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dyspepsia (indigestion)

A constellation of symptoms alone or in various combinations as outlined under clinical manifestations. Etiology: 1) generally occursas a consequence of delayed gastric emptying time 2) idiopathic (functional dyspepsia) 3) mechanical obstruction a) inflammation & edema with secondary scarring b) tumors in pyloric region c) Crohn's disease involving the stomach or duodenum d) idiopathic hypertrophic pyloric stenosis 4) non obstructive processes - cholecystitis - pancreatitis - hepatitis - appendicitis - peritonitis - gastroenteritis - peptic ulcer disease - sepsis - uremia - vagotomy - metabolic disorders - ketoacidosis - psychosocial factors - systemic lupus erythematosus - scleroderma - hyperplastic gastritis - sarcoidosis - neoplasm outside the GI tract - congestive heart failure - pulmonary tuberculosis - paraplegia - postsurgical immobilization - electrolyte abnormalities - diabetic neuropathy - pharmaceuticals - NSAIDs - bisphophonates - antibiotics - potassium supplements 5) other [2] - GERD - esophageal cancer - gastric cancer - pancreatic cancer - H pylori - gastroparesis - celiac disease - carbohydrate malabsorption - mesenteric ischemia - abdominal wall pain - alcohol - pregnancy Epidemiology: 1) prevalence is 20-30% 2) annual incidence of 1% Clinical manifestations: 1) upper abdominal pain or discomfort 2) postprandial fullness 3) abdominal bloating 4) belching 5) early satiety 6) anorexia 7) nausea/vomiting 8) pyrosis, epigastric burning (heartburn) 9) 'red flags' - anemia or occult gastrointestinal bleeding - dysphagia - weight loss - new onset dyspepsia age > 55 years 10) also see alarm features of dyspepsia Laboratory: - testing for Helicobacter pylori [11] - Helicobacter pylori antigen in stool - carbon-labeled urea breath test Special laboratory: 1) electrocardiogram prior to upper GI endoscopy (EGD) if acute dyspepsia 2) esophagogastroduodenoscopy (EGD) is normal [2] a) EGD reserved for patients >= 60 years of age [2,12] - EGD not routinely necessary if patient < 60 years - consider EGD for patient < 60 years if 'red flags' present* [2] - otherwise test for & treat H pylori & give PPI [2] - EGD for patients with refractory symptoms despite empiric PPI [2] - consider EGD for immigrants for Asia, Russia, South ?America [2] b) biopsy of gastric body & antrum for H. pylori c) do not biopsy other normal-appearing mucosa [10] 3) testing for specific malabsorption syndromes if indicated * ref [12] seems to discourage EGD in patients < 60 years even if 'red flags' present [12] Radiology: 1) abdominal ultrasound 2) computed tomography (CT) 3) CT angiography if mesenteric ischemic suspected [2] Differential diagnosis: 1) functional dyspepsia a) idiopathic b) may occur concurrently with irritable bowel syndrome 2) inflammation or infection a) esophagitis b) gastritis c) duodenitis 3) peptic ulcer disease 4) gastroesophageal reflux disease (GERD) 5) gastric malignancy 6) esophageal malignancy 7) cholecystitis 8) myocardial infarction 9) pericarditis 10) pancreatitis 11) pleurisy Complications: see alarm features of dyspepsia Management: 1) life-style modification a) tobacco cessation b) weight loss/food restriction c) avoidance of eating 2-3 hours before bedtime d) alcohol avoidance e) avoidance of aggravating foods f) elevating head of bed 2) test for H pylori & treat if positive if < 60 years of age [2] - EGD for elderly > 60 years of age [2] - test & treat more cost effective [13] - higher cost, higher patient satisfaction with EGD [13] - prevalence of H pylori of only 17% suggests EGD may be appropriate regardless of age [14] 3) antacids a) absorbable CaCO3 or NaHCO3 - Tums, Titralac, Rolaids b) nonabsorbable Al(OH)3, Mg(OH)2 +/- simethicone for gas - Maalox, Mylanta, Riopan, Gelusil, Amphojel, Basajel - Camalox c) Gaviscon tablets - antacid plus algginic acid - forms a foam that floats on gastric contents - lessens effects of refluxed material into esophagus 4) H2-receptor antagonists a) cimetidine (Tagamet) b) ranitidine (Zantac) c) famotidine (Pepcid) d) nizatidine (Axid) e) roxatidine 5) proton pump inhibitors (1st line) [2,11] a) omeprazole (Prilosec) superior to ranididine [3] - BID no better than QD [2] b) lansoprazole no better than placebo [5]; effective [11] & NEJM 6) low-dose tricyclic antidepressant if symptoms do not respond to once daily proton pump inhibitor [2] 7) promotility agents a) metoclopramide (Reglan) b) delayed gastric emptying does not effect quality of life [4] 8) mucosal coating agents - sucralfate 9) specific therapies for specific etiologies a) antifungal agents for Candidiasis b) antiviral agents for Herpes & Cytomegalovirus c) Helicobacter pylori - antibiotics, bismuth, proton-pump inhibitor 10) acupuncture may be of benefit for post-prandial dyspepsia [15]

