FOLLOW UP

• Dyspepsia is a remitting and relapsing disease, with symptoms recurring annually in about half of patients. Offer patients requiring long-term management of dyspepsia symptoms an annual review of their condition, encouraging them to try stepping down or stopping treatment [18]
• Post-treatment testing for H Pylori is not generally recommended. This testing may however be indicated in selected patients with complicated ulcer disease, low-grade gastric mucosa associated lymphoid tissue (MALT) lymphoma and following resection of early gastric cancer [1].
• If the patient had an H. pylori infection previously then testing for eradication with either a stool antigen test or a breath test would be reasonable [1].
• If previous dyspepsia symptoms recur 1 to 6 months after cessation of treatment, reevaluate person for alarm signals, taking into account timing of relapse and severity of symptoms [14].
• If previous dyspepsia symptoms recur after 6 months with no alarm signals, repeat empiric therapy [14]

SURVEILLANCE
• All patients should be told about alarm symptoms if they are not present initially.
• Because of the high incidence of gastric cancer in the East and in certain other countries, Japan, Chile and Venezuela alarm symptoms should be sought more carefully and at every yearly visit to detect gastric malignancy earlier though dyspepsia itself doesn’t confer increased risk of gastric malignancy
PROGNOSIS
• Dyspepsia is a remitting and relapsing disease, with symptoms recurring annually in about half of patients [18]
• Functional dyspepsia is generally a non-life-threatening disorder that is not associated with a need for surgery or a reduction in survival [24, 25].
• The majority of patients with uninvestigated dyspepsia will fall into the functional dyspepsia category, but the exact prognosis of this group remains variable and unexplained. No information is currently available on the periodicity of individual dyspeptic symptoms over time; understanding the cycling pattern of symptoms could have important management implications [25]
• Patients don’t have difference in prognosis whether they are H Pylori positive or negative
COUNCELLING
• Stop smoking
• Avoid NSAIDS, or if needed take with meal/H2 blocker. Paracetamol is a better choice. Or else COX II inhibitors can be used
• Lose weight
• Eat small meals
• Reduce consumption of caffeine, chocolate, fatty foods, alcohol, onions, peppermint and spearmint
• Elevate head end of bed by 6 to 9 inches
• Avoid tight fitting garments
If Patient has dyspepsia, advise to visit the doctor if:
• Over 50 years of age
• Recently lost weight without trying to
• Has trouble swallowing
• Has severe vomiting
• Has black, tarry bowel movements (this means blood in your stools)
• Can feel a mass in your stomach area
• Discomfort unrelated to eating
• Indigestion accompanied by shortness of breath, sweating, or pain radiating to the jaw, neck, or arm

REFRENCES
1. Institute for Clinical Systems Improvement (ICSI). Initial management of dyspepsia and GERD. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2006 Jul. 53 p.
2. Tack, J, Talley, NJ, Camilleri, M, et al. Functional gastroduodenal disorders. Gastroenterology 2006; 130:1466.
3. Noya Horowitz , Menachem Moshkowitz , Moshe Leshno , Joseph Ribak , Shlomo Bierkenfeld , Gabi Kenneth , Zamir Halpern . Symptom evaluation as an efficient diagnostic tool for upper abdominal diseases. Harefuah. 2006 Nov ;145 (11):807-10, 862 17183951
4. Talley, NJ, Zinmeister, AR, Schleck, CD, Melton, LJ III. Dyspepsia and dyspepsia subgroups: A population-based study. Gastroenterology 1992; 102:1259.
5. Kurata, JH, Nogawa, AN, Everhart, JE. A prospective study of dyspepsia in primary care. Dig Dis Sci 2002; 47:797.
6. SL Grainger, HJ Klass, MO Rake and JG Williams. Prevalence of dyspepsia: the epidemiology of overlapping symptoms. Postgraduate Medical Journal, 1994, Vol 70, 154-161
7. Talley NJ, Vakil NB, Moayyedi P. American Gastroenterological Association technical review (evaluation of dyspepsia). Gastroenterology. 2005;129:1756–1780.
8. Lin Chang, MD From Rome to Los Angeles -- The Rome III Criteria for the Functional GI Disorders. Digestive Week 2006.
9. Arents NL et al: Approach to treatment of dyspepsia in primary care: a randomized trial comparing "test and treat" with prompt endoscopy. Arch Intern Med 2003;163:1606.
10. Talley NJ: Dyspepsia. Gastroenterology 2003;125:1219
11. George F. Longstreth, M.D.Functional Dyspepsia — Managing the Conundrum. N Engl J Med 2006 February 23; 354(8):791-793
12. Talley NJ, Silverstein MD, Agreus L, et al, Gastroenterology 1998;114:582
13. Fisher RS, Parkman, HP, N Engl J Med 1998;339:1376.
14. Management of dyspepsia and heartburn. Wellington (NZ): New Zealand Guidelines Group (NZGG); 2004 Jun.
15. Howden CW, Hunt RH. Guidelines for the management of Helicobacter pylori infection. Am J Gastroenterol 1998;93:2330-2338
16. . Suerbaum S, Michetti P. Helicobacter pylori infection. N Engl J Med. 2002 Oct 10;347(15):1175-86.
17. Drumm B, Koletzko S, Oderda G. Helicobacter pylori infection in children: a consensus statement. J Pediatr Gastroenterol Nutr 2000;30:207-213
18. Management of dyspepsia in adults in primary care. Clinical Guidelines. June 2005. Developed by the Newcastle Guideline Development and Research Unit

