Dyspepsia

Kamela Ali abu-shalha 5th year medical student Hashemite university

Dyspepsia is defined as episodic or persistent symptoms that include abdominal pain or discomfort and which are referable to the upper gastrointestinal tract

The formal definition excludes patients whose only symptom is heartburn

nausea
fullness early satiety

upper
abdominal

bloating

Other symptoms

How common is it
Stomach pain, cramps, and spasms was the 11th most frequent reason for patients to present to their physicians, estimated to account for more than 13.5 million visits per year About 25% of persons in the United States or other western countries experience recurrent upper abdominal pain during a typical year

If one adds heartburn, then the prevalence is closer to 40%

Causes of dyspepsia
Upper gastrointestinal disorders
'Functional' Peptic ulcer disease Acute gastritis Gallstones Motility disorders, e.g. oesophageal spasm

Systemic disease
Renal failure Hypercalcaemia

Drugs
Non-steroidal anti-inflammatory drugs (NSAIDs) Iron and potassium supplements Corticosteroids Digoxin

Other gastrointestinal disorders

Pancreatic disease (cancer, chronic pancreatitis) Hepatic disease (hepatitis, metastases) Colonic carcinoma

Others
Alcohol Psychological, e.g. anxiety, depression

Diagnosis Functional dyspepsia Peptic ulcer disease Reflux esophagitis Gastric or esophageal cancer

Frequency 60 % 15-25 % 5-15% <2%

Rare causes

Rare causes of dyspepsia : Carbohydrate malabsorption Small intestinal mucosal disorders (e.g., sprue) Intestinal parasites Chronic pancreatitis Infiltrative diseases of the stomach (e.g., Crohn's disease) Metabolic disorders (e.g., hypothyroidism, hypercalcemia) Cardiac conditions (e.g., inferior myocardial ischemia) Pulmonary conditions (e.g., lower lobe pneumonia)

Peptic Ulcer Disease (PUD)

The primary causes of PUD are Helicobacter pylori infection and nonsteroidal anti-inflammatory drug (NSAID) use. While either of these alone is a significant cause, these two factors can act synergistically to further increase the risk of PUD .

Cigarette smoking is an additional risk factor that may impair the healing of an ulcer and increase the likelihood of recurrence after successful treatment

 Gastroesophageal reflux disease (GERD) is a condition in which the reflux of gastric contents into the esophagus results in symptoms such as heartburn or a bitter taste in the back of the mouth. Reflux events occur more often in the lying position as opposed to the upright position. It may also cause evidence of inflammation (esophagitis) and erosions in the esophageal mucosa There is a poor correlation between endoscopic findings and symptoms

Gastroesophageal Reflux Disease GERD

KEY FACTORS IN GERD

transient lower esophageal sphincter relaxations lower esophageal sphincter hypotension or anatomic deformities of the EGJ such as a hiatal hernia

esophago-gastric junction (EGJ) incompetence

impaired esophageal emptying esophageal peristalsis dysfunction decreased salivary neutralizing capacity .

ineffective esophageal clearance of acid and reflux material

Family hx.

Certain food

Increased BMI

risk factors for GERD

alcohol Smoking

Functional dyspepsia
In up to 60% of patients with dyspepsia, there is no identifiable cause on endoscopy. In this case, the patient is diagnosed as having functional dyspepsia.

Three major potential pathophysiologic mechanisms of functional dyspepsia have been identified.
The first is delayed gastric emptying that occurs in about 30% of patient with functional dyspepsia and is associated with postprandial fullness, nausea and vomiting. Another is impaired gastric accommodation that occurs in about 40% of patients with functional dyspepsia and is associated with early satiety.

1.

2.

Functional dyspepsia
3. Finally, hypersensitivity to gastric distention is noted in approximately 37% of patients with functional dyspepsia, and is associated with postprandial pain, belching and weight loss .

Clinical Evaluation

Alarm Symptoms
anorexia, unexplained recent weight loss dysphagia Odynophagia persistent vomiting Hematemesis longstanding gastroesophageal reflux symptoms melena blood in the stool anemia, previous gastric surgery a palpable abdominal mass gastrointestinal perforation or jaundice

 Age is another important factor; current guidelines recommend that all patients who are above 55 years of age with the new onset of dyspepsia should receive an endoscopy to evaluate for more serious disease

History
Any red flag

SOCRATES

Medication

Smoking

Physical examination
The patient's vital signs and appearanc e any alarm symptoms or concern about GI bleeding rectal exam

Abdominal examination

RSS & CVS

Gastroesophageal Reflux Disease

Patients with GERD commonly present with Symptoms may be aggravated by . Symptoms may be alleviated by . Findings on physical examination. Extra-esophageal symptoms are

