Dyspepsia
Alarm Features in Dyspepsia — NICE NG12 · CG184 · Act Immediately
| Alarm feature | Why dangerous | Action |
|---|---|---|
| Dysphagia — any age, any character | Progressive dysphagia solids → liquids = oesophageal cancer until proven otherwise. Sensory dysphagia (food sticking) may precede structural obstruction. NICE NG12 mandates 2WW at any age — there is no lower age threshold for this alarm feature. | 2WW upper GI referral |
| Unexplained weight loss with upper abdominal symptoms, age ≥40 | NICE NG12 criterion for gastric, oesophageal, and pancreatic cancer referral. Does not require dysphagia or other alarm features — weight loss alone with upper GI symptoms meets the threshold. Do not accept the patient's own explanation as clinically sufficient. | 2WW upper GI referral |
| Haematemesis — any episode | Upper GI bleed — peptic ulcer, oesophageal varices, Mallory-Weiss tear, or malignancy. Even a single small episode requires same-day hospital assessment. Do not prescribe PPI and arrange outpatient OGD for haematemesis. | Same-day hospital / 999 |
| Persistent vomiting with any upper GI symptom | NICE CG184 and NG12 alarm feature for upper GI malignancy. Persistent vomiting implies either gastric outlet obstruction or autonomic dysfunction secondary to malignancy. Do not treat as simple functional vomiting without investigation. | 2WW upper GI referral |
| Epigastric mass on examination | Palpable epigastric mass is a NICE NG12 criterion for 2WW gastric cancer referral regardless of other symptoms or age. Often represents advanced gastric cancer. | 2WW upper GI referral |
| Iron deficiency anaemia — unexplained (men any age; post-menopausal women) | NICE NG12: unexplained IDA in men or post-menopausal women = 2WW referral. In the context of dyspepsia, IDA implies an occult upper GI bleed from ulcer, coeliac disease, or malignancy. Always check FBC in new dyspepsia. | 2WW upper GI / coeliac screen |
| Age ≥55 with treatment-refractory dyspepsia | NICE CG184: patients aged ≥55 with dyspepsia that persists despite adequate H. pylori eradication and PPI therapy should be referred for urgent OGD. The pre-test probability of upper GI malignancy is sufficient to warrant endoscopy regardless of other features. | Urgent / 2WW OGD referral |
| Sudden onset of severe epigastric pain — out of character | Perforated peptic ulcer presents as sudden, catastrophic epigastric pain with peritonism — surgical emergency. Leaking AAA may also present with epigastric pain. Do not send home with a PPI if the history includes sudden-onset severe pain even if the patient is now more comfortable. | 999 / same-day surgical |
Safeguarding Considerations
🏠 Domestic Abuse
- Chronic dyspepsia in a patient with evidence of emotional or physical abuse — somatic presentations are common in domestic violence
- Inconsistent or minimising history; partner accompanies and answers for the patient
- Weight loss attributed to stress or "not eating" without clear explanation
💊 Medication Misuse / Self-Harm
- NSAID or paracetamol overuse causing gastric symptoms — may indicate self-harm or unmanaged chronic pain
- Alcohol dependency causing severe gastritis — use AUDIT-C; safeguarding children in household
- Covert NSAID use in young people — always ask about OTC analgesia in all age groups
🧒 Paediatric Dyspepsia
- Recurrent abdominal pain in a child with school refusal — consider emotional abuse, bullying, or adverse family environment
- Helicobacter pylori in children — unusual and may indicate overcrowded housing or poor sanitation; check FH and household members
👴 Older Adults
- Unexplained weight loss and dyspepsia in an older adult dependent on a carer — consider neglect or reduced food access
- Long-term NSAID use prescribed by others or self-medicating — increases ulcer risk dramatically; review who is managing medications
💼 Work Stress & HPA Axis Activation
Chronic occupational stress increases gastric acid secretion, reduces mucosal prostaglandin production, slows gastric emptying, and heightens visceral pain perception. Functional dyspepsia and stress-related GORD are among the most common occupational health presentations in the UK. The symptoms are physiologically real, not imagined.
"You mentioned things have been stressful at work — has that been going on for the same sort of time as the symptoms?"🧠 Health Anxiety & Cancer Fear
Dyspepsia with weight loss is a high-anxiety presentation. Health anxiety directly worsens functional dyspepsia symptoms by amplifying visceral sensitivity. Paradoxically, excessive investigation driven by health anxiety perpetuates it rather than resolving it. CBT targeting health anxiety is more effective than repeated negative investigations in reducing functional dyspepsia severity.
