Dyspepsia

Dyspepsia
Dyspepsia:
is a persistent and recurrent pain or discomfort
centered in the upper abdomen, is a common
condition that caused by a variety of disorders.
Dyspepsia is a symptom, not a medical diagnosis
The prevalence of dyspepsia around the world is
about 25%. In the united state only one person in four
with dyspepsia seeks medical care.

Dyspepsia
Functional
Dyspepsia

Non-GI
Causes of Symptoms
(cardiac disease,
muscular pain, etc.)

Structural Dyspepsia
(GERD, pancreatic
disease, gallstones, etc.)

Structural Dyspepsia
The structural dyspepsia has many causes:
1- gastroesophageal acid reflux (result from a variety of
physiological defects) -- reduce LES tone
2- ulcer (due to H. pylori, NSAIDs, Crohn disease &
Zollinger-Ellison syndromeetc )
3- helicobacter pylori
4- some medications e.g. analgestics, nitrate, calcium
chanel blockers, theophylline, ethanol, tobacco, and
caffeine.

Functional dyspepsia
It is defined as > 3 months dyspepsia without an
organic causes, Also known as nonulcer
dyspepsia, essential, or idiopathic dyspepsia
Appropriate evaluation using standard
diagnostic tests reveals no abnormalities
The functional dyspepsia a count 60% of cases
of dyspepsia.

Pathogenesis of Functional
dyspepsia
1- mucosal inflammatory and Helicobacter Pylori:
H. Pylori found in 30 to 60% of patients with functional dyspepsia

2- Gastric acid:
acid secretion in response to gastrin-releasing peptide will be high

3- disturbed motor function:

is a cause of acid reflux in some cases of indigestion.
40% have delayed gastric emptying for solid, and similar number
have antral hypomotility after meals

4- disturbed sensory function

5- central nervous system disturbances
Anxious, depress, higher neuroticism and somatization scores

continue
5- it is associated with reduces sense of physical and
mental well-being & exacerbated by psychological
factors like stress
6- diet and environmental factors:
Some patient with functional dyspepsia complain of specific
food intolerances.
-- coffee induce the symptoms in 50% of patients,
-- aspirin and NSAIDs cause asymptomatic mucosal
lesions in 30 to 60% of chronic users and can cause
dyspepsia

Symptoms of Functional
Dyspepsia
Ulcer-like dyspepsia
dyspepsia
Nocturnal
pain
Localized
epigastric
burning
Better
with food

Dysmotility-like

Nausea
Heartburn Postprandial
Retrostern bloating
Worse
al
with food
burning

Others features that arise alarm

Unexplained weight loss

Recurrent vomiting
Occult or gross G.I bleeding
Jaundice
Palpable mass or adenopathy
Epigastric tenderness and abdominal
distention

RED FLAG

Other symptoms
Bloating, fullness, nausea, and early satiety
are due to abnormal gastric fundic relaxation
Regurgitation of acid and water brash
Dysphagia

Causes of Dyspepsia
The major organic causes of
dyspepsia:
Chronic peptic ulcer disease
Gastroesophageal reflux (with or
without esophagitis)
Malignancy (rare but important)

Differential diagnosis
1- GERD -- 5% of patient with GERD develop esophageal
ulcers

2- ulcer disease -- 15 to 25% of cases of dyspepsia

developed from ulcer ( causes of ulcers must included )

3- malignancy -- < 2% of cases result from

gastroesophageal malignancy

4- alkaline reflux esophagitis produces like

symptoms -- in patient who have had surgery for peptic
ulcer disease.

5- biliary colic

continue
6- intestinal lactase deficiency -- produce gas,

bloating, discomfort, and diarrhea after lactose ingestion

7- carbohydrate intolerance syndrome ( e.g.

fructose, sorbitol ) produce similar symptoms
8- pancreatic diseases -- chronic pancreatitis and
pancreatic carcinoma

9- hepatocellular carcinoma
10- Infiltrative diseases of the stomach including;
esophageal gastritis, sarcoidosis, Crohns disease,
tuberculosis and syphilis

11- mesenteric ischemia

continue
12- thyroid and parathyroid diseases
13- abdominal wall strain
14- congestive heart failure
15- irritable bowel syndrome
16- biliary tract disease -- cholelithiasis causes biliary

pain, pain in the epigastrium or upper quadrant

17- drugs induced dyspepsia ( e.g. NSAIDs, iron or
potassium supplements, digitalis, theophylline, and oral
antibiotics ).
18- aerophagia -- it is characterized by excessive
unconscious swallowing of air that results in abdominal
distention or bloating

continue
19- other causes; which include
(a) Diabetes mellitus
(b) Metabolic disturbances (e.g.
hypothyroidisim and hypercalcemia )
(c) Ischemic heart disease
(d) Intestinal angina
(e) Colon cancer, gastric lymphoma or sarcoma

Diagnostic testing

Upper endoscopy
Esophageal PH testing
Esophageal manometry
Urea breath test, stool antigen measurement, or
blood serology testing

Further testing is indicated if other factors are

present; like:
Blood count (to exclude anemia)
Thyroid chemistries or calcium levels (for metabolic
disease )

Abdominal ultrasound or CT ( may give important

information )

Treatment
Drugs that cause acid reflux or dyspepsia should be
stopped if possible
Patient with GERD should limit ethanol, caffeine, chocolate
and tobacco use
Ingestion of a low-fat diet, avoidance of snacks before bed
time and elevation of the head of the bed
Acid suppressing or neutralizing medications ( for GERD & H.
Pylori )
-- histamine H2 receptor antagonists
-- proton pump inhibitors ( for severe symptoms or ulceration)

Motor stimulus ( have limited utility in GERD )

GABA-B ( reduce esophageal acid exposure )
Domperidone ( instead of acid suppressants )
Antireflux surgery ( for GERD and symptoms complications)
Psychological treatment ( for refractory functional dyspepsia)