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| DYSPEPSIA |
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Dr Gill Watermeyer E23, GIT clinic Groote Schuur Hospital
Dyspepsia is defined as “chronic or recurrent pain or discomfort, centred in
the upper abdomen”. 1 It is an extremely common symptom with an annual
prevalence approaching 25% in the West.
The exact incidence in South Africa is not known, but this common symptom is
responsible for the majority of referrals to specialist gastrointestinal clinics. In clinical
practice dyspepsia frequently overlaps with symptoms of gastro-oesophageal reflux
disease (GORD). Dyspepsia can be sub-classified into 3 groups highlighting
the overlap with other symptoms.
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Few patients fit neatly into these specific
categories:
1. Ulcer-like dyspepsia: pain predominant
2. Dysmotility-like dyspepsia: bloating, early satiety
3. Reflux-like dyspepsia: heartburn and regurgitation |
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There is a wide differential diagnosis of dyspepsia. After extensive
investigation up to 60% of patients with this symptom will have no obvious
pathology identified, and are labelled as “functional dyspepsia” or
non-ulcer dyspepsia (NUD). This sub-group of patients often have a long
history of dyspepsia and typically lack any warning signs or symptoms of
sinister GIT pathology. The pathophysiology of NUD remains unclear but may
relate to disordered visceral sensation in the upper gastrointestinal tract.
NUD frequently overlaps with other functional bowel disorders such as
irritable bowel syndrome.
The initial approach to the patient with dyspepsia begins with a detailed
history and examination. Of paramount importance is to determine if the
patient has any alarm features. The presence of any of these is an
indication for referral for endoscopy at the earliest opportunity, to
exclude peptic ulcer disease or gastric malignancy.
In the absence of any alarm features it is reasonable to give patients an
empiric trial of acid-suppressing medication (either a Proton-pump inhibitor
or an H2 receptor antagonist) for 4 to 8 weeks. Patients who remain
symptomatic or develop recurrent symptoms despite therapy should then be
referred for endoscopy.
More than 50% of individuals across the globe are chronically infected with
the bacterium Helicobacter pylori. Several international guidelines
recommend a “test and treat approach” for Helicobacter pylori in patients
with uninvestigated dyspepsia. Endoscopy is reserved for patients who have
persistent symptoms after completion of this treatment.
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| Differential diagnosis of Dyspepsia |
Alarm feature in patients with Dyspepsia |
1. GIT related:
a. PUD (10%)
b. GORD (10%)
c. Gastritis
d. Gastroparesis
e. Cancer (<2%)
2. Drugs:
a. NSAIDS
b. Salicylates
c. Ethanol
d. Corticosteroids
3. Pancreatic and biliary disorders
a. Gallstones
b. Chronic pancreatitis
c. Pancreatic cancer
4. Non-ulcer dyspepsia
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1. >55 years of age (new onset)
2. NSAID or salicylate use
3. GIT bleeding
4. significant weight loss
5. persistent vomiting
6. anaemia
7. abdominal mass or lymphadenopathy
8. dysphagia or odynophagia
9. family history of upper GIT cancer
10. jaundice
References
American Gastroenterology Association Technical Review on the evaluation of
Dyspepsia.
Gastroenterology 2005;129:1756-1780
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