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Dyspepsia

Dyspepsia, characterized by persistent epigastric pain, is a prevalent condition often resulting from stomach-related issues. It is distinct yet clinically overlapping with heartburn, which primarily describes esophageal symptoms. Key causes of dyspepsia include Helicobacter pylori infection, gastritis, esophagitis, GERD, and peptic ulcer disease. Accurate diagnosis requires a detailed history, physical examination, risk factor evaluation, and identification of red flag symptoms. Patients aged 60 or above, or those with red flag symptoms, should undergo EGD to exclude neoplasia prior to empirical treatment. Testing and treating H. pylori infection is essential in typical dyspepsia cases. Younger patients (<60 years) with typical heartburn and no major red flags may receive empirical acid suppression therapy, like PPIs. Non-responsive cases to empirical therapy demand additional diagnostic and therapeutic measures. Atypical dyspepsia symptoms necessitate exploration of other causes such as cholelithiasis, chronic pancreatitis, or stable angina. In cases where no organic pathology is found, functional dyspepsia, which constitutes about 70% of dyspepsia cases, should be considered and assessed using the Rome IV criteria.

Last updated: December 3, 2024 225 views

  • Dyspepsia:
    • Defined as epigastric pain or burning sensation.
    • Duration: Lasts for one month or longer.
  • Heartburn (Pyrosis):
    • Characterized as a burning discomfort behind the breastbone (retrosternal area).
    • Commonly occurs after eating and may worsen upon bending or lying down.
    • Along with regurgitation, it is a key symptom of gastroesophageal reflux disease (GERD).

 

Note  
Dyspepsia can be associated with a variety of symptoms, e.g., heartburn, nausea, regurgitation, bloating, belching. Dyspepsia and heartburn may be clinically indistinguishable because of the significant overlap in symptoms. ملاحظة

  • Initial Assessment:
    • Conduct a comprehensive medical history and physical examination.
    • Screen for risk factors common to peptic ulcer disease (PUD), GERD, and gastritis.
    • Evaluate for "red flag" features in all patients.
  • Red Flag Features of Dyspepsia:
    • Family history of gastrointestinal cancer.
    • Immunosuppression.
    • Significant unintentional weight loss.
    • Anorexia.
    • Dysphagia, odynophagia.
    • Early satiety.
    • Persistent vomiting.
    • Noncardiac chest pain (especially in patients with heartburn).
    • Signs of gastrointestinal bleeding (e.g., iron deficiency anemia, melena).
    • Patients aged ≥ 60 years.
  • Patients ≥ 60 Years:
    • Refer for esophagogastroduodenoscopy (EGD) to rule out neoplasia.
    • Test for Helicobacter pylori during esophagogastroduodenoscopy (EGD) using biopsies or a rapid urease test.
    • If esophagogastroduodenoscopy (EGD) identifies a clear etiology (like peptic ulcer, gastritis), manage accordingly.
    • If etiology remains unclear, consider further testing based on clinical judgment.
  • Patients < 60 Years:
    • With Red Flags: Consider esophagogastroduodenoscopy (EGD) on an individual basis.
    • Without Red Flags:
      • For typical dyspepsia: Implement a test-and-treat strategy for H. pylori (using noninvasive tests like the urea breath test).
        • If positive: Pursue H. pylori eradication therapy.
        • If negative: Start a trial of acid suppression with proton pump inhibitors (PPIs).
      • For typical heartburn: Begin empirical therapy with PPIs.

  • Esophagogastroduodenoscopy (EGD):
    • Indications:
      • Patients ≥ 60 years with dyspepsia, with/without red flags.
      • Selected patients < 60 years with red flags, assessed individually.
      • Inadequate response to empirical pharmacotherapy.
    • Findings: EGD can reveal causes like gastritis, peptic ulcer disease (PUD), gastric cancer, GERD, or esophagitis.
    • Biopsies: Obtain gastric biopsies for H. pylori evaluation in all dyspepsia EGDs.
  • Helicobacter pylori Diagnostics:
    • Indications:
      • Uninvestigated dyspepsia in patients < 60 without red flags.
      • Low-grade MALT lymphoma, PUD, post-endoscopic resection of early gastric cancer.
      • Prior to starting long-term NSAIDs.
      • Relative indications include ongoing NSAID/aspirin therapy, unexplained iron deficiency anemia, idiopathic thrombocytopenic purpura.
    • Testing Methods:
      • Discontinue PPIs 2 weeks prior to most tests (except histology).
      • Noninvasive: Urea breath test, stool antigen test, serum IgG antibodies.
      • Invasive: Biopsies for rapid urease test, histology (gold standard), culture and sensitivity, PCR of biopsy samples.
  • Further Workup:
    • Indicated for inconclusive/negative EGD, negative H. pylori tests, or inadequate response to therapy.
    • Assess pretest probability (PTP) of differential dyspepsia diagnoses:
      • RUQ ultrasound for cholelithiasis.
      • CT abdomen for chronic pancreatitis.
      • Cardiac stress testing for suspected CAD.
      • Esophageal pH monitoring for GERD, manometry or barium swallow for motility disorders.
      • Assess Rome IV criteria for functional dyspepsia.

