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ABC of the upper gastrointestinal tract
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Patients often complain of indigestion, but what do they mean? Indigestion is an old English word that means lack of adequate digestion, but patients and doctors interpret this in different ways. Many patients mean heartburn or acid regurgitation, the classic symptoms of gastro-oesophageal reflux disease. Some describe belching, abdominal rumblings, or even bad breath as indigestion. Others mean pain localised to the epigastrium or a non-painful discomfort in the upper abdomen which may be described as fullness, bloating, or an inability to finish a normal meal (early satiety). Dyspepsia is best restricted to mean pain or discomfort centred in the upper abdomen.

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  • Chronic peptic ulcer (duodenal or gastric)

  • Gastro-oesophageal reflux disease (>50% have no oesophagitis)

  • Gastric or oesophageal adenocarcinoma (rare but of concern for patient and doctor)

There are many causes of dyspepsia, but at least two thirds of patients have no structural or biochemical explanation for their symptoms. It has been suggested that dyspepsia can be subdivided based on groups (or clusters) of symptoms. However, subgroups have not proved to be of value in identifying the underlying cause of dyspepsia and overlap considerably. Some patients report having troublesome burping associated with abdominal bloating or discomfort that is transiently relieved by bringing up the wind. These patients have aerophagy, and repeated swallowing of air may be obvious during the consultation.

Causes of dyspepsia

History taking is key to identifying the likely cause of dyspepsia.

Gastro-oesophageal reflux disease

It is important and practical to distinguish gastro-oesophageal reflux disease (GORD) from dyspepsia. Frequent heartburn is a cardinal symptom of GORD; acid reflux causes a retrosternal or epigastric burning feeling that characteristically radiates up towards the throat, is relieved transiently the 1 last update 15 Jul 2020 by antacids, and is precipitated by a meal or by lying down. It is important and practical to distinguish gastro-oesophageal reflux disease (GORD) from dyspepsia. Frequent heartburn is a cardinal symptom of GORD; acid reflux causes a retrosternal or epigastric burning feeling that characteristically radiates up towards the throat, is relieved transiently by antacids, and is precipitated by a meal or by lying down.

Uncommon causes of upper abdominal pain or discomfort that may be confused with dyspepsia

  • Aerophagy (repetitive belching from air swallowing)

  • Biliary colic from gall stones

  • Abdominal wall pain (a clinical clue is localised tenderness on palpation the 1 last update 15 Jul 2020 not reduced by tensing the abdominal wall muscles)Abdominal wall pain (a clinical clue is localised tenderness on palpation not reduced by tensing the abdominal wall muscles)

  • Chronic pancreatitis (episodic dull steady upper the 1 last update 15 Jul 2020 abdominal pain that may be aggravated by meals and radiate through to the back)Chronic pancreatitis (episodic dull steady upper abdominal pain that may be aggravated by meals and radiate through to the back)

  • Malignancy (such as of pancreas or colon)

  • Mesenteric vascular insufficiency (postprandial pain, weight loss, and a fear of eating)

  • Angina

  • Metabolic disease (such as diabetes, renal failure, hypercalcaemia)

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Conditions to be recognised from a patient''t repeat tests without good reason

  • Heartburn Remedies Foods That Can Help (πŸ‘ Foods To Avoid) | Heartburn Remedies Natural Remedies Forhow to Heartburn Remedies for Determine the patient''s history with a judicious approach to testing is necessary. Older patients or those with alarm features warrant prompt referral for endoscopy and further investigations as required. Testing for H pylori infection will help in guiding management in the remainder; between 20% and 60% of those with H pylori infection will have peptic ulcer disease.

    For patients with H pylori infection, one course of action is to refer them for endoscopy to determine who has peptic ulcer disease or functional dyspepsia (the two main considerations) and plan treatment accordingly (the “test and endoscope” strategy). Alternatively, a reasonable course of action is to treat infected patients with appropriate antibiotics and observe the clinical course (the “test and treat” strategy). Although treatment of infection may not cure functional dyspepsia (see below), it will usually eliminate the peptic ulcer diathesis and hence will often relieve the symptoms. Moreover, recent trials suggest that “test and treat” is a safe and cost effective strategy that results in a long term outcome similar to that with a strategy of prompt endoscopy. Hence, “test and treat” has been gaining widespread acceptance.

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    Reassurance and explanation remain the key elements in managing documented or suspected functional dyspepsia. Patients should be advised that this is a real condition and that their symptoms are not imaginary. Furthermore, they should be advised that the condition never leads to cancer or other serious disease. Patients''s response to treatment if a predominant symptom can be identified, but relying on clusters of symptoms is generally not useful.

