Dyspepsia Overview and Causes

Dyspepsia

• Dyspepsia is an umbrella term for upper abdominal symptoms from five conditions: non-ulcer dyspepsia/functional dyspepsia, gastro-esophageal reflux disease (GORD), gastritis, duodenal ulcers, and gastric ulcers.
• These five conditions represent 90% of dyspepsia cases presented to GPs.
• The exact prevalence of dyspepsia is unknown due to people self-medicating or not reporting mild symptoms.
• Prevalence is modestly higher in women than men.

Etiology

• Decreased muscle tone: Leads to lower esophageal sphincter incompetence, often from medications or overeating, and is a primary cause of GORD.
• Increased acid production: Results in stomach inflammation (gastritis), usually from Helicobacter pylori infection or acute alcohol indigestion. H. pylori is central to duodenal and gastric ulceration (present in 95% of duodenal ulcers and 80% of gastric ulcers). The exact ulceration mechanism is unclear but the bacteria produce toxins that stimulate the inflammatory cascade.
• Medicine-induced ulcers: Increasingly frequent, mostly with NSAIDs and low-dose aspirin.

Differential Diagnosis

• Medical and drug history is important in ruling out serious pathology in patients with dyspepsia.
• Dyspepsia-specific questions should be asked to aid in diagnosis.
• In suspected ulcer cases, referral to a GP is necessary. Diagnosis is confirmed through endoscopy.

Clinical Features

• Vague abdominal discomfort above the umbilicus (possibly with belching), bloating, flatulence, fullness, nausea/vomiting, and heartburn.
• Retrosternal heartburn is a classic symptom of GORD, but dyspeptic symptoms are poor predictors of disease severity or underlying pathology.

Medicine-Induced Dyspepsia

• Aspirin and NSAIDs are often associated with dyspepsia, affecting up to 25% of patients.

Irritable Bowel Syndrome

• Patients under 45 with uncomplicated dyspepsia, lower abdominal pain, and altered bowel habits might have irritable bowel syndrome.

Other Unlikely Causes

• Gastric carcinoma is relatively rare, but community pharmacists should be aware of potential malignancy. Patients with alarm symptoms should be referred.
• Esophageal carcinoma might be asymptomatic in early stages, but typical symptoms include difficulty swallowing and food sticking in the esophagus.
• Atypical angina can present with dyspepsia-like symptoms and be associated with heavy meals.

OTC Treatment Options

• Antacids (e.g., sodium, potassium, magnesium, calcium salts).
• H2 antagonists (e.g., ranitidine, nizatidine, famotidine).
• Proton pump inhibitors (PPIs) (e.g., omeprazole).
• Lifestyle advice (diet and physical activity) should be given before treatment.

Antacids

• Efficacy is in neutralizing stomach acid.
• Solubility and duration of action vary based on the metal salt.
• Sodium and potassium salts have a quick onset, while magnesium and aluminum are slower-acting.
• Combined products are common to ensure a quick onset and prolonged action.

Alginates

• First-line treatment for GORD.
• Creates a sponge-like matrix that floats above stomach contents, neutralizing stomach acid.
• Often combined with antacids, best taken after meals.

H2 Antagonists

• Famotidine and Ranitidine are similar in dosing (single or double dose as needed).

Proton Pump Inhibitors (PPIs)

• Superior to H2 antagonists in treating dyspeptic symptoms.
• Omeprazole is licensed for acid-related problems (e.g. heartburn) in patients over 18.

Additional Notes

• Antacids can affect the absorption of many medications (e.g. tetracyclines, quinolones, imidazoles, phenytoin).
• A 1-hour gap between doses of different medicines should usually overcome interaction problems.
• Avoiding sodium-containing antacids is important for patients on salt-restricted diets.
• Antacids should be avoided in children under 12, though exceptions to the rule exist (check licensing details).

Acute Diarrhea

• Common causes are viral or bacterial infections.
• The community pharmacist can manage symptom relief and identify patients warranting GP referral.
• Dehydration is a major complication, especially in vulnerable populations.

Constipation

• Constipation is a reduction in normal bowel habits with difficult defecation and/or hard stools.
• Prevalence is high in the elderly. Lifestyle factors (diet, inactivity), chronic illness, and medication can also be causes.
• Diagnosis includes questioning about current bowel habits versus normal. Constipation is often a symptom of other problems.
• Lifestyle changes are preferred initial treatment.

Depression

• Symptoms that overlap with gastrointestinal symptoms.
• Report/referral to physicians is warranted for serious concern.

Dietary Factors

• Increasing intake of fiber (fruit, vegetables, whole grains) to increase bowel bulk and hydration (at a rate of 2L of water per day). This helps in preventing/reducing constipation.

Other Considerations

• Pregnancy, medications, and chronic illnesses should be factors of concern.

This quiz explores the various conditions that contribute to dyspepsia including GORD, gastritis, and ulcers. Learn about the prevalence, symptoms, and underlying causes of dyspepsia, along with the role of Helicobacter pylori. Test your understanding of this common gastrointestinal issue.