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					                               Dyspepsia

                  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.

                                Introduction

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.
                  Treatment
                                                            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
                                 controlled.
                             .   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
                                 degrees.
                                 If NG/gastrostomy-fed: alter feeding regime from large bolus to frequent small
                                 volume feeds. Continuous feeding can be tried but this sometimes aggravates
                                 symptoms.

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
                                 meals.
                             .   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)
                                 12-hourly.
                             .   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




                                             References
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.

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