"Sometimes when we're worried about our health it can actually make the symptoms feel worse — have you found yourself worrying a lot about what might be causing this?"🍽️ Diet, Eating Habits, and Lifestyle
Irregular meal timing, large evening meals, rapid eating, high fat and spice intake, carbonated drinks, excess coffee and alcohol are the modifiable lifestyle drivers of GORD and functional dyspepsia. These should be explored and addressed specifically before committing a patient to long-term PPI therapy.
"Can you walk me through what a typical evening meal looks like — what time you eat, how much, and what kind of food? Do you have coffee or alcohol after eating?"😔 Depression and Chronic Pain
Functional dyspepsia and depression are bidirectionally linked through shared serotonergic pathways. Patients with untreated depression have lower pain thresholds, increased visceral sensitivity, and poorer treatment response to PPIs. Low-dose antidepressants (TCAs, SSRIs) have evidence in functional dyspepsia as well as the comorbid mood disorder.
"How have you been feeling in yourself more generally — mood-wise, energy levels, that sort of thing?"💊 Medication-Related Causes
Many patients do not realise their symptoms are iatrogenic. OTC NSAID use for back pain or headache causing gastric symptoms is extremely common and underreported. Addressing the medication cause is more clinically effective than prescribing PPI on top of the offending drug.
"Do you take any over-the-counter painkillers — even things like ibuprofen for headaches or back pain, that you might not think of as a regular medicine?"🔄 Expectations About Long-Term Medication
A common and legitimate hidden concern in dyspepsia is reluctance to take medication long-term — "I don't want to be on tablets for life." This expectation, if not probed, leads to covert non-adherence and a poor treatment outcome that is wrongly attributed to clinical failure.
"How do you feel about the idea of taking medication for this? Is that something you'd be comfortable with — at least for a trial period to see if it makes a difference?"- Not asking about dysphagia — the single most important alarm feature in upper GI presentations
- Accepting the patient's own explanation for weight loss without probing it as an alarm feature
- Not screening for NSAID / OTC analgesic use in every dyspepsia consultation
- Missing the cancer fear — it will be subtly signalled in the case card and actor behaviour
- Moving straight to PPI prescription without H. pylori testing first
- Completing data gathering after 8+ minutes — leaving insufficient time for management
999 or Same-Day Hospital
Hospital today- HaematemesisAny volume, any episode — upper GI bleed. 999 if haemodynamically unstable. If stable, same-day hospital admission for urgent OGD.
- Perforated peptic ulcerSudden-onset catastrophic epigastric pain, peritonism, board-like abdomen, haemodynamic compromise — 999 immediately. Do not prescribe PPI and review.
- Melaena (black tarry stool) with haemodynamic instabilityUpper GI bleed with haemodynamic compromise — emergency. Stable melaena = same-day hospital assessment.
- Suspected cardiac cause of epigastric painPain radiating to jaw, arm, or interscapular region; associated diaphoresis, breathlessness — 12-lead ECG immediately; 999 if ACS confirmed or suspected.
2WW / Same-Week Referral
2 weeks or less- Dysphagia — any age, any character (NICE NG12)2WW upper GI endoscopy regardless of other features — no exceptions, no age threshold
- Age ≥55 with unexplained weight loss + upper GI symptomsNICE NG12: 2WW for gastric, oesophageal, or pancreatic malignancy
- Persistent vomiting with upper GI symptoms2WW upper GI endoscopy — NICE CG184 and NG12 alarm feature
- Palpable epigastric mass on examination2WW gastric cancer referral — NICE NG12 criterion
- Unexplained iron deficiency anaemia (men any age; post-menopausal women)2WW upper GI + lower GI (both simultaneously) — coexisting colorectal and upper GI pathology must both be excluded
- Age ≥55 + treatment-refractory dyspepsia despite H. pylori eradication and PPINICE CG184: urgent OGD referral even without other alarm features in this age group
Manage in Primary Care
GP practice- GORD — no alarm features, age <55Burning heartburn, worse post-meals and lying flat, responds to antacids, no weight loss or dysphagia — H. pylori test; lifestyle modification; PPI trial 4–8 weeks
- Functional dyspepsia — no alarm featuresEpigastric fullness, early satiety, bloating without heartburn, no alarm features — H. pylori test and treat; PPI 4–8 weeks; lifestyle; low-dose TCA if refractory
- Dyspepsia + H. pylori positive — no alarm featuresTest-and-treat strategy in patients <55 with uninvestigated dyspepsia and no alarm features — eradication therapy is definitive and curative
- NSAID-induced dyspepsiaStop NSAID or switch to safer alternative; add PPI; test and eradicate H. pylori; review at 4–6 weeks
- Missing 2WW for dysphagia — the most serious dyspepsia triage error
- Accepting weight loss without acting on it as an alarm feature
- Prescribing PPI without H. pylori testing first (NICE CG184 non-concordant)
- Using "I'm going to put in a 2WW" without explaining what this means
- Sending home a patient with haematemesis on a PPI with routine review
- Not offering abdominal examination in a new dyspepsia presentation
- Not checking weight — the one objective measure of an alarm feature
- Missing the Virchow's node check in a patient with weight loss and upper GI symptoms
- Not examining conjunctivae for pallor when IDA is a concern
- Prescribing PPI without testing for H. pylori first — the most common SCA error in dyspepsia
- Not mentioning that PPI must be stopped 2 weeks before H. pylori testing
- Not ordering FBC when weight loss is an alarm feature
- Not doing coeliac screen in young patients with GI symptoms and fatigue
- Ordering OGD before H. pylori testing in a patient <55 with no alarm features (not NICE-concordant)
"What I think is most likely going on is something called GORD — acid reflux — or functional dyspepsia, which is really just a name for the stomach being more sensitive than it should be. Think of it this way: the valve at the bottom of your food pipe is designed to stop acid coming back up, but in GORD it doesn't seal quite as tightly as it should. That means acid — which is very strong — escapes upwards and irritates the lining of the food pipe and stomach. The pain and burning sensation are caused by that irritation, not by any damage or ulcer. The good news is that we can treat this very effectively, and I'm going to do some tests first to make sure there isn't an additional cause — particularly a bug called H. pylori — that we should treat before just suppressing the acid."
