Dyspepsia

DESCRIPTION:
An ill-defined condition characterized
by the presence of chronic
intermittent symptoms of epigastric
pain and fullness, early satiety,
nausea and/or vomiting without
mucosal lesions or other structural
abnormalities of the gastrointestinal
tract

SIGNS AND SYMPTOMS:

Belching
Aerophagia, gaseousness, abdominal distension
Borborygmus
Epigastric pain, gnawing or burning; eating may
improve or worsen symptoms
Substernal pain, gnawing or burning
Anorexia, nausea, or vomiting
Change in bowel habits
Abdominal tenderness
No anatomic abnormalities

CAUSES:
Often unknown, may be of several
different etiologies
Evanescent ulcers (20-30% go on
to develop ulcers)
Gastric motility disorder
Adverse drug effects
Helicobacter pylori may be
causative in some patients, but this
is controversial

RISK FACTORS:
Other functional disorders
Anxiety
Depression

DIFFERENTIAL DIAGNOSIS:
Gastroesophageal reflux
Cholecystitis
Peptic ulcer disease
Gastric cancer
Esophageal spasm
Malabsorption syndromes
Pancreatic disease
Irritable bowel syndrome
Aerophagia
Ischemia heart disease
Diabetes mellitus
Thyroid disease
Connective tissue disorders
Conversion disorder

LABORATORY:
CBC
Chemistry panel
Stool for occult blood
SPECIAL TESTS:
Esophageal manometry (rarely
needed)
24-hour intra-esophageal pH
monitoring (rarely needed)

IMAGING:
Recommended in:
Patients over 45 years of age at onset
of symptoms
Patients with symptoms and signs
suggesting more serious disease
Patients who need added reassurance
Younger patients who do not respond
rapidly to empiric treatment
Usual:
Endoscopy, or
Upper GI series
Sometimes:
Barium enema
Gallbladder studies (e.g., ultrasound or
oral cholecystogram)
Nuclear medicine gastric emptying
study (in selected cases)

DIAGNOSTIC PROCEDURES:
Careful history and physical
Normal studies of esophagus,
stomach and duodenum (particularly
in patients over 45)

APPROPRIATE HEALTH CARE:

Outpatient
GENERAL MEASURES:
Supportive measures
Reassurance
Do not investigate excessively
Dietary changes (see below)
Elevate head of bed (where
applicable)
Maintain ideal body weight
Explore psychological issues

ACTIVITY:
Stress reduction
Relaxation techniques
Physical exercise
Reflux precautions where
applicable

DIET:
Avoid foods known to exacerbate
symptoms
Frequent small meals
Avoid regular and decaffeinated
coffee
Avoid tea, cocoa, chocolate
Avoid heavy alcohol use
Avoid cigarette smoking
Avoid aspirin containing compounds
and NSAIDs

DRUG(S) OF CHOICE:
60% of patients improve with placebo
Acid reduction drugs - H2 antagonists
Antacids
Contraindications:
Magnesium containing antacids should be
avoided in patients with significant renal
dysfunction
Precautions:
H2 antagonist dosage should be adjusted
in patients with renal disease
Calcium containing antacids may
precipitate the formation of kidney stones
Significant possible interactions:
H2 blockers interact with drugs
metabolized by, and affecting the liver
Antacids compete with digoxin, iron salts,
tetracycline, fluoroquinolones, and other
drugs for absorption from the stomach

ALTERNATIVE DRUGS:
Gastric motility drugs
Metoclopramide; although side
effects are significant
Erythromycin
Cisapride (Propulsid) (not generally
recommended)
Proton pump inhibitors
Omeprazole
Lansoprazole

PREVENTION/AVOIDANCE:
Continued health habits suggested
under Treatment (i.e., avoid activities
known to exacerbate problems,
maintain healthy lifestyle, continue
stress reduction techniques)
POSSIBLE COMPLICATIONS:
Undiagnosed serious pathology
EXPECTED COURSE AND PROGNOSIS:
Long-term or chronic symptoms with
periods that are symptom free

