Dyspepsia

What is dyspepsia?

Dyspepsia is defined as one or more of the following symptoms: epigastric pain, fullness after eating or bloating, early satiety, or burning sensation. Some people also have nausea, vomiting, lack of appetite, or weight loss. These are common symptoms with an extensive differential diagnosis. It occurs in at least 20% of the population, but most affected people don’t seek medical care. Although dyspepsia does not affect survival, it substantially affects quality of life and health care costs.

What causes dyspepsia?

Approximately 25% or patients with dyspepsia are found to have an underlying organic disease. However, approximately 75% of patients have functional (without identifiable cause) dyspepsia after thorough evaluation including direct visualization of the stomach lining through upper gastrointestinal endoscopy.

• Dyspepsia secondary to an organic cause

The most common organic cause of underlying dyspeptic symptoms are peptic ulcer disease (PUD) and gastroesophageal reflux disease (GERD). Cancer or tumors of the upper gastrointestinal tract and celiac disease are less common but important organic causes of the symptoms. Intolerance to certain foods (spices, coffee, or alcohol) or drugs (iron, antibiotics, narcotics, NSAIDs) can also manifest as dyspeptic symptoms probably secondary to sensorimotor response to food and through direct gastric mucosal injury, facilitation of reflux, or idiosyncratic mechanisms.

• Functional dyspepsia

The exact cause of functional dyspepsia is not clearly understood. Several factors may be involved as follows:

• Motor nerve problems. Digesting food involves a series of events involving coordinated muscle movements of the digestive tract. Problems such as slow emptying of the stomach contents can produce fullness, nausea, bloating, or vomiting.

• Pain sensitivity. The stomach normally stretches as we eat to hold more food, however, some people are sensitive to this stretching and feel pain
• Infection. Helicobacter pylori (H. pylori) is a bacterial infection of the stomach than can lead to inflammation (gastritis) or ulcers. There is evidence between H. pylori infection and functional dyspepsia. However, not all people with H. pylori infection have functional dyspepsia.
• Psychological and social factors. People with functional dyspepsia often have mood problems like anxiety or depression. Treatment of the underlying behavioral problem can improve symptoms of abdominal pain.

How do I know what type of dyspepsia do I have?

To help determine if you might have an organic cause of symptoms for dyspepsia or a functional type of dyspepsia, your doctor will ask you certain questions regarding your symptom and perform a physical examination. A detailed history will include description of the pain, relation to food intake, intake of medications, associated symptoms (such as weight loss, decreased appetite, vomiting, difficulty or painful swallowing, bloody or black tarry stools). Your history will also include your family history (especially cancer) and vices (smoking or drinking alcohol). These questions are directed towards eliciting the alarm features that would require more invasive evaluation such as an EGD. Physical examination might not reveal helpful findings aside from pain over the epigastrium on palpation. Advanced stages of an underlying cancer or tumor in the stomach or intestines might be obvious by the presence of a palpable abdominal mass, palpable lymph nodes, pallor from anemia secondary to bleeding, or muscle wasting from weight loss. Once a thorough evaluation to rule out an organic cause for the dyspepsia is performed, a diagnosis of functional dyspepsia can be made.

When do I need to undergo an esophagogastroduodenoscopy (EGD)?

International guidelines recommend an EGD for patients 60 years old or older or if you have serious symptoms such as repeated vomiting, weight loss, difficulty swallowing. The risk of cancer is predominantly related to age and so, experts recommend the procedure in the age group for it to be cost-effective. If you are younger than 60 years old or you don’t have serious symptoms or family history of gastrointestinal cancer, you might be offered other types of non-invasive testing which might be a breath, blood, or stool test for H. pylori. You might also be started on medications without the need for initial tests or procedure which most of the time already relieves the symptoms. If your symptoms do not get better within four to eight weeks of medications, your doctor might recommend further testing, including an EGD.

How is dyspepsia treated?

Dyspepsia can be managed medically using acid-reducing medications such as proton pump inhibitors (omeprazole, esomeprazole, lansoprazole, dexlansoprazole, pantoprazole, rabeprazole) which are more likely to improve pain than any other types of acid reducers. Histamine blockers (famotidine, ranitidine, cimetidine) are alternative acid inhibitors that might help some people. Antacids might relieve those patients with organic cause of dyspepsia but not those with functional dyspepsia.

If you are diagnosed with H. pylori infection, treatment with an antibiotic regimen (usually amoxicillin, clarithromycin, or metronidazole in combinations) for two weeks against the bacteria can help reduce symptoms.

Nonprescription pain medications or NSAIDs (such as aspirin, ibuprofen, naproxen) are not usually helpful and can actually worsen stomach upset and may induce ulcers in the lining of the stomach.

As mentioned, anxiety, depression or mood disorders might cause the dyspeptic symptoms and these can be treated using low dose antidepressants known as tricyclic antidepressants (TCAs).

Nonpharmacological means to manage dyspepsia include diet modification. This include avoiding fatty foods (which can slow the emptying of the stomach), eating small, frequent meals (instead of three large meals in a day, you may eat five or six small meals), avoiding foods that aggravate your symptom, and avoiding too much alcohol intake.

For more information on dyspepsia, consult your physician.