"It's probably just the stress."
"You're actually right that stress plays a real role — it can genuinely worsen acid reflux and stomach sensitivity, and I want to address that too. But let's also make sure we check for any physical cause, because treating H. pylori if it's there can sometimes completely resolve the symptoms rather than just managing them."
"Why can't you just give me something for it now?"
"I completely understand the temptation — but the reason I want to test first is that if H. pylori is there, antibiotics to clear it will often cure the problem. If I just give you a tablet to reduce the acid, it helps but it doesn't cure anything, and the symptoms are likely to come back when you stop. The test only takes a few days."
GORD (Gastro-Oesophageal Reflux Disease)
Burning retrosternal or epigastric pain, worse post-meals, lying flat, bending, relieved by antacids. Lower oesophageal sphincter dysfunction allows acid reflux. Diagnose clinically if no alarm features; H. pylori test; lifestyle + PPI trial 4–8 weeks. No OGD needed in patients <55 with no alarm features.
Functional Dyspepsia
Epigastric fullness, early satiety, bloating, pain without heartburn, no structural cause on investigation. Rome IV: bothersome postprandial fullness and/or early satiety ≥3 months. H. pylori test; PPI 4–8 weeks; low-dose TCA if refractory. Lifestyle modification essential.
NSAID / Medication-Induced Dyspepsia
Epigastric pain in a patient taking NSAIDs, aspirin, corticosteroids, or bisphosphonates. Stop or substitute the offending drug; H. pylori eradication; PPI for gastroprotection if drug cannot be stopped.
H. pylori-Related Peptic Ulcer Disease
Gnawing epigastric pain 1–2 hours post-prandially, relieved by food or antacids, may wake from sleep. Positive stool antigen test. Eradication therapy is curative — failure to test means missing the curable cause. Confirm eradication; OGD if symptoms persist post-eradication.
Coeliac Disease
Bloating, diarrhoea, iron deficiency, fatigue, epigastric discomfort. Anti-TTG IgA positive. Refer gastroenterology for duodenal biopsy confirmation before starting GFD. Do NOT start GFD before biopsy — histology falsely normalises within weeks of going gluten-free.
Biliary Colic / Cholecystitis
RUQ or epigastric colicky pain 30–60 min post-fatty meal, nausea. USS confirmation. Elective cholecystectomy referral if gallstones confirmed and symptomatic. Acute cholecystitis (fever + Murphy's positive) = same-day surgical assessment.
Diabetic Gastroparesis
Upper abdominal bloating, nausea, early satiety, vomiting in a patient with long-standing diabetes. Gastric emptying study; optimise glycaemic control; dietary modification; prokinetic (metoclopramide) short-term only.
Gastric Cancer
Age ≥55 with unexplained dyspepsia, weight loss, anorexia, epigastric mass, or IDA. UK incidence 7,000/year. 2WW OGD if alarm features present. Early cancer is asymptomatic or mildly symptomatic — the alarm feature triggers investigation before symptoms become severe.
Oesophageal Cancer
Progressive dysphagia from solids to liquids, weight loss, regurgitation, hoarseness. NICE NG12: dysphagia at any age = 2WW regardless of other features. Oesophageal adenocarcinoma (GORDs Barrett's) is now more common than squamous in the UK.
Pancreatic Cancer
Vague epigastric pain radiating to the back, weight loss, new-onset diabetes in middle-aged/elderly, jaundice (head of pancreas). One of the most diagnostically delayed cancers in UK primary care. 2WW if unexplained weight loss + upper GI symptoms age ≥40.
