Kennebec Region Health Alliance

Author: MaineGeneral Gastroenterology
Date: 4.27.16

Summary: Dyspepsia is defined as having one or more of the following symptoms:

1. Epigastric pain or burning (classified as epigastric pain syndrome)
2. Postprandial fullness (classified as postprandial distress syndrome)
3. Early satiation (classified as postprandial distress syndrome)

1. Approximately 25 percent of patients with dyspepsia have an underlying organic cause (see table).
2. Functional dyspepsia (up to 75%): A diagnosis of functional dyspepsia can only be established after exclusion of other causes of dyspepsia.

   Possible underlying causes of dyspepsia

   Peptic ulcer disease and H. Pylori infection GERD Biliary pain: gallstones, sphincter of Oddi dysfunction, functional gallbladder disorder Chronic abdominal wall pain Intra-abdominal cancer: Gastric or esophageal cancer, pancreatic cancer, hepatocellular carcinoma Gastroparesis Pancreatitis Carbohydrate malabsorption Medications: potassium, digitalis, iron, theophylline, antibiotics [especially ampicillin and erythromycin], NSAIDs, glucocorticoids, niacin, gemfibrozil, narcotics, colchicine, quinidine, estrogens, levodopa Infiltrative diseases of the stomach (e.g., Crohn disease, eosinophilic gastroenteritis, sarcoidosis) Metabolic disturbances (hypercalcemia, hyperkalemia) Ischemic bowel disease, celiac artery compression syndrome, superior mesenteric artery syndrome Systemic disorders (diabetes mellitus, thyroid and parathyroid disorders, connective tissue disease) Intestinal parasites (Giardia, Strongyloides, Anisakis)

1. History:
   1. GERD (heartburn, regurgitation, retrosternal burning pain) and NSAID use are common causes of dyspepsia
      Alarm features
      Age older than 55 years with new-onset dyspepsia
      Family history of upper gastrointestinal cancer
      Unintended weight loss
      Gastrointestinal bleeding
      Progressive dysphagia
      Odynophagia
      Unexplained iron deficiency anemia
      Persistent vomiting
      Palpable mass or lymphadenopathy
      Incidental findings on imaging suggesting organic disease
      
      
2. Examine for:
   1. Carnett’s sign: The presence of increased local tenderness during muscle tensing suggests the presence of abdominal wall pain.
   2. A palpable abdominal mass
   3. Lymphadenopathy (e.g., left supraclavicular or periumbilical in gastric cancer)
   4. Jaundice (e.g., secondary to biliary obstruction, liver metastasis)
   5. Pallor (secondary to anemia)
      
      
3. Labs:
   1. CBC, LFTs, Lipase

   Diagnostic strategies and initial management:

*5-biopsy Sydney System (lesser and greater curvature of antrum, lesser and greater curvature of body, incisura angularis) plus duodenal biopsy if indicated.
**Stool antigen assay preferred. Urea breath testing optional. Do not use serology testing. Test should be done 2-4 weeks (preferred 4 weeks) after stopping PPI, antibiotics, bismuth.
Notes:
- Endoscopy should be considered for patients in whom there is a clinical suspicion of malignancy even in the absence of alarm features.
- A negative endoscopy may reduce patient’s anxiety and increase patient satisfaction.

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