Clinical managementDyspepsia1
Section snippets
Clinical case
A 44-year-old man presents with a 1-year history of intermittent pain in the epigastric region, which often occurs one hour after meals. The pain does not radiate and he has no weight loss, vomiting, or symptoms of GI bleeding. He denies early satiety, bloating, constipation, or diarrhea. He reports heartburn about twice a month, typically when he goes to bed soon after eating a large meal. He is otherwise healthy, is not obese, and takes no medications.
Definitions
Dyspepsia is currently defined as discomfort or pain centered in the upper abdomen; there are often accompanying symptoms including fullness, bloating, or early satiety.1, 2 More recently, it has been proposed that weight loss is a specific dyspepsia symptom, suggesting that the current nosology may need revision.3 The exclusion of heartburn from dyspepsia continues to be debated.1, 2
Epidemiology and natural history
Our patient has uninvestigated dyspepsia, which is a very common complaint everywhere.4, 5, 6 In the United
Recommended initial management strategy
For our case (young patient with no alarm symptoms), I would apply a test-and-treat strategy unless I practiced in a region where H. pylori is uncommon (prevalence <20%); if the patient is H. pylori positive then I would prescribe triple therapy for 10 days as is standard in the USA (although 1 week may be sufficient).42, 48 I would re-test the patient for H. pylori infection to confirm eradication if symptoms recurred. The cost-effectiveness of testing everyone after therapy is likely to be
Evolution of the case
The patient is tested for H. pylori with a stool antigen test and the result is positive. He is treated with a 10-day course of twice-daily triple therapy. However, 6 weeks later, he reports his symptoms are unchanged. A urea breath test confirms eradication. A trial of PPI therapy given twice daily for 4 weeks leads to no more than a 10% improvement in symptoms. Upper endoscopy is then performed and is normal.
Re-evaluation
Here we have a problem because very limited second-line options are available for patients with documented functional dyspepsia. I would re-evaluate the data used to make the diagnosis. One could give even higher dose PPI therapy for another 2 to 4 weeks, or try and ensure atypical reflux disease has been excluded by 24-hour esophageal pH testing off therapy. Occasionally, an uncommon disease will masquerade as functional dyspepsia. Occult pancreatic adenocarcinoma can present this way although
Treatment options
I suggest that the next step in management after failing standard therapies is to consider a trial of an antidepressant or psychological therapy. There are very limited data that tricyclic antidepressants are efficacious in functional dyspepsia, and no adequate trials.57 No trials have tested the selective serotonin re-uptake inhibitors (SSRIs) although they may have a role in IBS.58 I would try to start off with a low-dose tricyclic initially (e.g., imipramine or desipramine 10 to 25 mg at
Conclusions
The patient who presents with dyspepsia needs an appropriate, evidence-based clinical evaluation. In patients with alarm features and in older patients with new symptoms, prompt EGD is considered the gold standard to ensure malignancy has not been missed and to plan further management. Patients under the age of 50 years with no alarm features should be tested for H. pylori with an appropriate nonendoscopic test (e.g., a stool antigen test or C13 or C14 urea breath test) and treated if positive
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Cited by (0)
- 1
Loren Laine, M.D.
Clinical Management Editor
University of Southern California
Los Angeles, California