Indigestion , also known as dyspepsia , is a condition of impaired digestion. Hence, unexplained newly onset dyspepsia in people over 55 or the presence of other alarming symptoms may require further investigations. Functional indigestion previously called nonulcer dyspepsia  is indigestion "without evidence of an organic disease that is likely to explain the symptoms". In most cases, the clinical history is of limited use in distinguishing between organic causes and functional dyspepsia. A large systematic review of the literature was recently performed to evaluate the effectiveness of diagnosing organic dyspepsia by clinical opinion versus computer models in patients referred for upper endoscopy.
The computer models were based on patient demographics, risk factors, historical items, and symptoms.
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The study showed that neither clinical impression nor computer models were able to adequately distinguish organic from functional disease. In a recent study, patients with peptic ulcer disease were compared with patients with functional dyspepsia in an age and sex-matched study. Although the functional dyspepsia group reported more upper abdominal fullness, nausea, and overall greater distress and anxiety, almost all the same symptoms were seen in both groups. The workup should be targeted to identify or rule out specific causes. Traditionally, people at high-risk have been identified by "alarm" features.
However, the utility of these features in identifying the presence of upper cancer of the esophagus or stomach has been debated. However, there was high heterogeneity between studies. The physical examination may elicit abdominal tenderness, but this finding is nonspecific. A positive Carnett sign, or focal tenderness that increases with abdominal wall contraction and palpation, suggests an etiology involving the abdominal wall musculature.
Cutaneous dermatomal distribution of pain may suggest a thoracic polyradiculopathy. Thump tenderness over the right upper quadrant may suggest chronic cholecystitis. In this case, dyspepsia is referred to as non-ulcer dyspepsia and its diagnosis is established by the presence of epigastralgia for at least 6 months, in the absence of any other cause explaining the symptoms.
Gastroenteritis increases the risk of developing chronic dyspepsia. Post infectious dyspepsia is the term given when dyspepsia occurs after an acute gastroenteritis infection. It is believed that the underlying causes of post-infectious IBS and post-infectious dyspepsia may be similar and represent different aspects of the same pathophysiology. This is the most common cause of chronic dyspepsia.
Symptoms may arise from a complex interaction of increased visceral afferent sensitivity, gastric delayed emptying gastroparesis or impaired accommodation to food. Anxiety is also associated with functional dyspepsia. In some people, it appears before the onset of gut symptoms; in other cases, anxiety develops after onset of the disorder, which suggests that a gut-driven brain disorder may be a possible cause.
Although benign, these symptoms may be chronic and difficult to treat.
Ulcer and Non-Ulcer Dyspepsias
Wheat and dietary fats can lead to dyspepsia and their reduction or withdrawal may improve symptoms. When dyspepsia can be attributed to a specific cause, the majority of cases concern gastroesophageal reflux disease GERD and gastritis disease. Less common causes include peptic ulcer , gastric cancer , esophageal cancer , coeliac disease , food allergy , inflammatory bowel disease , chronic intestinal ischemia and gastroparesis. These include cholelithiasis , chronic pancreatitis and pancreatic cancer. Acute, self-limited dyspepsia may be caused by overeating , eating too quickly, eating high-fat foods, eating during stressful situations, or drinking too much alcohol or coffee.
Many medications cause dyspepsia, including aspirin , nonsteroidal anti-inflammatory drugs NSAIDs , antibiotics metronidazole , macrolides , diabetes drugs metformin , Alpha-glucosidase inhibitor , amylin analogs , GLP-1 receptor antagonists , antihypertensive medications angiotensin converting enzyme [ACE] inhibitors, Angiotensin II receptor antagonist , cholesterol-lowering agents niacin, fibrates , neuropsychiatric medications cholinesterase inhibitors [donepezil, rivastigmine] , SSRIs fluoxetine, sertraline , serotonin-norepinephrine-reuptake inhibitors venlafaxine, duloxetine , Parkinson drugs Dopamine agonist , monoamine oxidase [MAO]-B inhibitors , corticosteroids , estrogens , digoxin , iron , and opioids.
Am Fam Physician ;, with additional information from references 5 and Establishing the diagnosis of peptic or duodenal ulcer greatly clarifies the treatment approach. Therefore, it is important to determine whether endoscopy is needed Figure 1. Am Fam Physician ;, with additional information from reference 4. Although the role of early endoscopy is controversial, some experts 4 suggest that endoscopy should be considered in patients with dyspepsia who are older than 55 years, especially if symptoms are not relieved by treatment with a histamine-H 2 receptor antagonist H2RA or a proton pump inhibitor PPI.
The guidelines outlined in the Maastricht European consensus report 25 recommend endoscopy for patients older than 45 years, whereas the American Digestive Health Foundation 26 recommends endoscopy for patients with dyspepsia who are older than 50 years. Other experts 27 suggest that because of cost, empiric therapy should be used first, even in older patients.
