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Dyspepsia and Gastro-oesophageal Reflux: A Systematic Review [Internet].


Swedish Council on Health Technology Assessment.


Stockholm: Swedish Council on Health Technology Assessment (SBU); 2007 Oct. SBU Yellow Report No. 185.
SBU Systematic Review Summaries.


Background Dyspepsia is a broad term for a range of symptoms – abdominal bloating after eating, early satiety, and pain or burning sensation in the upper gastrointestinal tract – that are assumed to originate from the stomach or duodenum. Dyspepsia is referred to as organic if clinical investigation can trace the symptoms to a demonstrable disease, such as a peptic ulcer or cancer, and functional if it cannot. Heartburn and acid regurgitation are no longer considered to be symptoms of dyspepsia, but of gastro-oesophageal reflux (the backflow of acid or stomach contents into the oesophagus). Uninvestigated dyspepsia and uninvestigated reflux symptoms are those that have not been subjected to an oesophago-gastro-duodenoscopy (OGD) or any other diagnostic examinations of the oesophagus, stomach and duodenum. Both the symptoms and underlying causes vary widely. Some patients may have peptic ulcers or oesophagitis (inflammation and superficial ulceration of the oesophagus), while others may have cancer. ConclusionsUninvestigated Gastro-oesophageal Reflux Symptoms: Both proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2RAs) are more effective than placebo for relieving gastro-oesophageal reflux symptoms (strong scientific evidence), and PPIs are more effective than H2RAs (strong scientific evidence). A considerable percentage of patients who are treated for acid gastro-oesophageal reflux symptoms without preceding investigation are satisfied with on-demand PPI therapy or continuous H2RA therapy (limited scientific evidence). Uninvestigated Dyspepsia: When it comes to relieving symptoms in patients with uninvestigated dyspepsia, no significant differences have been found between diagnosis of Helicobacter pylori (H. pylori) bacteria combined with treatment of detected infection and an OGD combined with treatment of detected disorders (moderately strong scientific evidence). Empirical therapy with acid inhibitors relieves symptoms as effectively as treatment based on an OGD (limited scientific evidence). Both advanced age and the presence of alarm symptoms in dyspepsia – including bleeding, dysphagia (difficulty swallowing) and weight loss – increase the probability of an underlying malignant tumour (limited scientific evidence). But a considerable percentage of patients with a tumour have no alarm symptoms at their first medical consultation (limited scientific evidence). Functional Dyspepsia: Acid inhibitors can provide some relief of the symptoms of functional dyspepsia (limited scientific evidence). But because the evaluated studies sometimes include patients with gastro-oesophageal reflux symptoms, the efficacy of the drugs is difficult to assess. Antibiotic therapy that eradicates H. pylori (eradication therapy) can offer a little relief of the symptoms of functional dyspepsia (limited scientific evidence), but most patients with functional dyspepsia are not infected with the bacteria and do not benefit (moderately strong scientific evidence). Treating Helicobacter pylori in Peptic Ulcer Disease: H. pylori eradication therapy considerably reduces the risk for reoccurrence of a peptic ulcer (strong scientific evidence). H. pylori eradication therapy is more effective than acid inhibitors alone in preventing reoccurrence of a bleeding peptic ulcer (strong scientific evidence). The conclusion applies only to patients without concurrent non-steroidal anti-inflammatory drug (NSAID) therapy. One week of triple therapy for H. pylori eradication that is not followed by acid inhibition therapy is as effective as one week of triple therapy for H. pylori eradication followed by 2–3 week acid inhibition therapy when it comes to both healing duodenal ulcers (limited scientific evidence) and relieving their symptoms (limited scientific evidence). Gastro-oesophageal Reflux Disease: Normal doses of PPIs are more effective than H2RAs for treating gastro-oesophageal reflux disease (GERD) with coexisting oesophagitis (strong scientific evidence). Longer treatment periods and higher doses of PPIs lead to healing of oesophagitis in more patients (strong scientific evidence). Continuous PPI therapy is more effective than on-demand PPI therapy for long-term treatment of GERD with coexisting oesophagitis (strong scientific evidence). On-demand PPI therapy and continuous PPI therapy are equally effective for long-term treatment of GERD without oesophagitis (strong scientific evidence). Long-term PPI therapy is safe (strong scientific evidence) and equally effective as surgery (moderately strong scientific evidence), making it suitable for younger people as well. Occasional deaths and frequent adverse effects have been reported in connection with surgical intervention (strong scientific evidence). Barrett’s Oesophagus: Barrett’s oesophagus increases the risk of developing oesophageal adenocarcinoma (limited scientific evidence), but the extent to which the risk increases is not fully known. No studies have proven the benefits of systematic endoscopic examinations (screening) to identify people with Barrett’s oesophagus or regular endoscopic examinations of people with Barrett’s oesophagus (surveillance). There is a lack of well-designed scientific studies showing that acid inhibitor therapy or anti-reflux surgery significantly reduce the risk of developing oesophageal adenocarcinoma in patients with Barrett’s oesophagus. Additional Research Needs Both the underlying causes and progress of functional dyspepsia are still unknown. That is largely true of GERD as well. Although researchers have identified the decisive role played by H. pylori, there are large gaps in our knowledge about the causes and progress of peptic ulcer disease, as well as the factors that determine whether or not life-threatening complications develop. Knowledge is largely lacking about the significance of gender in these conditions. The relevance of lifestyle factors – such as diet, physical activity and body weight – for the development of GERD and the prospects for influencing its progress also requires additional research. Clinical trials concerning the role of healing of oesophagitis, as well as the long-term effects of both medical and surgical intervention for reflux disorders, would also be beneficial. More studies are needed that examine the impact of H. pylori eradication therapy on a broader scale in the context of everyday health care. More reliable information is required about how much of a risk factor Barrett’s oesophagus is for oesophageal adenocarcinoma, as well as the effectiveness of endoscopic screening and surveillance. Additional efforts are needed to identify clinically useful indicators or markers for cancer risk. Both general and targeted health economic studies covering the entire field of dyspepsia and reflux disorders are badly needed. Independent, community-financed research is particularly urgent.

Copyright © 2007 by the Swedish Council on Health Technology Assessment.


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