DIFFRENTIAL DIAGNOSIS

Functional dyspepsia (up to 60 percent)
2. Dyspepsia caused by structural or biochemical disease
• Peptic ulcer disease
• Gastroesophageal reflux disease (GERD)
• Biliary pain
• Chronic abdominal wall pain
• Gastric or esophageal cancer
• Gastroparesis
• Pancreatitis
• Carbohydrate malabsorption
• Medications (including potassium supplements, digitalis, iron, theophylline, oral antibiotics [especially ampillin and erythromycin], NSAIDs, corticosteroids, niacin, gemfibrozil, narcotics, colchicine, quinidine, estrogens, levodopa)
• Infiltrative diseases of the stomach (eg, Crohn's disease, sarcoidosis)
• Metabolic disturbances (hypercalcemia, hyperkalemia)
• Hepatoma
• Ischemic bowel disease
• Systemic disorders (diabetes mellitus, thyroid and parathyroid disorders, connective tissue disease)
• Intestinal parasites (Giardia, Strongyloides)
• Abdominal cancer, especially pancreatic cancer

INVESTIGATIONS


The approach to uninvestigated dyspepsia based on the best available evidence is as follows.

For patients 45 years of age and younger without alarm features [7]:
• H. pylori test and treat, followed by PPI therapy if the patient remains symptomatic or is not infected, is the management strategy of choice.
• 13C-urea breath test or stool antigen testing should be used rather than serology.
• Endoscopy is not mandatory even in patients who remain symptomatic despite this strategy, although this should be considered on a case-by-case basis.

For patients older than 45 years, and those with alarm features:
• Early endoscopy with biopsy for H. pylori is the preferred initial approach [7].
• If patient is over age 45 years, initial laboratory work should include a blood count, electrolytes, liver enzymes, calcium, and thyroid function tests [10].

Indications for endoscopy in a patient of Dyspepsia [1]:
• If anemia is present, endoscopy should be done within 7-10 days.
• If acute onset dysphagia is present, endoscopy should be done within 1 day.
• If hematemesis and/ or melena is present, endoscopy should be done within 1 day if patient is ill.
• If persistent vomiting and/or weight loss greater than 5% (involuntary) is present, endoscopy should be done within 7-10 days
• If patients 55 years of age or younger whose condition does not have worrisome features, esophagogastroduodenoscopy is recommended only if the condition does not respond to proton-pump inhibitor therapy
• If patient has dyspepsia, symptoms continuing for a month or more into treatment should prompt endoscopy regardless of initial treatment. Further evaluation may be necessary.
• If patients presenting with dyspepsia and a prior documented ulcer, refer for EGD

OTHER INVESTIGATIONS

• If patient has dyspepsia, a single contrast barium study is not an acceptable alternative.
• If patient has dyspepsia, multiphase upper gastrointestinal (UGI) studies performed by radiologists with specific training in gastrointestinal radiology are an acceptable alternative to endoscopy.
• Routine blood counts and blood chemistry determinations are commonly obtained.

Test-and-treat for H. pylori in those [12]:
• Patients with dyspepsia who originate from areas of high (>30%) H. pylori prevalence
• With present or past history of peptic ulcer
• With Mucosa-associated lymphoid tissue lymphoma
• With a family history of gastric cancer

TESTS FOR H PYLORI
H. pylori infection can be diagnosed by noninvasive methods or by endoscopic biopsy of the gastric mucosa; the selection of the appropriate test depends on the clinical setting. [13]
NON INVASIVE TESTS
Non Invasive tests includes urea breath test and stool antigen test.
• If urea breath test is to be done, it has a sensitivity and specificity of 90% but requires more patient prepration and is more expensive [14]
• The urea breath test is reliable in children over the age of six years but needs further validation in younger children.[15]
• If urea breath test is to be done, the patient drinks C13 or C14 labeled urea.
• If urea breath test is to be done, antibiotics and bismuth should be withheld for at least 4 weeks.
• If urea breath test is to be done, patient should fast for 6 hrs prior to test. Patient provides breath sample usually by blowing up a small balloon or blowing bubbles in a small bottle of collection liquid. Samples of breath are then taken between 10 and 20 minutes after the capsule is given. About 2 L of sample is collected. Breath sample is measured in a mass spectrometer rather than a scintillation counter
• . Because of its lower sensitivity and specificity, serologic testing should not be performed unless fecal antigen testing or urea breath testing is unavailable [14]
• Stool antigen test is now the non-invasive office test of choice due to its high positive likelihood ratio (LR) over serologic testing.
• Stool antigen tests for H. pylori provide an alternative to the urea breath test, with a sensitivity of 89 to 98 percent and a specificity of over 90 percent [14]
• Stool tests perform well in children of all ages and may become the noninvasive method of choice for this group of patients.
• Stool antigen can also be used as a test of cure while serology cannot [14]
• If fecal antigen test is done, it has a sensitivity and specificity of 90%. The test requires collection of stool specimen of the size of acorn by either patient or clinician. Test is done in the lab by a trained personnel.
• The patient must discontinue PPI for 8 weeks for Urea Breath Test (UBT) and stool antigen testing [14]



INVASIVE TESTS:

• Patients with alarming symptoms, such as anemia, gastrointestinal bleeding, or weight loss, as well as patients more than 50 years of age, should undergo endoscopy for the diagnosis of H. pylori infection [14]
• If patients under going Upper G I endoscopy gastric mucosal biopsies are obtained for rapid urease test and histology [14].
• Though the test itself is inexpensive, it still requires an invasive procedure to obtain the sample. It permits cheap and rapid detection of urease activity in the biopsy material, with a sensitivity of 79 to 100 percent and a specificity of 92 to 100 percent [14].
• Sensitivity can be improved by additional biopsies, but false negative results are observed in patients with active or recent bleeding and in patients taking antibiotics or antisecretory compounds [14].
• If H pylori infection detected on rapid urease tests, specimen for histology are discarded
• If H Pylori is to be detected, histological examination of tissue biopsy samples (usually four, taken from different parts of the stomach lining) permits detection of the bacterium together with evaluation of tissue damage. Most infection can be detected with haematoxylin & eosin (H&E) stain of gastric tissue, but special stains like Giemsa can be used if H&E results are not conclusive
• If H Pylori is to be detected, culture is generally regarded as the 'gold standard' for detecting a bacterium. For H pylori, however, the success of the technique depends on local technique and access to facilities, and can be regarded as being no more than 60 - 90% sensitive, though being 100% specific; the cost of each test is high
• Culture for H Pylori is done, it is done on a variety of specialized agar plates at elevated temperatures for at least seven days
• Culture of H. pylori with antibiotic-sensitivity testing is not routinely performed for the initial diagnosis of H. pylori infection, but it is recommended after the failure of second-line therapy [14]

TREATMENT

NON PHARMACOLOGICAL TREATMENT

• Patients with dyspepsia should be asked about other physical problems, coexisting psychological symptoms, and stressful life events, because these factors influence the severity of the illness and affect its management [19]
• Patients should be asked about NSAIDs or aspirin intake which if present should be stopped.
• Alcohol and smoking should be omitted
• Simple lifestyle advice, including healthy eating, weight reduction
• Advise patients to avoid known precipitants they associate with their dyspepsia where possible. These include smoking, alcohol, coffee, chocolate, fatty foods and being overweight. Raising the head of the bed and having a main meal well before going to bed may help some people.