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Approach to the patient with dyspepsia

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Montasir Ahmed

on 25 May 2016

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Transcript of Approach to the patient with dyspepsia

Approach to patient with dyspepsia
Dyspepsia is a
common symptom
with an
extensive differential diagnosis
and a heterogeneous pathophysiology.

It occurs in approximately
25 percent
of the population each year, but most affected people do not seek medical care .

Although dyspepsia does not affect survival, it is responsible for substantial
health care costs
and significantly affects
quality of life
.
DEFINITION —
According to the Rome III criteria, dyspepsia is defined as one or more of the following symptoms :

1. Postprandial fullness
(classified as postprandial distress syndrome)
2. Early satiation
(inability to finish a normal sized meal, also classified as postprandial distress syndrome)
3. Epigastric pain or burning
(classified as epigastric pain syndrome)

ETIOLOGY
— Approximately
25
percent of patients with dyspepsia have an underlying organic cause.
However, up to
75
percent of patients have functional (idiopathic or nonulcer) dyspepsia with no underlying cause on diagnostic evaluation.
Dyspepsia caused by structural or biochemical disease

Upper GIT disorders:

Peptic ulcer disease;
Acute gastritis;
Esophageal spasm;
Non ulcer dyspepsia(functional)





Functional dyspepsia



Functional (idiopathic or nonulcer) dyspepsia is defined as the presence of one or more of the following:
postprandial fullness,
early satiation, epigastric pain or burning, and no evidence of structural disease to explain the symptoms .

These criteria should be fulfilled for the last three months with symptom onset at least six months before diagnosis.

A diagnosis of functional dyspepsia can therefore only be established exclusion of other causes of dyspepsia
INITIAL EVALUATION
History
— A detailed history is necessary to narrow the differential diagnosis and to identify GERD and NSAID-induced dyspepsia, as well as patients with alarm features.

Alarm features
in dyspepsia

Age
older than 55 years with new-onset dyspepsia

Family history
of upper gastrointestinal cancer
Unintended
weight loss
Gastrointestinal
bleeding
Progressive
dysphagia

Odynophagia
Unexplained
iron deficiency
anemia
Persistent
vomiting
Palpable
mass or lymphadenopathy

Jaundice

DIAGNOSTIC STRATEGIES

The approach to and extent of diagnostic evaluation of a patient with dyspepsia is based on the presence or absence of alarm features , patient age, and the local prevalence of Helicobacter pylori ( H. pylori ) infection.
Helicobacter pylori infection globally
EVALUATION OF PERSISTENT SYMPTOMS — Despite the approaches , some patients continue to have symptoms of dyspepsia.

Patients with continued symptoms of dyspepsia fall into the following categories:
patients with persistent H. pylori infection
,
patients with an alternate diagnosis
,
patients with functional dyspepsia
.
Patient without alarm features and age ≤55 years
— The two main strategies in patients ≤55 years without alarm features are to test and treat for H. pylori and to provide empiric antisecretory therapy.
Complications
: mild dyspepsia does not causes any complications vastly.
But severe dyspepsia may cause some complications.
such as
Esophageal stricture
Pyloric stenosis
Peritonitis

B.
Antacid
(acid neutralizers)
C.
H 2 receptor blockers
: they reduce the level of stomach acids, and last longer than antacids
D.
PPIs
: PPIs are very effective in GERD and PUD .they reduce stomach acid and stronger than H2 blocker
E.
Pro kinetics
: they are helpful if the stomach empty slowly
F.
Antibiotics
: if there is an infection caused by H.pylori. (amoxicillin ,clarithromycin)
G.
Anti Depressant
: it sometimes ease the discomfort by reducing the patients pain

Treatment :
Usually treatment is depends on what is causing it? And how severe symptoms are.



Advice:
Stop smoking
Avoid irritating food which irritates stomach
Reduce stress in life
If patient have acid reflux ,don’t take food at bed time
Don’t not use a lot of anti inflammatory medicines

Other investigations:
Blood test :
if patient have any symptoms of anaemia

Test to diagnosis helicobacter pylori infection:
these may includes urea breath test, a stool antigen test, a blood test

Liver function test:
if patient has symptoms of liver disease

X ray :
usually upper GIT and small bowels
Abdominal ultra sounds and CT scans


Clusters of symptoms are used to classify dyspepsia:
Reflux like dyspepsia(heartburn predominant dyspepsia)
Ulcer lke dyspepsia(epigastric pain relieved by food or antacids)
Dysmotility like dyspepsia(nausea,belching,bloating and premature satiety)

Mr. Ranju,19 years , MMW 11

Known case of Haemoglobin E beta thalassemia

Complaining about dyspepsia

Multiple gall stones discovered in ultrasonogram.
Mr. Topon Sarkar,53 years ,Ex cabin 107

seeking advice for abdominal pain ,fullness ,bloating.

