Dyspepsia: Difference between revisions
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'''Dyspepsia''' (from the [[Greek language|Greek]] "δυς-" (Dys-), meaning hard or difficult, and "πέψη" (Pepse), meaning digestion) is chronic or recurrent pain or discomfort centered in the upper abdomen <ref>N. Talley, et al., "Guidelines for the management of dyspepsia", ''American Journal of Gastroenterology'' 100 (2005), pp. 2324-2337.</ref> 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'''. | '''Dyspepsia''' (from the [[Greek language|Greek]] "δυς-" (Dys-), meaning hard or difficult, and "πέψη" (Pepse), meaning digestion) is chronic or recurrent pain or discomfort centered in the upper abdomen <ref>N. Talley, et al., "Guidelines for the management of dyspepsia", ''American Journal of Gastroenterology'' 100 (2005), pp. 2324-2337.</ref> 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:<ref name="pmid8224642">{{cite journal |author=Talley NJ, Weaver AL, Tesmer DL, Zinsmeister AR |title=Lack of discriminant value of dyspepsia subgroups in patients referred for upper endoscopy |journal=Gastroenterology |volume=105 |issue=5 |pages=1378–86 |year=1993 |pmid=8224642 |doi=}}</ref> | |||
* ulcerlike | |||
* dysmotilitylike | |||
* refluxlike | |||
* nonspecific | |||
However, there is not a strong correlation of symptom type and measures of abnormal motility or hypersensitivity.<ref name="pmid8224642"/><ref name="pmid16472585">{{cite journal |author=Karamanolis G, Caenepeel P, Arts J, Tack J |title=Association of the predominant symptom with clinical characteristics and pathophysiological mechanisms in functional dyspepsia |journal=Gastroenterology |volume=130 |issue=2 |pages=296–303 |year=2006 |pmid=16472585 |doi=10.1053/j.gastro.2005.10.019}}</ref> | |||
==Cause/etiology== | ==Cause/etiology== | ||
Several studies provide prevalences of underlying causes based on findings at [[ | Several studies provide prevalences of underlying causes based on findings at [[esophagogastroduodenoscopy]] (EGD).<ref name="pmid8224642">{{cite journal |author=Talley NJ, Weaver AL, Tesmer DL, Zinsmeister AR |title=Lack of discriminant value of dyspepsia subgroups in patients referred for upper endoscopy |journal=Gastroenterology |volume=105 |issue=5 |pages=1378–86 |year=1993 |pmid=8224642 |doi=}}</ref><ref name="pmid2904061">{{cite journal |author=Williams B, Luckas M, Ellingham JH, Dain A, Wicks AC |title=Do young patients with dyspepsia need investigation? |journal=Lancet |volume=2 |issue=8624 |pages=1349–51 |year=1988 |pmid=2904061 |doi=}}</ref><ref name="pmid2021764">{{cite journal |author=Johnsen R, Bernersen B, Straume B, Førde OH, Bostad L, Burhol PG |title=Prevalences of endoscopic and histological findings in subjects with and without dyspepsia |journal=BMJ |volume=302 |issue=6779 |pages=749–52 |year=1991 |pmid=2021764 |doi=}} [http://www.pubmedcentral.nih.gov/articlerender.fcgi?pubmedid=2021764 Fulltext]</ref> | ||
{| class="wikitable" style="text-align:center" | {| class="wikitable" style="text-align:center" | ||
| Line 28: | Line 37: | ||
|} | |} | ||
===Non-ulcer dyspepsia=== | ===Non-ulcer dyspepsia (NUD)=== | ||
When organic disease is excluded by [[ | 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.<ref name="pmid16472585">{{cite journal |author=Karamanolis G, Caenepeel P, Arts J, Tack J |title=Association of the predominant symptom with clinical characteristics and pathophysiological mechanisms in functional dyspepsia |journal=Gastroenterology |volume=130 |issue=2 |pages=296–303 |year=2006 |pmid=16472585 |doi=10.1053/j.gastro.2005.10.019}}</ref> | |||
====H. pylori==== | |||
[[H. pylori]] | |||
====Association with other diseases==== | |||
=====Psychiatric diagnoses===== | |||
=====Irritable bowel===== | |||
[[Irritable bowel syndrome]] | |||
==Diagnosis== | ==Diagnosis== | ||
| Line 49: | Line 72: | ||
===Laboratory tests=== | ===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%."<ref name="pmid16484121"/> | |||
Unexplained iron deficiency anemia is generally considered to possibly indicate important underlying cause of dyspepsia. [7] NEJM anemia study independent of guaiac | |||
=== | ====''H. pylori'' testing==== | ||