Perforated Peptic Ulcer
Sudden-onset catastrophic epigastric pain, board-like abdomen, peritonism. Surgical emergency — 999 immediately. History of NSAID use, H. pylori, or previous peptic ulcer increases risk.
- Diagnosing GORD/functional dyspepsia without addressing the weight loss or testing H. pylori first
- Not naming the cancer concern when the patient has signalled it (weight loss, anxiety in the history)
- Using jargon: "GORD," "H. pylori-positive dyspepsia," "proton pump inhibitor" without plain language explanation
- Reassuring the patient that the weight loss is "nothing to worry about" before investigation
- Missing the 2WW trigger by not connecting weight loss + upper GI symptoms + age ≥40
- Saying "I'll put in a 2WW" without explaining what an OGD is or what the timeline means
- Delaying referral to await H. pylori result when alarm features are already present
- Not explaining interim safety-netting while awaiting the appointment
- Advising GFD before confirmatory duodenal biopsy in suspected coeliac disease
- Not addressing the emotional impact of receiving a 2WW cancer referral
Validate — name their expectation
In dyspepsia with weight loss, the expectation is often an urgent camera test. In straightforward GORD, it may be "just give me something that works." Both are understandable and must be named before managing.
"I imagine you might have been hoping I could arrange a camera test today — especially given how long this has been going on and the fact that you've lost a bit of weight. That's a completely reasonable expectation to have."Explain — share your clinical reasoning
Explain the evidence-based reason for starting with a test-and-treat strategy. If alarm features are present, explain why the 2WW is the right path. If they are absent, explain what the investigations will achieve before starting treatment.
"The reason I'd like to test for H. pylori first is that if it's there, treating it will often completely cure the problem — not just manage it. If it's not there and the tests look reassuring, then a tablet to reduce the acid is the right next step, and we'll see you back in 4–6 weeks."Negotiate — offer something today
Every patient must leave with a concrete plan. In dyspepsia: a stool test arranged today, a blood test, lifestyle advice, an antacid or alginate for interim symptom relief, and a specific review appointment.
"I'm arranging the H. pylori test today, and I'll also do a blood count and a coeliac screen. In the meantime, Gaviscon after meals can really help with the burning sensation while we're waiting for the results. I'd like to see you back in two to three weeks."Large evening meals increase gastric volume and acid secretion immediately before lying flat. Gravity no longer assists gastric emptying when recumbent, increasing the duration of acid contact with the lower oesophagus. Smaller, more frequent meals reduce peak acid secretion.
Eat the largest meal at lunchtime rather than the evening if possible. Avoid eating within 3 hours of going to bed. Reduce portion sizes at the evening meal. Eat slowly — rapid eating worsens functional dyspepsia by accelerating gastric distension.
Gravity reduces nocturnal oesophageal acid exposure when the head is elevated above the level of the stomach. Sleeping on extra pillows is less effective than elevating the actual bed head — pillows cause spinal flexion that can worsen reflux.
Place a block or wedge under the head of the bed to raise it 15–20 cm. Left lateral decubitus position (lying on the left side) also reduces nocturnal GORD. Avoid extra pillows alone — they bend the stomach and worsen reflux.
Fatty food, chocolate, peppermint, and alcohol reduce lower oesophageal sphincter pressure — directly allowing reflux. Citrus juice and carbonated drinks are directly irritant to inflamed mucosa. Coffee increases gastric acid secretion and worsens symptoms in GORD and functional dyspepsia.
Keep a food and symptom diary for 2 weeks to identify personal triggers. Universal advice: reduce large fatty meals, alcohol (especially in the evening), and carbonated drinks. Coffee: trial reduction to 1–2 cups before noon; switch to decaffeinated if symptoms worsen post-coffee.
Increased abdominal adiposity raises intra-abdominal pressure, which increases the gastro-oesophageal pressure gradient and promotes reflux. Weight loss of even 5–10% of body weight significantly reduces GORD symptoms in overweight patients.
Referral to a structured weight management programme (e.g. NHS Digital Weight Management Programme). Swimming and cycling are preferable to running in overweight patients with GORD — impact exercise increases intra-abdominal pressure transiently.
Nicotine directly reduces lower oesophageal sphincter tone and impairs oesophageal motility. Smoking also impairs mucosal prostaglandin synthesis, slows peptic ulcer healing, and independently increases the risk of gastric and oesophageal cancer.
Smoking cessation referral (NHS Stop Smoking Service). Varenicline (Champix) is the most effective pharmacotherapy. In patients with confirmed peptic ulcer: smoking significantly delays ulcer healing even with PPI and H. pylori eradication.
