Best Dx/Best Rx: Dyspepsia

From: Subject: Best Dx/Best Rx: Dyspepsia Date: Wed, 3 Jun 2009 21:19:28 -0700 MIME-Version: 1.0 Content-Type: multipart/related; type="text/html"; boundary="----=_NextPart_000_0177_01C9E490.FA535A80" X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2900.5579 This is a multi-part message in MIME format. ------=_NextPart_000_0177_01C9E490.FA535A80 Content-Type: text/html; charset="Windows-1252" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.acpmedicine.com/acp/newrxdx/rxdx/dxrx0414.htm Best Dx/Best Rx: Dyspepsia

Dyspepsia

Henry P. Parkman, M.D.
Temple University = School of=20 Medicine

Defin= ition/Key=20 Clinical Features
Diffe= rential=20 Diagnosis
Best = Tests
Best = Therapy
Best = References

Definition/Key Clinical=20 Features

Functional Dyspepsia is a GI disorder that = causes upper=20 abdominal symptoms, generally in postprandial period=20
- epigastric pain or burning=20
- postprandial fullness=20
- early satiation
Functional dyspepsia has been recently divided = into=20
- postprandial distress syndrome=20
- epigastric pain syndrome
Pathogenetic features shared with other = functional GI=20 disorders=20
- Abnormal motility=20
- Heightened visceral sensation=20
- Psychosocial distress
Frequent psychological comorbidity=20
- Anxiety=20
- Depression=20
- Obsessive-compulsive disorder =

=20 bac= k to=20 top

Differential = Diagnosis

Gastroesophageal Reflux Disease = (Esophagitis)=20
Peptic ulcer disease=20
Helicobacter pylori gastritis=20
Cancer of esophagus or stomach =

=20 bac= k to=20 top

Best=20 Tests

History and physical exam are usually normal = and=20 nondiscriminatory=20
Perform upper endoscopy and test for H. = pylori=20 infection in new-onset cases=20
Begin therapeutic trial=20
- proton pump inhibitor=20
- prokinetic agent
If no response, consider further = evaluation:=20
- Gastric emptying test (scintigraphy, breath = test or=20 wireless capsule motility)=20
- Water or nutrient beverage tests: evaluate = response to=20 drinking 30 ml of Ensure per minute: maximum tolerated volume and = fullness,=20 satiety, bloating, nausea, and pain

Red Flags

Following are indications for endoscopy in = patients with=20 dyspepsia=20
- Dysphagia=20
- Bleeding=20
- Weight loss > 5 kg
- Epigastric mass=20
- Hepatomegaly=20
- Supraclavicular lymphadenopathy=20

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Best=20 Therapy

Therapy is often difficult; antacids, = H₂=20 blockers, and proton pump inhibitors are often ineffective=20
Eradication of H. pylori not indicated, = although=20 it may be treated because of concern with development of atrophy or = gastric=20 cancer=20
Reassurance: there is no mortality from = dyspepsia once=20 malignancy is excluded=20
Prokinetic agents (e.g., metoclopramide) = indicated when=20 gastric emptying is delayed=20
Antidepressants at low dose (tricyclic agents) = may be=20 beneficial; formal trials are needed

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Best References

Bramble, et al: Gut 46:464, 2000 [PMID=20 10716673]

Delaney, et al: Cochrane Database Syst Rev = (3):CD001961,=20 2001 [PMID=20 11687004]

Danesh, et al: Arch Intern Med 160:1192, 2000 [PMID=20 10789614]

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The authors and editors gratefully acknowledge the contributions of = the=20 previous author, Michael Camilleri, MD, to the development and writing = of this=20 module.

February=20 2009

=A9 2009 BC Decker Inc. 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