Oesophagus: heartburn. BMJ.
   systematic review of the literature. Family               323: 736±9.
   Practice. 17 (Suppl 2): S6±11. (SA, 59 refs)           14 Wasowska-Krolikowska         K,     Toporowska-
 4 Hawkey CJ (2000) Non-steroidal anti-in¯amma-              Kowalska E, Krogulska A (2002) Asthma and
   tory drug gastropathy. Gastroenterology. 119:             gastroesophageal re¯ux in children. Medical
   521±35. (R, 143 refs)                                     Science Monitor. 8(3): RA64±71. (R, 45 refs)
 5 Weil J, Langamn MJS, Wainwright P, Lawson              15 Mendell DA, Logemann JA (2002) A retrospec-
   DH, Rawlins M, Logan RFA, Brown TP, Vessey                tive analysis of the pharyngeal swallow in
   MP, Murphy M, Colin-Jones DG (2000) Peptic                patients with a clinical diagnosis of GERD
   ulcer bleeding: accessory risk factors and inter-         compared with normal controls: a pilot study.
   actions with non-steroidal anti-in¯ammatory               Dysphagia. 17(3): 220±6. (CT-18)
   drugs. Gut. 46: 27±31. (CT, MC-2000)                   16 Irwin RS, Madison JM (2002) Diagnosis and
 6 Nelson K, Walsh T, O'Donovan P, Sheehan F                 treatment of chronic cough due to gastro-
   and Falk G (1993) Assessment of upper gastro-             esophageal re¯ux disease and postnasal drip
   intestinal motility in the cancer-associated dys-         syndrome. Pulmonary Pharmacology & Thera-
   pepsia syndrome (CADS). Journal of Palliative             peutics. 15(3): 261±6. (R, 42 refs)
   Care. 9: 27±31.                                        17 Delaney BC, Innes MA, Deeks J, Wilson S,
 7 Armes PJ, Plant HJ, Allbright A, Silverstone T,           Oakes R, Moayyedi P, Hobbs FD, Forman D
   Slevin ML (1992) A study to investigate the               (2000) Initial management strategies for dys-
   incidence of early satiety in patients with               pepsia. Cochrane Database of Systematic Reviews
   advanced cancer. British Journal of Cancer. 65:           (computer ®le). 2: CD001961.
   481±4.                                                 18 Lam SK (1990) Why do ulcers heal with sucral-
 8 Bruera E, Catz Z, Hooper R, Lentle B and                  fate? Scandinavian Journal of Gastroenterology. 25
   MacDonald RN (1987) Chronic nausea and                    (Suppl 173): 6±16. (R, 106 refs)
   anorexia in advanced cancer patients: A possible       19 Caldwell JR, Roth SH, Wu WG, Semble EL,
   role for autonomic dysfunction. Journal of Pain           Castell DD, Heller MD, March WH
   and Symptom Management. 2: 19±21.                         (1987) Sucralfate treatment of nonsteroidal
 9 Sullivan PB (1997) Gastro-intestinal problems in          anti-in¯ammatory drug-induced gastrointestinal
   the neurologically-impaired child. Bailliere's            symptoms and mucosal damage. American
   Clinical Gastroenterology. 11(3): 529±46 (R)              Journal of Medicine. 83 (Suppl. 3B): 74±82.
10 Vandenplas Y, Ashkenazi A, Belli D, Boige N,              (RCT-143)
   Bouquet J, Cadranel S, Cezard JP, Cucchiara S,         20 Regnard CFB, Mannix K (1990) Palliation of
   Dupont C, Geboes K (1993) A proposition for the           gastric carcinoma haemorrhage with sucralfate.
   diagnosis and treatment of gastro-oesophageal             Palliative Medicine. 4: 329±30. (Let, CS-1)
   re¯ux disease in children: a report from a             21 Bazzoli F, Porro G, Bianchi MG, Molteni M,
   working group on gastro-oesophageal re¯ux                 Pazzato P, Zagari RM (2002) Treatment of
   disease. Working Group of the European Society            Helicobacter pylori infection. Indications and
   of Paediatric Gastro-enterology and Nutrition             regimens: an update. Digestive & Liver Disease.