Chronic psychological stress increases gastric acid secretion via HPA axis activation, reduces mucosal blood flow, and lowers visceral pain threshold. Stress is a well-established exacerbating factor for both GORD and functional dyspepsia.
NHS Talking Therapies self-referral for CBT. Identify and address the specific stressor — in this case, work pressure. Regular moderate exercise reduces cortisol and independently improves dyspepsia. Mindfulness-based stress reduction has evidence in functional dyspepsia.
H. pylori positive → eradication first, not PPI alone
- 7-day triple therapy: Lansoprazole 30mg BD + Clarithromycin 500mg BD + Amoxicillin 1g BD
- Penicillin allergy: substitute Metronidazole 400mg BD for amoxicillin
- Confirm eradication with stool antigen 4–6 weeks post-treatment (PPI off 2 weeks before)
- GORD / H. pylori negative: PPI trial — Omeprazole 20mg OD or Lansoprazole 30mg OD × 4–8 weeks
- Interim symptom relief during testing: Alginate (Gaviscon Advance) 10ml after meals and at bedtime
Review and adjust before escalating
- Double PPI dose (Omeprazole 40mg OD or 20mg BD) for 4–8 weeks in GORD with poor response
- Add H2 receptor antagonist at night (famotidine 20mg nocte) for nocturnal breakthrough symptoms
- Functional dyspepsia refractory to PPI: Low-dose TCA — Amitriptyline 10mg nocte (neuromodulatory effect on visceral sensitivity); evidence from RCTs equivalent to ATLANTIS data for IBS
- Prokinetic (Metoclopramide 10mg TDS) for gastroparesis / post-prandial fullness — short-term only (max 5 days per course; tardive dyskinesia risk with prolonged use)
Long-term PPI: lowest effective dose, annual review
- After 4–8 weeks of full-dose PPI with good response: attempt step-down to on-demand PPI (taken only when symptoms occur) or lowest effective dose
- NICE CG184: long-term PPI without annual review is not evidence-based — review indication annually
- Barrett's oesophagus: full-dose PPI indefinitely — do not step down without gastroenterology advice
- Refractory symptoms despite optimised PPI + H. pylori eradicated → OGD referral if ≥55, or gastroenterology if <55 with no alarm features after 12 months
Select patient characteristics — pharmacological guidance appears below
"Take the PPI 30 minutes before your main meal — the acid pump is only active when it's being stimulated by eating, so taking it before you eat means it blocks the pump when it's most active. If you're taking it for H. pylori treatment, take it twice a day for the full 7 days alongside the antibiotics."
SCA pearl: The two most common prescribing errors in dyspepsia are (1) starting PPI without testing H. pylori, and (2) prescribing omeprazole to a patient on clopidogrel. Both regularly appear as SCA clinical scenarios. Pantoprazole or rabeprazole are safe alternatives with clopidogrel.
"H. pylori is a bacterium that lives in the stomach lining and can cause ulcers and inflammation. These three medicines — taken over 7 days — will clear it in about 90% of people. You'll probably notice some side effects, especially a metallic taste and maybe some nausea — these are normal and it's important to complete the full course. After finishing, we'll do a simple stool test 4–6 weeks later to check it's been cleared. One important thing: if you're already taking any acid-reducing tablets, stop them 2 weeks before that stool test."
SCA pearl: The two critical facts for the SCA: (1) stop PPI 2 weeks before H. pylori testing (not 2 days, not 1 week — 2 weeks); (2) stop antibiotics 4 weeks before testing. These are specific numerical thresholds that examiners test. Stating them correctly to the patient is a high-scoring communication point in the Tasks domain.
"Gaviscon works differently from a PPI — instead of reducing acid, it forms a raft on top of your stomach contents, which physically stops the acid from coming back up. Take it after meals and at bedtime when stomach contents are most likely to reflux. It's safe, works quickly, and you can take it as needed while we're waiting for your test results."
SCA pearl: Gaviscon is excellent as a bridging agent while awaiting H. pylori test results or PPI response. In the SCA, offering "something to help with the symptoms in the meantime" while explaining why you are not yet starting long-term PPI scores both the Tasks domain (appropriate interim management) and Relating to Others (patient leaves with something tangible and not just a test).
"Antacids work by neutralising the acid in your stomach — they work quickly, within a few minutes, but the effect only lasts a couple of hours. They're best for occasional heartburn rather than regular symptoms. If you're finding you need them every day, that's actually a sign we should think about a more formal treatment."
SCA pearl: Daily antacid use for >2 weeks is a prompt for clinical review, not repeat supply. A patient who has been buying Rennie at the supermarket for 3 months before consulting is telling you the symptoms are more persistent than they appear. Document this in the clinical records and use it in triage.
