Dyspepsia: Difference between revisions

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imported>Robert Badgett
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===Eradication of ''H. pylori''===
===Eradication of ''H. pylori''===
The [[Cochrane Collaboration]] concluded "small but statistically significant effect in ''[[H. pylori]]'' positive non-ulcer dyspepsia. The [[number needed to treat]] was 14. An economic model suggests this modest benefit may still be cost-effective but more research is needed."<ref name="pmid16625554">{{cite journal |author=Moayyedi P, Soo S, Deeks J, ''et al'' |title=Eradication of Helicobacter pylori for non-ulcer dyspepsia |journal=Cochrane database of systematic reviews (Online) |volume= |issue=2 |pages=CD002096 |year=2006 |pmid=16625554 |doi=10.1002/14651858.CD002096.pub4}}</ref>
The [[Cochrane Collaboration]] concluded "small but statistically significant effect in ''[[H. pylori]]'' positive non-ulcer dyspepsia. The [[number needed to treat]] was 14. An economic model suggests this modest benefit may still be cost-effective but more research is needed."<ref name="pmid16625554">{{cite journal |author=Moayyedi P, Soo S, Deeks J, ''et al'' |title=Eradication of Helicobacter pylori for non-ulcer dyspepsia |journal=Cochrane database of systematic reviews (Online) |volume= |issue=2 |pages=CD002096 |year=2006 |pmid=16625554 |doi=10.1002/14651858.CD002096.pub4}}</ref>
The effect of eradication seems related to the presence of gastritis. Patients with antral predominant gastritis<ref name="pmid16803603">{{cite journal |author=Vakil N, Talley NJ, Stolte M, Sundin M, Junghard O, Bolling-Sternevald E |title=Patterns of gastritis and the effect of eradicating Helicobacter pylori on gastro-oesophageal reflux disease in Western patients with non-ulcer dyspepsia |journal=Aliment. Pharmacol. Ther. |volume=24 |issue=1 |pages=55–63 |year=2006 |pmid=16803603 |doi=10.1111/j.1365-2036.2006.02964.x}}</ref> or erosions<ref name="pmid16416218">{{cite journal |author=Mazzoleni LE, Sander GB, Ott EA, ''et al'' |title=Clinical outcomes of eradication of Helicobacter pylori in nonulcer dyspepsia in a population with a high prevalence of infection: results of a 12-month randomized, double blind, placebo-controlled study |journal=Dig. Dis. Sci. |volume=51 |issue=1 |pages=89–98 |year=2006 |pmid=16416218 |doi=10.1007/s10620-006-3090-6}}</ref> are more likely to have their symptoms resolve with eradication.


===Psychological interventions===
===Psychological interventions===

Revision as of 08:59, 12 October 2007

Dyspepsia (from the Greek "δυς-" (Dys-), meaning hard or difficult, and "πέψη" (Pepse), meaning digestion) is chronic or recurrent pain or discomfort centered in the upper abdomen [1][2] Discomfort, in this context, includes mild pain, upper abdominal fullness and feeling full earlier than expected with eating. It can be accompanied by bloating, belching, nausea or heartburn. It may be called indigestion. Heartburn is excluded from the definition of dyspesia in ICD 10, as it usually has a different cause and management pathway. When a patient has dyspepsia, but underlying disease is found, the patient is said to have non-ulcer dyspepsia or functional dyspepsia or idopathic dyspepsia.

Classification

Dyspepsia has been proposed to have symptomatic subgroups:[3][4]

  • ulcerlike
  • dysmotilitylike
  • refluxlike
  • nonspecific

However, there is not a strong correlation of symptom type and measures of abnormal motility or hypersensitivity.[4][5]

A cluster analysis identified 4 groups, the first two are associated with delayed gastric emptying and the second two are associated with gastric hypersensitivity:[6]

  • Factor 1 - "characterized by nausea, vomiting, early satiety, and weight loss...associated with delayed emptying...younger age, female sex, and sickness behavior"
  • Factor 2 - "characterized by postprandial fullness and bloating...associated with delayed emptying"
  • Factor 3 - "characterized by pain symptoms and associated with gastric hypersensitivity and several psychosocial dimensions including medically unexplained symptoms and health-related quality of life dimensions".
  • Factor 4 - "characterized by belching, is also associated with hypersensitivity, but is unrelated to psychosocial dimensions."

Cause/etiology

Some cases are caused by medications such as calcium antagonists, nitrates, theophyllines, bisphosphonates, corticosteroids and non-steroidal antiinflammatory drugs [NSAIDs]).[2]

Several studies provide prevalences of underlying causes based on findings at esophagogastroduodenoscopy (EGD).[4][7][8]

Findings in various populations
Patients referred to gastroenterologists for dyspesia[4] Primary care patients with dyspepsia[7] Volunteers without dyspepsia[8]
Normal
Macroscopically normal
by EGD
60% 54% 66%
Histologically normal
by biopsy at EGD
35%
Esophagus
Macroscopic esophagitis
by EGD
14% 12% 22%
(included Grade 1 & 2)
Hiatal hernia >2 cm by UGI 40% 26%
Hiatal hernia by EGD 3% 3%
Stomach/duodenum
Peptic ulcer disease (PUD) 20% 8% 4%
Gastritis/duodenitis 14% 20% 9-16%
Other
Malignancy 3% 0% 0%

Non-ulcer dyspepsia (NUD)

When organic disease is excluded by esophagogastroduodenoscopy and other tests, the patient is considered to have non-ulcer dyspepsia (NUD). This is also called functional dyspepsia.

Possible causes of NUD

The implied lack of organic disease may actually be incorrect as there may be physiological abnormalities that are too subtle for commonly used tests. For example, some patients may have gastric motor function or visceral sensitivity.[5][6]

Non-ulcer dyspepsia, when of acute onset, may be due to gastric dysmotor dysfunction following gastrointestinal infections.[9]

H. pylori

The role of H. pylori is not clear.

Association with other diseases

Psychiatric diagnoses

Psychiatric diagnoses are more prevalent among patients with normal endoscopies than abnormal endoscopies.[10]

Irritable bowel

There is much overlap among patients with non-ulcer dyspepsia and irritable bowel syndrome.[11]

Diagnosis

History and physical examination

The history and physical examination cannot reliably detect when organic disease underlies dypspepsia.[12]

Alarm features or red flags that may indicate serious underlying diseases are:[13]

  • Age older than 55 years with new-onset dyspepsia
  • Family history of upper gastrointestinal cancer
  • Unintended weight loss
  • Gastrointestinal bleeding
  • Progressive dysphagia
  • Odynophagia
  • Unexplained iron-deficiency anemia
  • Persistent vomiting
  • Palpable mass or lymphadenopathy
  • Jaundice

Although the value of these findings is hard to establish[14], one study found that the best predictions of abnormal investigations were:[15]

  • History of an previous ulcer
  • Age 50 or more
  • Pain better with food or milk (presumably identifies duodenal pathology)
  • Pain occurs < one hour after eating (presumably identifies gastric pathology)

Regarding gastric cancer, helpful findings are anemia and persistence of symptoms.[16]

Identifying a psychiatric disorder may reduce the chance than a serious organic disorder is present.[10]

On physical examination, pallor of conjunctiva, nail-bed or palmar crease, or the absence of nail-bed blanching are predictive of significant anemia (hemoglobin less than 12 gm/dl).[17]

Laboratory tests

Complete blood count

One study found that by using "H. pylori serology and a hemoglobin reading in the evaluation of dyspeptic patients under 45 years of age, the need for endoscopy can be reduced by 55%."[18]

In adults, 60% of patients with iron deficiency anemia may have underlying gastrointestinal disorders leading to chronic blood loss.[19]

H. pylori testing

Clinical practice guidelines by the American Gastroenterological Association state "H. pylori testing is optimally performed by a 13C-urea breath test or stool antigen test."[20]

Several studies indicate the need to test dyspeptic patients for H. pylori.[18][21][22][23] One study found that by using "H. pylori serology and a hemoglobin reading in the evaluation of dyspeptic patients under 45 years of age, the need for endoscopy can be reduced by 55%."[18]

The accuracy of the breath test for detecting peptic ulcer disease is:[24]

False negative tests

Testing should be delayed for 2 weeks after stopping PPI use to avoid false negative breath test or a stool antigen test.[2]

Radiology

UGI as historic significance as good before EGD.[25]

Esophagogastroduodenoscopy (EGD)

Direct visualization by esophagogastroduodenoscopy(EGD) is very sensitive, but may not detect all possible underlying causes of dyspepsia. For example, gastroesophageal reflux disease that does not cause macroscopic esophagitis will be missed by esophagogastroduodenoscopy.[26]

For patients with positive H. pylori tests, obtaining endoscopy may be reasonable alternative to empiric antibiotics though less well studied.[27][28] This strategy allows identification of patients with GERD and also may reduce discontinuing antibiotics due to adverse drug reactions.[29]

For patients with negative H. pylori testing, endoscopy is not needed if they are less than 45 years old and without alarm symptoms.[30]

Treatment

In order to treat underlying peptic ulcer, clinical practice guidelines by the American Gastroenterological Association recommend:[20]

  • "Patients 55 years of age or younger without alarm features should receive Helicobacter pylori test and treat followed by acid suppression if symptoms remain"

Regarding the treatment of non-ulcer dyspepsia, the value of simple reassurance is suggested by the response to placebo ranging from 40%[31] to 70%.[32]

The type of dyspepsia, motility versus acid, may weakly predict which medicine will reduce symptoms.[33][3]

Smaller meals

Acid suppression

A meta-analysis of randomized controlled trials by the Cochrane Collaboration concluded "there is evidence that anti-secretory therapy may be effective in NUD" with a number needed to treat for PPIs of 10.[34] Subsequent randomized controlled trials have had conflicting results reporting both benefit[35] and no benefit.[32]

Prokinetic drugs

Prokinetic drugs include:[36]

The Cochrane Collaboration concluded "trials evaluating prokinetic therapy are difficult to interpret as the...[positive] result could have been due to publication bias.".[34] More recently, a randomized controlled trial of itopride found that 100 mg three times per day benefited 17% of patients (number needed to treat is 6).[31]

Tricylic antidepressants

A meta-analysis found that patients needed to be treated to improve 1 patient (number needed to treat is 3).[37]

Eradication of H. pylori

The Cochrane Collaboration concluded "small but statistically significant effect in H. pylori positive non-ulcer dyspepsia. The number needed to treat was 14. An economic model suggests this modest benefit may still be cost-effective but more research is needed."[38]

The effect of eradication seems related to the presence of gastritis. Patients with antral predominant gastritis[39] or erosions[40] are more likely to have their symptoms resolve with eradication.

Psychological interventions

It is unclear if any form of psychological interventions is beneficial[41]

Prevention

Users of nonsteroidal anti-inflammatory (NSAID) medications

Patients with a history of bleeding ulcer have a 26% rate of ulcers with NSAIDs.[42] Patients with H. pylori

For patients starting long-term NSAIDs, screening for H. pylori with a breath test among patients with prior ulcer or dyspepsia and and treating positive patients reduced subsequent rate of ulcers.[43] [44]

For patients who must take NSAIDs, proton pump inhibitors may be effective in preventing dyspepsia.[45]

Asymptomatic adults

Community screening for H. pylori may be beneficial.[46]

References

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  2. Jump up to: 2.0 2.1 2.2 National Institute for Health and Clinical Excellence. 2004. Dyspepsia. August, 2004. http://guidance.nice.org.uk/CG17 (accessed October 12, 2007)
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