Later he diagnosed as chronic kidney disease

Mr.Mahfuzul,59 years ,MMW bed 03

Superior venacaval obstruction due to bronchogenic carcinoma(small cell ca.)

Etymology: The word dyspepsia is form the GREEK dys=bad/difficult and pepsis=digestion.

Indigestion is usually caused by stomach acid coming into contact with the mucosa of the protective lining of the digestive system. Stomach acid break down the mucosa causing irritation and inflammation which trigger the symptoms of indigestion.


Loss of appetite
Other gastrointestinal disorders:
Pancreatic disease; colonic carcinoma; Hepatic disease(hepatitis)

Systemic disease:
Renal failure; Hypercalcemia; Coronary disease; DM

Drugs:
NASIDS; corticosteroids; iron and potassium ; digoxin; antibiotics; Anti Diabetic drugs(metformin); ACEIs

Others:
Psychological

There is no sincerer love than the love of food.

George Bernard Shaw
"One cannot think well, love well,
sleep well,
if one has not dined well."

-Virginia Woolf
Welcome
Functional” dyspepsia Up to 60 percent



Peptic ulcer disease 15 to 25 percent



Reflux esophagitis 10 to 15 percent



Gastric or esophageal cancer < 2 percent
Physical examination
A guided physical examination should be performed.
Appearance, body build
Anaemia
Jaundice
Clubbing
Cyanosis
Oedema
Fever
Thyroid
Lymph nodes
Skin changes in GIT diseases
Psychosomatic and cognitive factors
are important in the evaluation of patients with chronic dyspepsia (6 months).
The
psychiatric hypothesis
holds that the symptoms of dyspepsia may be due to depression ,anxiety, or a somatization disorders.
Epidemiologic studies suggest, there is an
association between functional dyspepsia and psychological disorders
.
Symptoms of
neurosis ,anxiety ,hypochondriasis and depression
are more common in patients being evaluated for unexplained GIT complains than healthy controls.

Dyspepsia affects up to
80%
of the populations at some times in life and many have no serious underlying disease.
Etymology:
The word dyspepsia is form the GREEK
dys=bad/difficult
and
pepsis=digestion
.

Indigestion is usually caused by stomach acid coming into contact with the mucosa of the protective lining of the digestive system. Stomach acid break down the mucosa causing irritation and inflammation which trigger the symptoms of indigestion.

Loss of appetite
Abdominal pain and discomfort
Heart burn
Department of Medicine, TMC & RCH
Informed consent were obtained from patients for using their demographic details, images and videos.
Medicolegal issue
MMW bed 17,
Patient admitted into RCH with complains of upper abdominal pain related with taking food ,nausea and vomiting,burning sensation in centre of the chest with no radiations, abdominal fullness and bloating. Occasional constipation.later he diagnosed as PUD
He was prescribed "Triple therapy" and a prokinetic agent but symptoms did not resolved fully.

Adding TCA alleviated symptoms.
How our patients presents
Treatment
Different people,
different treatment.
-Optimus prime, Transformers
Mr. Khokon, 30 years,businessman, smoker, used to take lunch in restaurants.

Presented with abdominal discomfort, early satiety.

Dietary advice and PPI make him feel better.
A.
Diet and lifestyle modifications
: if patients symptoms are mild and indigestion not occurring often ,some lifestyle modifications probably ease symptoms. This usually involves consuming less fatty foods ,less caffeine , alcohol , and chocolates, sleeping at least 7 hours every nights,and avoiding spicy foods.
Mr. Abu Bakkar, 55 years presented with heartburn, abdominal pain, occasional vomiting.

Duodenal ulcer was evident on endoscopy.

Change in lifestyle and triple therapy was advised.
Dyspepsia or pyrosis complicates up to
80% of pregnancies
;
gastroesophageal reflux disease (GERD) is almost as common.

The causes include decreased motility of the GI during gestation and an increase in intra-abdominal pressure by the enlarging uterus, which in some patients, may even cause the cardial valve to herniate above the diaphragm.
Heartburn
Presenting complaints
Past illness
Treatment history
Family history
Socioeconomic condition
Dietary habit
Life style
Full transcript