Peptic Ulcer Disease

The classic presentation of PUD is epigastric abdominal pain that is burning in character. A variety of other symptoms, including vomiting, loss of appetite, and flatulence may also be present Epigastric tenderness may or may not be present on physical examination. The patient's stool may be heme-positive if bleeding has occurred
DU occur on an empty stomach or at least 2 hours after eating and are relieved by eating food or taking antacids. GU Gastric ulcers may occur sooner after eating and are less frequently relieved by food or antacids

Functional Dyspepsia
Functional dyspepsia is defined as having at least 12 weeks (not necessarily consecutive) of the following symptoms within the previous 12 months:

1) persistent or recurrent dyspepsia (upper abdominal pain or discomfort);

2) no evidence of organic disease (on endoscopy or other tests) that probably accounts for the symptoms; 3) It is not exclusively relieved by defecation or associated with the onset of a change in stool frequency or stool form and therefore, unlikely to be irritable bowel syndrome

GERD / diagnostic approach - Heartburn and/or regurgitation - often postprandial - aggravated by recumbency or bending over - and are relieved by antacids .

Offer empirical therapy for GERD

- Alarm symptoms (dysphagia, odynophagia, bleeding, weight loss, or anemia) -Sufficient duration of symptoms (risk for Barrett's esophagus)

No response

Endoscopy Ph-monitoring

Further diagnostic modalities

 ENDOSCOPY

direct visualization of the esophageal mucosa and documentation and biopsy

in documenting persistent acid reflux events in patients with symptoms that have not responded to usual treatment and have no endoscopic findings. in patients with atypical symptoms (such as a cough) to followup reflux symptoms in patients after a trial of medication or surgery.

Ph-monitoring

PUD / diagnosis
Both generalist physicians and gastroenterologists have difficulty in making the diagnosis of peptic ulcer disease based on history and physical alone. Therefore, other diagnostic studies are needed to confirm the diagnosis .

PUD diagnosis
Upper endoscopy
very sensitive and specific direct observation of the esophageal, gastric, and duodenal mucosa the ability to perform biopsies The risk of complications from an upper endoscopy is extremely low (<0.3%)

upper gastrointestinal series (UGI)

less sensitive and specific and results in radiation exposure for the patient may still have a role in the diagnosis if the patient is not able to tolerate endoscopy or if a trained endoscopist is not available in the community

Tests for diagnosing an H. pylori infection

Because H. pylori infection is the most common cause of peptic ulcer disease, the presence or absence of an H. pylori infection should guide the management of a patient with dyspepsia and suspected PUD 13C and 14C urea breath tests, serologic tests, and stool antigen tests

Tests for diagnosing an H. pylori infection

Breath tests
highly sensitive and specific PPIs may increase the likelihood of falsenegative results on breath tests for up to 24 weeks after stopping the PPI

 Serologic tests
include both serum antibody tests performed in a reference laboratory and whole blood tests performed at the point of care. The most commonly used serum antibody tests are enzyme-linked immunosorbent assays (ELISAs). Although whole blood tests used in the ambulatory setting may be more convenient for the physician and patient, they are less sensitive than serum antibody tests performed in a reference laboratory

 Stool antigen tests

detect H. pylori antigen in the stool are more accurate than whole blood or serologic tests, although somewhat less convenient . They can also be used to confirm eradication because they are an antigen and not an antibody test. However, concurrent use of PPIs can cause false negative stool antigen results

 Current guidelines recommend breath tests or stool antigen tests as the preferred initial test to detect H. pylori infection . Serologic tests at a reference laboratory are an alternative if :
breath tests or stool antigen tests are not available or if the patient has recently taken a PPI

Functional dyspepsia
Its a diagnosis of exclusion
History and physical findings alone are not sensitive or specific A diagnostic evaluation should be performed to exclude other conditions such as peptic ulcer disease, GERD and cancer Extensive diagnostic testing is not recommended in patients with functional dyspepsia, unless the patient's symptoms and signs suggest an alternate diagnosis.

Recommended Diagnostic Strategy

The recommended strategy outlined here is based on evidence-based guidelines published in 2005 on the management of dyspepsia from the American Gastroenterological Association (AGA) and management of GERD from the American College of Gastroenterology

give acid suppression treatment with a PPI to control symptoms.

Management

H.Pylori eradication therapy

The eradication rate after triple therapy is 79% and after quadruple therapy is 80% with no significant difference in side-effects between triple and quadruple therapy . Although one guideline recommends that patients should have a repeat H. pylori test at least 4 weeks after completing eradication therapy, this is not standard practice in the United States. If a patient remains symptomatic, the urea breath test or a stool antigen test (provided the patient is not taking a PPI) is best for evaluating whether the H. pylori infection has been eradicated .

For the patient whose H. pylori infection is not eradicated after two courses of treatment, it is appropriate for family physicians to refer the patient for an endoscopy at that point so that tissue culture and sensitivity can be obtained to guide further treatment.

Resources
Essentials of Family Medicine (Sloane) Davidsons principles and practice of medicine