Related

alarm features of dyspepsia bloat

Specific

functional dyspepsia gastroduodenitis pyrosis (heartburn)

General

sign/symptom gastric disease esophageal disease

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 297-300
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2006, 2009, 2012, 2015, 2018, 2021. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  3. Journal Watch 25(17):140, 2005 Veldhuyzen van Zanten SJ, Chiba N, Armstrong D, Barkun A, Thomson A, Smyth S, Escobedo S, Lee J, Sinclair P. A randomized trial comparing omeprazole, ranitidine, cisapride, or placebo in helicobacter pylori negative, primary care patients with dyspepsia: the CADET-HN Study. Am J Gastroenterol. 2005 Jul;100(7):1477-88. PMID: 15984968
  4. Talley NJ, Locke GR 3rd, Lahr BD, Zinsmeister AR, Tougas G, Ligozio G, Rojavin MA, Tack J. Functional dyspepsia, delayed gastric emptying, and impaired quality of life. Gut. 2006 Jul;55(7):933-9. Epub 2005 Dec 1. PMID: 16322108
  5. Leunk WK et al, Initial treatment with lansoprasole in young dyspeptic patients with negative urea breath test result: A randomized controlled trial with 12 month follow-up. Am J Gastroenterol 2007, 102:1483 PMID: 17593161
  6. Prescriber's Letter 17(12): 2010 GUIDELINES: Evidence-based recommendations for short- and long-term management of uninvestigated dyspepsia in primary care: An Update of the Canadian Dyspepsia Working Group (CanDys) clinical management tool Detail-Document#: 261204 (subscription needed) http://www.prescribersletter.com
  7. Camilleri M, Tack JF. Current medical treatments of dyspepsia and irritable bowel syndrome. Gastroenterol Clin North Am. 2010 Sep;39(3):481-93 PMID: 20951913
  8. Talley NJ, Ford AC Functional Dyspepsia. N Engl J Med 2015; 373:1853-1863. November 5, 2015 PMID: 26535514 http://www.nejm.org/doi/full/10.1056/NEJMra1501505
  9. Graham DY, Rugge M. Clinical practice: diagnosis and evaluation of dyspepsia. J Clin Gastroenterol. 2010 Mar;44(3):167-72 PMID: 20009950
  10. Yang YX, Brill J, Krishnan P et al American Gastroenterological Association Institute Guideline on the Role of Upper Gastrointestinal Biopsy to Evaluate Dyspepsia in the Adult Patient in the Absence of Visible Mucosal Lesions. Gastroenterology. 2015 Oct;149(4):1082-7 PMID: 26283143
  11. Moayyedi PM, Lacy BE, Andrews CN et al. ACG and CAG clinical guideline: Management of dyspepsia. Am J Gastroenterol 2017 Jun 20; PMID: 28631728 https://www.nature.com/ajg/journal/vaop/ncurrent/full/ajg2017154a.html
  12. Feld L, Cifu AS. Management of Dyspepsia JAMA. 2018;319(17):1816-1817. May 1, 2018 PMID: 29715342 https://jamanetwork.com/journals/jama/fullarticle/2679926
  13. Eusebi LH et al Effectiveness of management strategies for uninvestigated dyspepsia: systematic review and network meta-analysis. BMJ 2019;367:l6483 PMID: 31826881 Free Article https://www.bmj.com/content/367/bmj.l6483
  14. Sonnenberg A, Turner KO, Genta RM. Low prevalence of Helicobacter pylori-positive peptic ulcers in private outpatient endoscopy centers in the United States. Am J Gastroenterol 2020 Feb; 115:244 PMID: 31972622 https://journals.lww.com/ajg/Abstract/2020/02000/Low_Prevalence_of_Helicobacter_pylori_Positive.18.aspx
  15. Yang JW, Wang LQ, Zou X et al. Effect of acupuncture for postprandial distress syndrome: A randomized clinical trial. Ann Intern Med 2020 May 12; [e-pub]. PMID: 32422066 https://www.acpjournals.org/doi/10.7326/M19-2880
  16. NIDDK: Indigestion (Dyspepsia) https://www.niddk.nih.gov/health-information/digestive-diseases/indigestion-dyspepsia - American Gastroenterological Association http://journals.elsevierhealth.com/periodicals/ygast/content/aga