Definitions for the Levels of Evidence (Ia to 4) and Grades of Recommendation (A to C, and Good Practice Points) are given at the end of the "Major Recommendations" field.
Note: The Grades of Recommendation represent the strength of the supporting evidence, rather than the importance of the recommendations.
Undifferentiated Dyspepsia
Initial Management of Undifferentiated Dyspepsia
Recommendations
B If there are any alarm signals, or if the person is aged >50 years at first presentation, refer for oesophago-gastro-duodenoscopy (OGD).
A Empiric therapy
- For people with heartburn, manage as gastro-oesophageal reflux disease (GORD) (see recommendations for GORD).
- For people with dyspepsia but no heartburn (reflux) symptoms, either:
- treat initially with domperidone or H2 receptor antagonists (H2RAs) OR if aged <50 years and in an area of high (>30%) Helicobacter pylori prevalence
- test-and-treat* for H. pylori.
*Although data regarding the prevalence of H. pylori infection in New Zealand are patchy, the following statements can be made:
- Rates in the South Island are well below 30%.
- Rates tend to be >30% in adult Maori, Pacific peoples, native populations in Asia, and those with lower socio-economic status.
- Rates in adults living in Auckland have generally been found to be >30%.
Good Practice Points
- Review lifestyle factors (e.g., diet, weight, smoking, alcohol).
- If alarm signals indicate organic disease, refer to specialist for OGD.
- If there is heartburn and dyspepsia, treat as GORD in the first instance.
- Review person's intake of all medications, especially nonsteroidal anti-inflammatory drugs (NSAIDs).
- Commence empiric therapy in those without alarm signals or heartburn.
- If there is concurrent use of NSAIDs, evaluate for risk of gastrointestinal (GI) complications, and consider alternative strategies if risk is increased. (See Chapter 5 in the original guideline document: NSAIDs and GI Complications.)
Management of Recurring Undifferentiated Dyspepsia
Recommendations
C If there is failure to respond to treatment in 4 to 12 weeks, refer for OGD.
C If previous dyspepsia symptoms recur 1 to 6 months after cessation of treatment, reevaluate person for alarm signals, taking into account timing of relapse and severity of symptoms.
C If previous dyspepsia symptoms recur after 6 months with no alarm signals, repeat empiric therapy.
B If symptoms recur after test-and-treat, refer for OGD.
Management of Functional Dyspepsia
Recommendations
C Provide reassurance regarding the absence of organic pathology.
C Encourage lifestyle changes: diet, weight control, smoking cessation, and alcohol moderation.
A Consider drug therapy in the following order:
- Prokinetics (domperidone) number needed to treat (NNT) 2.8 (NNT based on total prokinetics studied)
- H2RAs NNT=5.9
- Proton pump inhibitors (PPIs) NNT=11.1
A Test-and-treat people aged <50 years with dyspeptic symptoms (excluding heartburn) and no alarm signals who originate from areas of high H. pylori prevalence (>30%).
A Consider H. pylori eradication in others.
Good Practice Points
Check patient:
- Does not have heartburn
- Is not taking NSAIDs
- Has normal blood tests (full blood count [FBC], erythrocyte sedimentation rate [ESR], c-reactive protein [CRP])
- Has normal OGD
Gastro-Oesophageal Reflux Disease (GORD)
GORD Symptoms
Recommendations
Consider GORD in people with:
- A Heartburn (burning sensation radiating from the epigastrium towards the neck)
- B Non-cardiac chest pain, asthma, chronic cough, hoarseness of voice, and erosion of teeth
Initial Management with Empirical Therapy
Recommendations
A If the person's symptoms are suggestive of GORD, treat with a step-down drug regimen, usually in 4- to 8-week steps:
- Step 1. Full-dose PPI (omeprazole 20 mg, lansoprazole 30 mg, pantoprazole 40 mg) daily
- Step 2. Half-dose PPI
- Step 3. H2RA (famotidine 20-40 mg, ranitidine 150-300 mg) twice daily
- Step 4. Antacids/alginate
B If there is no response to full dose PPI therapy, double the dose.
B Continue treatment for at least 3 to 6 months.
B If the person fails to respond, or if symptoms recur within 1 month after end of treatment, consider OGD rather than long-term empiric therapy.
Good Practice Points
Exclude people with alarm signals from empiric therapy, and refer for OGD.
Treatment of GORD Diagnosed After OGD
Recommendations
A People with grades 0, A, and B
- Treat with a step-down drug regimen (see Algorithm 3 in the original guideline document: Heartburn +/-Dyspepsia: Empiric Therapy).
- If symptoms recur at stepped-down dosage, continue on lowest effective dose; intermittent therapy may control symptoms.
People with grades C and D
- Treat with ongoing continuous full-dose PPI treatment.
C Consider surgery as an alternative to long-term drug treatment if:
- Age <50 years
- Age 50 years and over and there is no comorbidity
- There is inability or unwillingness to take medications.
- There is inadequate control with medical therapy.
B If high-dose PPI treatment fails, reevaluate symptoms and consider 24-hour pH telemetry.
B In people with Barrett's oesophagus or unresolved complications (grade D), reevaluate with OGD if necessary.