19. Longstreth G.F. Functional Dyspepsia — Managing the Conundrum. N Engl J Med Feb; 2006; 354 (8):791-793

20. Delaney B, Quine M, Moayyedi P. H pylori eradication versus empirical acid suppression in uninvestigated H pylori positive dyspepsia. Gastroenterology. 2005;130:A-38.
21. Barenys M, Rota R, Garcia-Altes A, et al. Score and scope versus test and treat strategies for the management of Dyspepsia: a randomized controlled trial. Gastroenterology. 2005;130:A-38.
22. Vakil N, Veldhuyzen van Zanten S, Flook N, et al. High prevalence of abnormal endoscopic findings in patients with non-GERD dyspepsia. Gastroenterology. 2005;130:A-157.
23. New Zealand Guidelines Group (NZGG). Management of dyspepsia and heartburn. Wellington (NZ): New Zealand Guidelines Group (NZGG); 2004 Jun.
24. Werdmuller B.F.M.; van der Putten A.B.M.M.; Veenendaal R.A.; Lamers C.B.H.W.; Balk A.G.; Loffeld R.J.L.F. Functional dyspepsia has a good prognosis irrespective of H. pylori status - Long-term follow-up of symptoms after anti H. pylori treatment.The Netherlands Journal of Medicine, Volume 55, Number 2, August 1999, pp. 64-70(7)
25. H.B. El-Serag; N.J. TalleyThe Prevalence and Clinical Course of Functional DyspepsiaAliment Pharmacol Ther 19(6):643-654, 2004
26.

Symptoms Persist >4 Weeks?

• Although ulcer healing may take 8 weeks or more, the majority of patients with a gastric or duodenal ulcer have improvement in symptoms at 4 weeks [1].
• The yield of esophagogastroduodenoscopy is improved by limiting evaluation to those with persistent symptoms persisting despite a short course of therapy [1].
Management of Symptomatic Relapse
Dyspepsia often comes and goes. Some patients will experience recurrent symptoms despite symptom resolution with the initial management
• If previous dyspepsia symptoms recur 1 to 6 months after cessation of treatment, reevaluate person for alarm signals, taking into account timing of relapse and severity of symptoms [14].
• If previous dyspepsia symptoms recur after 6 months with no alarm signals, repeat empiric therapy [14]
• If the patient had an H. pylori infection previously then testing for eradication with either a stool antigen test or a breath test would be reasonable.
• If persistent H. pylori infection is identified, then retreatment with a regimen different from the regimen used earlier would be appropriate.
• If the patient was H. pylori negative either at time of initial management or at the time of the testing of eradication then another trial of acid suppression could be considered
• If symptoms resolve, no further care is necessary.
• If symptoms persist then an endoscopy should be considered.
Functional Dyspepsia
• When no structural or biochemical abnormalities are identified to explain symptoms, patients may be given a diagnosis of functional or non-ulcer dyspepsia.
• Such patients require reassurance, and further diagnostic testing should be kept to a minimum. No medical treatment is clearly of proven benefit [19].
• The goal is to help patients accept, diminish, and cope with symptoms rather then eliminate them [19].
• At present, no firm recommendations can be made regarding the management of non-ulcer dyspepsia.
• Further care for functional dyspepsia should be done on a case by case basis.
• Elimination of certain foods (e.g., caffeine, alcohol, fat, etc.) may help.
• Elimination of certain medications (e.g., NSAIDs) may help.
• Consider drug therapy in the following order [23]:
1. Prokinetics (domperidone, Itopride)
2. H2RAs
3. Proton pump inhibitors

• Eradication of H. pylori (if not already done but benefits only minority of patients), or low-dose tricyclic antidepressant, and exploration of the contribution of psychologic distress may prove beneficial.
• There is no significant benefit from antacids or sucralfate
• Visceral analgesics, such as the serotonin receptor antagonists, the somatostatin analogue octreotide, and the kappa receptor opioid agonist fedotozine, are undergoing evaluation in the management of functional digestive disorders such as functional dyspepsia [19].