    Treatment for functional dyspepsia

    Initial treatment

    • Antisecretory drug (H2 receptor blocker, proton pump inhibitor)

    • for 1 last update 15 Jul 2020 oror

    • Prokinetic drug (domperidone) if antisecretory treatment fails

    • Switch treatment if first drug type fails

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    Resistant cases (failed initial treatment)

    • H pylori eradication

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    • Antispasmodic agent (such as mebeverine)

    • Antidepressant (such as selective serotonin reuptake inhibitor or tricyclic drug)

    • Behavioural therapy or psychotherapy

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    H2 receptor blockers are, at best, of only modest efficacy in functional dyspepsia. While some trials suggest that they are superior to placebo, other trials have not shown any additional benefit. Proton pump inhibitors are more efficacious than placebo in functional dyspepsia (by about 10-20%), but not in the subgroup of patients with dysmotility-like dyspepsia.

    Heartburn Remedies Foods For Acid Reflux (πŸ”₯ Heartburn Relief) | Heartburn Remedies Foods To Eat And Avoidhow to Heartburn Remedies for If a patient fails to respond to an antisecretory drug after four weeks, it is reasonable to consider increasing the dose or switching to an alternative or a prokinetic drug. If the patient has failed to respond after eight weeks, then it is reasonable to refer the case to a specialist for further evaluation.

    When to consider referring a dyspeptic patient to a specialist

    • If prompt investigation is required (such as recent onset of alarm symptoms)

    • Severe pain

    • Failure of symptoms to resolve or substantially improve after appropriate treatment

    • Progressive symptoms

    Eradicating H pylori infection cures functional dyspepsia in only a minority of cases. A meta-analysis has suggested a small therapeutic gain over 12 months follow up (15 needed to be treated to cure one case). Whether sucralfate or bismuth is better than placebo in treating functional dyspepsia is unclear, but it is unlikely; misoprostol may actually aggravate symptoms and cause diarrhoea in some patients.

    Long term management

    Heartburn Remedies How To Naturally Treat (πŸ‘ Quick Relief) | Heartburn Remedies Foods That Fight Hearbturnhow to Heartburn Remedies for Functional dyspepsia is generally a relapsing and remitting condition. Treatment should not be prolonged, and frequent drug holidays should be prescribed. In patients with symptoms that are difficult to control a trial of an antispasmodic or antidepressant may be useful, but specialist referral to confirm the diagnosis and exclude rare causes of dyspepsia should first be considered. Some patients will benefit from behavioural therapy or psychotherapy.

    Aerophagy

    Air swallowing is often extremely resistant to treatment. Options include avoidance of chewing gum, aerated drinks, and smoking; use of anti-gas agents (such as activated dimeticone or charcoal); and relaxation therapy. However, no treatment is of proved benefit, and anti-gas agents are no better than placebo.

    ​

    Overlap of subgroups of dyspepsia based on symptoms in patients with documented functional dyspepsia

    Prevalence of “alarm” symptoms in patients with gastric cancer

    Antral erythema and erosions in patient with functional dyspepsia

    Pathogenesis of functional dyspepsia

    Results of systematic review comparing H pylori eradication treatment for non-ulcer dyspepsia with for 1 last update 15 Jul 2020 placeboResults of systematic review comparing H pylori eradication treatment for non-ulcer dyspepsia with placebo

    Algorithm for management of the 1 last update 15 Jul 2020 functional dyspepsiaAlgorithm for management of functional dyspepsia

    Empiric treatment for functional the 1 last update 15 Jul 2020 dyspepsiaEmpiric treatment for functional dyspepsia

    Acknowledgments

    The graph of prevalence of alarm symptoms in patients with gastric cancer is adapted from Gillen D, McColl KE. Am J Gastroenterol 1999;94:75-9. The forest plot comparing H pylori eradication treatment with placebo is reproduced from Moayyedi P, et al. BMJ 2000;321:659-64.

    Footnotes

    Nicholas J Talley is professor of medicine, Nghi Phung is a gastroenterologist, and Jamshid S Kalantar is a staff specialist in gastroenterology, department of medicine, University of Sydney, Nepean Hospital, Penrith, New South Wales, Australia.

    The ABC of the upper gastrointestinal tract is edited by Robert Logan, senior lecturer in the division of gastroenterology, University Hospital, Nottingham; Adam Harris, consultant physician and gastroenterologist, Kent and Sussex Hospital, Tunbridge Wells; J J Misiewicz, honorary consultant physician and joint director of the department of gastroenterology and nutrition, Central Middlesex Hospital, London; and J H Baron, honorary professorial lecturer at Mount Sinai School of Medicine, New York, USA, and former consultant gastroenterologist at St Mary's Hospital, London.


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