8 Dyspepsia

Definition
Dyspepsia is the feeling of discomfort or pain in the upper abdomen or lower chest. Indigestion may be used by the patient to mean dyspepsia, regurgitation symptoms or flatulence.
KEY POINTS
• Dyspepsia maybe the only presenting symptom of upper Cl malignancy. All older patients and patients with atypical history should have endoscopy.
• In young adults, gastro-oesophageal reflux and 1-/elicobacter-positive gastritis are common causes.
• Dyspepsia is rarelythe only symptom of gallstones they are more often incidental findings.
Differential diagnosis
Oesophagus
• Reflux oesophagitis: retrosternal dyspepsia, worse after large meal/lying down, associated symptoms of regurgitation, pain on swallowing.
• Oesophageal carcinoma: new-onset dyspepsia in older patient, associated symptoms of weight loss/dysphagia/haematemesis, failure to respond to acid suppression treatment.
Stomach
• Gastritis: recurrent episodes of epigastric pain, transient or short-lived symptoms, may be associated with diet, responds well to antacids/acid suppression.

• Gastric ulcer: typically chronic epigastric pain, worse with food, ‘food fear’ may lead to weight loss, exacerbated by smoking/alcohol, occasionally relieved by vomiting.
• Carcinoma stomach: progressive symptoms, associated weight loss/anorexia, iron-deficient anaemia common, early satiety, epigastric mass.
Duodenum
• Duodenal ulcer: epigastric and back pain, chronic exacerbations lasting several weeks, relieved by food especially milky drthks, relieved by bed rest, commoner in younger men, associated with Helicobacter infection.
• Duodenitis: often transient, mild symptoms only, associated with alcohol and smoking.
Gallstones
Dyspepsia is rarely the only symptom, associated RUQ pain, needs normal OGD and positive ultrasound to be considered as cause for dyspeptic symptoms.

KEY INVESTIGATIONS
• EBO: anaemia suggests malignancy.
• OCD: tumours, PUD, assessment of oesophagitis.
• 24-hour pH monitoring: WORD.
• Ultrasound: ?gallstones.