Direct visualization by [[ | [[Clinical practice guideline]]s by the American Gastroenterological Association recommend "[[H. pylori]] testing is optimally performed by a <sup>13</sup>C-urea breath test or stool antigen test."<ref name="pmid16285970">{{cite journal |author=Talley NJ |title=American Gastroenterological Association medical position statement: evaluation of dyspepsia |journal=Gastroenterology |volume=129 |issue=5 |pages=1753–5 |year=2005 |pmid=16285970 |doi=10.1053/j.gastro.2005.09.019}} [http://www.ngc.gov/summary/summary.aspx?ss=15&doc_id=8442&nbr=004711 National Guideline Clearinghouse]</ref> | ||
Several studies indicate the need to test dyspeptic patients for ''[[H. pylori]]''.<ref name="pmid16484121">{{cite journal |author=Valle PC, Breckan RK, Amin A, ''et al'' |title="Test, score and scope": a selection strategy for safe reduction of upper gastrointestinal endoscopies in young dyspeptic patients referred from primary care |journal=Scand. J. Gastroenterol. |volume=41 |issue=2 |pages=161–9 |year=2006 |pmid=16484121 |doi=10.1080/00365520500286881}}</ref><ref name="pmid16771937">{{cite journal |author=Jarbol DE, Kragstrup J, Stovring H, Havelund T, Schaffalitzky de Muckadell OB |title=Proton pump inhibitor or testing for Helicobacter pylori as the first step for patients presenting with dyspepsia? A cluster-randomized trial |journal=Am. J. Gastroenterol. |volume=101 |issue=6 |pages=1200–8 |year=2006 |pmid=16771937 |doi=10.1111/j.1572-0241.2006.00673.x}}</ref><ref name="pmid16638253">{{cite journal |author=Shaw IS, Valori RM, Charlett A, McNulty CA |title=Limited impact on endoscopy demand from a primary care based 'test and treat' dyspepsia management strategy: the results of a randomised controlled trial |journal=The British journal of general practice : the journal of the Royal College of General Practitioners |volume=56 |issue=526 |pages=369–74 |year=2006 |pmid=16638253 |doi=}}</ref> 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%."<ref name="pmid16484121"/> | |||
The accuracy of the breath test for detecting gastric or duodenal ulcer is:<ref name="pmid9135516">{{cite journal |author=McColl KE, el-Nujumi A, Murray L, ''et al'' |title=The Helicobacter pylori breath test: a surrogate marker for peptic ulcer disease in dyspeptic patients |journal=Gut |volume=40 |issue=3 |pages=302–6 |year=1997 |pmid=9135516 |doi=}}</ref> | |||
* [[sensitivity (tests)|sensitivity]] 93% | |||
* [[specificity (tests)|specificity]] 60% | |||
===Radiology=== | |||
UGI as historic significance as good before EGD.<ref name="pmid3917639">{{cite journal |author= |title=Endoscopy in the evaluation of dyspepsia. Health and Public Policy Committee, American College of Physicians |journal=Ann. Intern. Med. |volume=102 |issue=2 |pages=266–9 |year=1985 |pmid=3917639 |doi=}}</ref> | |||
===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.<ref name="pmid9322676">{{cite journal |author=Tefera L, Fein M, Ritter MP, ''et al'' |title=Can the combination of symptoms and endoscopy confirm the presence of gastroesophageal reflux disease? |journal=The American surgeon |volume=63 |issue=10 |pages=933–6 |year=1997 |pmid=9322676 |doi=}}</ref> | |||
==Treatment== | ==Treatment== | ||
[[Clinical practice guideline]]s by the American Gastroenterological Association recommend:<ref name="pmid16285970"/> | [[Clinical practice guideline]]s by the American Gastroenterological Association recommend:<ref name="pmid16285970"/> | ||
*"Patients 55 years of age or younger without alarm features should receive ''Helicobacter pylori'' test and treat followed by acid suppression if symptoms remain" | *"Patients 55 years of age or younger without alarm features should receive ''Helicobacter pylori'' test and treat followed by acid suppression if symptoms remain" | ||
===Smaller meals=== | |||
===Acid suppression=== | ===Acid suppression=== | ||
| Line 67: | Line 105: | ||
The [[Cochrane Collaboration]] concluded "trials evaluating prokinetic therapy are difficult to interpret as the...[positive] result could have been due to publication bias.".<ref name="pmid17054151"/> | The [[Cochrane Collaboration]] concluded "trials evaluating prokinetic therapy are difficult to interpret as the...[positive] result could have been due to publication bias.".<ref name="pmid17054151"/> | ||
===Tricylic antidepressants=== | |||
===Eradication of ''H. pylori''=== | ===Eradication of ''H. pylori''=== | ||
| Line 72: | Line 112: | ||
==Prevention== | ==Prevention== | ||
===Users of nonsteroidal anti-inflammatory medications=== | |||