"This tablet works similarly to the acid-reducing tablet you may already be taking, but it works on a slightly different pump in the stomach. Taking it at night can help reduce the overnight acid that's not always fully controlled by a tablet taken in the morning. It's not a replacement for the omeprazole — think of it as an add-on for night-time symptoms."
SCA pearl: Ranitidine has been permanently withdrawn in the UK due to NDMA contamination concerns. Prescribing it — even inadvertently — fails the Tasks domain. Famotidine is the only available H2RA in UK primary care. Know this.
"I'm suggesting amitriptyline — not because I think this is in your mind, but because there's a very well-established brain-gut connection, and at this low dose it specifically reduces the gut's oversensitivity to pain signals rather than treating depression. It takes 4–6 weeks to build up, and it will probably make you a bit drowsy at first — take it an hour before bed. The dose we use for gut problems is a fraction of what's used for mood disorders."
SCA pearl: Pre-empting the stigma concern proactively — "I know this is technically an antidepressant and you might be wondering why I'm suggesting it for a stomach problem" — dramatically improves adherence and scores high in Relating to Others. Waiting for the patient to challenge you, then explaining, scores less than anticipating it.
Dietary Restriction and Social Eating
Patients with symptomatic GORD and functional dyspepsia often self-restrict their diet far beyond what is clinically necessary, avoiding meals out, work events, and social occasions. This leads to significant quality-of-life reduction and increasing social isolation.
"Has this been affecting what you can eat socially — going out for meals, that sort of thing? Sometimes patients end up avoiding situations unnecessarily."Work Productivity and Presenteeism
Dyspepsia with post-prandial pain affects workplace functioning — particularly for workers who eat at their desk, work through lunch, or are in client-facing roles where discomfort is difficult to manage. Presenteeism (being present but not fully functional) is often more economically significant than absenteeism.
"Has this been affecting your work at all? I know you've been under a lot of pressure recently — is the pain making it harder to concentrate or get through the day?"Sleep Disturbance from Nocturnal GORD
Nocturnal acid reflux is one of the most disruptive symptoms of GORD — waking the patient at 2–3am with burning pain, acid in the throat, or coughing. Chronic sleep disruption causes cognitive impairment, mood deterioration, and worsening of stress-related dyspepsia symptoms.
"Has the heartburn been waking you at night? That can have a really big knock-on effect on everything else — energy, mood, concentration the next day."Cancer Anxiety and Health Preoccupation
Upper GI symptoms — particularly with weight loss — frequently generate significant cancer anxiety. This is not irrational, but health anxiety that persists despite investigation and reassurance requires active psychological intervention, not repeated negative investigations which reinforce the anxiety cycle.
"Now that we've got a plan in place, has that reassured you a little? Or is the worry still quite present? If it is, there are really effective psychological approaches that can help with that."Concerns About Long-Term Medication
Many patients resist long-term PPI because they are concerned about being "on tablets for life" or worried about side effects they have read about online. Addressing this proactively — and explaining the step-down plan — dramatically improves adherence to the short course that is actually needed.
"I want to reassure you that we're not planning to put you on these tablets forever — the plan is to take them for 4–8 weeks, see if they work, and then we'll try reducing them. If H. pylori is there and we treat it, you might not need tablets at all after that."Relationship and Intimate Life
Chronic dyspepsia and GORD symptoms — particularly post-prandial bloating and regurgitation — can affect intimate relationships. Patients may avoid shared meals, restrict social activity, or experience discomfort during physical intimacy. These impacts are rarely volunteered unless explicitly asked about.
"Sometimes when something is affecting your day-to-day like this for a while, it can have knock-on effects on other parts of life too. Has it been causing any difficulties in your personal life or relationships?"2–3 weeks: investigation results review
H. pylori stool antigen result. FBC and coeliac screen if ordered. If 2WW referral made: confirm appointment received. Initiate eradication therapy if H. pylori positive or PPI trial if H. pylori negative. Assess weight again.
4–6 weeks post-eradication: confirm H. pylori cleared
H. pylori eradication confirmation: stool antigen test (PPI off for 2 weeks before test). If eradicated and symptoms resolved: no further treatment needed. If eradicated but symptoms persist: OGD if age ≥55; continue PPI trial if <55. If eradication failed: second-line bismuth quadruple therapy.
6–8 weeks: PPI response review
If PPI trial: assess symptom response. If good response: step down to on-demand or lowest effective dose. If partial response: double PPI dose for further 4–8 weeks. If poor response: consider low-dose amitriptyline; OGD if age ≥55 or new alarm features.
3 months: consolidation and psychosocial review
Review lifestyle modification adherence. Assess psychosocial impact (sleep, work, anxiety). If amitriptyline started: titrate if partial response, review side effects. If 2WW results available: communicate findings and update management plan accordingly.