   (ESPGAN). European Journal of Pediatrics.                 34(1): 70±83. (R, 139 refs)
   152(9): 704±11. (R, 44 refs)                           22 Twycross RG (1995) The use of prokinetic drugs
                                                                                                  Dyspepsia 89

     in palliative care. European Journal of Palliative        Pediatric Gastroenterology & Nutrition. 34(1):
     Care. 4: 141±5. (R)                                       23±5. (RCT-20)
23   Shivshanker K, Bennett RW, Haynie TP (1983)          30   Bernstein J, Kasich M (1974) A double-blind trial
     Tumor-associated gastroparesis: correction with           of simethicone in functional disease of the
     metoclopramide. American Journal of Surgery.              upper gastrointestinal tract. Journal of Clinical
     145: 221±5. (OS-10)                                       Pharmacology. 14: 614±23. (CT)
24   Kris MG, Yeh SDJ, Gralla RJ, Young CW (1985)         31   Ogilvie AL (1986) MA. Does dimethicone
     Symptomatic gastroparesis in cancer patients. A           increase the ecacy of antacids in the treatment
     possible cause of cancer-associated anorexia that         of re¯ux oesophagitis? Journal of the Royal
     can be improved with oral metoclopramide.                 Society of Medicine. 79(10): 584±7. (RCT-45)
     Proceedings of the American Society of Clinical      32   Mandel KG, Daggy BP, Brodie DA, Jacoby HI
     Oncology. 4: 267.                                         (2000) Review article: alginate-raft formulations
25   Sanger GJ, King FD (1988) From metoclo-                   in the treatment of heartburn and acid re¯ux.
     pramide to selective gut motility stimulants              Alimentary Pharmacology & Therapeutics. 14(6):
     and 5HT3 receptor antagonists. Drug Design                669±90. (R, 106 refs)
     and Delivery. 3: 273±95. (R, 143 refs)               33   Watters KJ, Murphy GM, Tomkin GH,
26   Loose FD (1979) Domperidone in chronic                    Ashford JJ (1979) An evaluation of the bile
     dyspepsia: a pilot open study and a multicentre           acid binding and antacid properties of hydro-
     general practice crossover comparison with                talcite in hiatus hernia and peptic ulceration.
     metoclopramide and placebo. Pharmathera-                  Current Medical Research Opinion. 6: 85±7.
     peutica. 2(3): 140±6.                                     (OS-25)
27   Berne JD, Norwood SH, McAuley CE, Vallina            34   Norrashidah AW, Henry RL (2002) Fundoplica-
     VL, Villareal D, Weston J, McClarty J (2002)              tion in children with gastro-oesophageal re¯ux
     Erythromycin reduces delayed gastric emptying             disease. Journal of Paediatrics & Child Health.
     in critically ill trauma patients: a randomized,          38(2): 156±9. (RS-79)
     controlled trial. Journal of Trauma-injury           35   Doede T, Faiss S, Schier F (2002) Jejunal feeding
     Infection & Critical Care. 53(3): 422±5. (RCT-68)         tubes via gastrostomy in children. Endoscopy.
28   Booth CM, Heyland DK, Paterson WG (2002)                  34(7): 539±42. (OS-52)
     Gastrointestinal promotility drugs in the critical   36   Wales PW, Diamond IR, Dutta S, Muraca S,
     care setting: a systematic review of the evidence.        Chait P, Connolly B, Langer JC (2002) Fund-
     Critical Care Medicine. 30(7): 1429±35. (SA, 70           oplication and gastrostomy versus image-guided
     refs)                                                     gastrojejunal tube for enteral feeding in neuro-
29   Costalos C, Gounaris A, Varhalama E, Kokori F,            logically impaired children with gastro-
     Alexiou N, Kolovou E (2002) Erythromycin as a             esophageal re¯ux. Journal of Pediatric Surgery.
     prokinetic agent in preterm infants. Journal of           37(3): 407±12. (RS-111)

Shared By: