Dyspepsia
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] 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.
Cause/etiology
Several studies provide prevalences of underlying causes based on findings at gastroesophagoscopy (EGD).[2][3][4]
| Patients referred to gastroenterologists for dyspesia[2] | Primary care patients with dyspepsia[3] | Volunteers without dyspepsia[4] | |
|---|---|---|---|
| Normal | |||
| Macroscopically normal by EGD |
60% | 54% | 66% |
| Histologically normal by biopsy at EGD |
35% | ||
| Esophagus | |||
| Macroscopic esophagitis by EGD |
14% | 12% | 22% |
| Hiatal hernia >2 cm by UGI | 40% | 26% | |
| Hiatal hernia by EGD | 3% | 3% | |
| Stomach | |||
| Peptic ulcer disease (PUD) | 20% | 8% | 4% |
Non-ulcer dyspepsia
When organic disease is excluded by gastroesophagoscopy and other tests, the patient is considered to have non-ulcer dyspepsia (NUD). This is also called functional dyspepsia. This may be a misnomer 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]
Diagnosis
History and physical examination
The history and physical examination cannot reliably detect when organic disease underlies dypspepsia.[6]
Alarm features or red flags that may indicate serious underlying diseases are:[7]
- 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
However, the value of these findings is hard to establish.[8]
Laboratory tests
Clinical practice guidelines by the American Gastroenterological Association recommend "H. pylori testing is optimally performed by a 13C-urea breath test or stool antigen test."[9]
Several studies indicate the need to test dyspeptic patients for H. pylori.[10][11][12] 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%."[10]
Visualization
Direct visualization by gastroesophagoscopy(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 gastroesophagoscopy.[13]
Treatment
Clinical practice guidelines by the American Gastroenterological Association recommend:[9]
- "Patients 55 years of age or younger without alarm features should receive Helicobacter pylori test and treat followed by acid suppression if symptoms remain"
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".[14]
Prokinetic drugs
Prokinetic drugs include serotonin-3 (5-HT3) receptor antagonists (cisapride and mosapride)[15], dopamine antagonists (metoclopramide and domperidone), and opiate agonists (trimebutine).[16] Trimebutine also has antiserotonergic activity.
The Cochrane Collaboration concluded "trials evaluating prokinetic therapy are difficult to interpret as the...[positive] result could have been due to publication bias.".[14]
Eradication of H. pylori
The Cochrane Collaboration concluded "small but statistically significant effect in H pylori positive non-ulcer dyspepsia. An economic model suggests this modest benefit may still be cost-effective but more research is needed."[17]
Prevention
Community screening for H. pylori may be beneficial.[18]
References
- ↑ N. Talley, et al., "Guidelines for the management of dyspepsia", American Journal of Gastroenterology 100 (2005), pp. 2324-2337.
- ↑ 2.0 2.1 Talley NJ, Weaver AL, Tesmer DL, Zinsmeister AR (1993). "Lack of discriminant value of dyspepsia subgroups in patients referred for upper endoscopy". Gastroenterology 105 (5): 1378–86. PMID 8224642. [e]
- ↑ 3.0 3.1 Williams B, Luckas M, Ellingham JH, Dain A, Wicks AC (1988). "Do young patients with dyspepsia need investigation?". Lancet 2 (8624): 1349–51. PMID 2904061. [e]
- ↑ 4.0 4.1 Johnsen R, Bernersen B, Straume B, Førde OH, Bostad L, Burhol PG (1991). "Prevalences of endoscopic and histological findings in subjects with and without dyspepsia". BMJ 302 (6779): 749–52. PMID 2021764. [e] Fulltext
- ↑ Karamanolis G, Caenepeel P, Arts J, Tack J (2006). "Association of the predominant symptom with clinical characteristics and pathophysiological mechanisms in functional dyspepsia". Gastroenterology 130 (2): 296–303. DOI:10.1053/j.gastro.2005.10.019. PMID 16472585. Research Blogging.