Helicobacter Pylori and Peptic Ulceration
Initial Diagnostic Investigation for H. Pylori
Recommendations
Test-and-treat for H. pylori in those:
- A Who originate from areas of high (>30%) H. pylori prevalence
- A With present or past history of peptic ulcer
- B With Mucosa-associated lymphoid tissue lymphoma
- C With a family history of gastric cancer
Recommended diagnostic tests
- A Urea breath test (UBT) is the recommended noninvasive test. Stop treatment (other than antacids) for 2 weeks prior to UBT.
- A Although UBT and faecal antigen tests are also valid options, serology (validated with sensitivity and specificity of at least 90%) is recommended where the prevalence of H. pylori is high (>30%).
- A Faecal antigen test is also recommended, although it is not yet universally available in New Zealand. Omeprazole can interfere with the result.
- B If OGD is being performed for investigation of dyspepsia, consider testing with the rapid urea test, histology, or culture.
Initial Treatment of H. Pylori
Recommendations
A Give triple therapy: regimens containing PPI, clarithromycin, and amoxicillin or metronidazole, have consistently high eradication rates after one week.
A Substitute metronidazole for amoxicillin in penicillin-allergic individuals.
B Emphasise to the person that successful eradication depends on compliance with treatment regimen.
H. pylori Treatment Failure
Recommendations
A For initial treatment failure, use either of the following for 1 week:
- An alternative triple therapy regimen (PPI plus two of the following: clarithromycin, amoxicillin, metronidazole, tinidazole, tetracycline, and bismuth), OR
- Quadruple therapy (standard triple therapy plus bismuth)
Repeated treatment failure:
- B Review compliance factors and consider testing for bacterial resistance.
- C Consider retreatment for 2 weeks.
Confirmation of H. Pylori Eradication
Recommendations
B Confirm eradication of H. pylori in those with a peptic ulcer complication, important comorbidity factors, symptom recurrence, or residence in isolated areas.
Recommended tests
- B UBT is the recommended noninvasive test (serology should not be used because it takes 6 to 12 months to become negative).
- A H. pylori stool antigen may be used for confirmation of eradication at least 4 weeks after stopping treatment. Omeprazole can interfere with result.
- C For people having OGD to check for healing of gastric ulcer, confirm eradication by histology.
Timing of tests
- B Perform at least one month after completion of eradication regimen.
- C For people taking PPIs, perform at least one week after cessation of PPI.
Management of H. Pylori-Negative Peptic Ulcers
Recommendations
A Treat duodenal ulcers with H2RAs or PPIs for 4 to 8 weeks.
A Treat gastric ulcers with PPIs or H2RAs for 8 to 12 weeks and confirm healing with OGD.
C Use maintenance treatment with H2RA or PPI if:
- Ulcer recurrences are frequent (e.g., more than once per 12 months) or severe.
- There is a previous peptic ulcer complication.
- There are comorbid factors that might make any complications life-threatening.
NSAIDS and GI Complications
Individuals at Increased Risk of NSAID-Induced GI Complications
Recommendations
A Begin treatment with either of the following:
- Misoprostol at doses of 200 micrograms/day. Increase dose over two weeks as tolerated, to a maximal dose of 800 micrograms/day.
- Standard doses of PPI once daily
A Eradicate H. pylori, if testing is positive.
Treatment of NSAID-Related Dyspepsia
Recommendations
C Review person's history for risk factors.
C Stop NSAID if possible.
C In person with symptoms and risk factors, refer for OGD.
If ongoing symptom relief is needed:
- A Continue NSAID with coprescription of PPI or misoprostol OR
- B Replace NSAID with cyclo-oxygenase-2 (COX-2) selective inhibitor.
A Eradicate H. pylori if testing is positive.
Management of NSAID-Induced Peptic Ulcer
Recommendations
A If NSAID can be stopped, treat with an H2RA (ranitidine 150 mg twice daily or famotidine 20 mg twice daily) or PPI (omeprazole 20 mg, lansoprazole 30 mg, or pantoprazole 40 mg) for 8 weeks for duodenal ulcers and 12 weeks for gastric ulcers.
If NSAID needed:
- A Treat with PPI for 8 weeks for duodenal ulcer and 12 weeks for gastric ulcer; if unsuccessful increase dose. Ongoing maintenance treatment is advised (as for individuals at increased risk of NSAID-induced GI complications)
- C Consider replacement of NSAID with COX-2 selective inhibitor.*
A Eradicate H. pylori if testing is positive.
C Refer individuals with complications (i.e., bleeding, perforations, obstruction) to specialists.
C Check healing of gastric ulcer with OGD.
Definitions:
Levels of Evidence
Ia
Evidence obtained from meta-analysis of randomised controlled trials (RCTs)
Ib
Evidence obtained from at least one randomised controlled trial
IIa
Evidence obtained from at least one well-designed controlled study without randomisation
IIb
Evidence obtained from at least one other type of well-designed quasi-experimental study
III
Evidence obtained from well-designed descriptive studies, such as comparative studies, correlation studies, and case studies
IV
Evidence obtained from expert committee reports or opinions, and/or clinical experiences of respected authorities
Grades of Recommendation
Grade A
Evidence levels Ia & Ib
Requires at least one RCT as part of the body of literature of overall good quality and consistency addressing specific recommendation
Grade B
Evidence levels IIa, IIb & III
Requires availability of well-conducted studies but no RCTs addressing specific recommendation
Grade C
Evidence level IV
Requires evidence obtained from expert committee reports or opinions, and/ or clinical experiences of respected authorities
Indicates absence of directly applicable clinical studies of good quality