Annual: PPI review and red flag re-screen
Annual review of PPI indication for all long-term users. Attempt step-down or on-demand PPI annually. Re-screen for alarm features (weight loss, dysphagia, change in pain character). Serum magnesium if on diuretics or digoxin. Endoscopic surveillance if Barrett's oesophagus.
Memory rule — monitoring in dyspepsia
H. pylori: confirm eradication with stool antigen 4–6 weeks post-treatment (PPI off 2 weeks / antibiotics off 4 weeks before); Anaemia: FBC annually if any ongoing GI symptom; PPI: step down annually and check Mg with diuretics; Palpable mass: re-examine at every visit if epigastric symptoms persist; Y (HAPPY): if H. pylori eradicated + symptoms resolved → no further investigation needed in patients <55 without alarm features
⚠ Three scenario-specific safety-net phrases — use these verbatim
Why safety-netting matters beyond clinical care
- Prescribing PPI without testing H. pylori first — the cardinal dyspepsia SCA error
- Not giving specific safety-net symptoms for dyspepsia (dysphagia, haematemesis, black stools)
- Not asking a closing question — patient leaves with unvoiced concerns
- Reassuring the patient that weight loss is not important without investigation
- Ending without a named follow-up timepoint
- Not acknowledging the patient's anxiety about the weight loss in the closing summary
- Systematic history: alarm features screened, NSAID history, response to antacids, weight loss quantified
- H. pylori testing before PPI prescription — documented as mandatory first step
- Investigations individually justified; FBC; coeliac screen if indicated
- Working diagnosis shared in plain language with accessible analogy
- Specific safety-net symptoms named: dysphagia, haematemesis, black stools, weight loss progression
- Named follow-up timepoint communicated clearly
- Open question used to begin the consultation without exception
- All three ICE components named and addressed in the management plan
- Cancer fear explicitly named and empathetically acknowledged
- Weight loss addressed directly and honestly without falsely reassuring
- Expectation about OGD or "something now" validated before being managed
- Closing question asked and patient's response genuinely explored
Who you are
Mr P, 48, senior accountant at a large firm. Married with two children. Currently in the middle of a major audit season — working late most nights, eating at his desk, skipping lunch, having two or three coffees in the morning and a large meal late in the evening with a couple of glasses of wine. He hasn't been to the GP in four years. He came in now because his wife insisted after he mentioned the weight loss at dinner.
Hidden agenda
Mr P is significantly worried about stomach cancer but doesn't want to say it directly — he feels "stupid" for catastrophising and is scared of what the answer might be. His father had stomach cancer, diagnosed late, and died within 18 months — though he hasn't mentioned this yet and will only volunteer it if asked directly about family history. If the candidate names cancer directly and empathetically, he visibly relaxes. If the candidate starts prescribing without addressing the weight loss, he becomes increasingly anxious and asks the challenge question.
Symptoms if asked directly
- Burning epigastric pain and heartburn, 5–6/10 severity, occurring 4–5 times per week
- Worse after his evening meal and when lying down — woke him at 2am twice last week
- Relieved somewhat by Rennie and by sitting up
- Some nausea, no vomiting
- No blood in vomit, no black stools, no blood when he wipes — he has specifically checked
- Appetite reduced — "I just don't feel like eating much at the moment"
- Weight: lost approximately 3–4 kg over the last 2 months — he has been weighing himself; clothes feel looser
- No dysphagia — swallowing is normal
- No change in bowel habit
- Takes ibuprofen 400mg about 3 times per week for tension headaches — he does not consider this a "regular medicine"
Lifestyle + bonus details
- Diet: large late evening meal (9–10pm most nights), skips breakfast, eats lunch at his desk at 1pm. High-fat takeaways 3–4 nights per week. 3 strong coffees before 10am.
- Alcohol: 2–3 glasses of wine most evenings, more at weekends — approximately 20–25 units per week
- Exercise: none since last summer
- Stress: very high — major client audit, performance review in 6 weeks, junior team underperforming
- Family history (only if directly asked): "My dad had stomach cancer, actually — he was diagnosed at 62, and he passed away 18 months later."
- Bonus detail (only if specifically asked about medications): "Oh, I do take ibuprofen quite a bit for headaches — probably three times a week. Does that matter?"
Resolution: Mr P will accept the management plan if the candidate (1) names and directly addresses his cancer concern, including acknowledging the family history of gastric cancer and explaining why this makes investigation more important; (2) explains clearly why H. pylori testing is the right first step and what will happen if it is positive (eradication = potential cure), and what will happen next if tests are normal and symptoms persist (OGD will follow, especially given his age and family history); (3) takes the NSAID history and explicitly makes the connection — "ibuprofen is actually one of the most common causes of this kind of stomach pain, and it significantly increases your risk of an ulcer, especially combined with the stress and the alcohol." He does not need an immediate camera test — he needs to feel that his cancer fear has been heard, that the investigation plan is thorough and monitored, and that the weight loss is being taken seriously rather than explained away.
