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 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:

• ulcerlike
• dysmotilitylike
• refluxlike
• nonspecific

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

Cause/etiology

Several studies provide prevalences of underlying causes based on findings at esophagogastroduodenoscopy (EGD).

Findings in various populations

	Patients referred to gastroenterologists for dyspesia	Primary care patients with dyspepsia	Volunteers without dyspepsia
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/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.

H. pylori

H. pylori

Association with other diseases

Irritable bowel

Irritable bowel syndrome

Diagnosis

History and physical examination

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

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

• 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, one study found that the best predictions of abnormal investigations were:

• 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)

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).

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%."

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

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."

Several studies indicate the need to test dyspeptic patients for H. pylori. 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%."

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

• sensitivity 93%
• specificity 60%

Radiology

UGI as historic significance as good before EGD.

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.

Treatment

Clinical practice guidelines by the American Gastroenterological Association recommend:

• "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".

Prokinetic drugs

Prokinetic drugs include serotonin-3 (5-HT3) receptor antagonists (cisapride and mosapride), dopamine antagonists (metoclopramide and domperidone), and opiate agonists (trimebutine). 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.".

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."

Prevention

Asymptomatic adults

Community screening for H. pylori may be beneficial.