Approach to Dyspepsia

Definition : Rome III diagnostic

criteria, Functional dyspepsia
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)

No evidence of structural disease
*These criteria should be fulfilled for the last 3 months with symptom onset at
least 6 months before diagnosis

ROME III Criteria : B1 Functional

Dyspepsia

ROME III Criteria : B1 Functional

Dyspepsia

Etiology
25-40% : Underlying Organic cause ,the main
causes are peptic ulcer disease, GERD, gastric malignancy,
and NSAID-induced dyspepsia

60-75% : Functional (idiopathic or non-ulcer)

dyspepsia with no underlying cause on diagnostic
evaluation

Adapted from Up to date

Talley NJ, Silverstein MD, Agreus L, et al. Gastroenterology 1998; 114:582.

Fisher RS, Parkman HP. N Engl J Med 1998; 339:1376.

History taking
Narrow the Differential diagnosis
- GERD : history of heartburn, regurgitation, or cough
- NSAID dyspepsia and peptic ulcer disease : pain radiate to the
back or personal or family history of pancreatitis may be indicative
of underlying chronic pancreatitis
- Malignancy : Significant weight loss, anorexia, vomiting,
dysphagia, odynophagia, and a family history of gastrointestinal
cancers
- Symptomatic cholelithiasis : severe episodic epigastric or RUQ
abdominal pain lasting > an hour or occurs at any time

History taking : Alarm feature

Talley NJ, Vakil NB, Moayyedi P. American Gastroenterological Association technical review on the evaluation of dyspepsia. Gastroenterology 2005; 129:1756.

Physical examination
Palpable abdominal mass (eg, hepatoma)
Lymphadenopathy (eg, left supraclavicular or periumbilical
in gastric cancer)
Jaundice (eg, secondary to liver metastasis)
Pallor secondary to anemia
Ascites
Muscle wasting, loss of subcutaneous fat, and peripheral
edema due to weight loss

Physical examination
Epigastric tenderness cannot accurately distinguish organic
dyspepsia from functional dyspepsia
Carnetts sign : determine pain arising from the abdominal
wall rather than due to inflammation of the viscera
Carnetts sign + : Increased local tenderness during muscle
tensing, suggests the presence of abdominal wall pain
Carnetts sign - : Decreased tenderness, the origin of pain is
likely from an intra-abdominal organ, as the tensed
abdominal wall muscles protect the viscera

Physical examination
Abdominal wall pain can originate from a
hernia ,hematoma or the abdominal wall
musculature

Laboratory tests
CBC and blood chemistry including LFT
should be performed to identify patients with
alarm features (eg, iron deficiency anemia)
and underlying metabolic diseases that can
cause dyspepsia (eg, diabetes, hypercalcemia)

GI symptoms ;
Constipation, anorexia, and
nausea occur commonly
Pancreatitis and peptic ulcer
disease occur less frequently
Peptic ulcer disease has
been described in patients
with hypercalcemia due to
primary
hyperparathyroidism (may
caused by calcium-induced
gastrin secretion)

Evaluation and Management

based on 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 PPI for 8 weeks and NSAIDs should
be discontinued

Test and treatment for H.pylori

Testing should be performed with a urea breath test or
stool antigen assay (Serologic testing should not be
used due to low positive predictive value)
Test + for H. pylori should treat with eradication
therapy
Patients with H. pylori + and who are treated with
appropriate antibiotics therapy persist with dyspeptic
symptoms; the number needed to treat to successfully
relieve dyspeptic symptoms is estimated at 1 in 14

Test and treatment for H.pylori

Patients who have continued symptoms after

successful eradication of H. pylori should be
treated with antisecretory therapy with a
proton pump inhibitor for 4-8 weeks

Evaluation of persistent symptoms

One of following categories:
- 1. persistent H. pylori infection
- 2. alternate diagnosis
- 3. functional dyspepsia
*paying specific attention to the degree of
symptoms which have improved or worsened, and
compliance with medications

Evaluation of persistent symptoms

~ 75% have functional (idiopathic or

nonulcer) dyspepsia with no underlying
cause on diagnostic evaluation

Evaluation of persistent symptoms

EGD should be performed
Ultrasound of the gallbladder should be performed
only in patients with pain suggestive of biliary disease
Distinguishing between patients with true biliary pain
and those with coincident but unrelated dyspepsia
and cholelithiasis is important, as it may lead to an
unnecessary cholecystectomy that is unlikely to relieve
dyspepsia

Evaluation of persistent symptoms :

Normal EGD

Evaluation of persistent symptoms

Delayed gastric emptying has been found in 30-50%
of patients complaining of dyspeptic symptoms
Gastroparesis should be considered in patients with
persistent nausea and vomiting and in patients with
risk factors for delayed gastric emptying (eg, DM)
Treatment directed at accelerating delayed gastric
emptying in these patients may not necessarily
improve symptoms

Evaluation of persistent symptoms

Diarrhea, constipation, bloating, and flatulence may be
associated with IBD and a colonoscopy and small bowel
radiography may be indicated
Chronic intestinal ischemia should be considered in severe
peripheral vascular disease or CAD
Chronic mesenteric ischemia, CT and MRA may
demonstrate high grade stenoses in mesenteric vessels
Symptoms suggestive of an anxiety or panic disorder
should be sought and treated if present

Thanks you for your attention :)

Peptic ulcer disease(1)

Upper abdominal pain or discomfort is the most prominent symptom
(usually centered in the epigastrium, it may occasionally localize to
RUQ or LUQ) , may radiate to the back (back pain as the primary
symptom is atypical)
classic symptoms of DU occur when acid is secreted in the absence of
a food buffer (2-5 hr after meals or on an empty stomach)
PU associated with food-provoked symptoms. Thus, pain related to
the timing of a meal cannot accurately distinguish a duodenal ulcer
from a gastric ulcer
can also be associated with postprandial belching, epigastric fullness,
early satiation, fatty food intolerance, nausea, and occasional vomiting

Peptic ulcer disease(2)