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Dyspepsia

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Dyspepsia, Nonulcer Dyspepsia, Functional Dyspepsia, Gastritis, Duodenitis, Acid-Related Dyspepsia

  • Definition
  1. Chronic or recurrent Epigastric Pain
  • Epidemiology
  1. Dyspepsia overall Prevalence: 40% of adults in U.S
  • Pathophysiology
  1. Unclear etiology, however may be related to altered gastric motility
  2. Helicobacter Pylori often found in patients with Dyspepsia, but causality is not clear
  • Symptoms
  1. Epigastric burning, pain or discomfort
  2. Early satiety
  3. Associated symptoms
    1. Abdominal Bloating (difficult to treat)
    2. Belching and Flatulence
    3. Nausea and Vomiting
    4. Halitosis
  • Diagnosis
  • Rome III Criteria
  1. Symptoms for at least 12 weeks of the last 12 months
  2. No evidence for structural disease (including on upper endoscopy) that could explain symptoms and
  3. Symptom criteria (at least one is present)
    1. Epigastric Pain
    2. Epigastric burning
    3. Early satiety
    4. Bothersome postprandial fullness
  • Differential Diagnosis
  • Approach
  • Step 1 - Consider differential Diagnosis
  1. See Dyspepsia Causes
  2. See Medication Causes of Dyspepsia
  3. Most common conditions in differential diagnosis
    1. Idiopathic (functional disorder) in 60% of cases
    2. Gastroesophageal Reflux disease (often comorbid)
    3. Peptic Ulcer Disease
    4. Biliary pain (Cholelithiasis)
    5. Irritable Bowel Syndrome
      1. Symptoms relieved by Defecation
      2. Associated with change in stool frequency or form
  • Approach
  • Step 2 - Upper Endoscopy for high risk patients
  1. See Dyspepsia Red Flags for Indications
  2. Perform early upper endoscopy
  • Approach
  • Step 3 - Consider empiric antisecretory therapy
  1. Timing
    1. Initial trial for 2-4 weeks
    2. Longterm antisecretory use is often needed
  2. General Measures
    1. Avoid Gastric Irritants
  3. Antisecretory Agents
    1. H2 Blocker (e.g. Ranitidine)
      1. Cost effective initial trial
      2. Switch to Proton Pump Inhibitor if not effective
    2. Proton Pump Inhibitor (e.g. Omeprazole)
      1. Highly effective agents at much higher cost
      2. No advantage to higher Omeprazole doses
      3. Meineche-Schmidt (2004) Am J Gastroenterol 99:1050 [PubMed]
  4. Adjunctive medication options
    1. Metoclopramide (prokinetic agent)
      1. May offer benefit in Nonulcer Dyspepsia
      2. Risk of tardive diskinesia
  5. Ineffective Medications (avoid)
    1. Sucralfate offers no benefit in Nonulcer Dyspepsia
    2. Misoprostel offers no benefit in Nonulcer Dyspepsia
  1. Indications
    1. Lack of relief with empiric antisecretory therapy
    2. Undifferentiated Dyspepsia
      1. H. pylori treatment does not benefit without ulcer
        1. However ulcer status unknown without endoscopy
      2. Test and treat strategy is cost effective
        1. Reserve endoscopy for Dyspepsia Red Flags (see Dyspepsia Red Flags)
        2. Dyspepsia Red Flags include age >55 years old, unexplained weight loss, Dysphagia
  2. Testing
    1. See Helicobacter pylori Noninvasive Testing
  3. Protocol
    1. Treat with H. pylori management if positive
    2. Retest for cure if symptoms persist after treatment
      1. Urea Breath Test
      2. H. pylori Stool Antigen (HpSA)
      3. Endoscopic Biopsy for H. pylori
  • Approach
  • Step 5 - Upper Endoscopy Indications (if not already done above)
  1. Incomplete relief with above management
  • Approach
  • Step 6 - Alternative Therapies
  1. Selective Serotonin Reuptake Inhibitors (SSRI)
  2. Amitriptyline (Elavil) titrated to 30-75 mg nightly
  3. Hypnotherapy
    1. May be indicated in chronic Functional Dyspepsia
    2. Calvert (2002) Gastroenterology 123:1778-85 [PubMed]