Who hasn’t had tummy pains at one time or another? Did you
know that the soft drink Pepsi was named Pepsi-Cola after dyspepsia and kola
nuts used in the ingredient? It had been designed as a drink that aided
digestion. With that in mind, today we talk about this common condition.
Formally defined per Rome III criteria, dyspepsia is one or
more of the following symptoms: postprandial fullness, early satiation,
epigastric pain, or burning. It can be caused by a multitude of diseases such
as esophagitis, GERD, peptic ulcer, drugs, or stomach cancer; but overall
functional (idiopathic) disease is most common. In the history, it’s important
to note the age, associated symptoms (such as weight loss and vomiting), and
drugs (especially NSAIDs); other red flags, raising suspicion of gastric
malignancy, include progressive dysphagia, odynophagia, unexplained anemia or
iron deficiency, hematemesis, jaundice, palpable abdominal mass or
lymphadenopathy, family history of upper GI cancer, or previous gastric surgery.
On physical examination, look for adenopathy, abdominal
mass/organomegaly, Carnett’s sign (if pain is due to abdominal wall muscle
problem, then the pain will increase during muscle contraction, such as during
a sit-up).
The laboratory tests will vary depending on specific
associated symptoms and risk factors of the patient, but generally they will
include CBC, electrolytes, liver enzymes, glucose, amylase, albumin, calcium,
protein electrophoresis, thyroid function tests, and H. pylori serology.
Empiric trial of anti-secretory drug therapy, non-invasive testing for H.
pylori infection, or endoscopy referral is usually considered while waiting for
lab results. BARIUM RADIOGRAPHY IS OUTDATED.
Because dyspepsia is such a broad symptom, let’s go through
some particular scenarios—different circumstances will require the medical
practitioner to tailor physical examination, laboratory testing, and the
management to the needs of different patients.
Case 1: A 36-year-old woman who complains of abdominal
discomfort after eating meals.
Q: What is the likely differential diagnosis?
A: The likely differentials are functional dyspepsia and
peptic ulcer disease. The patient is too young for gastric outlet obstruction
or carcinoma of the stomach.
Q: What information in the history supports the diagnosis?
A: Non-ulcer dyspepsia is a functional disorder often
exacerbated by stress. Stressors should be investigated. If the patient also
experience early satiety then functional dyspepsia is the most likely
diagnosis. If there is persistent vomiting, then obstructive cases or cancer
should be considered.
Q: What additional features in the history would you seek to
support a particular diagnosis?
A: The patient’s past medical history would definitely shed
light on the presentation (such as a history of H. pylori infection and
treatment); ethnic background and family history should also be
considered—either of which can increase the risk of peptic ulcer disease.
Exposure to NSAIDs should be inquired, as well as history of alcohol and
cigarette use.
Q: What clinical examination would you perform? Why?
A: A full examination should be performed, looking
specifically for lymphadenopathy and epigastric mass. If these don’t exist,
then the differentials of functional dyspepsia and peptic ulcer disease can
remain most likely.
Q: What investigations would be most helpful? Why?
A: Non-invasive tests for H. pylori would be most helpful,
as peptic ulcer disease is strongly associated.
Q: What treatment options are appropriate?
A: Triple therapy for H pylori eradication if the patient
tests positive for H pylori. Anti-secretory therapy can be tried. Domperidone
may also be prescribed to aid gastric emptying by increasing its motility.
Case 2: A 65-year-old man presents with epigastric pain,
vomiting, and weight loss.
Q: What is the likely differential diagnosis?
A: The likely differential diagnoses are pyloric stenosis
secondary to H. pylori-associated peptic ulcer disease, carcinoma of the
stomach, rare duodenal tumors, polyps, Crohn’s disease, and dysmotility
syndrome.
Q: What in the given history supports the diagnosis?
A: Vomiting suggests gastric outlet obstruction. The
patient’s age is a risk factor for malignancy.
Q: What additional features in the history would you seek to
support a particular diagnosis?
A: The patient’s past medical history and drug history would
be very helpful. If the patient is previously using OTC remedies for
indigestion, untreated chronic peptic ulcer may be most likely. Duodenal Crohn’s
disease and polyps would probably result in recurrent/chronic symptoms.
Dysmotility syndrome is rare, except in those with diabetes.
Q: What clinical examination would you perform? Why?
A: A full examination looking for signs of anemia,
lymphadenopathy, epigastric mass, and irregular liver edge should be performed.
Q: What investigations would be most helpful? Why?
A: Endoscopy or barium meal should be performed urgently; CT
of the upper abdomen should be considered. If these investigations are negative,
gastric emptying studies should be performed.
Q: What treatment options are appropriate?
A: If the patient is found to have a benign peptic
stricture, endoscopic balloon dilatation should be considered; if the patient
has duodenal obstruction, a gastroenterostomy should be performed. If the
patient has carcinoma, staging should be performed and surgery considered. If
the patient has dysmotility syndrome, Domperidone or erythromycin should be
prescribed.
