Dyspepsia

What is dyspepsia?

Dyspepsia (also referred to as indigestion) refers to upper abdominal pain/discomfort. It may be due to conditions affecting the oesophagus, stomach, duodenum, gallbladder, bile duct, liver or pancreas. Dyspepsia is not typically related to intake of food.

When should you see a doctor for dyspepsia?

When accompanied by other features such as nausea, weight loss, lethargy, jaundice etc., alarm should be raised, and referral for expedient work-up be made. 

Infrequently, the colon, abdominal aorta or spine may be the site of pathology. From the clinical history, the likely cause of pain is usually apparent, such as a bleeding ulcer or gallstones flatulence.

How is dyspepsia diagnosed?

Clinical examination is helpful for differential diagnoses (e.g., hepatomegaly suggests hepatocellular carcinoma), and in directing the investigations. 

Whilst empirical treatment such as anti-acid for presumed gastritis will usually be effective, recurrent or progressive symptoms warrant further work-up. 

The various procedures or imaging involved in the initial evaluation of dyspepsia or reflux may include the following (listed along with the common conditions which may be diagnosed):

• OGD (oesophago-gastroduodenoscopy): oesophagitis, gastritis, ulcer, polyps or tumour may be identified and biopsy taken.
  

• Ultrasound of the abdomen: gallbladder stones, cysts or tumours in liver or kidney, obstructed bile ducts or mass in pancreatic head.
  

• CT scan of the abdomen & pelvis: tumours, or in solid organs (e.g., pancreas), lymphadenopathy, occult infections or lesions in spine.
  

• Manometry & pH studies: reflux and retention of acid in the lower oesophagus, and peristalsis and tonic contractions of the oesophagus.
  

• Barium meal: ulcers, polyps or tumours. This may be offered as an alternative to OGD, but it is not possible to perform biopsy nor test for Helicobacter pylori infection. Subtle changes including early gastric cancer may be missed.
  

• Colonoscopy: polyps, tumours or diverticular disease.
  

How is dyspepsia treated?

Once the cause of abdominal pain is found, treatment is relatively standard. For example, proton pump inhibitors and antibiotics are used for ulcers related to helicobacter pylori infection. 

It is important to appreciate that common conditions typically respond well to treatment. Hence, when symptoms persist or worsen in spite of treatment, further clinical examinations and tests or procedures may be required. Some patients may in fact have functional disorders, which would require longer periods of treatment and monitoring.