Jay W. Marks, MD, is a board-certified internist and gastroenterologist. He graduated from Yale University School of Medicine and trained in internal medicine and gastroenterology at UCLA/Cedars-Sinai Medical Center in Los Angeles.
Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.
Dyspepsia is diagnosed primarily on the basis of typical symptoms and the
exclusion of non-functional gastrointestinal diseases (including acid-related
diseases), non-gastrointestinal diseases, and psychiatric illness. There are
tests for identifying abnormal gastrointestinal function directly, but they are
limited in their ability to do so.
Exclusion of other diseases
Exclusion of non-functional gastrointestinal disease
As always, a detailed history from the patient and a physical examination frequently will suggest the cause of dyspepsia. Routine screening blood tests often are performed looking for clues to unsuspected diseases. Examinations of stool also are a part of the evaluation since they may reveal infection, signs of inflammation, or blood and direct further diagnostic testing. Sensitive stool testing (antigen/antibody) for
Giardia lamblia would be reasonable because this parasitic infection is common and can be acute or chronic. Some physicians do blood testing for
celiac disease (sprue), but the value of doing this is unclear. (Moreover, if an
EGD is planned, biopsies
of the duodenum usually will make the diagnosis of celiac disease.) If bacterial
overgrowth of the small intestine is being considered, breath hydrogen testing can be considered.
There are many tests to
exclude non-functional gastrointestinal diseases. The primary issue, however, is
to decide which tests are reasonable to perform. Since each case is individual,
different tests may be reasonable for different patients. Nevertheless, certain
basic tests are often performed to exclude non-functional gastrointestinal
disease. These tests identify anatomic (structural) and histological
(microscopic) diseases of the esophagus, stomach, and intestines.
Both x-rays and endoscopies can identify anatomic diseases. Only endoscopies,
however, can diagnose histological diseases because biopsies (samples of tissue)
can be taken during the procedure. The x-ray tests include:
The esophagram and video-fluoroscopic swallowing
study for examining the esophagus
The upper gastrointestinal series for examining the
stomach and duodenum
The small bowel series for examining the small
intestine
The barium enema for examining the colon and terminal ileum.
Upper gastrointestinal endoscopy
(esophago-gastro-duodenoscopy or EGD) to examine the esophagus, stomach and
duodenum
Colonoscopy to examine
the colon and terminal ileum
Endoscopy also is available to examine the small intestine, but this type
of endoscopy is complex, not widely available, and of unproven value in
dyspepsia.
For examination of the small intestine, there is also a capsule containing a tiny
camera and transmitter that can be swallowed (capsule
endoscopy). As the capsule travels through the
intestines, it transmits pictures of the inside of the intestines to an external
recorder for later review. The capsule is not widely available and its value,
particularly in dyspepsia, has not yet been proven.
X-rays are easier to perform and less costly than endoscopies. The skills necessary
to perform gastrointestinal x-rays, however, are becoming rare among radiologists
because they are doing them less often. Therefore, the quality of the x-rays
often is not as high as it used to be, and, as a result, CT scans of the small intestine are replacing small intestinal x-rays. As noted previously, endoscopies have an
advantage over x-rays since at the time of endoscopies, biopsies can be taken to
diagnose or exclude histological diseases, something that x-rays cannot do.
Exclusion of acid-related gastrointestinal diseases
Because they are so
common, the most important non-functional gastrointestinal diseases to exclude
are acid-related diseases that cause inflammation and ulceration of the
esophagus, stomach, and duodenum. Infection of the stomach with Helicobacter
pylori, an infection that is closely associated with some acid-related diseases,
is included in this group. It is not clear, however, how often Helicobacter
pylori causes dyspepsia. Moreover, the only way of excluding this bacterium as a
cause of dyspepsia in a particular patient is by eliminating the infection (if
it is present) with appropriate antibiotics. If dyspepsia is substantially
improved by eradication, it is likely that the bacterium was responsible.
Helicobacter pylori infection can also be diagnosed (or excluded) by blood
tests, biopsy of the stomach, urea breath test, or a stool test.
Endoscopy is a good way of diagnosing or excluding
acid-related inflammation. If no signs of inflammation are present, acid-related diseases are
unlikely. Nevertheless, some patients without signs of inflammation respond to potent
and prolonged suppression of acid, suggesting that acid is causing their
dyspepsia. Therefore, many physicians will use potent suppression of acid in dyspepsia as
a means to both treat and diagnose. Thus, if dyspepsia improves
substantially (more than 50% to 75%) with suppression of acid, they consider it likely that acid is
responsible for the dyspepsia. For this purpose, it is important to use potent
acid suppression with proton pump inhibitors (PPIs), such as:
Treatment often is given at higher than
recommended doses for 12 weeks or more before a decision is made about the
effect of treatment on the symptoms. (A short course for just a few days or
weeks is not enough.) If the symptoms of dyspepsia do not improve, it even may
be reasonable to check the amount of acid produced by the stomach (and also the
reflux of acid into the esophagus) by 24 hour ph monitoring to be certain that
the acid-suppressing drugs are effectively suppressing acid. (Up to 10% of
patients are resistant to the effects of even the PPIs.)
