Dyspepsia overview
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Dyspepsia (from the Greek "δυς-" (Dys-), meaning hard or difficult, and "πέψη" (Pepse), meaning digestion) is chronic or recurrent pain or discomfort centered in the upper abdomen [1] Discomfort, in this context, includes mild pain, upper abdominal fullness and feeling full earlier than expected with eating. It can be accompanied by bloating, belching, nausea or heartburn. Heartburn is excluded from the definition of dyspesia in ICD 10, as it usually has a different cause and management pathway. Many people get dyspepsia. It is often caused by lifestyle factors, such as smoking and diet, but there are some serious causes such as cancer of the stomach, peptic ulcer disease and some medications. When people have dyspepsia but no risk factors for any of the serious causes, it can be labeled undifferentiated dyspepsia and treated without further investigations. When people have been investigated for dyspepsia but no cause has been found it can be labeled as functional dyspepsia.
Historical Perspective
The current understanding of the pathogenesis of dyspepsia began with the first description of gastric ulcer disease in 1799. The term was first used in its current form in 1916 by Walter Alvarez.
Classification
Dyspepsia is broadly classified into two major types: ulcer and non-ulcer dyspepsia. The latter is also known as functional dyspepsia.
Pathophysiology
The symptoms of functional dyspepsia are directly caused by two major pathophysiological abnormalities abnormal gastric motility and visceral hypersensitivity.These mechanisms occur in patients who have acquired excessive responsiveness to stress as a result of the environment during early life, genetic abnormalities, residual inflammation after gastrointestinal infections, or other causes, with the process modified by factors including psychophysiological abnormalities, abnormal secretion of gastric acid, Helicobacter pylori infection, diet, and lifestyle.
Causes
Life threatening causes of dyspepsia include coronary disease and ischemic bowel disease. Other common causes of dyspepsia include gastroesophageal reflux, gastritis, lactose intolerance, and peptic ulcer.
Differentiating dyspepsia from Other Diseases
Dyspepsia must be differentiated from other diseases that presents with epigastric pain such as gastritis, gastroesophageal reflux disease, acute pancreatitis, primary biliary cirrhosis, cholelithiasis, gastric outlet syndrome, myocardial infarction, pleural empyemae appendicitis
Epidemiology and Demographics
The incidence of new cases of H. pylori infection each year ranges from 3,000 to 10,000 per 100,000 individuals in developing countries. It has been observed that with advancing age, the incidence of H. pylori infection increases. In united states, 20% of adolescents are infected with H. pylori when compared to 90% by 5 years of age in the developing countries. In United States, H. pylori infection associated gastritis is more common in African Americans (54%), Hispanics (52%), and the elderly compared to Whites (21%). In acute gastritis, females are usually more affected than men. In H. pylori infection associated gastritis, males are more commonly affected than females. The incidence rates of H. pylori infection are high in Japan, Columbia, Costa Rica and China, and comparatively low in the United States. H. pylori infection is common in Southern and Eastern Europe, Mexico, South America, Africa, most Asian countries, and aboriginal people in North America.
Risk Factors
The secondary prevention strategies for gastritis following H. pylori infection to prevent recurrence of peptic ulcer disease and gastric cancer include the use of antibiotics to prevent recurrence of infection and the post-treatment confirmation of H. pylori eradication after treatment using diagnostic tests.
Screening
There is insufficient evidence to recommend routine screening for Dyspepsia.
Natural History, Complications, and Prognosis
Natural History
Dyspepsia usually persists throughout life and the chance of spontaneous healing is rare. Dyspepsia is most commonly associated with Helicobacter pylori infection. Increase in the prevalence of dyspepsia is attributed to the increasing age and the onset varies among different ethnicities. The increased risk of developing duodenal and peptic ulcers have been observed in individuals with persistent dyspepsia.
Complications
Dyspepsia is associated with complications such as peptic ulcers, anemia due to gastritis, stomach cancer, vitamin B12 deficiency, pernicious anemia.
Prognosis
Functional dyspepsia is a long-lasting disorder with an excellent prognosis regardless of H. pylori infection.
Diagnosis
History and Symptoms
The history and symptoms of dyspepsia are as follows: pain or a burning feeling in the upper portion of the stomach, nausea, bloating, sometimes uncontrollable burping, heartburn, fever, metallic taste, rumbling in the stomach, sense of fullness after eating, feeling as though something is lodged in the esophagus, pain and discomfort at the xiphoid region, sudden chills, comparable to those felt during fevers
Physical Examination
Patients with dyspepsia may appear pale. Some patients may appear fatigued and in distress, is associated with abdominal pain. Vital signs generally appear to be normal. When associated with gastrointestinal bleed, vital signs include tachycardia. Pallor may observed in patients presenting with melena and hematemesis. On examination of the eyes, conjunctival pallor may be observed. Halitosis may be observed in case of chronic gastritis. Chest tenderness may be present on palpation in case of Helicobacter pylori infection associated gastritis. Epigastric tenderness may be present. Gastritis associated with gastric ulcers may result in blood loss and the stool test may be guaiac-positive.
Laboratory Findings
There is no specific diagnostic laboratory test for dyspepsia but in the patient with the history of dyspepsia, the laboratory test is used to rule out bleeding and to document the status of eradication therapy and to test refractory ulcers
Imaging Findings
Esophagogastroduodenoscopy
People without risk factors for serious causes of dyspepsia usually do not need investigation beyond an office-based clinical examination. However, people over the age of 55 years and those with alarm features are usually investigated by esophagogastroduodenoscopy (EGD or OGD in Britain). In this painless investigation the esophagus, stomach, and duodenum are examined through an endoscope passed down through the mouth. This will rule out peptic ulcer disease, medication-related ulceration, malignancy and other rarer causes.
Other Diagnostic Studies
There are no other diagnostic studies associated with dyspepsia.
Treatment
Medical Therapy
Functional and undifferentiated dyspepsia have similar treatments. Decisions around the use of drug therapy are difficult because trials included heartburn in the definition of dyspepsia. This led to the results favoring proton pump inhibitors (PPIs), which are questionably effective for the treatment of heartburn.
Surgery
Surgical intervention is not recommended for the management of dyspepsia
Prevention
Primary prevention
Effective measures for the primary prevention of dyspepsia include avoiding long-term or extended use of medications such as NSAIDs, abstinence from alcohol, smoking cessation, coffee or acidic beverages, spicy foods and avoiding stress. Inculcating healthy eating habits, exercising regularly and maintaining healthy body weight may help in avoiding dyspepsia. Effective measures for primary prevention of the H. pylori infection include hand washing (antibacterial soaps), avoid contaminated food and water, maintain proper hygiene (hand sanitizers, antiseptic washes) and avoid close contact with infected family members ( e.g., kissing, sharing eating utensils and drinking glasses).
Secondary prevention
The secondary prevention strategies for dyspepsia following H. pylori infection to prevent recurrence of peptic ulcer disease and gastric cancer include the use of antibiotics to prevent recurrence of infection and the post-treatment confirmation of H. pylori eradication after treatment using diagnostic tests.
References
- ↑ N. Talley, et al., "Guidelines for the management of dyspepsia", American Journal of Gastroenterology 100 (2005), pp. 2324-2337.