Non-ulcer dyspepsia
Functional or non-ulcer dyspepsia is defined as at least three
months of dyspepsia in which no definite biochemical or
structural cause can be found to explain symptoms. There
is no confirmatory test and the diagnosis can only be made
after exclusion of the aforementioned structural causes.
A diagnosis of non-NSAID, non-H pylori ulcer should
only be entertained after:
■ exclusion of surreptitious NSAID use
■ careful exclusion of H pylori infection by several
biopsies
■ use of more than one H pylori diagnostic test
■ exclusion of confounders that would alter the sensitivity
of these tests, such as concurrent proton pump inhibitor
(PPI) use, recent antibiotic therapy or gastrointestinal
bleed.
Management involves 4-8 weeks of PPI therapy.
Although rare, exclusion of gastric carcinoma and other
upper gastrointestinal malignancies is important in those
with “alarm symptoms”, which the American Gastroenterological
Association guidelines summarise as:
■ age older than 55 years with new-onset dyspepsia
■ family history of upper gastrointestinal cancer
■ unintended weight loss
■ gastrointestinal bleeding
■ progressive dysphagia
■ odynophagia
■ unexplained iron-deficiency anemia
■ persistent vomiting
■ palpable lymphadenopathy
■ jaundice.
However, the presence of alarm symptoms has been
found to have poor predictive value for malignancy – rather
they alert the practitioner to the need for early endoscopy
to avoid the risk of missing a neoplastic process.
Functional dyspepsia can be difficult to manage. There
is evidence showing a small benefit with H pylori eradication
and PPI therapy. Although impaired gastric emptying
is noted in 25-40% of patients with functional dyspepsia,
there is inadequate evidence for the efficacy of
prokinetic therapy.
Despite its similarities to irritable bowel syndrome in
pathophysiology, there is also inadequate evidence to support
routine use of anti-depressants and psychological
therapies, although these should be considered as alternatives
for refractory patients. Counselling and reassurance
is essential.
