Dyspepsia is a chronic or recurrent pain or discomIort centered in the upper abdomen 1.

Patients
presenting with predominant epigastric pain or discomIort who have not undergone any
investigations are deIined as having uninvestigated dyspepsia. Those patients with an obvious
source such as abdominal wall pain are not considered to have dyspepsia. In patients with
dyspepsia who are investigated, there are 4 major causes: chronic peptic ulcer disease,
gastroesophageal reIlux (with or without esophagitis), malignancy, and Iunctional (or nonulcer)
dyspepsia 2.
DIAGNOSTIC TESTING
Dyspeptic patients more than 55 yr old, or those with alarm Ieatures (bleeding, anemia, early
satiety, unexplained weight loss (~10 body weight), progressive dysphagia, odynophagia,
persistent vomiting, a Iamily history oI gastrointestinal cancer, previous esophagogastric
malignancy, previous documented peptic ulcer, lymphadenopathy, or an abdominal mass) should
undergo prompt endoscopy to rule out peptic ulcer disease, esophagogastric malignancy, and
other rare upper gastrointestinal tract disease. In patients aged 55 yr or younger with no alarm
Ieatures, the clinician may consider two approximately equivalent management options: (i) test
and treat Ior H. pylori using a validated noninvasive test and a trial oI acid suppression iI
eradication is successIul but symptoms do not resolve or (ii) an empiric trial oI acid suppression
with a proton pump inhibitor (PPI) Ior 48 wk. The test-and-treat option is preIerable in
populations with a moderate to high prevalence oI H. pylori inIection (_10), whereas the
empirical PPI strategy is preIerable in low prevalence situations 1.


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1 sophagogastroduodenoscopy (D)$ upper Cl Lndoscopy

Fibreoptic technology allowed the development of direct imaging of the upper gastrointestinal tract using
endoscopy in the 1960s. This has now become the 'gold standard' test for detecting oesophageal, gastric
and duodenal lesions. Studies suggest the patient acceptability of upper gastrointestinal endoscopy is
similar59 or greater than DCBM.60 t is possible to biopsy suspicious lesions and biopsies for H. pylori can
also be obtained at endoscopy and this is an advantage over DCBM. Endoscopy can be performed with
local anaesthetic throat spray, although light intravenous benzodiazepine sedation is often given. The
patient is unable to work or drive for 24 hours if sedation is given. The morbidity and mortality rates of
upper gastrointestinal endoscopy are low (1 in 200 and 1 in 2000 respectively in the UK),. This figure is
based on secondary-care data and therefore includes high risk patients. t is likely that the risks of
endoscopy in healthy patients will be lower. Complications can be minimised by obtaining intravenous
access before the procedure, careful monitoring of the patient and giving oxygen via nasal cannulae
whilst performing the endoscopy 5.
&pper gastrointestinal radiographs are still Irequently ordered to exclude peptic ulcer and other
diseases in patients with dyspepsia in primary care. However, endoscopy has been established to
provide superior diagnostic accuracy in detecting structural causes oI dyspepsia compared with
radiography.1,102 ndoscopy has been generally preIerred over barium radiography when, aIter
the procedures, they were directly compared 2. ndoscopy provides a gold-standard Ior the
diagnosis oI dyspepsia. The diagnostic yield oI endoscopy in patients with dyspepsia increases
with age. There is little role Ior barium meal in the routine evaluation oI patients with dyspepsia.
Barium meal is cheaper than endoscopy Ior the diagnosis oI peptic ulcer disease, but is less
accurate 3.
A potential beneIit oI endoscopy is that gastric ulcers can be conIirmed to be benign by
perIorming biopsies; the prevalence oI unsuspected cancer in gastric ulcer disease in Western
nations, however, remains very low, ranging Irom 0 to 3.1,104,105 ndoscopy permits
gastric biopsy specimens to be taken to diagnose 547 status; rapid urease testing (eg, the
CLO test) is relatively inexpensive and is sensitive (95) and speciIic (up to 95).1,106 Note,
however, that a single biopsy will miss 510 oI cases, and recent antibiotic use or
antisecretory therapy will increase the Ialse-negative rate 2.
Disadvantages of Endoscopy
There are several potential disadvantages oI prompt endoscopy Ior all dyspeptic patients that
need to be careIully considered. ndoscopy is invasive and although the risks oI this procedure
in relatively healthy patients are very low, the issue oI the risk-beneIit ratio needs careIul
weighing, particularly as the procedure is very unlikely to identiIy an unexpected structural cause
in a young patient with no alarm Ieatures. Finding esophagitis, the most likely structural
abnormality, may oIten not lead to a change in management (94, 95). Moreover, the high
prevalence oI dyspepsia means that a general recommendation to perIorm endoscopies on all
patients would be very costly and would overwhelm endoscopy services. Furthermore, it is
contentious that prompt D provides any direct beneIits despite some positive studies quoted
above. One study evaluated management strategies in 326 primary care patients with dyspepsia;
endoscopy was not superior to any oI the empirical treatment strategies utilized in this study
(96). A systematic review concluded that most data Iailed to support the view that endoscopy
alone improves patient outcome in dyspepsia compared with other empiric strategies (97) 1.