First-Line Therapies

Proton-Pump-Inhibitor–Based Triple Therapies
• Treatment of H Pylori twice daily for seven days with 20 mg of omeprazole, given either with 1 g of amoxicillin and 500 mg of clarithromycin, or with 400 mg of metronidazole and 250 mg of clarithromycin [16].
• Several comparative trials have demonstrated the equivalence of 30 mg of lansoprazole twice daily, 40 mg of pantoprazole twice daily, 20 mg of rabeprazole daily, and 20 mg of esomeprazole twice daily with omeprazole in these triple therapies [16].
• The duration of therapy remains controversial. In Europe, 7-day treatment is recommended,whereas in the United States, 14-day courses have been found to be better than shorter courses and are approved by the FDA. In a recent meta-analysis, 14-day treatment achieved rates of cure 7 to 9 percentage points better than 7-day treatment [16].
• Primary resistance to clarithromycin and metronidazole decreases rates of cure by 50 percent and 37 percent, respectively [16].

Ranitidine Bismuth Citrate–Based Therapies
• Ranitidine bismuth citrate in dual therapy with clarithromycin for two weeks has been approved by the FDA [16].
• Bismuth citrate with clarithromycin and amoxicillin, or with clarithromycin and a nitroimidazole, performs as well as corresponding proton-pump-inhibitor–based therapies [16].
• Ranitidine bismuth citrate–based regimens may be less influenced by antibiotic resistance than their proton-pump-inhibitor–based counterparts. No ranitidine bismuth citrate–based triple therapy has been approved by the FDA [16].

Bismuth-Based Triple Therapies
• A proton-pump inhibitor, clarithromycin, and either amoxicillin or metronidazole for two weeks; ranitidine bismuth citrate, clarithromycin, and amoxicillin, metronidazole, or tetracycline for two weeks; and a proton-pump inhibitor, bismuth, metronidazole, and tetracycline for one to two weeks had been approved earlier [16].
• The regimens recommended by the European Maastricht 2–2000 conference are a proton-pump inhibitor (or ranitidine bismuth citrate), clarithromycin, and amoxicillin or metronidazole for seven days [16].
Second-Line Therapies
• Eradication is more difficult when a first treatment attempt has failed, usually because of either poor patient compliance or the development of antibiotic resistance. Therefore, a 10-to-14-day treatment course is advocated for second-line therapies [16].
• However, the optimal strategy for retreatment after the failure of eradication has not yet been established [16].
• Because the failure of therapy is often associated with secondary antibiotic resistance, retreatment should ideally be guided by data on susceptibility. However, such information is often unavailable, so quadruple therapies, in which a proton-pump inhibitor or an H2-receptor antagonist is added to a bismuth-based triple regimen with high-dose metronidazole, have been suggested as optimal second-line therapy [16].
• Another approach to retreatment without susceptibility testing is to prescribe a second course of proton-pump-inhibitor–based triple therapy, avoiding antimicrobial agents against which prior therapy may have induced resistance and avoiding less effective combinations, such as amoxicillin and tetracycline [16].
• If a clarithromycin-based regimen is used first, a metronidazole-based regimen should be used afterward, or vice versa [16].
• Alternative approaches to second-line proton-pump-inhibitor–based therapies have been reported recently, but mostly in abstract form. Rifabutin, given in association with amoxicillin and pantoprazole for 10 days, achieved an 86 percent rate of cure, even in patients with resistant strains [16].
• Regardless of which therapy course is chosen, patients with significant symptoms at presentation may continue to use a standard dose of a PPI for 3 extra weeks at the end of the combination drug treatment. The optimal rates of eradication are obtained within 14-day dosing but 7-day dosing are almost similar
Patients on nonsteroidal anti-inflammatory drugs (NSAIDs)
• Patients on NSAIDs should have these discontinued if possible.
• If it is not possible to discontinue NSAIDs, duration of PPI therapy of 12 weeks is recommended.
• In person with symptoms and risk factors, refer for endoscopy [14].
• If ongoing symptom relief is needed [14]:
• Continue NSAID with co prescription of PPI or misoprostol OR
• Replace NSAID with cyclo-oxygenase-2 (COX-2) selective inhibitor.

