Dyspepsia

Dyspepsia is a feeling of pain or discomfort in the upper abdomen. It may be characterized as indigestion, gas, early satiety, bloating after eating, hunger, or burning.

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What causes dyspepsia?

The most common causes of dyspepsia include peptic ulcer disease, motility disorders, gastroesophageal reflux, medications (eg, erythromycin, nonsteroidal anti-inflammatory drugs, alendronate), and esophageal and gastric malignancies. However, many patients have no underlying organic disorder (functional or nonulcer dyspepsia). Others have disorders (eg, duodenitis, pyloric dysfunction, motility disorders, Helicobacter pylori gastritis, lactose deficiency, cholelithiasis) that do not correlate well with the symptoms (i.e., treating the underlying disorder does not resolve the dyspepsia).

Symptoms of dyspepsia

Dyspepsia symptoms are sometimes considered to be consistent with peptic ulcer disease, dysmotility, and reflux disease; these symptoms suggest but do not confirm the etiology. Peptic ulcer-like symptoms include pain that is limited to the epigastric region and is often present before meals or relieved by food, antacids, or H2 _blockers. Dyspepsia-like symptoms include discomfort but not pain, along with early satiety, postprandial bloating, nausea, vomiting, bloating, and symptoms that worsen after meals. Dyspepsia symptoms that are consistent with reflux disease include heartburn or acid regurgitation. However, these symptoms often occur together.

Intermittent constipation and diarrhea with dyspepsia suggest irritable bowel syndrome or abuse of non-prescribed laxatives or antidiarrheal drugs.

"Alarm symptoms" for dyspepsia include anorexia, nausea, vomiting, weight loss, anemia, blood in the stool, dysphagia, pain on swallowing, and a negative response to standard therapy such as H2 _blockers.

Diagnosis of dyspepsia

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Physical examination

Examination rarely reveals the cause of dyspepsia, but the detection of occult blood in the stool indicates the need for further investigation.

Survey

Routine tests include a complete blood count, stool occult blood test (to exclude gastrointestinal bleeding), and routine blood chemistry. If test results are abnormal, additional tests (eg, imaging, endoscopy) are indicated. Because of the risk of malignancy, upper gastrointestinal endoscopy should be performed in patients over 45 years of age and in individuals with new alarming symptoms. In patients under 45 years of age without alarming symptoms, some authors recommend empirical therapy with antisecretory or prokinetic drugs followed by endoscopy if treatment is ineffective. Other authors recommend screening for H. pylori infection with a C ₁₄ urea breath test or stool examination. However, a differentiated assessment of the results obtained is necessary if H. pylori is proven or any other nonspecific signs are identified to explain the symptoms.

Esophageal manometry and gastric pH testing are indicated in cases of persistent reflux symptoms after upper GI endoscopy and prophylactic use of proton pump inhibitors for 2-4 weeks.

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Treatment of dyspepsia

Specific conditions require treatment. Patients without a clear diagnosis should be followed long-term and be assured of success. Dyspepsia requires proton pump inhibitors, H2 _blockers, and cytoprotective agents (eg, sucralfate). Prokinetic agents (eg, metoclopramide, erythromycin) as a liquid suspension may be used in patients with dyspepsia and dysmotility-like symptoms. However, there are no data to suggest differential effects of drug class on specific symptoms (eg, antireflux in dysmotility). Misoprostol and anticholinergics are ineffective in functional dyspepsia. Drugs that alter sensory perception (eg, tricyclic antidepressants) may be effective.