Gastroenterology Book

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

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  1. See Also
    1. Epigastric Pain
    2. Peptic Ulcer Disease
    3. Dyspepsia in Pregnancy
  2. Definition
    1. Chronic or recurrent epigastric pain
  3. Epidemiology
    1. Incidence: 25%
  4. Causes
    1. See Dyspepsia Causes
    2. See Medication Causes of Dyspepsia
  5. Symptoms
    1. Epigastric burning
    2. Associated symptoms
      1. Abdominal bloating (difficult to treat)
      2. Belching and Flatulence
      3. Nausea
      4. Halitosis
  6. Diagnosis: Rome Criteria
    1. Symptoms for at least 12 weeks of the last 12 months
    2. Persistent or recurrent epigastric pain
    3. No organic disease signs (including on upper endoscopy)
    4. No evidence for Irritable Bowel Syndrome
      1. Symptoms not exclusively relieved by Defecation
      2. Not associated with change in stool frequency or form
  7. 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
  8. Approach: Step 2 Upper Endoscopy for high risk patients
    1. See Dyspepsia Red Flags for Indications
  9. 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
    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
  10. Approach: Step 4 Consider Helicobacter Pylori testing
    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. Reserves endoscopy for Dyspepsia Red Flags
    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
  11. Approach: Step 5 Upper Endoscopy Indications
    1. Incomplete relief with above management
  12. Approach: Step 6: Alternative Therapies
    1. Selective Serotonin Reuptake Inhibitors (SSRI)
    2. Hypnotherapy
      1. May be indicated in chronic Functional Dyspepsia
      2. Calvert (2002) Gastroenterology 123:1778
  13. References
    1. Bazaldua (1999) Am Fam Physician 60(6):1773
    2. Dickerson (2004) Am Fam Physician 70:107
    3. Fisher (1998) N Engl J Med 339:1376
    4. Laine (2001) An Intern Med 134:361
    5. Richter (1991) Scand J Gastroenterol 182:11
    6. Talley (2005) Am J Gastroenterol 10:2324

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