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Managing Dyspepsia

Title: Managing Dyspepsia
Author: Michael Malone, MD
Source: The Journal of family Practice, Volume 64, Number 6
Date: June 2015

The primary symptoms of dyspepsia include bothersome post- prandial fullness, early satiety, and epigastric pain and burning.

Medication, Gastroduodenal Motility and Accomodations, Visceral Hypersensitivity, H pylori, Dysfunctional Intestinal Epithelium
The primary differential diagnosis for dyspepsia includes gastroesophageal reflux disease (GERD), esophagitis, chronic PUD (including both gastric and duodenal ulcers), and malignancy.

Start by determining whether the patient has any red flags, or alarm features, that may be associated with a more serious condition—particularly an underlying malignancy.
Indication for an esophagogastroduodenoscopy (EGD): Family and/or personal history of upper GI cancer, Unintended weight loss, GI bleeding, Progressive dysphagia, Unexplained iron deficiency anemia, Persistent vomiting, Palpable mass or lymphadenopathy, Jaundice, patients with new onset dyspepsia who are 55 years or older.

Physical Examination

Usually normal, but may reveal epigastric tenderness on abdominal palpation.

Laboratory Work Up
Complete blood count is a reasonable part of an initial evaluation but other routine blood work is not needed.

H pylori
Test for H pylori could be included in the initial work-up of all patients with dyspepsia, a better and more cost effective strategy is to initially test only those at high risk.

Acid Suppression Therapy for Low-risk Patients

Patients at low risk for H pylori should be tested for the bacterium only if therapy fails to alleviate their symptoms.

H2RAs or PPIs

A look at the evidence

Both H2 receptor antagonists (H2RAs) and proton pump inhibitors (PPIs) were signicantly more effective than placebo for treating FD.
H2RAs can lead to tachyphylaxiswithin 2 to 6 weeks, thus limiting their long term efficacy.
PPIs appear to be more effective than H2RAs, and are the AGA’s acid suppression drug of choice.
There is no specified time limit for the use of PPIs.

When to test for H pylori
Testing is indicated for patients who have risk factors for the bacterium or who fail to respond to acid suppression therapy.

Ways to test for the presence of H pylori
IgG Serology Testing, Stool Antigen, Urea Breath Testing, Biopsy-Based Testing

H pylori Treatment
The triple therapy regimen (a PPI + amoxicillin + clarithromycin), Sequential therapy, LOAD (Levofloxacin, Omeprazole, Nitazoxanide, and Doxycycline) therapy, Quadruple therapy.
If dyspepsia persist after H pylori treatment.
Also indicated if the patient has an H pylori-associated ulcer or a prior history of gastric cancer.
Performed at least 4 to 6 weeks after treatment is completed.

More Options for Challenging Cases
Unproven but low-risk treatments include modification of eating habits, reducing stress, discontinuing medications that may be related to symptoms, avoiding foods that seem to exacerbate symptoms, and cutting down or eliminating tobacco, caffeine, alcohol, and carbonated beverages, Bismuth salts, peppermint oil and caraway oil for the treatment of FD, Prokinetics, acupuncture for the treatment of dyspepsia, Ginger.

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