Dyspepsia/indigestion

Dyspepsia, commonly known as indigestion, is a frequent clinical presentation characterized by discomfort or pain in the upper abdomen. It’s a symptom rather than a disease and can be associated with a variety of gastrointestinal conditions.

Causes of Dyspepsia:

  • Functional Dyspepsia: The most common cause, where no obvious organic cause is found.
  • Gastroesophageal Reflux Disease (GORD): Acid reflux causing heartburn and discomfort.
  • Peptic Ulcer Disease: Ulcers in the stomach or duodenum due to Helicobacter pylori infection or NSAIDs.
  • Gastric Cancer: Less common but a significant concern, especially in older patients or those with alarm symptoms.
  • Medications: NSAIDs, aspirin, certain antibiotics, and others.
  • Gastritis: Inflammation of the stomach lining, for example from excess alcohol consumption.
  • Biliary Tract Disease: Gallstones or cholecystitis.
  • Pancreatitis: Inflammation of the pancreas.
  • Other Causes: Including gastroparesis, celiac disease, and food intolerances.

Diagnosis:

  • History:
    • Nature of discomfort (burning, gnawing), location, timing related to meals.
    • Associated symptoms like nausea, vomiting, bloating, belching.
    • Alarm features: unintended weight loss, gastrointestinal bleeding, anemia, progressive dysphagia, persistent vomiting, family history of cancer.
    • Medication history, including NSAIDs and alcohol use.
  • Physical Examination:
    • Abdominal examination to identify any masses, tenderness, or organomegaly.
    • Examination for signs of anemia or jaundice.
  • Investigations:
    • For Uncomplicated Dyspepsia (especially in younger patients without alarm features): Empirical therapy without initial investigation.
    • Upper Endoscopy: Recommended in patients over 50-55 years or with alarm features. Can detect ulcers, gastritis, cancer.
    • H. pylori Testing: Urea breath test, stool antigen test, or biopsy during endoscopy.
    • Other Tests: Blood tests (complete blood count, liver function tests), abdominal ultrasound, and gastric emptying studies for specific indications.

Differential Diagnosis (DDx):

  • GORD
  • Peptic Ulcer Disease
  • Gastric or esophageal cancer
  • Biliary tract disease
  • Irritable Bowel Syndrome (IBS)
  • Pancreatitis
  • Myocardial ischemia (especially in older patients or those with cardiac risk factors)

Management:

  • Lifestyle Modifications:
    • Dietary changes: Avoid trigger foods, eat smaller meals.
    • Reduce alcohol and caffeine intake.
    • Stop smoking.
    • Weight loss if overweight.
  • Pharmacological Treatment:
    • For H. pylori Positive: Eradication therapy (combination of antibiotics and proton pump inhibitor – PPI).
    • For GERD: PPIs or H2 receptor antagonists.
    • For Functional Dyspepsia: Prokinetic agents for motility disorders, PPIs, or low-dose antidepressants for neuropathic pain.
    • Antacids or Simethicone: For symptomatic relief.
  • Follow-Up:
    • Reassess after initial treatment.
    • Consider alternative diagnoses or referral for gastroenterology evaluation if symptoms persist.
  • Surgery:
    • Rarely required, mainly for complications like bleeding ulcers or in the case of gallstone disease.

Conclusion:

The approach to dyspepsia involves a careful evaluation to exclude serious underlying causes, treatment based on likely etiology, and re-evaluation if initial management fails. Lifestyle modifications and empirical pharmacotherapy are often effective initial strategies.