Dyspepsia

• Dyspepsia affects up to 40% of the general population and is a symptom complex of epigastric pain or discomfort thought to arise from the upper gastrointestinal tract 5
• Symptoms may also include those of gastro-oesophageal reflux (GORD) – heartburn and acid regurgitation – excessive belching, bloating, early satiety and nausea, although the recent Rome III definition excludes symptoms of gastro- oesophageal reflux, such as heartburn and belching 6
• The causes of dyspepsia include peptic ulcer disease, erosive oesophagitis from GORD, and oesophago-gastric malignancy. 7 However, in patients presenting with dyspeptic symptoms, at least half will have no demonstrable structural disease to account for their symptoms and will be labelled as having non-ulcer dyspepsia or more appropriately, “functional dyspepsia” (FD) 8,9
• FD describes these symptoms in the absence of an identifiable organic, systemic, or metabolic aetiology and is best defined by the Rome III criteria 6
• One or more of epigastric pain or burning, early satiety or bothersome post-prandial fullness or bloating, with onset of at least 6 months ago, and present during the last 3 months
• FD can be divided into two categories by the Rome III criteria, although there is considerable overlap between the two. The first is postprandial distress syndrome, characterized by postprandial fullness and early satiety; the second is epigastric pain syndrome characterized by epigastric pain and burning
• The Rome III definition does not include symptoms of gastro- oesophageal reflux, such as heartburn and belching
• Diseases that can mimic symptoms of dyspepsia include biliary tract disease, pancreatic disease, cardiac and mesenteric “angina”, and irritable bowel syndrome. These alternative diagnoses should be considered especially if patients do not respond to empirical therapy for dyspepsia
• Endoscopy (rather than barium meal) is considered to be the investigation of choice for diagnosis, 3 but the management of dyspepsia in primary care has shifted from urgent endoscopy to empirical approaches such as acid suppression therapy or “test and treat” for Helicobacter pylori (NICE guidelines) 4,10,11,12,13
• Patients who fail to respond to H pylori eradication, empirical treatment and/or have no structural abnormality at endoscopy should be reassessed for an alternative cause of dyspepsia (e.g. biliary or pancreatic disease) or functional dyspepsia
• Suspected biliary disease should be initially investigated with ultrasound. However, it has not been shown to be cost effective to investigate all patients with dyspepsia with US at presentation 14
• Pancreatic disease is likely to be accompanied by alarm symptoms such as weight loss. Pain radiating through to the back should also suggest possible pancreatic disease. CT scan is the most effective primary investigation (in addition to endoscopy) in these patients

• Prompt investigation is recommended for patients with "warning" features although the overall predictive value of these symptoms is limited. These "warning" features include 24
  1. Age >55 yrs and recent onset of symptoms
  2. Daily constant pain
  3. Weight loss
  4. NSAID use
  5. Vomiting
  6. Past history of gastric ulcer or gastric surgery
  7. Anaemia
  8. Dysphagia
  9. Bleeding
  10. Epigastric mass
• Younger patients without alarm features (see below) have a very low risk of gastric malignancy and may be investigated with H pylori serology or breath test (‘test and treat’) or treated empirically with anti-secretory medication

• Endoscopy is the test of choice to exclude gastro-duodenal ulceration, reflux oesophagitis, and upper gastro-intestinal tract malignancy 3
• Patients who fail to respond to H pylori eradication, empirical treatment and/or have no structural abnormality at endoscopy should be reassessed for an alternative cause of dyspepsia (e.g. biliary or pancreatic disease) or functional dyspepsia
• Advantages - ability to biopsy lesions suspicious for malignancy and to perform invasive tests for Helicobacter pylori infection

• The prevalence of H.pylori infection in a developed country is variable. Risk factors known to be associated with a higher risk of infection include older age, male gender, lower socio-economic status and smoking 23
• Patients with risk factors should be tested for H.pylori infection and treated appropriately. Those with few risk factors should undergo a trial of proton-pump inhibitor therapy first

• Younger patients who do not display "warning" features have a very low risk of gastric malignancy and may be investigated for Helicobacter pylori by serology/breath test or treated empirically with anti-secretory medication
• Empirical treatment is more cost-effective when the prevalence of H.plyori infection is low (<5%) 15,16
• Antisecretory therapies are composed of drug groups like H2-receptor antagonists (e.g. ranitidine) and PPIs (e.g. omeprazole)

• A 'test and treat' approach is more cost effective when H.pylori prevalence is > 10% and uncertain at prevalence rates 5-10% 16
• The ¹³C-urea breath test is 95% sensitive and specific for H pylori; however, it is not universally available. H pylori serology is widely available but is considerably less sensitive and specific (85% and 79%, respectively). 7 In populations with a high prevalence of H pylori, H pylori serology is a reasonable first-line test
• Patients who test negative for H.pylori may be treated symptomatically 17
• Patients with positive H.pylori testing may be treated with Helicobacter pylori eradication therapy or may be investigated endoscopically 11,12
• H.pylori eradication has the potential, although by no means proven, to prevent the formation of chronic gastritis and hence gastric carcinoma. 15,18 There is a suggestion with more recent studies that the eradication of H.pylori in concert with weight loss and/or better glycaemic control may decrease the risk of gastric cancer 19,20,21,22

• Patients whose symptoms do not improve after one month of empiric therapy with PPI should be reviewed. Alternative diagnosis such as gall-bladder pathology, pancreatitis, coeliac disease, irritable bowel syndrome and an anxiety syndrome should be considered
• Following this H.pylori detection as discussed elsewhere should be considered. Eradication of positive cases and review of symptoms are the initial steps 15
• Patients who fail to respond to this course of management should be considered for endoscopy, though the yield for a positive finding in this context is low 15

• Patients who test negative for H.pylori but whose symptoms persist should be reviewed. Alternative diagnosis such as gall-bladder pathology, pancreatitis, coeliac disease, irritable bowel syndrome and an anxiety syndrome should be considered
• Following this, a short course of Proton Pump Inhibitor (PPI) therapy should be offered. The patient should be reviewed after one month and if symptoms have resolved, therapy should be discontinued 15
• Management of ongoing symptoms is difficult. One should consider gastroscopy, though be mindful of the low yield for positive findings in this context 15

• Endoscopy should be performed instead of DCBM for the evaluation of dyspepsia if available
• DCBM has a high sensitivity for diagnosis of gastric carcinoma and gastric ulcers. 1,2 However in most cases, gastroscopy is required for definitive investigation
  • Particular strengths include the diagnosis of minor strictures, motility disorders, malrotations (including gastric volvulus), herniations and other structural abnormalities
  • Advantages - no sedation
  • Limitations - inability to show subtle mucosal lesions 3,4
  • Disadvantages - exposure to ionising radiation

Pancreatic and Biliary System Pathways