DYSPEPSIA

Definition: According to the Rome III criteria, dyspepsia is defined as one or more of the following symptoms :

◆Postprandial fullness (classified as postprandial distress syndrome)

◆Early satiation (inability to finish a normal sized meal, also classified as postprandial distress syndrome)

◆Epigastric pain or burning (classified as epigastric pain syndrome)

Etiology

A, Approximately 25 percent of patients with dyspepsia have an underlying organic cause.

B, However, up to 75 percent of patients have functional (idiopathic or non ulcer) dyspepsia with no underlying cause on diagnostic evaluation .

DYSPEPSIA SECONDARY TO ORGANIC DISEASE

Although there are several organic causes for dyspepsia, the main causes are :-

◆peptic ulcer disease

◆gastroesophageal reflux

◆gastric malignancy, and

◆NSAID-induced dyspepsia.

Peptic Ulcer Disease

Upper abdominal pain or discomfort is the most prominent symptom in patients with peptic ulcers.

Although discomfort from ulcers is usually centered in the epigastrium, it may occasionally localize to the right or left upper quadrants.

While the pain may radiate to the back, back pain as the primary symptom is atypical of peptic ulcer disease.

GASTROESOPHAGEAL REFLUX

The most common symptoms of gastro esophageal reflux disease (GERD) are retrosternal burning pain and regurgitation.

GERD should be suspected when these symptoms accompany dyspepsia and are the predominant complaints

GASTROESOPHAGEAL MALIGNANCY

Gastro esophageal malignancy is an uncommon cause of chronic dyspepsia.

The incidence of malignancy also increases with age. When present, abdominal pain tends to be epigastric, vague and mild early in the disease but more severe and constant as the disease progresses.

BILIARY PAIN

Classic biliary pain is characterized by episodic acute and severe upper abdominal pain, usually in the epigastrium or right upper quadrant. It is not colicky.

The pain typically lasts for at least one hour and may persist for several hours.

The pain may radiate to the back or scapula, and is often associated with restlessness, sweating, or vomiting.

Episodes are typically separated by weeks to months and patients are completely pain free between attacks.

DRUG-INDUCED DYSPEPSIA

◆Nonsteroidal antiinflammatory drugs (NSAIDs) and COX-2 selective inhibitors can cause dyspepsia even in the absence of peptic ulcer disease.

◆Other medications include calcium channel blockers,methylxanthines,  alendronate, orlistat ,potassium supplements, acarbose and certain antibiotics, including erythromycin .

B.FUNCTIONAL DYSPEPSIA

Functional (idiopathic or non ulcer) dyspepsia is defined as the presence of one or more of the following

postprandial fullness

early satiation

epigastric pain or burning

These criteria should be fulfilled for the last three months with symptom onset at least six months before diagnosis.

DIAGNOSTIC STRATEGIES AND INITIAL MANAGEMENT

The approach to and extent of diagnostic evaluation of a patient with dyspepsia is based on the presence or absence of alarm features , patient age, and the local prevalence of Helicobacter pylori ( H. pylori ) infection.

Patients with GERD and NSAID-induced dyspepsia should be treated with an empiric trial of proton pump inhibitors (PPI) for eight weeks and NSAIDs should be discontinued .

Patients who test positive for an infection with H. pylori should undergo treatment with eradication therapy.

◼Omeprazole 20mg BID  or

◼Esomeprazole 40 mg QD   or          PPI

◼Pantoprazole 40 mg BID  And

◼Clarithromycin 500 mg BID And

◼Amoxicillin  1g BID OR 

◼Metronidazole 500 mg BID for 7-14 days

Patients who have continued symptoms after successful eradication of H. pylori should be treated with anti-secretory therapy with a proton pump inhibitor for four to eight weeks. 

Table: Regimens for Eradication of H.pylori infection