Osteopathic Family Physician (2013) 5, 79–85 An overview: Current clinical guidelines for the evaluation, diagnosis, treatment, and management of dyspepsia$ Peter Zajac, DO, FACOFP, Abigail Holbrook, OMS IV, Maria E. Super, OMS IV, Manuel Vogt, OMS IV From University of Pikeville-Kentucky College of Osteopathic Medicine (UP-KYCOM), Pikeville, KY. KEYWORDS: Dyspeptic symptoms are very common in the general population. Expert consensus has proposed to Dyspepsia; define dyspepsia as pain or discomfort centered in the upper abdomen. The more common causes of Functional dyspepsia dyspepsia include peptic ulcer disease, gastritis, and gastroesophageal reflux disease.4 At some point in (FD); life most individuals will experience some sort of transient epigastric pain. This paper will provide an Gastritis; overview of the current guidelines for the evaluation, diagnosis, treatment, and management of Gastroesophageal dyspepsia in a clinical setting. reflux disease (GERD); r 2013 Elsevier Ltd All rights reserved. Nonulcer dyspepsia (NUD); Osteopathic manipulative medicine (OMM); Peptic ulcer disease (PUD); Somatic dysfunction Dyspeptic symptoms are very common in the general common causes of dyspepsia include peptic ulcer disease population, affecting an estimated 20% of persons in the (PUD), gastritis, and gastroesophageal reflux disease United States.1 While a good number of these individuals (GERD).4 However, it is not unusual for a complete may never seek medical care, a significant proportion will investigation to fail to reveal significant organic findings, eventually proceed to see their family physician. Several and the patient is then considered to have “functional reports exist on the prevalence and impact of dyspepsia in the dyspepsia.”5,6 The term “functional” is usually applied to general population.2,3 However, the results of these studies disorders or syndromes where the body’s normal activities in are strongly influenced by criteria used to define dyspepsia. terms of the movement or sensitivity of the intestinal nerves, Expert consensus has proposed to define dyspepsia as pain or the way in which the brain controls some of the or discomfort centered in the upper abdomen. The more gastrointestinal (GI) functions, are impaired. However, there are no structural abnormalities that can be seen by upper GI $Special thanks to Diana S. Wetzel for all of her assistance in the endoscopy or x-ray or by blood tests. Thus, it is identified by preparation and layout of this paper. the characteristics of the symptoms and, less frequently, when Corresponding author: Peter Zajac, DO, FACOFP, University of considered necessary, limited tests.5,6 Pikeville-Kentucky College of Osteopathic Medicine (UP-KYCOM), Pikeville, KY. At some point in their lives most individuals will experience E-mail address: [email protected]. some sort of transient epigastric pain. As mentioned earlier, the 1877-573X/$ - see front matter r 2013 Elsevier Ltd All rights reserved. http://dx.doi.org/10.1016/j.osfp.2012.10.005 80 Osteopathic Family Physician, Vol 5, No 2, March/April 2013 causes of this pain can be attributed to a variety of etiologies, Table 1 Clinical manifestations of dyspepsia4,8 some of which may occur in conjunction with others. In a Peptic ulcer disease (PUD) Duodenal ulcer disease comprehensive assessment of the reporting of symptoms of functional GI disorders, 69% of the patients were found to have Epigastric pain (most common Epigastric pain can be sharp, at least 1 of a number of different functional GI syndromes.5-7 symptom) dull, burning, or penetrating The Rome diagnostic criteria categorize the functional GI Gnawing or burning sensation Hunger disorders and define symptom-based diagnostic criteria for each Occurs 2-3 h after meals Pain may radiate into the back category.5 Relieved by food or antacids About 20%-40% of patients describe bloating, belching, or symptoms suggestive of PUD GERD Patient awakens with pain at Ulcer-related pain generally In the United States, PUD affects approximately 4.5 million night occurs 2-3 h after meals and people annually.8 The prevalence of PUD has shifted from a often awakens the patient at predominance in males to similar occurrences in both males night. This pattern is and females.8 Lifetime prevalence is approximately 11%- believed to be the result of increased gastric acid 14% in men and 8%-11% in women.8 Age trends for ulcer secretion, which occurs after occurrence reveal declining rates in younger men, particu- meals and during the late larly for duodenal ulcer, and increasing rates in older night and early morning 8 women. PUD is most frequently associated with Helico- hours when circadian bacter pylori infection, the use of acetylsalicylic acid stimulation of gastric acid (Aspirin), non-steroidal