Treatment
Surgery/switching medical
prescription
Physical modification
Swallow modification
Food modification

Dysphagia

Dysphagia is
common symptom thats usually easy to localize.
It may be constant or intermittent and is classified by the
phase of swallowing it affects.
Among the factors that interfere with swallowing are
severe pain, obstruction, abnormal peristalsis, impaired
gag reflex, and excessive, scanty, or thick oral secretions.
Dysphagia is the most commonand sometimes the only
symptom of esophageal disorders.
However, it may also result from oropharyngeal,
respiratory, neurologic, and collagen disorders or from the
effects of toxins and treatments
Dysphagia increases the risk of choking and aspiration and
may lead to malnutrition and dehydration.

epid
Diseases of the esophagus are among the top
50 reasons that patients seek medical care
in frequency, rank alongside problems such
as pneumonia, bronchitis and otitis media.
Conditions that cause dysphagia can produce
esophageal rupture, nutritional deficits and
aspiration pneumonia.
Elderly patients are at the highest risk of
dysphagia and its subsequent complications,
especially silent aspiration.

Sign of dysphagia
You swallow repeatedly
You cough and splutter frequently
Your voice is unusually husky and you often need
to clear your throat
When you try to eat you dribble. Food and saliva
escape from your mouth or even your nose
You find it easier to eat slowly
You quite often keep old food in your mouth,
particularly when you have not had a chance to
get rid of it unseen
You feel tired and lose weight

Medical causes
Achalasia
Airway obstruction
Amyotrophic lateral
sclerosis
Botulism
Bulbar paralysis
Dysphagia lusoria
Esophageal cancer
Esophagitis
Hypocalcemia
Laryngeal cancer (extrinsic)
Laryngeal nerve damage
Pharyngitis (chronic)
Plummer-Vinson syndrome
Scleroderma (progressive
systemic sclerosis)
Tetanus

Esophageal compression
(external)
Esophageal diverticulum
Esophageal leiomyoma
Esophageal obstruction by
foreign body
Esophageal spasm
Esophageal stricture
Gastric carcinoma
Lower esophageal ring
Mediastinitis
Myasthenia gravis
Oral cavity tumor
Parkinsons disease
Rabies
Syphilis
Systemic lupus
erythematosus

Other causes
Lead poisoning
Procedures: A recent tracheostomy
or repeated or prolonged intubation
may cause temporary dysphagia.
Radiation therapy: When use to
treat oral cancer
Special considerations

Treatment
Surgery/switching medical
prescription
Physical modification
Swallow modification
Food modification

Differential diagnosis

Oropharyngeal dysphagia

Esophageal dysphagia

Neuromuscular disease
Diseases of the central nervous system
Cerebrovascular accident
Parkinson's disease
Brain stem tumors
Degenerative diseases
Amyotrophic lateral sclerosis
Multiple sclerosisHuntington's disease
Postinfectious
Poliomyelitis
Syphilis
Peripheral nervous system
Peripheral neuropathy
Motor end-plate dysfunction
Myasthenia gravis
Skeletal muscle disease
(myopathies)
Polymyositis
Dermatomyositis
Muscular dystrophy (myotonic dystrophy,
oculopharyngeal dystrophy)
Cricopharyngeal
(upper esophageal sphincter), achalasia
Obstructive lesions
TumorsInflammatory masses
Trauma/surgical resection
Zenker's diverticulum
Esophageal webs
Extrinsic structural lesions
Anterior mediastinal masses
Cervical spondylosis

Neuromuscular disorders
Achalasia
Spastic motor disorders
Diffuse esophageal spasm
Hypertensive lower esophageal
sphincter
Nutcracker esophagus
Scleroderma
Obstructive lesions
Intrinsic structural lesions
Tumors
Strictures
Peptic
Radiation-induced
Chemical-induced
Medication-induced
Lower esophageal rings (Schatzki's ring)
Esophageal webs
Foreign bodies
Extrinsic structural lesions
Vascular compression
Enlarged aorta or left
atrium
Aberrant vessels
Mediastinal masses
Lymphadenopathy
Substernal thyroid