- ↑ Moayyedi P, Talley NJ, Fennerty MB, Vakil N (2006). "Can the clinical history distinguish between organic and functional dyspepsia?". JAMA 295 (13): 1566–76. DOI:10.1001/jama.295.13.1566. PMID 16595759. Research Blogging.
- ↑ Talley NJ, Vakil NB, Moayyedi P (2005). "American gastroenterological association technical review on the evaluation of dyspepsia". Gastroenterology 129 (5): 1756–80. DOI:10.1053/j.gastro.2005.09.020. PMID 16285971. Research Blogging.
- ↑ Hammer J, Eslick GD, Howell SC, Altiparmak E, Talley NJ (2004). "Diagnostic yield of alarm features in irritable bowel syndrome and functional dyspepsia". Gut 53 (5): 666–72. PMID 15082584. [e]
- ↑ 9.0 9.1 Talley NJ (2005). "American Gastroenterological Association medical position statement: evaluation of dyspepsia". Gastroenterology 129 (5): 1753–5. DOI:10.1053/j.gastro.2005.09.019. PMID 16285970. Research Blogging. National Guideline Clearinghouse
- ↑ 10.0 10.1 Valle PC, Breckan RK, Amin A, et al (2006). ""Test, score and scope": a selection strategy for safe reduction of upper gastrointestinal endoscopies in young dyspeptic patients referred from primary care". Scand. J. Gastroenterol. 41 (2): 161–9. DOI:10.1080/00365520500286881. PMID 16484121. Research Blogging.
- ↑ Jarbol DE, Kragstrup J, Stovring H, Havelund T, Schaffalitzky de Muckadell OB (2006). "Proton pump inhibitor or testing for Helicobacter pylori as the first step for patients presenting with dyspepsia? A cluster-randomized trial". Am. J. Gastroenterol. 101 (6): 1200–8. DOI:10.1111/j.1572-0241.2006.00673.x. PMID 16771937. Research Blogging.
- ↑ Shaw IS, Valori RM, Charlett A, McNulty CA (2006). "Limited impact on endoscopy demand from a primary care based 'test and treat' dyspepsia management strategy: the results of a randomised controlled trial". The British journal of general practice : the journal of the Royal College of General Practitioners 56 (526): 369–74. PMID 16638253. [e]
- ↑ Tefera L, Fein M, Ritter MP, et al (1997). "Can the combination of symptoms and endoscopy confirm the presence of gastroesophageal reflux disease?". The American surgeon 63 (10): 933–6. PMID 9322676. [e]
- ↑ 14.0 14.1 Moayyedi P, Soo S, Deeks J, Delaney B, Innes M, Forman D (2006). "Pharmacological interventions for non-ulcer dyspepsia". Cochrane database of systematic reviews (Online) (4): CD001960. DOI:10.1002/14651858.CD001960.pub3. PMID 17054151. Research Blogging.
- ↑ Gullikson GW, Loeffler RF, Viriña MA (1991). "Relationship of serotonin-3 receptor antagonist activity to gastric emptying and motor-stimulating actions of prokinetic drugs in dogs". J. Pharmacol. Exp. Ther. 258 (1): 103–10. PMID 2072288. [e]
- ↑ Hiyama T, Yoshihara M, Matsuo K, et al (2007). "Treatment of functional dyspepsia with serotonin agonists: A meta-analysis of randomized controlled trials". J. Gastroenterol. Hepatol. 22 (10): 1566–70. DOI:10.1111/j.1440-1746.2006.04723.x. PMID 17845684. Research Blogging.
- ↑ Moayyedi P, Soo S, Deeks J, et al (2006). "Eradication of Helicobacter pylori for non-ulcer dyspepsia". Cochrane database of systematic reviews (Online) (2): CD002096. DOI:10.1002/14651858.CD002096.pub4. PMID 16625554. Research Blogging.
- ↑ Ford AC, Forman D, Bailey AG, Axon AT, Moayyedi P (2005). "A community screening program for Helicobacter pylori saves money: 10-year follow-up of a randomized controlled trial". Gastroenterology 129 (6): 1910–7. DOI:10.1053/j.gastro.2005.09.016. PMID 16344059. Research Blogging.