  • Typical Heartburn (GERD):
    • 8-week trial of acid suppression therapy with proton pump inhibitors (PPIs).
    • Refer to “Management of GERD” for further management based on response.
  • Typical Dyspepsia and Negative for H. pylori:
    • 8-week trial of acid suppression therapy with PPIs.
  • Positive Test for H. pylori Infection:
    • H. pylori eradication therapy.
    • Confirm eradication 4–6 weeks after therapy completion.
  • General Patient Management:
    • Consider antacids for rapid symptomatic relief as needed.
    • Implement nonpharmacological measures and lifestyle changes.
  • Pharmacological Therapy:
    • Acid Suppression Medications (PPIs):
      • Newer PPIs may have higher healing rates in PUD than omeprazole.
      • Potential adverse effects include osteoporosis (long-term use) and micronutrient malabsorption.
    • H2 Antagonists:
      • Used mostly for maintenance or in combination with PPIs.
      • Cimetidine can cause drug interactions and may lead to erectile dysfunction and gynecomastia.
    • Antacids:
      • Used alongside acid suppression for rapid symptom relief.
      • Potential adverse effects include hypokalemia, bloating, and specific concerns for each type (e.g., hypercalcemia with calcium carbonate).
  • Nonpharmacological Recommendations:
    • Dietary: Reduce portion size, avoid eating before lying down, avoid triggering foods/beverages.
    • Physical: Weight loss in obesity, elevate the bed head for nighttime symptoms.
    • Lifestyle: Reduce stress, avoid nicotine, alcohol, and caffeine, and possibly avoid certain medications.
  • Helicobacter pylori Eradication Therapy:
    • For all patients testing positive for H. pylori.
    • Typically comprises PPIs twice daily PLUS two antibiotics with/without bismuth for 10–14 days.
    • Follow local resistance patterns and ensure treatment adherence.
    • First-Line Options:
      • Clarithromycin Triple Therapy: Preferred where clarithromycin resistance is low.
      • Bismuth Quadruple Therapy: Preferred where clarithromycin resistance is high.
Note  
Bismuth binds to the affected mucosa, providing physical protection from acids, and stimulates gastric HCO3- secretion, which helps to restore the mucosal pH gradient and is hence used to treat peptic ulcers and H.pylori infection (as a part of Bismuth quadruple therapy). Bismuth subsalicylate is also an antidiarrheal agent and is used to treat traveler's diarrhea (caused by enterotoxigenic Escherichia coli). ملاحظة

 

  • Follow-Up:
    • Confirm H. pylori eradication 4–6 weeks post-treatment using urea breath test, stool antigen test, or biopsy.
    • Discontinue acid suppression medication once eradication is confirmed.

  • Overview of Functional Dyspepsia:
    • Also known as nonulcer dyspepsia.
    • Characterized by upper GI symptoms like epigastric pain and bloating, without an identifiable cause.
    • Symptoms vary in intensity and can significantly affect patient's life.
    • Heterogeneous and multifactorial; pathophysiology not fully understood.
  • Rome IV Criteria for Functional Dyspepsia:
    • Diagnosis of exclusion, made after ruling out organic causes in dyspepsia workup.
    • Symptoms experienced at least 3 days per week over the past 3 months, including:
      • Epigastric burning or pain.
      • Early satiety.
      • Postprandial fullness.
      • Interference with daily activities.
      • Symptom duration of ≥ 6 months.
  • Treatment Approach:
    • First-Line Treatment:
      • Proton pump inhibitors (PPIs) for 8 weeks at standard dose.
    • Second-Line Treatment (if no improvement with PPIs):
      • Tricyclic antidepressants (e.g., amitriptyline).
    • Third-Line Treatment (if no response to PPIs or tricyclic antidepressants):
      • Prokinetic therapy (e.g., metoclopramide).
      • Psychological therapy (e.g., cognitive behavioral therapy).