DyspepsiaNeil C. Jackson

General

Common symptom with extensive differential diagnosis and heterogenous pathophysiology.

Epidemiology

25% of general population/year 25% with evidence of organic cause

75% without

Symptoms

Chronic or recurrent pain or discomfort in the upper abdomen

Ulcer-like or acid dyspepsia

Burning pain, epigastric huger-like pain

Relief with food/antacids/antisecretory agents

Food-provoked dyspepsia or indigestion

Postprandial epigastric discomfort and fullness

Belching, early satiety, nausea, occasional vomiting

Reflux-like dyspepsia

Rome III Criteria

Postprandial fullness

Early satiation

Inability to finish a normal sized meal

Epigastric Pain or Burning

Organic dyspepsia

PUD

GERD

GE malignancy

Biliary

Meds (NSAIDs)

Other Celiac / chronic pancreatitis

Infiltrative dz (Eosinophilic gastritis / crohn’s / sarcoid)

DM radiculopathy / hypercalcemia / heavy metal toxicity

Hepatoma / steatohepatitis / mesenteric ischemia

PUD

A spectrum from gastritis to ulceration complicated by bleeding, pain and perforation.

Poor correlation with reported symptoms and EGD findings

Includes Duodenal and gastric ulcers

Commonly due to H.Pylori and/or NSAID, tobacco, EtOH

Treatment = H.pylori eradication and removal of inciting agents

Duodenal vs. Gastric Ulcers

Gastric ulcer Worse with meals

Poor response to antacids/otcs

Duodenal ulcer Pain when acid is secreted in absence of a food buffer

Improves with meals, alkali, antisecretory agents

Worse 3-5 hours after a meal

Worse at night between 11pm – 2am

Maximal circadian stimulation of acid secretion

GERD

Some degree of reflux is physiologic

Montreal classification: A condition that develops when reflux of stomach contents

causes troublesome symptoms and/or complications

Prevalence= 10-20% in western world, <5% in Asia

Heartburn = retrosternal burning, most common

Regurgitation = gastric content into mouth/throat

Dysphagia = common in longstanding GERD due to Reflux esophagitis

Stricture

More GERD

Globus sensation Almost constant perception of a lump in the throat

Water brash (foaming at the mouth) Rare hypersalivation caused by reflux

Chest pain Mimics angina, typically squeezing/burning

Substernally with radiation to back/neck/jaw/arms

Lasts minutes to hours

Spontaneous resolution with antacids

Occurs after meals, awakens from sleep

Worse with emotional stress

GE Malignancy

Uncommon cause of chronic dyspepsia in Western Hemisphere

More common in Asian, Hispanic, Afro-Caribbean populations

Increases with age

Epigastric pain vague, mild in early disease – more severe and constant with progression

Weight loss from insufficient caloric intake

Dysphagia related to esophageal or proximal gastric malignancy

NSAIDs

Direct effect Ionization upon absorption into gastric mucosa

Topical epithelial injury

Systemic effect Inhibition of GI mucosal COX activity (COX1)

Decreased mucosal prostaglandin protection

History

Association of symptoms with meals

Heartburn / regurgitation / cough

NSAID use ??

Radiation to back, personal/fhx of pancreatitis

Significant weight loss / anorexia / vomiting / dysphagia / odynophagia / fhx of GI malignancy

Severe episodic epigastric / RUQ pain lasting more than one hour

Exam

Usually normal except for epigastric tenderness

Jaundice, pallor, ascites, muscle wasting

Palpable abdominal mass

Palpable lymphadenopathy L supraclavicular = Virchow’s node

Periumbilical = Sister Mary Joseph’s node

Carnett sign Double straight leg raise or head raise while supine

Finger presses point of tenderness

+ test = Increased pain with muscle tensing

Labs

CBC

Electrolytes + Calcium

Hepatic Function Panel

Alarm Features

Age > 55 yrs with new-onset dyspepsia

FHx of upper GI malignancy

Unintended weight loss

GI bleeding

Progressive dysphagia

Odynophagia (painful swallowing)

Unexplained Iron deficiency

Persistent vomiting

Palpable mass or node

Jaundice

Diagnosis: Pt with alarm features

Upper endoscopy within two weeks with stomach biopsy for H.pylori

Yield of EGD increases with age

Per meta-analysis of 9 studies, 5389 pts:

6% erosive esophagitis

8% PUD

If normal, most will have functional dyspepsia

Further evaluation warranted if alarm features

Age cutoff controversial AGA suggests 60-65 yrs

45-50 with Asian, Hispanic, Afro-Caribbean descent

Reflux Esophagitis

Barrett’s Esophagus

Gastric Ulcer

Esophageal Ulcer

Diagnosis: No alarm features

Test and treat for H.pylori If local h.pylori prevalence >10 %

Empiric PPI / H2blocker If local h.pylori presence <5%

Test and Treat for H.Pylori

Urea breath test or stool Ag

Serologic testing should not be used

NNT is 14

H. Pylori eradication

Quadruple Therapy

Triple therapy + bismuth 525mg 4xdaily for 10-14 days

With clarithromycin/metronidazole resistance > 15%

With recent/repeated exposure to clarithro/flagyl

Triple Therapy

PPI (multiple options)

Omeprazole 20mg bid

Pantoprazole 40mg bid

Amoxicillin: 1g BID 7-14 days

Clarithromycin: 500mg BID 7-14 days

Alternative antibiotics

Doxycycline 100mg bid / Flagyl 250mg 4xdaily

Anti-Secretory Therapy

PPIs > H2 blockers PPI (Omeprazole / pantoprazole / lansoprazole )

Irreversibly binds/inhibits H/K atp pump on parietal cells

Only effective in active parietal cells

Must be taken 30-60 minutes before meals

Twice daily dosing if :

Failed standard therapy

Large gastric ulcer

H2 blockers (Ranitidine / cimetidine / famotidine)

Inhibit Histamine H2 receptors on parietal cells

Functional Dyspepsia

Presence of one or more: Postprandial fullness

Early satiation

Epigastric pain/burning

Negative diagnostic evaluation for organic disease

Symptoms for last three months

Onset more than 6 months previously

Pathophysiology

Gastric motility / compliance

Delayed gastric emptying (30%)

rapid gastric emptying (10%)

Visceral hypersensitivity

Increased pain with normal gastric stretching/compliance

Independent of delayed gastric emptying

H.pylori infection

Unclear mechanism, ?smooth muscle dysfunction 2/2 inflammatory modulation of enteric nervous system

Altered gut microbiome

Symptoms more likely after episode of AGE

Psychosocial dysfunction

Association with GAD, somatization, Major Depression

Higher prevalence in pts with self-reported hx of child abuse

Treatment

H.Pylori test and treat

Tricyclic anti-depressants If persistent symptoms despite PPI x8wks

PPI / H2 blockers

Metoclopramide (Prokinetic) If failed above therapy

5-10 mg TID half hour before meals and at night x4wks

References

Uptodate Approach to the Adult with Dyspepsia

Functional dyspepsia in adults

Clinical manifestations of peptic ulcer disease

Clinical manifestations and diagnosis of GERD in adults

Clinical features,diagnosis,staging of gastric cancer

Epidemiology, pathobiology and clinical manifestations of esophageal cancer

Differential diagnosis of abdominal pain in adults

AGA AGA medical position statement: evaluation of dyspepsia –

Gastroenterology, 2005

AFP Evaluation and management of non-ulcer dyspepsia

H.Pylori Infection