Dyspepsia

Dyspepsia is derived from the Greek dys and peptein, which literally interpret as bad digestion. The term dyspepsia encompasses a variety of symptoms of persistent upper abdominal pain and discomfort. The predominant symptoms may include pain, heartburn, nausea, early satiety, or postprandial fullness or bloating. This is the most common type of functional upper GI disorder, with a prevalence rate in Western countries estimated at 25%, although less than half will seek medical attention. There are subtypes of dyspepsia, which can be better approached by focusing on the predominant symptom. Ulcer-like symptoms are characterized by upper abdominal pain relieved by certain foods or antacids. Reflux-like symptoms include heartburn and acid regurgitation. Many patients with dyspepsia are thought to have a dysmotility-like disorder with less pain but more symptoms of early satiety, postprandial fullness and bloating, or nausea and vomiting. With an exhaustive evaluation, approximately 50% of patients will demonstrate some type of motility disorder such as impaired fundic relaxation, antral hypo-motility, gastroparesis, small bowel dysmotility, or abnormal duodenogastric reflexes.

A traditionally defined disease with definable pathology such as an ulcer or erosive esophagitis will be found only in a minority of patients presenting with dyspepsia. The term nonulcer dyspepsia (NUD) is given to patients with no definable structural disease after a standard work-up. Patients with a histologic diagnosis of gastritis or duodenitis should be included in the category of NUD, because a clear link between the histologic abnormality and the symptoms is not established.

The aggressiveness of evaluation with endoscopy is variable depending on the circumstance. Because of concern for gastric cancer, endoscopy is recommended for all patients older than 45 years presenting with new onset dyspepsia. For younger patients, it is reasonable to delay endoscopy as long as alarm symptoms of dysphagia,weight loss, bleeding, and recurrent vomiting are not present. For younger patients, an empiric trial with an antisecretory agent is reasonable, reserving endoscopy for patients who are not helped with this therapy. Recent studies have demonstrated proton pump inhibitors such as omeprazole (Prilosec®) or lansoprazole (Prevacid®) to be more effective in treating uninvestigated dyspepsia than H 2 receptor antagonist or antacids. Other routine evaluations for older patients, and younger patients who fail an empiric trial, include routine hematologic and biochemical tests (complete blood count, liver function test, electrolytes, creati-nine, and thyroid function tests). An ultrasound of the right upper quadrant would be reasonable, although it is not clear if gallstones should be considered causative of symptoms of dyspepsia. Other tests to be considered for patients with refractory and disabling symptoms include 24-hour pH testing, gastric emptying testing, and, where available, gastroduodenal motility testing.

The role of Helicobacter pylori in patients with dyspeptic symptoms remains controversial. It is reasonable to perform serologic testing and to treat for Helicobacter if positive, especially in the uninvestigated patient with dyspepsia. However, for patients with functional dyspepsia, that is, patients who have undergone an investigation that does not reveal evidence of ulcer disease, large studies have shown that treatment for H. pylori does not result in symptomatic improvement.

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