anti-inflammatory drug (NSAID) secretion is the highest. use, and cigarette smoking. Though the management of Pain may radiate into the back About 50%-80% of patients H. pylori infection has improved radically in recent years, (consider penetration) with duodenal ulcers prescribing of acetylsalicylic acid and NSAIDs, especially experience nightly pain, as in older populations, has increased over the same period.4,8,9 opposed to only 30%-40% Peptic ulcers are focal areas of deep erosion through the of patients with gastric ulcers and 20%-40% of mucosa and, sometimes, submucosa. They commonly occur patients with nonulcer either in the stomach or duodenum. Excess gastric acid must dyspepsia (NUD). be present for duodenal ulcers to form, whereas in gastric Nausea Pain is often relieved by food, ulcers there is often normal or reduced gastric acid a finding often cited as 4,8 secretion. H. pylori is causally related to serious disorders being specific for a duodenal of the upper GI tract in adults and children. Over 50% of the ulcer. However, this world’s population is infected with H. pylori, with the symptom is present in only highest prevalence observed in developing countries.9,10 20%-60% of patients and is Although some reports have shown that H. pylori-positive probably not specific for patients tend to have dyspepsia, the relationship between duodenal ulcers. H. pylori and dyspepsia remains controversial.11 Approxi- Vomiting Dyspepsia, including belching, mately only 1 in 6 individuals who are infected with bloating, distention, and H. pylori develop ulcers, and only a small (1%-2%) number of 4,10,12 fatty food intolerance H. pylori-infected individuals develop gastric cancer. Heartburn On physical examination, patients with ulcers may Chest discomfort display epigastric tenderness (Table 1). Other possible Anorexia, weight loss associated findings on examination may include the Hematemesis or melena following4,8: resulting from gastrointestinal bleeding 1) A succussion splash. Sound produced by air and fluid in Dyspeptic symptoms that a distended stomach several hours following a meal might suggest PUD are not because of gastric outlet obstruction. specific because only 20%- 2) Peritoneal signs such as rebound, rigidity, and guarding 25% of patients with in the setting of a perforation. symptoms suggestive of 3) Occult blood on rectal examination. peptic ulceration are found on investigation to have a peptic ulcer. In addition to lifestyle modifications, treatment goals, particularly in the acute setting, include the relief of prolonged and complicated process requiring confirmation discomfort and protection of the gastric mucosal barrier to of the presence of the organism and eventual evidence of promote healing. Eradication of H. pylori infection is a eradication. Cessation of the causative agent and antacids Zajac et al. Current clinical guidelines for dyspepsia 81 Table 2 Treatment options Drug class Mechanism of action Examples Antacids: Aluminum-containing and They neutralize gastric acidity, resulting in Maalox, Mylanta magnesium-containing antacids can be an increase in stomach and duodenal bulb helpful in relieving symptoms of gastritis pH. Aluminum ions inhibit smooth muscle by neutralizing gastric acids. These agents contraction, thus inhibiting gastric are inexpensive and safe. emptying. Magnesium and aluminum antacid mixtures are used to avoid bowel function changes. Proton pump inhibitors (PPIs): Proton pump Decrease gastric acid secretion by inhibiting inhibitors relieve pain and generally heal the parietal cell Hþ/Kþ ATP pump. Used peptic ulcers more rapidly than H2 for up to 4 wk to treat and relieve receptor antagonists. Drugs in this class symptoms of active duodenal ulcers. May are equally effective. Standard doses of be prescribed for up to 8 wk to treat all PPIs inhibit more than 90% of 24-h acid grades of erosive esophagitis. secretion, compared to 50%-80% with H2- blockers. They all decrease serum concentrations of drugs that require gastric acidity for absorption, such as Dexiansoprazole (Dexilant): a dual delayed ketoconazole or itraconazole. Six drugs, as release (DDR) formulation; esomeprazole listed here, are now FDA approved in this à (Nexium): an S-isomer of omeprazole; category, and omeprazole, lansoprazole, In addition, for short-term (4-8 wk) lansoprazole (Prevacid); omeprazole and pantoprazole are now available in treatment and symptomatic relief of (Prilosec), pantoprazole generic form. They are most effective when gastritis. As noted above, used for up to (Protonix),Ãrabeprazole (Aciphex),Ãand a taken 30-60 min before the first meal of 4 wk to treat and relieve symptoms of rapid release form of omeprazole the day. active duodenal ulcers. (Zegerid) H2-receptor antagonists