Dyspepsia Totally Explained

Everything about Dyspepsia totally explained

Dyspepsia (from the Greek "δυς-" (Dys-), meaning hard or difficult, and "πέψη" (Pepse), meaning digestion) is chronic or recurrent pain or discomfort centered in the upper abdomen Discomfort, in this context, includes mild pain, upper abdominal fullness and feeling full earlier than expected with eating. It can be accompanied by bloating, belching, nausea or heartburn. Heartburn is excluded from the definition of dyspepsia in ICD 10, as it usually has a different cause and management pathway.
Many people get dyspepsia. It is often caused by lifestyle factors, such as smoking and diet, but there are some serious causes such as cancer of the stomach, peptic ulcer disease and some medications. When people have dyspepsia but no risk factors for any of the serious causes, it can be labeled undifferentiated dyspepsia and treated without further investigations. When people have been investigated for dyspepsia but no cause has been found it can be labeled as functional dyspepsia.

ALARMS Symptoms in Dyspepsia

It is essential to inquire about the following ALARMS Symptoms when assessing dyspepsia

Anaemia
Loss of Weight
Anorexia
Recent onset of progressive symptoms
Melaena or haematemesis
Swallowing difficulties

Investigation of dyspepsia

People under 55 years, without ALARM Symptoms, can be treated without investigation. People over 55 years with recent onset dyspepsia or those with ALARM Symptoms should be urgently investigated by Upper Gastrointestinal Endoscopy. This will rule out peptic ulcer disease, medication related ulceration, malignancy and other rarer causes.
People under the age of 55 years with no alarm features don't need OGD but are considered for investigation for peptic ulcer disease caused by Helicobacter pylori infection. Investigation for H.pylori infection is usually performed when there's a moderate to high prevalence of this infection in the local community or the person with dyspepsia has other risk factors for H. pylori infection, related for example to ethnicity or immigration from a high-prevalence area. If infection is confirmed it can usually be eradicated by medication.
Medication related dyspepsia is usually related to Non-Steroidal Anti-inflammatory Drugs (NSAIDs) and can be complicated by bleeding or ulceration with perforation of stomach wall.

Treatment of Functional Dyspepsia and Undifferentiated Dyspepsia

Functional and undifferentiated dyspepsia have similar treatments. Decisions around the use of drug therapy are difficult because trials included heartburn in the definition of dyspepsia. This led to the results favoring proton pump inhibitors (PPIs), which are questionably effective for the treatment of heartburn.
   Traditional therapies used for this diagnosis include lifestyle modification, antacids, H2-receptor antagonists (H2-RAs), prokinetic agents, and antiflatulents. It has been noted that one of the most frustrating aspects of treating functional dyspepsia is that these traditional agents have been shown to have little or no efficacy.
   Antacids and sucralfate were found to be no better than placebo in a literature review. H2-RAs have been shown to have marked benefit in poor quality trials (30% relative risk reduction due to serious adverse events such as torsades¬, and publication bias has been cited as a potential partial explanation for such a high benefit. This German-made phytopharmaceutical was found to be equivalent to cisapride and significantly superior to metochlopramide at reducing the symptoms of functional dyspepsia over a four week period. Retrospective surveillance of 40,961 children (12 years and under) found no serious side-effects.
   Currently, PPIs are, depending on the specific drug, FDA indicated for erosive esophagitis, gastroesophageal reflux disease (GERD), Zollinger-Ellison syndrome, eradication of H. pylori, duodenal and gastric ulcers, and NSAID-induced ulcer healing and prevention, but not functional dyspepsia. There are, however, evidence-based guidelines and literature that evaluate the use of PPIs for this indication. A helpful chart summarizing the major trials is available from the functional dyspepsia guidelines published in the World Journal of Gastroenterology in 2006. The study evaluated these agents in patients at 4 weeks and 6 months and noted that omeprazole had a significantly better response at 6 months (31%) than cisapride (13%) or placebo (14%) (p = 0.001) while it was just above the cutoff for being statistically significantly better than ranitidine (21%) (p = 0.053). Omeprazole also showed a significant increase in quality of life scores over the other agents and placebo in all but one category measured (p = 0.01 to 0.05).
   The ENCORE study, which was a follow-up of patients from the OPERA study, showed responders to omeprazole therapy had fewer clinic visits than non-responders (1.5 vs 2.0) over a three month period (p < 0.001).

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