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ufrl fsll pemerlsffn endoscopy ersebu dldfpffn fsll The endoscopic Iindings oI 50 patients with
dyspepsia were studied. Out oI 50 patients, 35(70) were males while 15(30) were Iemales. ighty two percent
(41/50) were in the age group oI 30-50 years. The most common presentations were epigastric pain in 45 (90)
cases, heartburn in 36 (72) and Ilatulence in 35 (70) cases. The endoscopic Iindings were normal in 25 (50)
patients. The abnormal Iindings included esophagitis in 6 (12) patients, gastric ulcer in 5 (10) patients, duodenal
ulcer in 4 (8) patients, gastritis in 4 (8) patients and duodenitis in 2 (4) patients; while esophagogastritis,
gastroduodenitis, esophagogastroduodenitis and carcinoma stomach were present in 1 (2) patient each. All the
endoscopically abnormal as well as normal Iindings were conIirmed by histopathology 3.


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keslmpulfn dfrl penelll ersebu bff ndoscopy is very important procedure Ior the assessment
oI dyspepsia. The endoscopic Iindings were normal in majority oI patients with dyspepsia. The
common abnormal endoscopic Iindings included esophagitis, gastric ulcer, duodenal ulcer and
gastritis. Multiple blind biopsies improve the diagnostic yield and it is aIter negative endoscopy
and biopsy report that one can be labeled as suIIering Irom non ulcer dyspepsia 3.
European dyspepsia guidelines and those from the National nstitute for Clinical Excellence (NCE) say that patients with
persistent or recurrent uncomplicated dyspepsia should have a non-invasive Helicobacter pylori test and, if the test is
positive, receive triple therapy 4.
The urea breath test and serology were the first non-invasive tests available; the urea breath test is the more accurate. This
test detects products of the enzyme urease produced by live H pylori in the stomach and is 95% sensitive and specific.
Serology is the main non-invasive test used in the United Kingdom and is notably less accurate than the
urea breath test.5 6 A positive serology result can mean one of three things: that the patient is infected at the time of the test;
that the patient was once infected, but by the time of the test, infection has resolved, either by specific therapy or naturally;
or that the test is detecting non-specific cross reacting antibodies.
Another accurate non-invasive test is now available. The stool antigen test detects H pylori antigens passed in the faeces.
The first commercially available test, which used polyclonal antibody raised in rabbits, has been used in thousands of
patients across Europe and is almost as specific (91.9%) and sensitive (92.4%) as the urea breath test.7 Some centres have,
however, found appreciable variation between batches, and a monoclonal antibody kit is now available commercially, which
avoids this.8 The monoclonal test is reported to be as accurate as the urea breath test (specificity 97.5%, sensitivity 94.7%)8
t uses similar laboratory methods to the serology test and can be introduced with ease into routine laboratory practice.9 w1
Antibody concentrations to H pylori fall slowly after eradication of the infection.10 n contrast to serology, stool antigen testing
is useful for confirming eradication of the infection following treatment.7 8 w1 Although equivalent to the urea breath test in
performance (see table on bmj.com), the stool test is considerably less expensive and less time consuming, and
investigators have found it acceptable to patients.11 A disadvantage of breath and stool antigen tests is that patients must
stop taking proton pump inhibitors for at least two weeks before the test and H2 receptor antagonists for one day.7 w2 w3 Any
antibiotics must be stopped four weeks before. The accuracy of H pylori tests has been determined mainly in patients at
endoscopy in whom the prevalence of H pylori is high and the positive predictive value of all tests therefore high. However,
as the prevalence of H pylori falls, the positive predictive value of all tests falls.12 The lower the specificity of a test, the
greater the fall in positive predictive value with falling prevalence. When using the urea breath test or monoclonal stool
antigen test in developed countries, where typically 25% ofdys peptic patients are H pylori positive, only 3% (62 for stool, 65
for urea breath test of 2000) of patients will receive unnecessary antibiotics.3 5 n contrast, using a serology based test 255 of
the 2000 patients tested are likely to receive an incorrect diagnosis of active H pylori infection and receive inappropriate
treatment.
Serology leads to at least four times as many false positive results as the urea breath test or second generation
monoclonal stool antigen test, with associated unnecessary treatment and increasing risks of antibiotic resistance in other
bacterial flora. f the dyspepsia "test and treat guidance is implemented widely across Europe the number of patients
receiving treatment to eradicate H pylori could easily double. We need to have an easy, accurate diagnostic test and the
stool antigen test is just that. The European Helicobacter Study Group4 and NCE dyspepsia guidance3 now endorse the use
of urea breath tests or stool antigen tests over serology. Any small additional cost to the healthcare provider will be far offset
by improved diagnostic accuracy and reduced use of antibiotics. Furthermore, as these tests replace serology and market
forces come into play, the price of the breath and stool tests is likely to come down. Clinicians are therefore best advised to
inform patients that the minor inconvenience of providing a stool or breath sample is far outweighed by the increased
accuracy of the tests. Clinicians should request healthcare providers to fund office based tests or local laboratories to
include these tests in their repertoire 4.


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1 uidelines Ior the Management oI Dyspepsia
2 American Gastroenterological Association Technical
Review on the Evaluation of Dyspepsia
3 &PP# AST#OINTSTINAL NDOSCOPIC ASSSSMNT
OF PATINTS P#SNTIN WITH DYSPPSIA
4 Test and treat for dyspepsia-but which test?
3 Dyspepsia
6 Dyspeps|a w|th or w|thout ne/icobocter py/ori |nfect|on C||n|ca| Approach |n Adu|ts