DYSPEPSIA

Gastroduodenal disease produces varied symptoms described by the term 'dyspepsia'. Dyspeptic symptoms are extremely common in the general population. An agreed international definition is 'episodic or persistent abdominal symptoms, often related to the intake of food, which patients or physicians believe to be due to disorders of the proximal portion of the digestive tract'. The symptoms included in this generic definition of dyspepsia are:

•         pain or discomfort in the upper abdomen;

•         nausea and vomiting;

•         early satiety;

•         epigastric fullness and regurgitation.

There are two categories of dyspepsia: organic and nonorganic (no demonstrable focal lesion). The prevalence of organic dyspepsia increases above the age of 40-45 years. There are four subgroups of dyspeptic patients based on the predominant symptoms:

•          ulcer-like;
•          reflux-like;
•          dysmotility-like;
•          non-specific.

Symptoms alone do not differentiate between organic and non-organic disease. Hence history does not always predict the underlying cause of dyspepsia and for this reason investigation by endoscopy is necessary for certain

groups:

•          patients who are H. pylori positive;
•          patients with a history of using non-steroidal anti-inflammatory drugs (NSAIDs);
•          patients with alarm/sinister symptoms (loss of appetite, weight loss, bleeding).

Alarm symptoms

Loss of appetite, weight loss, recent-onset dyspepsia, constant upper abdominal pain and evidence of bleeding are regarded as alarm or sinister symptoms and thus require urgent endoscopy, particularly if the patient is over 40 years of age. Weight loss and loss of appetite associated with early satiety/abdominal discomfort are suspicious of a gastric neoplasm.

Investigations

Endoscopy and radiology

Upper gastrointestinal endoscopy is necessary for the following

groups of patients.

•         Individuals > 45 years old testing positive for H. pylori, with persistent symptoms despite eradication treatment.

•         Individuals > 45 years old, never investigated, H. pylori-negative and no intake of NSAIDs, with persistent symptoms despite acid-lowering treatment.

•         Individuals > 45 years old with a previous history of gastric ulcer, no H. pylori testing or H. pylori test negative, with persistent symptoms despite acid-lowering drugs.

•         Gastrointestinal bleeding: acute and chronic. Contrast swallow and meal examination is seldom used in the investigation of patients with dyspepsia because endoscopy has a higher diagnostic yield and permits biopsy with histological diagnosis. However, contrast radiology is needed in:

•         patients with gastric cancer undergoing surgery (precise location of lesion);

•         patients with hiatus hernia undergoing surgery (type and size of hernia);

•         suspected perforation/anastomotic leak (water-soluble contrast must be used). Barium studies are unreliable in the assessment of a patient with acute upper gastrointestinal bleeding. Endoscopy is the preferred investigation in this situation.

Tests for H. pylori infection

The most commonly performed are the rapid ureasetests, which are carried out on endoscopic biopsies. These tests use kits such as the Campylobacter-like organism (CLO), Hpfast and Pyloritec and provide a result within 3 h of endoscopy. Other tests include culture in a microaerobic environment, polymerase chain reaction, histology of the antrum and corpus (Giemsa or Warthin-Starry silver stain), 13C urea breath test, and serology for detection of H. pylori-specific antibodies.