• Eradicate H. pylori if testing is positive [14].

PHARMACOLOGICAL TREATMENT

• Patients who are younger than 55 years can be managed with an initial empirical strategy that is based on the prevalence of Helicobacter pylori infection in the community [20-23].
• In communities where the prevalence of H pylori infection is 10% or greater, an initial strategy of testing and treating for H pylori is recommended. Patients who fail this strategy are given proton-pump inhibitors (PPIs), with endoscopy reserved for those who fail to respond [20-23].
• In populations where the prevalence of H pylori infection is less than 10%, the initial strategy may be empirical PPI therapy, with endoscopy reserved for those who fail to respond [20-23].
• Offer empirical full-dose PPI therapy for 1 month to patients with dyspepsia [18]
• PPIs are more effective than antacids at reducing dyspeptic symptoms in trials of patients with uninvestigated dyspepsia. The average rate of response taking antacid was 37% and PPI therapy increased this to 55%: a number needed to treat for one additional responder of six [18]
• PPIs are more effective than H2RAs at reducing dyspeptic symptoms in trials of patients with uninvestigated dyspepsia. The average response rate in H2RA groups was 36% and PPI increased this to 58%: a number needed to treat for one additional responder of five.
• Patients with dyspepsia should not receive therapy indefinitely [1]
• Early endoscopy has not been demonstrated to produce better patient outcomes than empirical treatment [18].
• If treatment with PPI is not effective in 4 weeks recommend endoscopy [7]
• If endoscopy is normal recommend H Pylori testing. If patient already taken the eradication therapy recommend testing again after 2 weeks off PPI [7]
• If H Pylori is negative reassess the diagnosis [7]
• If still the diagnosis is dyspepsia consider antidepressants, hypno or behavior therapy [7]
• Test and endoscopy has not been demonstrated to produce better patient outcomes than empirical treatment.
• Management of endoscopically determined non-ulcer dyspepsia involves initial treatment for H. pylori if present, followed by symptomatic management and periodic monitoring [18].
• If patient is greater than 55 years of age and has new onset dyspepsia, recommend endoscopy first and then treat accordingly.

Treatment of Ulcer related Dyspepsia
• Testing and treatment of H. pylori is the cornerstone of the management of peptic ulcer disease.
• Maintenance PPI treatment is not indicated for those experiencing symptom resolutions after treatment. Patients with complicated peptic ulcer disease may be considered for maintenance treatment using PPI at one-half the therapeutic dose after successful treatment.
• Documenting H. pylori eradication should be limited to those with a history of complicated peptic ulcer disease.
• Patients who continue nonsteroidal anti-inflammatory drugs (NSAIDs) during treatment for peptic ulcers should have the duration of PPI treatment extended to twelve weeks total.
• Symptoms continuing for a month or more into treatment should prompt endoscopy regardless of initial treatment. Further evaluation may be necessary.

H. pylori Infection
• In most patients with dyspepsia, testing for H. pylori infection is the first step.
• H. pylori testing without endoscopy, followed by eradication treatment for patients with positive results, is a cost-effective approach for initial long-term management of dyspepsia
• Post-treatment testing is not generally recommended. This testing may however be indicated in selected patients with complicated ulcer disease, low-grade gastric mucosa associated lymphoid tissue (MALT) lymphoma and following resection of early gastric cancer.
• If testing is performed for eradication, it should be delayed at least 4 weeks after the completion of therapy and/or the use of proton pump inhibitors.
• Many regimens are effective in treating H. pylori. However, all regimens require more than one drug.

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.

