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Abstract: Dyspepsia
is a term originated from the Greek prefix dys- (bad) and the word
pepsis (digestion) and it means indigestion. Dyspepsia is a symptom
which indicates occasional or constant pain in the region of the
upper abdomen or discomfort which is described in the form of early
satiety or a feeling of fullness in the stomach. Sometimes it can be
accompanied by nausea, vomiting and heartburn. The symptoms of
dyspepsia are not specific enough to indicate a particular disease.
And if indicated, additional diagnostics are performed in order to
prove or rule out a physical disorder.
Dyspepsia is a frequent reason for visiting the doctor. About 40% of
the world's population has symptoms of dyspepsia, most often the
working population aged between 20-40 years, equally in both sexes.
About 25% of patients seek doctor’s help, while the rest seek help
for their problems at a pharmacy. Dyspepsia is the reason for 40% of
performed gastroenterology consultations.
This article presents the clinical picture, therapeutic and
diagnostic course, as well as the outcome of the treatment of a
53-year-old patient who came to the doctor with symptoms of
dyspepsia. The symptoms of dyspepsia had lasted for several years
before coming to the doctor. During the first examination, an
anamnesis was taken, the review of systems was performed, and a
basic blood test done in the local Health center. Given that there
was no data on the existence of alarming symptoms in this patient,
symptomatic therapy and advised change of habits were included, as
well as a planned checkup in one month. At the checkup, the patient
reported a decrease in frequency and intensity of abdominal pain, so
it was decided to perform additional diagnostics: test for
Helicobacter pylori, fecal occult blood test, and ultrasound
examination of the abdomen. Requested result of FOBT was negative,
but the test for Helicobacter pylori was positive.
Ultrasound examination revealed the presence of small calculi in the
gallbladder, but there were no other significant clinical findings.
Eradication therapy for helicobacter infection was included, and an
examination by a gastroenterologist for further diagnostics (esophagogastroduodenoscopy)
was planned. Gastroscopy findings were described as chronic
non-atrophic gastritis, predominantly antral. A follow-up
gastroscopy was planned in five-year interval, the patient was given
the proton pump inhibitors therapy, as well as dietary instructions.
Given that dyspepsia often occurs in clinical practice, it was
necessary to make a proper assessment regarding further diagnostics,
on the one hand for economic reasons and on the other hand for
medical reasons. Here, the decision was made to carry out further
diagnostics considering the duration of the health problems, the
presence of the problems during symptomatic therapy, the age of the
patient and his concerns. Given the absence of alarming symptoms,
appointments were scheduled for all examinations, so a complete
diagnosis of organic dyspepsia was reached after 13 months.
Key words: dyspepsia, clinical picture, diagnostic tests,
therapy
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INTRODUCTION
Dyspepsia is a term originated from the Greek prefix dys- (bad)
and pepsis (digestion) and it means indigestion. Dyspepsia is a
symptom that indicates occasional or constant pain in the region of
the upper abdomen or discomfort that is described in the form of
early satiety or a feeling of fullness in the stomach. Sometimes it
can be accompanied by nausea, vomiting and heartburn. The symptoms
of dyspepsia are not specific enough to indicate a particular
disease.
Dyspepsia is a frequent reason for visiting the doctor. About 40% of
the world's population has symptoms of dyspepsia, most often the
working population aged between 20-40 years, equally in both sexes.
About 25% of patients seek doctor’s help, while the rest seek help
at a pharmacy. Dyspepsia is the reason for 40% of performed
gastroenterology consultations.
The cause of dyspepsia can be an organic disease such as stomach
ulcer disease, gastroesophageal reflux disease, stomach or
pancreatic cancer and others, when it is marked as organic
dyspepsia. If an organic disease is not identified, then they are
marked as functional dyspepsia.
The most common causes of dyspepsia are: functional dyspepsia up to
60%, peptic ulcer 15-25%, reflux esophagitis 5-15%, stomach and
esophagus cancer less than 2%. Less common causes of dyspepsia are:
biliary diseases, pancreatitis, taking some medicines, ischemic
bowel diseases, parasitosis, malabsorption of carbohydrates,
systemic diseases, pancreatic cancer, and other abdominal tumors.
The main symptoms are burning, a feeling of discomfort and fullness
in the stomach that occurs before or after eating. It can also be
accompanied by a feeling of nausea, vomiting, heartburn, general
weakness, as well as belching. If the predominant symptom of
functional dyspepsia is pain, it is designated as ulcer-like
dyspepsia, and if the predominant symptom is a feeling of discomfort
in the epigastrium, it is designated as dysmotility-like dyspepsia.
