Dyspepsia and how to avoid them

Symptoms of chronic abdominal pain, early satiety, bloating and nausea in younger patients are characteristic of functional dyspepsia, but are not alarm symptoms and do not normally require extensive investigation.

At presentation, guidelines recommend standard laboratory tests be performed, including a full blood count, clinical chemistry for renal and liver function, calcium, thyroid function and coeliac serology (these may not be indicated routinely in patients of non-European ethnicity). Serological tests or a urea breath test should also be performed to allow a ‘test-and-treat’ approach to be adopted for those who have a H. pylori infection.^3,4

Abdominal ultrasound to exclude gallbladder stones and other abdominal pathology is part of the routine evaluation in many European countries; however, the diagnostic yield is low unless there is a clinical suspicion of specific disorders.^11,12 Computed tomography should not be performed routinely, especially in young females, to avoid unnecessary exposure to radiation.

Scintigraphy or ¹³C breath tests document abnormal gastric emptying—slow (gastroparesis’) or rapid (dumping)—in up to 40% of patients with dyspepsia.¹³ The impact of these findings on treatment decisions is modest,¹³ although objective evidence of gastroparesis may predict poor response to antidepressant therapy.¹⁴ Instead, a ‘drink test’ that reproduces typical symptoms after ingestion of low volumes of a liquid nutrient drink (<400mL, ~1kcal/ml) can support the diagnosis of functional dyspepsia.¹⁵

In patients who have ongoing symptoms, it is not appropriate to repeat endoscopic or other investigations without a clear indication (see ‘Mistake 1’). The reassurance provided by repeated tests in patients with functional gastrointestinal disease is minimal, as is the impact they have on treatment.¹⁶

Dyspeptic symptoms are common in the community; however, many individuals who have these symptoms do not seek medical attention. Psychiatric comorbidity (e.g. anxiety or somatization disorder)^17,18 and external factors, such as work and social pressures, increase consultation rates for dyspeptic symptoms.^8,9 Furthermore, psychosocial comorbidity increases negative perceptions of the condition (e.g. fear of cancer), subjective symptom severity, time off work and the likelihood that the patient will not respond to standard treatment.¹⁸ Publically available, short questionnaires completed ahead of a consultation facilitate collection of this information (e.g. Hospital Anxiety and Depression Score [HADS], Patient Health Questionnaire [PHQ15; Somatization Score]). Awareness of these factors can clarify the causes of disease and guide the clinician towards a more holistic and effective management strategy. In general, psychiatric treatment such as cognitive behavioural therapy (CBT) should be directed at those patients who have specific issues.¹⁷

Dyspeptic symptoms are reported by up to 90% of patients with anorexia nervosa and can be used to excuse food refusal and distract attention from the eating disorder.¹⁹ The possibility of an eating disorder must be considered. The risk factors for eating disorders include: female sex, young adult age group, a family history of an eating disorder, an inappropriate body image (i.e. fear of being or becoming fat even though they are underweight), repeated dieting, unusual dietary beliefs or behaviours, excessive physical activity, and psychosocial stress.

Many patients will label any return of food to the mouth as vomiting, but direct questioning can clarify the issue. Vomiting is often preceded by nausea and waterbrash (rush of saliva into the mouth), and involves the forceful evacuation of large volumes (>100ml) of digested gastric contents. Regurgitation is the return of small volumes (<100ml) of fresh or semi-digested food from the oesophagus or stomach. Regurgitation can occur in dyspeptic patients due to reflux or rumination. In those with reflux disease ‘volume regurgitation’ rarely occurs more than once or twice after meals, but may also occur in bed at night. In rumination syndrome, regurgitation usually occurs multiple times after meals due to repeated voluntary, albeit subconscious, contractions of the abdominal wall muscles in response to dyspeptic symptoms.²⁰ The distinction between these conditions is important because reflux requires medical or surgical therapy, whereas rumination responds well to physiotherapy. If the clinical assessment is unclear then a definitive diagnosis can be established by observation during high-resolution manometry with a test meal.²⁰

Pharmaceutical management in patients with functional dyspepsia is complicated by a high rate of patient-reported ‘medication allergies’. These reports should be questioned because true allergic reactions are rare. Many adverse reactions are actually nocebo effects (i.e. incorrect attribution of symptoms to medication) or due to medication intolerance in patients who have heightened sensitivity to a range of stimuli. Although not dangerous, these issues can limit the use of potentially beneficial medications in patients with functional dyspepsia (e.g. antiemetics or antidepressants). Patients should be reassured that, unlike true allergies, intolerance is not dangerous and can be mitigated by commencing treatment at low doses. This is often necessary when prescribing antidepressant medications. To avoid drowsiness and anticholinergic effects, the starting dose of any antidepressant should be very low (e.g. 10–20mg amitriptyline) and increased every 1–2 weeks by small increments. The most appropriate dose is the maximum dose tolerated by the patient (often well below that used in psychiatric medicine). The efficacy of these medications for dyspepsia does not appear to be related to the absolute dose.

The presence of gallstones in an otherwise normal gallbladder should not be considered a routine indication for surgical cholecystectomy.^28–30 Similarly, as for patients without functional dyspepsia, a clear indication for appendectomy and other abdominal procedures (e.g. ovarian cystectomy) is required. If surgery is performed without definitive evidence of surgical pathology, then the success of any operation is very low and severe, postsurgical exacerbation of functional gastrointestinal symptoms is common.³¹

The causes of dyspepsia are many and patient responses to dyspeptic symptoms are varied, including dietary change and physical and alternative therapies (e.g. yoga or acupuncture).³² If the resources are available, then a multidisciplinary approach that can address an individual patient’s needs and wants has many advantages. Dieticians are required to introduce an effective exclusion diet (e.g. FODMAP diet) that maintains nutritional requirements. This is necessary because many patients find it difficult to identify foods that trigger their symptoms.³³ Similarly, physiotherapists can teach abdominal breathing exercises and relaxation techniques that are effective for the treatment of functional bloating and of rumination syndrome.^20,34 The support of psychiatric services is appropriate for patients with major depression, an anxiety disorder or eating disorder who can present with dyspeptic symptoms.^17,18

An effective and trusting doctor–patient relationship is the basis for successful management of functional gastrointestinal disease. If such a relationship is in place, then presenting the patient with a clear diagnosis, an explanation of what causes symptoms and simple advice about how to self manage the condition may be all that is required. For the related condition of functional noncardiac chest pain, it has been shown that well-informed patients are more satisfied, cope with symptoms better and seek medical attention less frequently.³⁵ These findings were independent of the final diagnosis and disease severity.³⁵ By contrast, there is very little evidence that comprehensive investigation provides lasting reassurance in this patient group. Good communication is an essential part of any treatment plan!