What are the differences in managing pain for heartburn vs dyspepsia?

Heartburn vs Dyspepsia Pain: Key Differences and Management

Heartburn and dyspepsia pain are distinct but frequently overlapping symptoms that require different initial management approaches: heartburn responds best to proton pump inhibitors (PPIs), while dyspepsia requires H. pylori testing first, followed by PPIs or prokinetics depending on symptom subtype.

Distinguishing the Two Conditions

Symptom Characteristics

Heartburn is defined as a burning sensation that rises from the stomach or lower chest upward toward the neck, often described as an upward movement of discomfort 1, 2. This specific word description helps patients accurately identify heartburn versus other upper abdominal symptoms 1.

Dyspepsia encompasses pain or discomfort centered in the upper abdomen (epigastrium), including bothersome epigastric pain, burning, postprandial fullness, or early satiation 1. The pain does not typically have the upward movement characteristic of heartburn 1.

The Overlap Problem

These conditions coexist far more commonly than previously recognized. In patients with heartburn (GERD), 66-75% also have epigastric pain 1. Conversely, among patients with dyspepsia, 31% have GERD symptoms 3. Approximately 19% of patients cannot identify their predominant symptom when asked to choose between heartburn and epigastric pain 1.

Management Approach for Heartburn

First-Line Treatment

Start with standard-dose PPI once daily, taken 30-60 minutes before meals, for 4-8 weeks 4. Any commercially available PPI is appropriate as first-line therapy since absolute differences in efficacy are small when dosed correctly 4.

Treatment Escalation

• If symptoms persist after 4-8 weeks of once-daily PPI, increase to twice-daily PPI dosing for an additional 4-8 weeks 4
• PPIs are superior to H2-receptor antagonists for heartburn relief, with omeprazole 20mg daily achieving 55% heartburn relief at 4 weeks compared to 27% with ranitidine 150mg twice daily 5
• If symptoms persist despite twice-daily PPI for 8 weeks, proceed to endoscopy 4

Adjunctive Measures

• Alginates can form a physical barrier and may be added to PPI therapy 6
• Antacids provide rapid, short-term relief for breakthrough symptoms 6
• Lifestyle modifications include avoiding trigger foods (fatty foods, chocolate, mints, citrus, tomatoes, carbonated beverages), eating smaller meals, elevating the head of the bed, and weight loss if overweight 6, 7

Management Approach for Dyspepsia

Mandatory First Step

All patients with dyspepsia must undergo H. pylori testing (urea breath test or stool antigen) and receive eradication therapy if positive 8, 4. This is the initial intervention regardless of symptom subtype 8. While H. pylori eradication accounts for only 5% of dyspepsia improvement in the community, it identifies most peptic ulcer disease cases 4.

Symptom-Based Treatment After H. pylori Management

For Epigastric Pain Syndrome (EPS) - predominant epigastric pain or burning:

• First-line: PPI or H2-receptor antagonist 8
• Full-dose PPI therapy is the first choice, with symptom response confirming acid-related nature 4

For Postprandial Distress Syndrome (PDS) - predominant fullness, bloating, early satiety:

• First-line: Prokinetic agent 8
• PPI monotherapy remains reasonable even for dysmotility-like symptoms 4

Second-Line Treatment

Tricyclic antidepressants at low doses are recommended as second-line therapy, particularly for EPS 8. Consider adding a prokinetic agent to PPI therapy for dysmotility-like symptoms 4.

Treatment Escalation

• Combination therapies may be considered, such as dual therapy with different medication classes 8
• For severe or refractory cases, involve a multidisciplinary team including primary care physicians, dietitians, gastroenterologists, and psychologists 8

Critical Diagnostic Considerations

When to Perform Endoscopy

Urgent endoscopy is warranted in:

• Patients ≥55 years with weight loss 8
• Patients >40 years from high-risk areas for gastric cancer or with family history of gastro-oesophageal cancer 8

Non-urgent endoscopy should be considered in:

• Patients ≥55 years with treatment-resistant dyspepsia 8
• Patients with raised platelet count, nausea, or vomiting 8
• Patients who fail initial PPI therapy with persistent symptoms 6

Additional Testing

• Full blood count should be performed in patients ≥55 years with dyspepsia 8
• Coeliac serology in patients with overlapping IBS-type symptoms 8
• Urgent abdominal CT scanning in patients ≥60 years with abdominal pain and weight loss to exclude pancreatic cancer 8

Common Pitfalls to Avoid

Do not assume normal endoscopy means no pathology. Functional dyspepsia is caused by gut-brain interaction issues, not psychological factors, and requires explanation to patients 8.

Do not prescribe overly restrictive diets. While patients should avoid foods that trigger symptoms, there is insufficient evidence for specialized diets including low FODMAP diets for functional dyspepsia 8. Early dietitian involvement prevents malnutrition 8.

Do not use opioids or surgery in patients with severe or refractory functional dyspepsia to minimize iatrogenic harm 1.

Recognize that H2-receptor antagonists develop tolerance within 6 weeks of continuous use, potentially limiting long-term effectiveness 6.

Long-Term Management

• If symptoms resolve with initial therapy, taper PPI to the lowest effective dose 4
• Consider on-demand therapy with the successful agent for maintenance 4
• For patients requiring long-term PPI therapy, objective reflux testing should be considered to confirm the diagnosis 4
• Screen patients with severe functional dyspepsia presenting with weight loss and food restriction for eating disorders including avoidant restrictive food intake disorder (ARFID) 8