- Haematemesis (any volume) → same-day hospital / 999
- Sudden severe epigastric pain + peritonism → 999 (perforated PU)
- Dysphagia (any age, any character) → 2WW upper GI
- Unexplained weight loss + upper GI symptoms age ≥40 → 2WW
- Persistent vomiting + upper GI symptoms → 2WW
- Palpable epigastric mass → 2WW
- Age ≥55 + refractory dyspepsia despite H. pylori eradication + PPI → urgent OGD
- IDA (men any age, post-menopausal women) + GI symptoms → 2WW upper + lower GI
- Known Barrett's oesophagus — ensure surveillance programme active
- H. pylori eradication failure (second attempt) → gastroenterology referral
- GORD — no alarm features, age <55, burning heartburn, responds to antacids
- Functional dyspepsia — epigastric fullness, early satiety, no alarm features
- H. pylori positive + uninvestigated dyspepsia, age <55, no alarm features
- NSAID-induced dyspepsia — stop NSAID, test H. pylori, add PPI
If positive: 7-day triple eradication therapy → confirm eradication stool antigen 4–6 weeks later
If negative + symptoms persist: PPI trial 4–8 weeks → step down if response; OGD if ≥55 or refractory
Key rule: Never prescribe PPI without H. pylori testing first in uninvestigated dyspepsia
- H. pylori stool antigen (PPI off 2 weeks)
- FBC — iron deficiency anaemia (2WW if confirmed in men/post-menopausal women)
- Anti-TTG IgA + total IgA — coeliac screen (if bloating, diarrhoea, fatigue, IDA)
- LFTs — if biliary or hepatic cause suspected
- Serum amylase — if pain radiates to back, consider pancreatitis
- Weight (documented in notes as a baseline for monitoring)
- OGD via 2WW — if any alarm feature present (do not delay for other investigation results)
Step 1 — GORD / H. pylori negative: Omeprazole 20mg OD or Lansoprazole 30mg OD × 4–8 weeks; Gaviscon Advance 10ml after meals and at bedtime as interim / adjunct
Step 2 — Partial PPI response: Double PPI dose (Omeprazole 40mg OD) + consider famotidine 20mg nocte for nocturnal breakthrough
Step 2 — Refractory functional dyspepsia: Amitriptyline 10mg nocte → titrate to 30–75mg
Metoclopramide: Max 5 consecutive days only (tardive dyskinesia risk); for gastroparesis / post-prandial fullness short-term only
NSAID unavoidable: Full-dose PPI for gastroprotection; test and eradicate H. pylori (NSAID + H. pylori = 60× ulcer risk)
Pregnancy: Gaviscon / calcium carbonate antacids first-line; omeprazole if refractory (specialist advice)
Penicillin allergy (H. pylori eradication): Lansoprazole + Clarithromycin + Metronidazole × 7 days
Bisphosphonate oesophagitis: Review administration technique; switch to IV if symptomatic
Ranitidine: WITHDRAWN — do NOT prescribe. Use famotidine instead
| Treatment / Condition | Monitor | Timing | Action threshold |
|---|---|---|---|
| H. pylori eradication | Stool antigen or ¹³C urea breath test | 4–6 weeks post-treatment (PPI off 2 wks) | Positive → second-line bismuth quadruple. After 2 failures → gastroenterology for culture-guided therapy |
| Long-term PPI (>6 months) | Serum Mg (with diuretics/digoxin); DEXA if ≥5 years + osteoporosis risk | Annual PPI review; Mg every 6 months if diuretics co-prescribed | Mg <0.7 mmol/L → supplement. Attempt step-down to on-demand at every annual review |
| Barrett's oesophagus | OGD surveillance (scheduled); ensure patient in programme | Non-dysplastic: every 3–5 years. Low-grade dysplasia: every 6 months × 2, then annually | High-grade dysplasia → endoscopic mucosal resection or surgical referral |
| Coeliac disease (on GFD) | Anti-TTG IgA; haematinics; DEXA | Annual bloods; DEXA at diagnosis and every 3–5 years | Raised antibodies on GFD → dietitian review for compliance issues |
| Any patient ≥50 with dyspepsia | Weight; new dysphagia; change in pain character | Every appointment | Any new alarm feature → 2WW regardless of prior normal investigations |
| Amitriptyline (functional dyspepsia) | Symptom response; side effects; QTc if cardiac history | 4 weeks, 3 months, 6 months, annually | No response at 3 months → switch to nortriptyline or SSRI; gastroenterology if refractory |