CLINICAL FEATURES

• Patient usually presents with pain or discomfort felt to arise in the upper gastrointestinal (GI) tract with symptoms on greater than 25% of days over the past 4 weeks [1].
• Patients can have epigastric pain or discomfort, or nausea.
• Patients with symptoms every day for seven days are said to have dyspepsia[1]
• Alarm features should be sought in all patients presenting with dyspepsia. If alarm features are present, endoscopy should be performed. They include [1]
o Anemia
o Acute onset dysphagia
o Hematemesis
o Melena
o Persistent vomiting
o Weight loss greater than 5% (involuntary)
o Other alarm features include family history of upper gastrointestinal cancer, gastrointestinal bleeding, odynophagia, persistent vomiting, palpable mass or lymphadenopathy and jaundice [7]

• If patient has dyspepsia, elicit a detailed history to identify patients whose symptoms may be attributable to medication use, gastroesophageal reflux disease, gallstone
• If patient has dyspepsia, they 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
SIGNS

• If patient has dyspepsia, they should undergo a physical examination for tenderness, which is usually nonspecific

ETIOLOGY

1. Gastrointestinal Tract Dysfunction
• Peptic ulcer disease 5-15% of patients with dyspepsia.
• Gastro esophageal reflux disease is present in up to 20%
• Gastric cancer identified in 1% but rare in persons under age 45 years
• Gastro paresis (especially in diabetes mellitus)
• Lactose intolerance
• Malabsorptive conditions
• Parasitic infection (Giardia, strongyloides).

2. Food Intolerance
Acute, self-limited "indigestion" may be caused by
• Overeating
• Eating too quickly
• Eating high-fat foods
• Eating during stressful situations
• Drinking too much alcohol.
• Drinking too much coffee.

3. Drug Intolerance
Many medications cause dyspepsia, including
• Aspirin
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Antibiotics (metronidazole, macrolides)
• Corticosteroids
• Digoxin
• Theophylline
• Iron
• Narcotics
4. Helicobacter Pylori Infection
Chronic gastric infection with H pylori as a cause of dyspepsia remains controversial. The prevalence of H pylori-associated chronic gastritis in patients with dyspepsia without peptic ulcer disease is 20-50%, the same as in the general population

5. Pancreatic Disease
• Pancreatic carcinoma
• Chronic pancreatitis


6. Biliary Tract Disease
• Cholelithiasis
• Choledocholithiasis

7. Functional or "Nonulcer" Dyspepsia
• Most common cause
• Accounts for up to 60 % of dyspepsia cases
8. Other Causes
• Diabetes
• Thyroid disease
• Renal insufficiency
• Myocardial ischemia
• Intra-abdominal malignancy
• Gastric volvulus
• Para esophageal hernia

DYSPEPSIA

DEFINITION

Dyspepsia is defined as pain or discomfort felt to arise in the upper gastrointestinal tract with symptoms on greater than 25% of the days over the past four weeks [1]

DIAGNOSTIC CRITERIA

An international committee of clinical investigators (Rome III Committee) defined dyspepsia as one or more of the following symptoms [2]:
• Postprandial fullness (termed postprandial distress syndrome)
• Early satiation (meaning inability to finish a normal sized meal or postprandial fullness)
• Epigastric pain or burning (termed epigastric pain syndrome)

These criteria were preferred to the previous criteria (Rome II), which included pain or discomfort centered in the upper abdomen.

EPIDEMIOLOGY
It occurs in approximately 25 percent (range 13 to 40 percent) of the population each year, but most affected people do not seek medical care [3,4]. Dyspepsia is responsible for substantial health care costs and considerable time lost from work [5]. General practitioners see only a fraction of the dyspepsia within the community, the majority of which is either ignored or treated by self-medication. However, dyspepsia still accounts for about 3-4% of all general practice consultations and for about 14% of all patients attending. In about half of all cases, even extensive investigation reveals no underlying organic lesion

TYPES:
There are 4 major types of dyspepsia according to causes [7]:
• Chronic peptic ulcer disease,
• Gastroesophageal reflux (with or without esophagitis),
• Malignancy
• Functional (or nonulcer) dyspepsia.
Rome III Diagnostic Criteria for Functional Dyspepsia are [8]

1. At least 3 months, with onset at least 6 months previously, of 1 or more of the following:
• Bothersome postprandial fullness
• Early satiation
• Epigastric pain
• Epigastric burning

And
2. No evidence of structural disease (including at upper endoscopy) that is likely to explain the symptoms

Rome III Diagnostic Criteria for Epigastric Pain Syndrome are [8]:
At least 3 months, with onset at least 6 months previously, with ALL of the following:

Pain and burning that is:
• intermittent
• localized to the epigastrium of at least moderate severity, at least once per week,
• and NOT:
1. generalized or localized to other abdominal or chest regions
2. relieved by defecation or flatulence
3. fulfilling criteria for gallbladder or sphincter of Oddi disorders

Rome group also suggested that it might be useful to subcategorize nonulcer dyspepsia into ulcer-like, reflux-like, dysmotility-like, and nonspecific dyspepsia [7]