Approach To A Patient With Dyspepsia

Approach to A
Patient with
Dyspepsia
Presented by
Dr. Abdullah Al Mamun
Intern Doctor
Shaheed Syed Nazrul Islam Medical
College, Kishoreganj.
Introduction
Dyspepsia describes symptoms such as

discomfort, bloating, nausea, which
are thought to originate from the
upper gastrointestinal tract.
Introduction
It affects up to 80% of the population

at some time in life & most patients
have no serious underlying disease.
Causes of Dyspepsia
Food intolerance:
• Tomatoes
• Spicy foods
• Excessive alcohol
• Fatty foods
• Coffee.
Causes of Dyspepsia
Upper GIT disorders:

• Peptic ulcer disease
• Gastro-esophageal reflux disease
• Acute gastritis
• Non-ulcer dyspepsia
• Gallstones
• Irritable bowel syndrome
Causes of Dyspepsia
Other GIT disorders:

• Pancreatic disease (cancer, pancreatitis)
• Hepatic disease (hepatitis, metastases)
• Colonic carcinoma
Systemic disease:
• Renal failure
• Thyroid disease
Causes of Dyspepsia
Drugs:
• NSAIDs
• Iron & potassium supplements
• Corticosteroids
• Digoxin
Others:
• Anxiety disorders
• Depressive disorders
History Taking
Peptic ulcers
• Recurrent upper abdominal pain having 03 charecteristics
feature
• localize in epigestrium
• relationship with food
• episodic occurrence
• Vomiting or early satiety after meal or melena
• personal history or family history of ulcers
• Is the patient a smoker?
• History of taking NSAID’s
History Taking
Gastroesophageal reflux disease

• Does the patient complain of heartburn or regurgitation?
• Are symptoms worse when the patient is bending,
straining or lying down?
• Does the patient have excessive salivation?
• Does the patient have a chronic cough , asthma or
hoarseness of voice?
History Taking
Functional dyspepsia:
 Age < 40 years
 Female affected twice
 Nausea, satiety, bloating after meal
 Alcohol
 Morning symptoms (pain & nausea on waking)
 Anxiety, depression
 Pregnancy should excluded
History Taking
Hepatobiliary tract disease

• Upper abdominal pain
• Yellow colouration of eye
• Dark urine
• Prodromal symptoms: headache, myalgia, arthralgia,
anorexia, nausea
History Taking
Acute gestritis:
It may be associated with Anorexia, nausea, vomiting,
haematemesis, melaena
History Taking
Pancreatitis
• Is the pain stabbing, and does it radiate to the patient's
back?
• Is the pain abrupt, is it unbearable in severity and does it
last for many hours without relief?
• Does the patient have a history of heavy alcohol use?
History Taking
Cancer
• Is the patient over 50 years of age?
• Has the patient had a recent significant weight loss?
• Does the patient have trouble swallowing?
• Has the patient had recent protracted vomiting?
• Does the patient have a history of maelena?
• Is the patient a smoker?
History Taking
Irritable bowel syndrome

• Is dyspepsia associated with an increase in stool frequency?
• Is pain relieved by defecation?
• Associated with constipation/ diarrhoea.
Irritable Bowel Syndrome
Rome criteria IV
Recurrent abdominal pain, on average, at least 1
day/week in the last 3 months, associated with two or
more of the following criteria:
• Related to defecation
• Associated with a change in frequency of stool
• Associated with a change in form (appearance) of stool.
Criteria fulfilled for the last 3 months with symptom

onset at least 6 months before diagnosis.
History Taking
Metabolic disorders
• Does the patient have a medical history of diabetes
mellitus, hypothyroidism or hyperthyroidism, or
hyperparathyroidism?
Drug History
NSAIDs, Iron & potassium supplements, Corticosteroids
Digoxin
History Taking
Renal Failure:
 Oliguria, Anuria
 Anorexia, nausea, vomiting
 Drowsiness, confusion, muscle twitching, hiccoughs
Physical Examination
• The physical examination should be normal in patients

with uncomplicated dyspepsia
• Anemia should be excluded as because in some patients
the ulcer may completely silent presenting first time with
anemia from chronic undetected blood loss
• Mild epigastric tenderness is commonly found in patient
with peptic ulcer & functional dyspepsia
Physical Examination
• Signs of severe organic damage: weight loss,

organomegaly, Jaundice, abdominal mass
• Signs of systemic disorders: Cardiac disease,
thyroid disease
Evaluation of Dyspepsia
Uninvestigated Dyspepsia
Clinical Evaluation
Determine reason for presentation
History & physical examination
Look for alarm feature
Alarm Features in Dyspepsia
 Weight loss
 Anaemia
 Vomiting
 Haematemesis and/or Malena
 Dysphagia
 Paplpable abdominal mass
If age> 55 years or patient have

alarm features
Endoscopy
Organic Disease Normal
Treat as indicated Non-ulcer dyspepsia

