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General
Common symptom with extensive differential diagnosis and heterogenous pathophysiology.
Epidemiology
25% of general population/year 25% with evidence of organic cause
75% without
Symptoms
Chronic or recurrent pain or discomfort in the upper abdomen
Ulcer-like or acid dyspepsia
Burning pain, epigastric huger-like pain
Relief with food/antacids/antisecretory agents
Food-provoked dyspepsia or indigestion
Postprandial epigastric discomfort and fullness
Belching, early satiety, nausea, occasional vomiting
Reflux-like dyspepsia
Rome III Criteria
Postprandial fullness
Early satiation
Inability to finish a normal sized meal
Epigastric Pain or Burning
Organic dyspepsia
PUD
GERD
GE malignancy
Biliary
Meds (NSAIDs)
Other Celiac / chronic pancreatitis
Infiltrative dz (Eosinophilic gastritis / crohn’s / sarcoid)
DM radiculopathy / hypercalcemia / heavy metal toxicity
Hepatoma / steatohepatitis / mesenteric ischemia
PUD
A spectrum from gastritis to ulceration complicated by bleeding, pain and perforation.
Poor correlation with reported symptoms and EGD findings
Includes Duodenal and gastric ulcers
Commonly due to H.Pylori and/or NSAID, tobacco, EtOH
Treatment = H.pylori eradication and removal of inciting agents
Duodenal vs. Gastric Ulcers
Gastric ulcer Worse with meals
Poor response to antacids/otcs
Duodenal ulcer Pain when acid is secreted in absence of a food buffer
Improves with meals, alkali, antisecretory agents
Worse 3-5 hours after a meal
Worse at night between 11pm – 2am
Maximal circadian stimulation of acid secretion
GERD
Some degree of reflux is physiologic
Montreal classification: A condition that develops when reflux of stomach contents
causes troublesome symptoms and/or complications
Prevalence= 10-20% in western world, <5% in Asia
Heartburn = retrosternal burning, most common
Regurgitation = gastric content into mouth/throat
Dysphagia = common in longstanding GERD due to Reflux esophagitis
Stricture
More GERD
Globus sensation Almost constant perception of a lump in the throat
Water brash (foaming at the mouth) Rare hypersalivation caused by reflux
Chest pain Mimics angina, typically squeezing/burning
Substernally with radiation to back/neck/jaw/arms
Lasts minutes to hours
Spontaneous resolution with antacids
Occurs after meals, awakens from sleep
Worse with emotional stress
GE Malignancy
Uncommon cause of chronic dyspepsia in Western Hemisphere
More common in Asian, Hispanic, Afro-Caribbean populations
Increases with age
Epigastric pain vague, mild in early disease – more severe and constant with progression
Weight loss from insufficient caloric intake
Dysphagia related to esophageal or proximal gastric malignancy
NSAIDs
Direct effect Ionization upon absorption into gastric mucosa
Topical epithelial injury
Systemic effect Inhibition of GI mucosal COX activity (COX1)
Decreased mucosal prostaglandin protection
History
Association of symptoms with meals
Heartburn / regurgitation / cough
NSAID use ??
Radiation to back, personal/fhx of pancreatitis
Significant weight loss / anorexia / vomiting / dysphagia / odynophagia / fhx of GI malignancy
Severe episodic epigastric / RUQ pain lasting more than one hour
Exam
Usually normal except for epigastric tenderness
Jaundice, pallor, ascites, muscle wasting
Palpable abdominal mass
Palpable lymphadenopathy L supraclavicular = Virchow’s node
Periumbilical = Sister Mary Joseph’s node
Carnett sign Double straight leg raise or head raise while supine
Finger presses point of tenderness
+ test = Increased pain with muscle tensing
Labs
CBC
Electrolytes + Calcium
Hepatic Function Panel
Alarm Features
Age > 55 yrs with new-onset dyspepsia
FHx of upper GI malignancy
Unintended weight loss
GI bleeding
Progressive dysphagia
Odynophagia (painful swallowing)
Unexplained Iron deficiency
Persistent vomiting
Palpable mass or node
Jaundice
Diagnosis: Pt with alarm features
Upper endoscopy within two weeks with stomach biopsy for H.pylori
Yield of EGD increases with age
Per meta-analysis of 9 studies, 5389 pts:
6% erosive esophagitis
8% PUD
If normal, most will have functional dyspepsia
Further evaluation warranted if alarm features
Age cutoff controversial AGA suggests 60-65 yrs
45-50 with Asian, Hispanic, Afro-Caribbean descent
Reflux Esophagitis
Barrett’s Esophagus
Gastric Ulcer
Esophageal Ulcer
Diagnosis: No alarm features
Test and treat for H.pylori If local h.pylori prevalence >10 %
Empiric PPI / H2blocker If local h.pylori presence <5%
Test and Treat for H.Pylori
Urea breath test or stool Ag
Serologic testing should not be used
NNT is 14
H. Pylori eradication
Quadruple Therapy
Triple therapy + bismuth 525mg 4xdaily for 10-14 days
With clarithromycin/metronidazole resistance > 15%
With recent/repeated exposure to clarithro/flagyl
Triple Therapy
PPI (multiple options)
Omeprazole 20mg bid
Pantoprazole 40mg bid
Amoxicillin: 1g BID 7-14 days
Clarithromycin: 500mg BID 7-14 days
Alternative antibiotics
Doxycycline 100mg bid / Flagyl 250mg 4xdaily
Anti-Secretory Therapy
PPIs > H2 blockers PPI (Omeprazole / pantoprazole / lansoprazole )
Irreversibly binds/inhibits H/K atp pump on parietal cells
Only effective in active parietal cells
Must be taken 30-60 minutes before meals
Twice daily dosing if :
Failed standard therapy
Large gastric ulcer
H2 blockers (Ranitidine / cimetidine / famotidine)
Inhibit Histamine H2 receptors on parietal cells
Functional Dyspepsia
Presence of one or more: Postprandial fullness
Early satiation
Epigastric pain/burning
Negative diagnostic evaluation for organic disease
Symptoms for last three months
Onset more than 6 months previously
Pathophysiology
Gastric motility / compliance
Delayed gastric emptying (30%)
rapid gastric emptying (10%)
Visceral hypersensitivity
Increased pain with normal gastric stretching/compliance
Independent of delayed gastric emptying
H.pylori infection
Unclear mechanism, ?smooth muscle dysfunction 2/2 inflammatory modulation of enteric nervous system
Altered gut microbiome
Symptoms more likely after episode of AGE
Psychosocial dysfunction
Association with GAD, somatization, Major Depression
Higher prevalence in pts with self-reported hx of child abuse
Treatment
H.Pylori test and treat
Tricyclic anti-depressants If persistent symptoms despite PPI x8wks
PPI / H2 blockers
Metoclopramide (Prokinetic) If failed above therapy
5-10 mg TID half hour before meals and at night x4wks
References
Uptodate Approach to the Adult with Dyspepsia
Functional dyspepsia in adults
Clinical manifestations of peptic ulcer disease
Clinical manifestations and diagnosis of GERD in adults
Clinical features,diagnosis,staging of gastric cancer
Epidemiology, pathobiology and clinical manifestations of esophageal cancer
Differential diagnosis of abdominal pain in adults
AGA AGA medical position statement: evaluation of dyspepsia –
Gastroenterology, 2005
AFP Evaluation and management of non-ulcer dyspepsia
H.Pylori Infection