Dyspepsia

Dr. Karwan Hawez Sulaiman

Family Medicine Specialist
College of Medicine
 Outline of the Lecture
1. Clinical case approach.

2. Introduction.

3. Differential Diagnosis (causes).

4. Diagnosis.

5. Rx.
 Clinical Case Approach
A 52-yr-old male with a 4-month hx of epigastric
pain. The pain is dull and achy and is intermittent
with no radiation. Exacerbating factors include
coffee intake. Infrequently, he is awakened at night
from the pain. Temporary alleviating factors include
eating a meal or taking H2-antagonists. The
intensity of the pain is approximately 6/10. The
pain has not changed since it began 4 months ago.
 Clinical Case Approach
No other GIT symptoms have been noted, but nausea
does occur at times. He has no prior history of
chronic abdominal pain, and he takes no regular
medications or analgesics.

On exam: some epigastric tenderness with no

rebound or guarding. The remainder of the exam is
unremarkable.
 Clinical Case Questions

1. What is the best term to describe the patient’s

chief complaint?

2. What are your differential diagnosis?

2. What is the most likely dx in this patient?

3. How you approach to manage this patient?

 1. The best term to describe

The patient’s chief complaints

Dyspepsia
 Introduction
• Dyspepsia (indigestion) is defined as chronic or
recurrent upper abdominal pain or discomfort.
• Dyspepsia affects up to 80% of the population at
some time, often with no abnormality on
investigation.
• Approximately 40% of the population
experiences symptoms referable to the upper
GIT every 6ms, and the 2 most common
symptoms are epigastric pain and heartburn,
frequently coexisting.
 2. Differential Diagnosis (cont.)
• Approximately 10% of dyspepsia is caused by PUD.
Other common causes include GERD and functional
dyspepsia and there is significant overlap between
the symptoms of these 3 diseases.
• Finding RUQ tenderness may suggest gallbladder or
biliary disease.
• Epigastric pain radiating to the back and associated
with nausea and vomiting may be pancreatitis.
• Patients with symptoms primarily of heartburn or
acid regurgitation are more likely to have GERD.
 3. The most likely Diagnosis

Peptic Ulcer Disease (Duodenal Ulcer)

 4. Diagnostic and management
approach

The diagnostic workup and treatment of

patients with dyspepsia varies and is
dependent on the age of the patient, the
presenting S/S, and the response to the
initial management offered.
 4. Diagnostic and management approach
• Classic symptoms associated with PUD
(especially DU) include epigastric abdominal
pain that is improved with the ingestion of food,
or pain that develops a few hours after eating.
• Nocturnal symptoms are also common with
PUD. The symptoms are often gradual in onset
and present for weeks or months. Patients
often self-medicate with OTC antacids, which
usually provide some relief, prior to presenting
to the physician.
 4. Diagnostic and management approach
(cont.)

• The examination should both attempt to confirm

your suspicion of PUD and rule out other diagnoses
that may present with abdominal pain.
• PUD often will only have the examination finding of
epigastric tenderness.
• The presence of GI bleeding may be documented
by stool occult blood testing. Signs of anemia
should be evaluated and managed as needed.
• Pelvic infections, pelvic pathology, and even
ectopic pregnancy must be considered as
possibilities in women.
 4. Diagnostic and management
approach (cont.)
Early diagnostic endoscopy should be considered for
patients with new onset dyspepsia who are:

• Older than age 55 years or

• Who have symptoms that may be associated with

upper GI malignancy (next slide).
 4. Diagnostic and management
approach (cont.)
• “ALARM” SYMPTOMS FOR WHICH EARLY UPPER GI
ENDOSCOPY IS RECOMMENDED.
• Weight loss.

• Progressive dysphagia.

• Recurrent vomiting.

• Gastrointestinal bleeding.

• Family history of cancer.

 4. Diagnostic and management
approach (cont.)
Alarm Features of Dyspepsia:
• Weight loss.
• Dysphagia.
• Vomiting.
• GI bleeding.
• Palpable abdominal mass.
• Anemia.
 4. Diagnostic and management
approach (cont.)
• For those younger than age 55 years and without
alarm symptoms, testing for H pylori, either by urea
breath test or stool Ag testing, is recommended.
• For those who test +ve, treating the H pylori
followed by acid-suppression therapy is indicated.
• For persons who test -ve, empiric Rx with a PPI for
4-8wks is a cost-effective intervention.
• Endoscopy or reconsideration of the diagnosis
should be considered for those who continue to be
symptomatic following these interventions.
 Management of the patient
Because our patient age is 52 years and he has no
alarm symptoms:
• No need for early endoscopy.
• H. pylori testing done by urea breath or stool Ag
test.
• If +ve, triple therapy is indicated for 2 weeks, then
PPI for another 2 weeks.
• If test –ve, a trial of PPI is indicated.
• If resolved, only need F/up.
• If not resolved by above, endoscopy is indicate.
 Conclusion
• Dyspepsia means indigestion and is a common
GIT symptoms encountered in PHC setting.

• Dyspepsia has a wide range of DDX.

• Management depends mainly on presenting

symptoms, age of the patient and the presence or
absence of alarms symptoms.
Thank You