===Asymptomatic adults=== | |||
Community screening for ''H. pylori'' may be beneficial.<ref name="pmid16344059">{{cite journal |author=Ford AC, Forman D, Bailey AG, Axon AT, Moayyedi P |title=A community screening program for Helicobacter pylori saves money: 10-year follow-up of a randomized controlled trial |journal=Gastroenterology |volume=129 |issue=6 |pages=1910–7 |year=2005 |pmid=16344059 |doi=10.1053/j.gastro.2005.09.016}}</ref> | Community screening for ''H. pylori'' may be beneficial.<ref name="pmid16344059">{{cite journal |author=Ford AC, Forman D, Bailey AG, Axon AT, Moayyedi P |title=A community screening program for Helicobacter pylori saves money: 10-year follow-up of a randomized controlled trial |journal=Gastroenterology |volume=129 |issue=6 |pages=1910–7 |year=2005 |pmid=16344059 |doi=10.1053/j.gastro.2005.09.016}}</ref> | ||
Revision as of 22:31, 11 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] 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:[2]
- ulcerlike
- dysmotilitylike
- refluxlike
- nonspecific
However, there is not a strong correlation of symptom type and measures of abnormal motility or hypersensitivity.[2][3]
Cause/etiology
Several studies provide prevalences of underlying causes based on findings at esophagogastroduodenoscopy (EGD).[2][4][5]
| Patients referred to gastroenterologists for dyspesia[2] | Primary care patients with dyspepsia[4] | Volunteers without dyspepsia[5] | |
|---|---|---|---|
| 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 (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.[3]
H. pylori
Association with other diseases
Psychiatric diagnoses
Irritable bowel
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
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%."[9]
Unexplained iron deficiency anemia is generally considered to possibly indicate important underlying cause of dyspepsia. [7] NEJM anemia study independent of guaiac
H. pylori testing
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."[10]
Several studies indicate the need to test dyspeptic patients for H. pylori.[9][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%."[9]
The accuracy of the breath test for detecting gastric or duodenal ulcer is:[13]
- sensitivity 93%
- specificity 60%
Radiology
UGI as historic significance as good before EGD.[14]
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.[15]
Treatment
Clinical practice guidelines by the American Gastroenterological Association recommend:[10]
- "Patients 55 years of age or younger without alarm features should receive Helicobacter pylori test and treat followed by acid suppression if symptoms remain"
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".[16]
Prokinetic drugs
Prokinetic drugs include serotonin-3 (5-HT3) receptor antagonists (cisapride and mosapride)[17], dopamine antagonists (metoclopramide and domperidone), and opiate agonists (trimebutine).[18] 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.".[16]
Tricylic antidepressants
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."[19]
Prevention
Users of nonsteroidal anti-inflammatory medications
Asymptomatic adults
Community screening for H. pylori may be beneficial.[20]
References
- ↑ N. Talley, et al., "Guidelines for the management of dyspepsia", American Journal of Gastroenterology 100 (2005), pp. 2324-2337.
- ↑ 2.0 2.1 2.2 2.3 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 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.
- ↑ 4.0 4.1 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]
- ↑ 5.0 5.1 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
- ↑ 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 9.2 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.
- ↑ 10.0 10.1 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
- ↑ 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]
- ↑ McColl KE, el-Nujumi A, Murray L, et al (1997). "The Helicobacter pylori breath test: a surrogate marker for peptic ulcer disease in dyspeptic patients". Gut 40 (3): 302–6. PMID 9135516. [e]
- ↑ (1985) "Endoscopy in the evaluation of dyspepsia. Health and Public Policy Committee, American College of Physicians". Ann. Intern. Med. 102 (2): 266–9. PMID 3917639. [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]
- ↑ 16.0 16.1 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.