Alarming symptoms are symptoms that may indicate the existence of an
organic disease manifested by dyspepsia, such as ulcer disease,
cancer of the esophagus or stomach. These include: sudden anemia due
to bleeding from the digestive tract (within the last 10 days),
severe unwanted weight loss (> 5% within 10 days), persistent
vomiting within 10 days, dysphagia, and the presence of a palpable
mass in the abdomen. In the presence of alarming symptoms, a quick
consultation of a gastroenterologist is necessary within two weeks.
CASE REPORT
A 53-year-old patient comes to the doctor with symptoms that have
been going on for several years in the form of discomfort in the
upper abdomen, occasionally a feeling of early satiety, occasionally
followed by pain and heartburn. The symptoms are stronger after
taking some food and larger meals. Appetite is normal, he has not
lost weight. The stools are tidy, without any appearance of blood
and mucus. In case of the symptoms’ aggravation, he takes baking
soda. He occasionally drinks alcohol (once or twice a week, 0.3-0.5
l of beer), smokes about 10 cigarettes a day and has done so for the
last 20 years. Due to back pain, he takes NSAIDs (ibuprofen,
naproxen, ketoprofen). Family history is negative in terms of
malignancy of the digestive tract. The patient’s son has ulcerative
colitis.
Physical examination is performed, the patient is in a good general
condition, pre-obese, the review of the systems is normal, except
for the light pain in the epigastrium region during deep palpation
examination. The patient is given a written diet on food to avoid,
as well as an advice on reducing the amount of meals he eats and the
dynamics of their intake. Recommendation to avoid alcohol intake and
referral to the Smoking Cessation Counseling Center. Pantoprazole
40mg is introduced half an hour before breakfast for the next two
weeks, with further recommendation to reduce the dose to 20mg per
day for another 2-4 weeks. In case of heartburn, sodium alginate
suspensions are recommended. Checkup planned in 4-6 weeks with a
basic blood test done at the local Health center.
At the checkup, the patient reports a decrease in frequency and
intensity of abdominal pain, no weight loss, frequent regular
stools. Blood test and biochemical results with no clinical
significance. Given that the symptoms are still present, it is
decided to perform additional diagnostics: test for Helicobacter
pylori, fecal occult blood test, and ultrasound examination of the
abdomen. Requested result of FOBT was negative, but the test for
Helicobacter pylori was positive.
On ultrasound, apart from the presence of small calculi in the
gallbladder, there are no other significant clinical findings. A
14-day eradication therapy for helicobacter infection is included (clarithromycin
2x500mg, amoxicillin 2x1000mg, bismuth subcitrate 4xdaily,
pantoprazole 2x40mg, probiotics). After the therapy, the patient
feels better, symptoms occasionally present.
For further diagnostics an examination by a gastroenterologist (esophagogastroduodenoscopy)
is appointed after 4 months.
The gastroenterologist's diagnosis is Morbus refluxualis gastro-oesophageus,
and the patient is put on the waiting list for gastroscopy, which is
performed after 7 months. Gastroscopy findings are described as
chronic non-atrophic gastritis, predominantly antral. A follow-up
gastroscopy is planned in five-year interval, the patient is given
the proton pump inhibitors therapy, as well as dietary instructions.
The patient suffers from dyspepsia only when he does not pay
attention to his diet, during frequent use of NSAIDs analgesics and
in stressful situations, but since the cause of dyspepsia symptoms
is known, his concern for his own health is significantly less.
CONCLUSION
Given that dyspepsia often occurs in clinical practice, it is
necessary to make a proper assessment regarding further diagnostics,
on the one hand for economic reasons and on the other hand for
medical reasons. Here, the decision is made to carry out further
diagnostics considering the duration of the health problems, the
presence of problems during symptomatic therapy, the age of the
patient and his concerns. Given the absence of alarming symptoms,
appointments were scheduled for all examinations, so a complete
diagnosis of organic dyspepsia is reached after 13 months.
In the subsequent checkups, the patient is motivated to follow the
dietary advice, it is explained to him when he needs to take proton
pump inhibitors and sodium alginate and for how long. The controlled
use of analgesics, mandatory with proton pump inhibitors, is
explained. He stopped smoking and reduced his alcohol intake to a
few times a year. Due to his stressful lifestyle, he is involved in
working with a psychologist for training in relaxation techniques,
which also contributes to the reduction of complaints. It is
explained to him which symptoms and signs are worrisome and when it
is necessary to report urgently for an examination. The patient, who
rarely visited the doctor, is now interested in conducting
preventive examinations, and if he has new health issues, he
consults the doctor and avoids self-medication.
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