Exclusion of non-gastrointestinal disease
Patients with dyspepsia often
undergo abdominal ultrasonography (US), computerized tomography (CT or CAT
scans), or magnetic resonance imaging (MRI). These tests are used primarily to
diagnose non-intestinal diseases. (Although the tests also are capable of
diagnosing intestinal diseases, their value for this purpose is limited. X-ray
and endoscopy are better.) It is important to realize that US, CT, and MRI are
powerful tests and may uncover abnormalities that are unrelated to dyspepsia.
The most common example of this is the finding of gallstones that, in fact, are
causing no symptoms. (Up to 50% of gallstones cause no symptoms.) This can cause
a problem if the gallstones are assumed to be causing the dyspepsia. Surgical
removal of the gallbladder with its gallstones (cholecystectomy) is unlikely to
relieve the dyspepsia. (Cholecystectomy would be expected to relieve only the
characteristic symptoms that gallstones can cause.) Additional tests to exclude
non-gastrointestinal diseases may be appropriate in certain specific situations,
although certainly not in most patients.
Exclusion of psychiatric disease
The possibility of psychiatric
(psychological or psychosomatic) illness often arises in patients with dyspepsia
because the symptoms are subjective and no objective abnormalities can be
identified. Psychiatric illness may complicate dyspepsia, but it is unclear if
psychiatric illness causes dyspepsia. If there is a possibility of psychiatric
illness, a psychiatric evaluation is appropriate.
Abdominal pain is pain in the belly and can be acute or chronic. Causes include inflammation, distention of an organ, and loss of the blood supply to an organ. Abdominal pain can reflect a major problem with one of the organs in the abdomen such as the appendix, gallbladder, large and small intestine, pancreas, liver, colon, duodenum, and spleen.
Gallstones are stones that form when substances in the bile harden. Gallstones (formed in the gallbladder) can be as small as a grain of sand or as large as a golf ball. There can be just one large stone, hundreds of tiny stones, or any combination. The majority of gallstones do not cause symptoms.
Anxiety is a feeling of apprehension and fear characterized by physical symptoms. Anxiety disorders are serious medical illnesses that affect approximately 19 million American adults.
Gas or "intestinal gas" means different things to different people. Everyone has gas and eliminates it by belching or farting (passing it through the rectum).
GERD (gastroesophageal reflux disease) is a condition in which the acidified liquid
contents of the stomach backs up into the esophagus. The symptoms of uncomplicated GERD are heartburn,
regurgitation, and nausea. Effective treatment is available for most patients with GERD.
Diabetes mellitus is a chronic condition characterized by high levels of sugar (glucose) in the blood. The two types of diabetes are referred to as type 1 (insulin dependent) and type 2 (non-insulin dependent). Symptoms of diabetes include increased urine output, thirst, hunger, and fatigue. Treatment of diabetes depends on the type.
Nausea is an uneasiness of the stomach that often precedes vomiting. Nausea and vomiting are not diseases, but they are symptoms of many conditions. The causes of vomiting differ according to age, and treatment depends upon the cause of nausea and vomiting.
Stress occurs when forces from the outside world impinge on the individual. Stress is a normal part of life. However, over-stress, can be harmful. There is now speculation, as well as some evidence, that points to the abnormal stress responses as being involved in causing various diseases or conditions.
Depression is an illness that involves the body, mood, and thoughts and affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. The principal types of depression are major depression, dysthymia, and bipolar disease (also called manic-depressive disease).
Ulcerative colitis is a chronic inflammation of the colon. Symptoms include abdominal pain, diarrhea, and rectal bleeding. Ulcerative colitis is closely related to Crohn's disease, and together they are referred to as inflammatory bowel disease. Treatment depends upon the type of ulcerative colitis diagnosed.
In lactose intolerance, the digestive system cannot digest lactose (the main sugar in milk). Symptoms of lactose intolerance include diarrhea, flatulence, abdominal pain, abdominal bloating, abdominal distention, and nausea. There are several tests to diagnose lactose intolerance. Treatment is generally made with dietary changes, supplements, and adaptation to small amounts of milk.