If Age< 55 years & have no

alarming feature
If symptoms persist
Empirical treatment with Noninvasive test for
PPI H. pylori
If positive
If negative, treat
H. pylori
symptomatically
eradication
or consider other
diagnosis
If symptoms
persist
endoscopy
Investigations
• The initial evaluation of dyspepsia should include

a complete blood count to rule out anemia.
• If the history and physical examination suggest
the presence of gallstones or another
hepatobiliary condition, liver function tests and
sonographic evaluation should be ordered.
• If renal failure is suspected S.creatinine &
suggestive investigations should done
Investigations
• if pancreatitis is suspected, serum lipase and

amylase levels should be obtained.
• Patients with nausea, vomiting and epigastric
fullness may also have generalized electrolyte
imbalances. Therefore, electrolyte measurements
should be considered
• Patient suspected DM or thyroid disorder, Blood
sugar, thyroid function test should be done
Treatment
Supportive:
 Antacids or Bismuth compounds
 Anti- secretory agents
Specific:
According to cause
Treatment of Acute Gastritis
o Antacids
o PPI
o Domperidone
o Anti emetics (metoclopramide)
o Treatment of underlying cause
Treatment of Peptic Ulcer Disease
1. H. pylori eradication:
• Tripple therapy: PPI + Two antibiotics
(Amoxicillin/Clarithromycin/Metronidazole)
for 10-14 days
• Quadruple therapy: PPI + bismuth subcitrate+
Metronidazole+ Tetracycline for 10-14 days
Treatment of Peptic Ulcer Disease
2. General measures: cigarette smoking,

aspirin & NSAIDs should be avoided
3. Maintenance treatment: low dose PPI
should be used
4. Surgical treatment.
Treatment of Functional Dyspepsia
• Explanation & reassurence

• Life style modifications
• Anti-secretory agents: H2 receptor antagonist
• Pro-motility agents ( metoclopramide 10 mg 3 times daily
or domperidone 10-20 mg 3 times daily)
• Anti-depressants: Tricyclic anti depressant is preffer
• H. pylori eradication therapy: 10% patients shows
response.
Treatment of GERD
• Life-style modifications
• H2 receptor blocking agents
• Prokinetic agents
• Sucralfate
• Proton-pump-inhibitors
• Combination therapy
• Antireflux surgery
Treatment of IBS
Severity Clinical picture Management

Mildly troubled/ primary Fear of serious disease, •Positive diagnosis
care anxious, worried, stress •Explanation & reassurance
•Dietary management
•Regular follow up
Complainer/secondary care Uncertainly re- •Reinforce above measure

diagnosis; disturbed life •Stress management
style •Target drugs to specific
complaints
Difficult/tertiary care Coexisting psychiatric •Treatment of depression
disease, possible •Treatment of anxiety
secondary gain, •Pain clinic
disability, chronic pain
Treatment of IBS
Symptoms Medication
Constipation Bulking agents, Lactulose, Enemas
Diarrhoea Loperamide, cholestyramine
Bloating Simethicone, Charcoal
Flatus Vegetable meals
Postprandial pain Anticholinergic
Chronic pain Anti-depressent

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Approach to A

Dyspepsia describes symptoms such as

It affects up to 80% of the population

Upper GIT disorders:

Other GIT disorders:

Gastroesophageal reflux disease

Hepatobiliary tract disease

Irritable bowel syndrome

Criteria fulfilled for the last 3 months with symptom

• The physical examination should be normal in patients

• Signs of severe organic damage: weight loss,

If age> 55 years or patient have

Organic Disease Normal

Treat as indicated Non-ulcer dyspepsia

If Age< 55 years & have no

• The initial evaluation of dyspepsia should include

• if pancreatitis is suspected, serum lipase and

2. General measures: cigarette smoking,

• Explanation & reassurence

Severity Clinical picture Management

Complainer/secondary care Uncertainly re- •Reinforce above measure

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