“ALARMS”
Anaemia
Loss of weight
Anorexia
Recurrent symptoms
(dysphagia, odynophagia)
Persistent continuous
vomiting
Epigastric mass
GI bleed/ melaena
Previous gastric surgery
Progressive swallowing
problems (dysphagia)
Urgent referral to
G.I. Consultant
Positive –
H.pylori
eradication
therapy as per
BNF – one week
course is
recommended
Persistent or
recurrent
symptoms –
refer for
endoscopy
Negative –
aluminium /
magnesium
mixture eg
Maalox Plus®
Ranitidine
Low dose PPI
Lifestyle advice
GORD
Mild – alginate
suspension
Severe –
lansoprazole or
omeprazole
Dyspepsia Guidelines
Recent onset
dyspepsia
Under 55 years –
Test for H. pylori using stool
antigen test (preferred
option),
serology or urea breath test
No Alarm symptoms
Over 55 years -
Refer for endoscopy
Abnormal –
Appropriate
treatment or
further
referral
Normal –
treat as for
under 55
years and H.
pylori
negative
Additional Information on PPIs
•
PPIs are over-prescribed.
•
Many patients can be adequately treated
with a cost effective alginate such as Peptac
•
Patients should have a documented and
appropriate indication for receiving a PPI
•
PPIs suppress gastric acid and cause
bacterial overgrowth eg with C difficile
•
Long-term use of PPIs can cause
temporary problems of rebound
hyperacidity on withdrawal
•
Increased risk of hip fracture with long-
term PPI use
•
If NSAID treatment is essential and the
patient has an ulcer, prescribe the
treatment dose of omeprazole or
lansoprazole (cost effective options)
•
If NSAID treatment must continue and the
patient has non-ulcer dyspepsia, use a
maintenance PPI dose
When Not to Refer for Endoscopy
•
Aged under 55 years and no alarm
signs
•
Not yet tested for H. pylori and
treated, if necessary
•
Recent normal endoscopy result but
persistent symptoms
•
Long established dyspepsia that has
not become worse over a period of
time
NB
•
Most GI ulcers are strongly
associated with H. pylori infection
•
30% of endoscopy results are normal
•
2% diagnose oesophago/gastric
cancer
•
Endoscopy is expensive
