Recurrent Dyspepsia

A 38 year old secretary is referred to a gastroenterologist by her primary care physician (PCP) because of epigastric pain which has been present during the last year (Box 1, Fig 1). The pain is located between the umbilicus and the lower end of the sternum. It is intermittent, though present on most days of the week, and lasts between 10 minutes and 2 hours. It is often moderately severe, and described as ‘nagging’ in character, with no colicky component, and associated with epigastric burning (Box 1). The pain does not radiate up the sternum, nor to the right subscapular region nor through to the back. It is not related to food ingestion, is not associated with nausea or vomiting, and is not relieved by defecation or passage of flatus. Her bowel habit is normal. Occasionally the pain may prevent her from falling asleep but it does not wake her at night (Box 2). She has no dysphagia, weight loss (Box 3), or typical heartburn (Box 4). There is occasional mild postprandial fullness, but this is infrequent and does not occur at the time of the epigastric pain, and there is no early satiation (Box 1), or excessive belching, and rarely does she have upper abdominal bloating.

A similar episode of pain occurred 3 years ago, which was not responsive to antacids. It only lasted for several weeks and then spontaneously disappeared. The patient does not take NSAIDS, is a non-smoker and uses alcohol only sporadically. There are no previous or current medical conditions to explain the pain (Box 2), and she reports no family history of gastrointestinal disease (Box 3). Physical examination is normal (Box 2). Her PCP had arranged blood tests, including a serum test for H. pylori (Box 8), which was negative. She was treated with an H2-blocker for 6 weeks (Box 11), but this did not provide relief (Box 12). The PCP recommended metoclopramide, but there is no clear benefit with this medication.

The gastroenterologist performs an upper gastrointestinal endoscopy (Box 14), which does not reveal any peptic or other lesions, and biopsies from the antrum are negative for H. pylori (Boxes 15-18). A diagnosis of functional dyspepsia – epigastric pain syndrome (EPS) is made (Boxes 21, 23). Full-dose PPI therapy is prescribed for the next 8 weeks (Box 25).

At the end of this period, the patient reports no improvement in the pain (Box 26), and she feels unable to function properly. She is concerned that the symptoms are continuing despite PPI treatment, and that no abnormality has been found. The condition – functional dyspepsia, epigastric pain syndrome – is explained and the concept of visceral hypersensitivity is discussed as a potential underlying mechanism. The option of starting a low-dose tricyclic agent is proposed, and the disadvantages of other possible strategies such as an increase in the PPI dose (no evidence that this would provide better symptom control), a formal trial with a prokinetic agent (more likely to be effective in PDS), or undertaking additional investigations (unlikely to yield another diagnosis) are discussed (Box 28). The patient agrees to start a tricyclic agent after explanation of the concept of visceral hypersensitivity and the possible beneficial effects of this class of agents.

A 24 year old student is referred to a gastroenterologist because of increasing difficulty tolerating food. She was well until 7 months earlier, when she noticed progressively increasing symptoms of bothersome fullness, early satiation and upper abdominal bloating after meals (Box 1, Fig 1). This was accompanied by an inability to finish a meal of normal size and composition. The fullness and bloating is reported in the region between the umbilicus and the lower end of the sternum, and the experience is clearly different from pain (Box 2). There was no gastroenteritis-like episode prior to the onset of the symptoms. The symptoms improved to some degree when the patient eliminated fatty and spicy foods, and switched to multiple small meals, and this allowed her to maintain a stable body weight. Currently, the symptoms are triggered by, and continue after, every normal-sized meal, and may persist for up to 4 hours. There is no relief with belching, defecation or passage of flatus. Nausea occurs when the symptoms are most intense, but without vomiting (Box 2). She has no dysphagia or weight loss, and there is no heartburn (Box 3, 4). Her bowel habit is normal and unchanged. The patient is a non-smoker and takes alcohol only occasionally. She does not take any regular medications, including NSAIDs. She has no previous or current medical conditions which may explain the pain (Box 2), and there is no family history of gastrointestinal disease (Box 3).

Physical examination does not reveal any specific abnormalities (Box 2). The patient has tried over-the-counter antacids without any improvement. Her primary care physician arranged blood tests which were reportedly normal. She was treated with a single dose PPI for 8 weeks (Box 11), but this failed to provide any relief (Box 12). The primary care physician referred her to the gastroenterologist.

The gastroenterologist performs an upper gastrointestinal endoscopy (Box 14), which does not reveal any peptic disease or other lesions, and biopsies from the antrum do not reveal H. pylori (Boxes 15-18). A diagnosis of functional dyspepsia – postprandial distress syndrome (PDS) is made (Boxes 21, 22). A low dose of metoclopramide is prescribed for the next 8 weeks (Box 25).

At the follow-up visit, she reports no benefit from the metoclopramide (Box 26). The gastroenterologist explains that she has functional dyspepsia, postprandial distress syndrome, and discusses the concept of abnormal motility (delayed emptying, impaired accommodation) as a potential underlying mechanism. A therapeutic trial with a prokinetic agent (different specific agents are available in different parts of the world: e.g. domperidone, erythromycin, cleboprid) or a fundus-relaxing agent (e.g. buspirone) is proposed, and the limitations of other possible strategies such as an increase in the PPI dose (no evidence that this would provide better symptom control), a trial with a low-dose tricyclic agent (more likely to be effective in EPS), or undertaking additional investigations such as abdominal ultrasound or gastric motility testing (unlikely to yield another diagnosis or to change management) are discussed (Box 28). The patient agrees to start a prokinetic drug before meals.