Mistakes in dyspepsia and how to avoid them

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Mistakes in dyspepsia and how to avoid them

Mark Fox

Summary

AI Generated

Dyspepsia is upper abdominal discomfort with diverse causes including functional dyspepsia, GORD, peptic ulcer disease, and malignancy, and its management is challenging due to broad definition, lack of specific treatments, and psychosocial factors.

Dyspepsia presents with epigastric pain, bloating, early satiety, belching, nausea, and heartburn arising from the upper gastrointestinal tract.
Common causes include functional dyspepsia, gastro-oesophageal reflux disease, peptic ulcer disease, and malignancy.
Endoscopy is not always necessary for diagnosis, and clinical guidelines recommend considering clinical presentation without alarm symptoms.
Management challenges include the broad definition of dyspepsia, lack of specific treatments, and psychosocial issues.
The material addresses 10 common mistakes in diagnosis and treatment, relevant for clinicians managing dyspepsia.

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References

Mistakes

References

Mistake 1 Mistake 2 Mistake 3 Mistake 4 Mistake 5 Mistake 6 Mistake 7 Mistake 8 Mistake 9 Mistake 10

Tack J, Talley N. Functional dyspepsia: symptoms, definitions and validity of the Rome III criteria. Nat Rev Gastroenterol Hepatol 2013; 10: 134–141.

Ford AC, Marwaha A, Lim A. What is the prevalence of clinically significant endoscopic findings in subjects with dyspepsia? Systematic review and meta-analysis. Clin Gastroenterol Hepatol 2010; 8: 830-837 2.

National Institute for Health and Care Excellence NICE. Clinical Guideline 184. Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management, https://www.nice.org.uk/guidance/cg184 (2014, accessed 22 February 2024).

Talley N, Vakil N. Guidelines for the management of dyspepsia. Am J Gastroenterol 2005; 100: 2324–2337.

Farré R, Vanheel H, Vanuytsel T. In functional dyspepsia, hypersensitivity to postprandial distention correlates with meal-related symptom severity. Gastroenterology 2013; 145: 566–573.

Vanheel H, Vanuytsel T, Oudenhove L. Postprandial symptoms originating from the stomach in functional dyspepsia. Neurogastroenterol Motil 2013; 25: 911–703.

Ford AC, Marwaha A, Lim A. Systematic review and meta-analysis of the prevalence of irritable bowel syndrome in individuals with dyspepsia. Clin Gastroenterol Hepatol 2010; 8: 401–409.

Hungin AP, C H, Raghunath A. Systematic review: frequency and reasons for consultation for gastro-oesophageal reflux disease and dyspepsia. Aliment Pharmacol Ther 2009; 30: 331–342.

Ford AC, Forman D, Bailey AG. Initial poor quality of life and new onset of dyspepsia: results from a longitudinal 10-year follow-up study. Gut 2007; 56: 321–327.

10.

Rich G, Shah A, Koloski N, et al. A randomized placebo-controlled trial on the effects of Menthacarin, a proprietary peppermint- and caraway-oil-preparation, on symptoms and quality of life in patients with functional dyspepsia. Neurogastroenterol Motil 2017; 29: e13132.

11.

Melzer J, Rösch W, Reichling J, et al. Meta-analysis: phytotherapy of functional dyspepsia with the herbal drug preparation STW 5 (Iberogast). Aliment Pharmacol Ther 2004; 20: 1279–1287.

12.

Thomas E, Wade A, Crawford G. Randomised clinical trial: relief of upper gastrointestinal symptoms by an acid pocket-targeting alginate-antacid (Gaviscon Double Action)—a double-blind, placebo-controlled, pilot study in gastro-oesophageal reflux disease. Aliment Pharmacol Ther 2014; 39: 595–602.

13.

Pinto‐Sanchez MI, Yuan Y, Hassan A, et al. Proton pump inhibitors for functional dyspepsia. Cochrane Database Syst Rev 2017; 2017: CD011194.

14.

Pittayanon R, Yuan Y, Bollegala NP, et al. Prokinetics for functional dyspepsia. Cochrane Database Syst Rev 2018; 2018: CD009431.

15.

Kapoor N, Bassi A, Sturgess R. Predictive value of alarm features in a rapid access upper gastrointestinal cancer service. Gut 2005; 54: 40–45.

16.

Horowitz N, Moshkowitz M, Leshno M. Clinical trial: evaluation of a clinical decision-support model for upper abdominal complaints in primary-care practice. Aliment Pharmacol Ther 2007; 26: 1277–1283.

17.

Heikkinen M, Pikkarainen P, Takala J. Etiology of dyspepsia: four hundred unselected consecutive patients in general practice. Scand J Gastroenterol 1995; 30: 519–523.

18.

Spiegel BM, Gralnek IM, Bolus R. Is a negative colonoscopy associated with reassurance or improved health-related quality of life in irritable bowel syndrome? Gastrointest Endosc 2005; 62: 892–899.

19.

Soo S, Forman D, Delaney BC. A systematic review of psychological therapies for nonulcer dyspepsia. Am J Gastroenterol 2004; 99: 1817–1822.