Proponents of endoscopy cite several advantages, including the information that endoscopy provides about reflux, ulcers, and upper gastrointestinal cancers. During endoscopy, samples can be obtained to determine whether a patient has H. However, the cost of endoscopy and the low yield of treatable gastric cancers have dampened enthusiasm for an endoscopy-based approach.
If no organic disorder is found on endoscopy, empiric therapy appears to be the most reasonable approach. Although evidence clearly supports the treatment of peptic ulcer disease, data on the management of nonulcer dyspepsia are conflicting, with treatment sometimes depending on the predominant symptom. Patients with predominant nausea and bloating may have motility dysfunction and may benefit from treatment with a promotility agent.
Patients with pain as the predominant symptom may have mucosal disease or H. Patients with prominent somatic complaints, anxiety, or depression are more likely to have a psychologic basis for their symptoms. Gastric acid suppressants have been evaluated extensively in the treatment of nonulcer dyspepsia, despite lack of evidence for the involvement of acid in the pathophysiology of the condition.
While antacids have not been found to be beneficial, bismuth salts have been shown to be somewhat more effective than placebo. A meta-analysis of randomized controlled trials RCTs found that H2RAs were more effective than placebo in patients with non-ulcer dyspepsia, although many of the trials had suboptimal study designs.
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Therefore, H2RAs are preferred, because of their lower cost. PPIs other than omeprazole have not been studied in the management of nonulcer dyspepsia. No evidence supports the use of sucralfate Carafate and misoprostol Cytotec in patients with nonulcer dyspepsia. Prokinetic agents often are touted as the most effective medications for the management of nonulcer dyspepsia.
Studies have shown that symptomatic improvement is 45 to 50 percent greater with cisapride, domperidone, or metoclopramide therapy than with placebo. In addition, most of the studies evaluated cis-apride and domperidone, and access to these agents is restricted in the United States.
The prokinetic agent metoclopramide Reglan is available in this country for the management of nonulcer dyspepsia. This agent should be used with caution, because it occasionally is associated with the development of tardive dyskinesia. Metoclopramide is a low-cost drug, but antidopaminergic side effects limit its use in elderly patients. Studies comparing H2RAs with metoclopramide have not been performed. Several systematic reviews and meta-analyses 30 — 32 have evaluated the benefits of eradicating H.
In general, the trials included patients with documented H. For every 15 patients with nonulcer dyspepsia in whom H. More studies are needed to resolve the conflicting study results and to determine whether, as some investigators claim, a modest benefit for H. Patients with nonulcer dyspepsia frequently are treated with tricyclic antidepressants, selective serotonin reuptake inhibitors SSRIs , and anxiolytic agents. One meta-analysis 35 of 11 good-quality clinical trials evaluated the use of tricyclic antidepressants in patients with functional gastrointestinal disorders, defined as irritable bowel syndrome or non-ulcer dyspepsia.
Improvement of abdominal pain was significant; the number needed to treat was 3. Currently, use of tricyclic antidepressants is limited, because of the potential side effects of these agents and the availability of newer antidepressants. No published studies have evaluated the use of SSRIs in the management of nonulcer dyspepsia. Because these patients often have depression and anxiety, SSRI therapy may be effective. Therefore, these medications should be initiated at the lowest dosage, and the dosage should be increased slowly.
As reported in a Cochrane review, 20 three trials have evaluated the effects of psychologic interventions on dyspepsia symptoms and quality of life in patients with nonulcer dyspepsia. The studied interventions included psychotherapy, psychodrama, cognitive behavior therapy, relaxation therapy, and guided imagery or hypnosis. All three trials reported short-term week improvement of symptoms, and one study also reported some improvement in psychologic parameters.
However, at one year, the improvement in symptoms was not statistically significant in two of the studies. Overall, psychotherapy should be reserved for use in patients with a significant comorbid psychiatric condition or as an adjunct to medical management. Agents that alter pain perception have been considered for use in the management of nonulcer dyspepsia, because of some evidence showing augmented pain perception in such patients.
Alternative therapies, such as peppermint oil and traditional Chinese medicine, have been reported to improve symptoms in patients with dyspepsia. However, published studies have been of poor quality, and the results should be interpreted with caution. Already a member or subscriber?
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Log in. Dickerson completed her doctor of pharmacy degree and a clinical pharmacy residency in family medicine at the Medical University of South Carolina. DANA E. King graduated from the University of Kentucky College of Medicine, Lexington, and completed a family practice residency at the University of Maryland Hospital, Baltimore.
Address correspondence to Lori M. Dickerson, Pharm. Reprints are not available from the authors. The authors indicate that they do not have any conflicts of interests. Sources of funding: none reported.
- Managing dyspepsia and heartburn in general practice - an update.
- About this book.
- Innhold A-Å.
- Bo Obama: How I Landed in Washington.
- Evaluation and Management of Nonulcer Dyspepsia.
Guest editor of the series is William J. Hueston, M. Richter JE. Dyspepsia: organic causes and differential characteristics from functional dyspepsia. Scand J Gastroenterol Suppl. Am Fam Physician ;—84,—8. Management of nonulcer dyspepsia.
