Dyspepsia (cont.)
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.
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