IndigestionIndigestion

Encompasses N/V, heart burn, regurgitation, Encompasses N/V, heart burn, regurgitation, dyspepsiadyspepsia

Most common causes are gastroesophageal Most common causes are gastroesophageal acid reflux and functional dyspepsiaacid reflux and functional dyspepsia

-LES tone reduced: caffeine, tobacco, ethanol-LES tone reduced: caffeine, tobacco, ethanol

-nitrate, CaCB, theophylline, progesterone-nitrate, CaCB, theophylline, progesterone

Gastric motor dysfunctionGastric motor dysfunctionImpaired gastric fundus relaxation after eating may underlie selected dyspeptic symptoms like Impaired gastric fundus relaxation after eating may underlie selected dyspeptic symptoms like

bloating, nausea, and early satiety.bloating, nausea, and early satiety.

Visceral afferent hypersensitivityVisceral afferent hypersensitivity OtherOther-H. pylori, Psychogenic-H. pylori, Psychogenic

Gastroesophageal RefluxGastroesophageal Reflux

Gastroesophageal reflux can result from a variety of physiologic defects. Gastroesophageal reflux can result from a variety of physiologic defects. Reduced lower esophageal sphincter (LES) tone is an important cause of Reduced lower esophageal sphincter (LES) tone is an important cause of

reflux in scleroderma and pregnancyreflux in scleroderma and pregnancy Many individuals exhibit frequent Many individuals exhibit frequent transient LES relaxations transient LES relaxations during which during which

acid or nonacidic fluid bathes the esophagus. acid or nonacidic fluid bathes the esophagus. Overeating and aerophagia can transiently Overeating and aerophagia can transiently override the barrier function override the barrier function of of

the LES, whereas impaired esophageal body motility and reduced salivary the LES, whereas impaired esophageal body motility and reduced salivary secretion prolong fluid exposure. secretion prolong fluid exposure.

The role of The role of hiatal hernias hiatal hernias is controversial—although most reflux patients is controversial—although most reflux patients exhibit hiatal hernias, most individuals with hiatal hernias do not have exhibit hiatal hernias, most individuals with hiatal hernias do not have excess heartburn.excess heartburn.

DDx.DDx.

GERDGERD Functional dyspepsiaFunctional dyspepsia (postprandial fullness, early satiety, (postprandial fullness, early satiety,

epigastric pain or burning)epigastric pain or burning)

Ulcer dis. Ulcer dis. 15–25% of cases of dyspepsia stem from ulcers of the stomach or duodenum15–25% of cases of dyspepsia stem from ulcers of the stomach or duodenum

MalignancyMalignancy Biliary colicBiliary colic Extra peritoneal: CHF, TBExtra peritoneal: CHF, TB

Functional DyspepsiaFunctional Dyspepsia

Nearly 25% of the populace has dyspepsia at least 6 times yearlyNearly 25% of the populace has dyspepsia at least 6 times yearly 10–20% of these individuals present to physicians10–20% of these individuals present to physicians Functional dyspepsia, the cause of symptoms in 60% of dyspeptic patients, Functional dyspepsia, the cause of symptoms in 60% of dyspeptic patients,

is defined as 3 months of bothersome postprandial fullness, early satiety, or is defined as 3 months of bothersome postprandial fullness, early satiety, or epigastric pain or burning with symptom onset at least 6 months before epigastric pain or burning with symptom onset at least 6 months before diagnosis in the absence of organic cause. diagnosis in the absence of organic cause.

Most cases follow a benign course, but some patients with Most cases follow a benign course, but some patients with H. pyloriH. pylori infection or on nonsteroidal anti-inflammatory drugs (NSAIDs) develop infection or on nonsteroidal anti-inflammatory drugs (NSAIDs) develop ulcers. ulcers.

As with idiopathic gastroparesis, some cases of functional dyspepsia result As with idiopathic gastroparesis, some cases of functional dyspepsia result from prior gastrointestinal infection.from prior gastrointestinal infection.

Alarming featureAlarming feature

Unexplained weight lossUnexplained weight loss Recurrent vomitingRecurrent vomiting Occult organ GI bleedingOccult organ GI bleeding JaundiceJaundice Palpable mass or LAPPalpable mass or LAP OdynophagiaOdynophagia Family history of GI malignancyFamily history of GI malignancy

Diagnostic testDiagnostic test

Endoscopy: atypical symptoms, no response to Endoscopy: atypical symptoms, no response to acid-suppressing Tx., alarm factors, >55 Y, >50 acid-suppressing Tx., alarm factors, >55 Y, >50 y in duration, (NSAID), y in duration, (NSAID),

Heartburn <5 years in duration, especially in Heartburn <5 years in duration, especially in patients <50 years old, endoscopy is patients <50 years old, endoscopy is recommended to screen for Barrett's metaplasia recommended to screen for Barrett's metaplasia

Ambulatory PH testing in refractory to Tx.Ambulatory PH testing in refractory to Tx. Bernstein testBernstein test