REVIEW ARTICLES
EVALUATION AND MANAGEMENT OF DYSPEPSIA – CURRENT PERSPECTIVES
KL Goh, MBBS (Mal), FRCP (Glasg), FRCP (London), MD, FACG
Professor of Medicine, University of Malaya, Kuala Lumpur, Malaysia
Address for correspondence: Professor Goh Khean Lee, Department of Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia. Fax: 603 7955 6936, Email: gohkl@um.edu.my
Conflict of Interest: None declared
Key points
- Spend time taking a good history and performing a physical examination even though the majority of patients have “functional” symptoms. Exclude “non-dyspepsia” conditions and be careful in excluding a “surgical” abdomen.
- Consider gastroscopy or an ultrasound or CT scan of the abdomen, if alarm symptoms are present. The threshold to investigate should be lower with older male patients as there is a higher chance of organic disease.
- When patients’ symptoms are unclear, a close follow-up and review is useful. Symptoms persisting over many months or years are unlikely to have an organic basis.
- Explore, understand and address patients’ concerns including psychological problems. Patients need to be reassured.
- Sensible advice on food/meal and lifestyle modifications is useful. Antacids often give immediate relief to acute dyspeptic symptoms. Gastroesophageal reflux symptoms may be atypical - a trial of PPI therapy may be useful. Patients with wind, bloating and discomfort often benefit from a course of prokinetic agents.
INTRODUCTION
Dyspepsia is a common yet poorly understood problem. In the majority of cases, no underlying structural abnormality can be identified and it then becomes a frustrating problem for both patients, who expect an explanation for their discomfort and doctors, who do not know what to do for these patients. Symptoms can be severe and occasionally incapacitating and it cannot be dismissed as a trivial problem. Taking into account the costs of doctor consultations, medications and utilization of healthcare services, impairment of work performance and absenteeism from work, dyspepsia is indeed a burden to society.1
How prevalent is dyspepsia?
Dyspepsia is one of the most common complaints of patients attending a primary care clinic and constitutes at least 40% of cases in a gastroenterology practice.2 Consulters however form a small proportion of the total; a large proportion, perhaps 70% of dyspeptics do not consult doctors but self-medicate with antacids or other medications that can be purchased “over the counter”.3 Cross-sectional surveys performed on a Western population show that approximately 25% of the general population have recurrent dyspepsia over a 12-month period.3-9 Data on Asians although sparse but show similar figures.10-13
Definition of dyspepsia
There are numerous definitions of dyspepsia and patients and doctors often use it to mean different things. Many refer to any discomfort or pain in the abdomen as dyspepsia. The best definition is probably that of an International Working Party in 1991 who defined dyspepsia broadly as pain or discomfort centered in the upper abdomen.14
Dyspepsia can be divided into organic and functional dyspepsia (FD). Organic dyspepsia refers to peptic ulcer disease, gastric cancer, oesophagitis or other structural abnormalities in the upper gastrointestinal tract. The great majority of patients varying from 50-90% of patients suffer from what is termed as functional or non-ulcer dyspepsia. Functional dyspepsia is a clinical syndrome that encompasses several heterogeneous disorders where no definite structural cause can be found to explain the symptoms.
Dyspepsia connotes a relationship to the upper gastrointestinal tract and symptoms should be related to meals. Many symptoms constitute the clinical syndrome of dyspepsia; these symptoms are as shown in Box 1. These symptoms may occur singly but usually multiple symptoms occur together. The description of symptoms and terminology vary geographically and reflect the local cultural and social background of the population studied (Box 2).