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.
What is a reasonable approach to the diagnosis and treatment of dyspepsia (indigestion)?
The initial approach to dyspepsia, whether it be treatment or testing,
depends on the patient's age, symptoms and the duration of the symptoms. If
the patient is younger than 50 years of age and serious disease, particularly
cancer, is not likely, testing is less important. If the symptoms are typical
for dyspepsia and have been present for many years without change, then there is
less need for testing, or at least extensive testing, to exclude other
gastrointestinal and non-gastrointestinal diseases.
On the other hand, if the symptoms are of recent onset (weeks or months),
progressively worsening, severe, or associated with "warning" signs, then
early, more extensive testing is appropriate. Warning signs include
loss of
weight, nighttime awakening, blood in the stool or the material that is vomited
(vomitus), and signs of inflammation, such as
fever or abdominal tenderness.
Testing also is appropriate if, in addition to symptoms of dyspepsia, there are
other prominent symptoms that are not commonly associated with dyspepsia.
If there are symptoms that suggest conditions other than dyspepsia, tests
that are specific for these diseases should be done first. The reason is that if
these other tests disclose other diseases, it may not be necessary to do
additional testing. Examples of such symptoms and possible testing include:
Vomiting: upper gastrointestinal endoscopy to diagnose inflammatory or
obstructing diseases; gastric emptying studies and/or electrogastrography to
diagnose impaired emptying of the stomach.
Abdominal distention with or without increased flatulence: upper
gastrointestinal and small intestinal x-rays to diagnose obstructing diseases;
hydrogen breath testing to diagnose bacterial overgrowth of the small intestine.
For a patient with typical symptoms of dyspepsia who requires testing to
exclude other diseases, a standard screening panel of blood tests would
reasonably be included. These tests might reveal clues to non-gastrointestinal
diseases. 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. A plain x-ray of the abdomen might be done during an episode of
abdominal pain (to look for intestinal blockage or obstruction). Testing for
lactose intolerance or a trial of a strict lactose-free diet should be
considered. The physician's clinical judgment should determine the extent to
which initial testing is appropriate.
Once testing has been done to an extent that is appropriate for the clinical
situation, it is reasonable to first try a therapeutic trial of stomach acid
suppression to see if symptoms improve. Such a trial probably should involve a
PPI (proton pump inhibitor) for 8 to 12 weeks. If there is no clear response of
symptoms, the options then are to discontinue the PPI or confirm its
effectiveness in suppressing acid with 24 hour acid testing. If there is a clear
and substantial decrease in symptoms with the PPI, then decisions need to be
made about continuing acid suppression and which drugs to use.
Another therapeutic approach is to test for Helicobacter pylori infection of
the stomach (with blood, breath or stool tests) and to treat patients with
infection to eradicate the infection. It may be necessary to retest patients
after treatment to prove that treatment has effectively eradicated the
infection, particularly if dyspeptic symptoms persist after treatment.
If treatment with a PPI has satisfactorily suppressed acid according to acid
testing (or acid suppression has not been measured) and yet the symptoms have
not improved, it is reasonable to conduct further testing as described above.
Esophago-gastro-duodenoscopy, or EGD, (and, possibly, colonoscopy) would be the
next consideration, probably with multiple biopsies of the stomach and duodenum
(and colon if colonoscopy is done). Finally, small intestinal x-rays and an
ultrasound examination of the gallbladder might be done. An abdominal ultrasound
examination, CT scan, or MRI scan can exclude non-gastrointestinal diseases.
Once appropriate testing has been completed, empiric trials of other drugs
(for example, smooth muscle relaxants, psychotropic drugs, and promotility drugs) can
be done. (An empiric trial of a drug is a trial that is not based on an
understanding of the exact cause of the symptoms)
If all of the appropriate testing reveals no disease that could be causing
the symptoms and the dyspeptic symptoms have not responded to empiric
treatments, other, more specialized tests should be considered. These tests
include hydrogen breath testing to diagnose bacterial overgrowth of the small
intestine, gastric emptying studies, EGG, small intestinal transit studies, and
antro-duodenal motility and barostatic studies. These specialized studies
probably should be done at centers that have experience and expertise in
diagnosing and treating functional diseases.
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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