IBS (irritable bowel syndrome) is a common gastrointestinal disorder involving abnormal gut contractions (motility) characterized by abdominal pain,
bloating, mucous in stools, and irregular bowel habits with alternating diarrhea
and constipation, symptoms that tend to be chronic and to wax and wane over the
years. Treatment options include medication and lifestyle changes such as diet, exercise, and stress management to control symptoms. Also called spastic colitis, mucus colitis, nervous colon syndrome.
Normal vaginal bleeding (menorrhea) occurs through the process of menstruation. Abnormal vaginal bleeding in women who are ovulating regularly most commonly involves excessive, frequent, irregular, or decreased bleeding. Causes of abnormal may arise from a variety of conditions.
Helicobacter pylori (H. pylori) is a bacterium that causes chronic inflammation (gastritis) of the inner lining of the stomach in humans. This bacteria also is the most common cause of ulcers worldwide.
Chest pain is a common complaint by a patient in the ER. Causes of chest pain include broken or bruised ribs, pleurisy, pneumothorax, shingles, pneumonia, pulmonary embolism, angina, heart attack, costochondritis, pericarditis, aorta or aortic dissection, and reflux esophagitis. Diagnosis and treatment of chest pain depends upon the cause and clinical presentation of the patient's chest pain.
Small intestinal bacterial overgrowth (SIBO) refers to a condition in which abnormally large numbers of bacteria (at least 100,000 bacteria per ml of fluid) are present in the small intestine and the types of bacteria in the small intestine resemble more the bacteria of the colon than the small intestine. There are many conditions associated with small intestinal bacterial overgrowth, to include: diabetes, scleroderma, Crohn's disease, and others. There is a striking similarity between the symptoms of irritable bowel syndrome and SIBO. It has been theorized that SIBO may be responsible for the symptoms of at least some patients with irritable bowel syndrome. Symptoms of SIBO include: excess gas, abdominal bloating, diarrhea, and abdominal pain.
Learn about osteoporosis, a condition characterized by the loss of bone density, which leads to an increased risk of bone fracture. Unless one experiences a fracture, a person may have osteoporosis for decades without knowing it. Treatment for osteoporosis may involve medications that stop bone loss and increase bone strength and bone formation, as well as quitting smoking, regular exercise, cutting back on alcohol intake, and eating a calcium- and vitamin D-rich balanced diet.
A peptic ulcer is an ulcer in the lining of the stomach, duodenum, or esophagus. Ulcer formation is related to Helicobacter pylori bacteria in the stomach, use of anti-inflammatory medications, and cigarette smoking.
Gastritis is an inflammation of the stomach lining. Causes of gastritis include drinking too much alcohol, medications such as NSAIDs, ibuprofen, aspirin, H. pylori infection, severe infections, burns, anemia, and autoimmune disorders. Gastritis is diagnosed with endoscopy, blood tests, or stool tests. Treatment depends upon the cause of gastritis.
The major goal in treating diabetes is controlling elevated blood sugar without causing abnormally low levels of blood sugar. Treatment for type 1 diabetes is with insulin, exercise, and a diabetic diet. Treatment for type 2 diabetes is first treated with weight reduction, a diabetic diet, and exercise. When these measures fail to control the elevated blood sugar, oral medications are used. If oral medications are still insufficient, insulin medications are considered.
Menstruation (menstrual cycle) is also referred to as a "period." When a woman menstruates, the lining of the uterus is shed. This shedding of the uterine linking is the menstrual blood flow. The average menstrual cycle is 28 days. There can be problems with a woman's period, including heavy bleeding, pain, or skipped periods. Causes of these problems may be amenorrhea (lack fo a period), menstrual cramps (dysmenorrhea), or abnormal vaginal or uterine bleeding. There are a variety of situations in which a girl or woman should see a doctor about her menstrual cycle.
Managing your diabetes is important. The goal of diabetic therapy is to control blood glucose levels and prevent the complications of diabetes. Information about exercise, diet diet, and medication will help you manage your diabetes better. Blood glucose reagent strips, blood glucose meters, urine glucose tests, tests for urinary ketones, continuous glucose sensors, and Hemoglobin A1C testing information is also provided in this article.
In hypoparathyroidism, the parathyroid gland does not produce enough parathyroid hormone. Causes of hypoparathyroidism include injury to the parathyroid glands, autoimmune disorder association, or may be present ab birth. Symptoms of hypoparathyroidism include: tingling fingers, toes, and lips, brittle nails, dry, coarse skin, dry hair; memory loss, headaches, severe muscle cramps, cataracts, malformed teeth, and convulsions. Treatment of hypoparathyroidism is to restore the calcium and phosphorus to normal levels in the body.
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