N Engl J Med. Drossman DA, et al. Excess sick-listing in nonulcer dyspepsia. J Clin Gastroenterol. Functional dyspepsia: a classification with guidelines for diagnosis and management. Gastroenterol Int. Malagelada JR, Stanghellini V. Manometric evaluation of functional upper gut symptoms. NSAIDs, including aspirin, are a major cause of dyspepsia and peptic ulcers and these medicines are more frequently prescribed in people over 65, who in turn are more susceptible to complications.
- Indigestion - Wikipedia.
- Table of contents.
- Subjectivity and Being Somebody: Human Identity and Neuroethics (St Andrews Studies in Philosophy and Public Affairs).
- Dyspepsia with or without Helicobacter pylori infection - Clinical Approach in Adults.
- Evaluation and Management of Nonulcer Dyspepsia - American Family Physician.
There are no accurate figures linking the prevalence of dyspepsia with ethnicity in New Zealand. However, H. In dyspepsia without heartburn that has not been investigated undifferentiated dyspepsia , first rule out the possibility of serious disease, based on the presence of red flags. Review lifestyle factors and use of medicines that may be exacerbating symptoms. Patients can then be managed by either empiric treatment usually with a PPI or testing for H.
For most people, empiric treatment is appropriate. A suggested approach is as follows: 1. The pros and cons of a test and treat strategy testing for H. Newer articles have been published related to this information, The changing face of Helicobacter pylori testing and Microbiological and Serological Tests. In the past, testing and treating for H. As the prevalence of H. Screening of asymptomatic patients is not recommended unless there is a family history of cancer or ulcer disease. If testing for H. There are three tests, apart from performing endoscopy, to check for H. The most accurate test, in all clinical scenarios, is the Carbon urea breath test.
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- Managing dyspepsia and heartburn in general practice – BPJ34.
- Defining dyspepsia and heartburn.
- The Emerald Path.
- John Rawls. Theorie der Gerechtigkeit und Drogen (German Edition).
This test will determine if the patient has an active infection. However, this test is expensive and is not generally available. The faecal antigen test can also determine if active infection is present, but false-negative results are possible, which will limit interpretation when a diagnosis is required. Serology, using a blood sample, will show exposure to the infection, but this does not always mean that active infection is still present.
From a general practice perspective, serology is easy to obtain and is a reasonable approach for testing for H. A faecal antigen test is recommended to detect loss of infection after treatment. For H. Note that the combination pack Losec HP7 OAC is no longer subsidised but triple therapy is subsidised if all three medicines are co-prescribed.
Many people have now been taking a PPI for several years and there have been a number of studies investigating long-term safety. Most studies are observational which cannot establish causality. There is no proven link with an increased risk of gastric cancer or nutritional deficiencies. From a general safety standpoint, PPIs should be used at the lowest effective dose for the shortest possible time and regularly reviewed.
The data is conflicting as to whether PPI use is associated with an increased risk of bone fracture. There is a possible increased risk of fractures of the hip, wrist and spine. In case controlled studies, long term PPI use has been associated with an increased risk of bone fracture, and this increased risk depends on the duration and dose of chronic use of the PPI.
Use of a PPI for five years or more can increase the risk of osteoporotic fractures by 1.
Long-term use of PPIs does not lead to vitamin B12 deficiency except possibly in elderly people, or in people with Zollinger-Ellison Syndrome who are on high doses of a PPI for prolonged periods of time. PPIs are a relatively safe group of medicines and serious adverse events are rare. However, there have been case reports of interstitial nephritis with omeprazole, hepatitis with omeprazole and lansoprazole and visual disturbances with omeprazole and pantoprazole. For further information see: www. Omeprazole can be used to reduce the risk of gastrointestinal complications from antithrombotic treatment.
However, omeprazole has been shown to decrease the formation of the active metabolite of clopidogrel and potentially reduce its anti-platelet effect. There is ongoing debate as to whether concomitant use of omeprazole and clopidogrel translates to adverse cardiovascular outcomes. Current advice from Medsafe is to avoid concomitant use. This advice may change as more evidence becomes available. Defined pathology is unable to be identified in approximately half of the patients referred for endoscopy, and this is classified as functional dyspepsia.
The cause of functional dyspepsia is not clearly understood and is likely to be multi-factorial. Some cases appear to be related to hyperacidity with associated heartburn and reflux symptoms, whereas others appear to be related to a disorder of gastrointestinal motility. Psychosocial and psychological factors may be involved but it is not known how significant these factors are on a population basis.
A PPI is considered first line treatment for functional dyspepsia, with or without symptoms of hyperacidity. Management follows the same approach as for undifferentiated dyspepsia. Functional dyspepsia in patients, that have not responded to a PPI or prokinetic and are H. Follow us on facebook. Forgot your login?
Login to my bpac. Remember me. Managing dyspepsia and heartburn in general practice - an update Dyspepsia is not a diagnosis but rather a description of symptoms that may indicate disease of the upper gastrointestinal tract.