20.

Drossman DA, Whitehead WE, Toner BB. What determines severity among patients with painful functional bowel disorders? Am J Gastroenterol 2000; 95: 974–980.

21.

Santonicola A, Siniscalchi M, Capone P. Prevalence of functional dyspepsia and its subgroups in patients with eating disorders. World J Gastroenterol 2012; 18: 4379–4385.

22.

Hay P, Mitchison D, Collado AEL, et al. Burden and health-related quality of life of eating disorders, including Avoidant/Restrictive Food Intake Disorder (ARFID), in the Australian population. J Eat Disord 2017; 5: 21.

23.

Tucker E, Knowles K, Wright J. Rumination variations: aetiology and classification of abnormal behavioural responses to digestive symptoms based on high-resolution manometry studies. Aliment Pharmacol Ther 2013; 37: 263–274.

24.

Delaney B, Ford AC, Forman D. Initial management strategies for dyspepsia. Cochrane Database Syst Rev 2005; 4: 001961.

25.

Delaney BC, Qume M, Moayyedi P. Helicobacter pylori test and treat versus proton pump inhibitor in initial management of dyspepsia in primary care: multicentre randomised controlled trial (MRC-CUBE trial. BMJ 2008; 336: 651–654.

26.

Wang WH, Huang JQ, Zheng GF. Effects of proton-pump inhibitors on functional dyspepsia: a meta-analysis of randomized placebo-controlled trials. Clin Gastroenterol Hepatol 2007; 5: 178–185.

27.

Reimer C, Søndergaard B, Hilsted L. Proton-pump inhibitor therapy induces acid-related symptoms in healthy volunteers after withdrawal of therapy. Gastroenterology 2009; 137: 80–87.

28.

Schwizer W, Menne D, Schütze K. The effect of Helicobacter pylori infection and eradication in patients with gastroesophageal reflux disease: a parallel-group, double-blind, placebo-controlled multicenter study. United Eur Gastroenterol J 2013; 1: 226–235.

29.

Fox M, Forgacs I. Gastro-oesophageal reflux disease. BMJ 2006; 332: 88–93.

30.

Stanghellini V, Tack J. Gastroparesis: separate entity or just a part of dyspepsia? Gut 2014; 63: 1972–1978.

31.

Boeckxstaens GE, Hirsch DP, Den Elzen BDJ. Impaired drinking capacity in patients with functional dyspepsia: relationship with proximal stomach function. Gastroenterology 2001; 121: 1054–1063.

32.

Vijayvargiya P, Camilleri M, Chedid V, et al. Effects of Promotility Agents on Gastric Emptying and Symptoms: A Systematic Review and Meta-analysis. Gastroenterology 2019; 156: 1650–1660.

33.

Saleem S, Aziz M, Khan AA, et al. Gastric Electrical Stimulation for the Treatment of Gastroparesis or Gastroparesis-Like Symptoms: A Systemic Review and Meta-Analysis. Neuromodulation J Int Neuromodulation Soc 2024; 27: 221–228.

34.

Labonde A, Lades G, Debourdeau A, et al. Gastric peroral endoscopic myotomy in refractory gastroparesis: long-term outcomes and predictive score to improve patient selection. Gastrointest Endosc 2022; 96: 500-508.e2.

35.

Talley NJ, Locke GR, Saito Y. Effect of amitriptyline and escitalopram on functional dyspepsia: A multicenter, randomized controlled study. Gastroenterology 2015; 149: 340-349 2.

36.

Mertens MC, Vries J, Scholtes VP. Prospective 6 weeks follow-up post-cholecystectomy: the predictive value of pre-operative symptoms. J Gastrointest Surg 2009; 13: 304–311.

37.

Luman W, Adams WH, Nixon SN. Incidence of persistent symptoms after laparoscopic cholecystectomy: a prospective study. Gut 1996; 39: 863–866.

38.

Fenster LF, Lonborg R, Thirlby RC. What symptoms does cholecystectomy cure? Insights from an outcomes measurement project and review of the literature. Am J Surg 1995; 169: 533–538.

39.

Sperber AD, Morris CB, Greemberg L. Development of abdominal pain and IBS following gynecological surgery: a prospective, controlled study. Gastroenterology 2008; 134: 75–84.

40.

Lacy BE, Weiser KT, Kennedy AT. Functional dyspepsia: the economic impact to patients. Aliment Pharmacol Ther 2013; 38: 170–177.

41.

Böhn L, Störsrud S, Törnblom H. Self-reported food-related gastrointestinal symptoms in IBS are common and associated with more severe symptoms and reduced quality of life. Am J Gastroenterol 2013; 108: 634–641.

42.

Barba E, Burri E, Accarino A. Abdominothoracic mechanisms of functional abdominal distension and correction by biofeedback. Gastroenterology 2015; 148: 732–739.

43.

Ward BW, Wu WC, Richter JE. Long-term follow-up of symptomatic status of patients with noncardiac chest pain: is diagnosis of esophageal etiology helpful? Am J Gastroenterol 1987; 82: 215–218.

Abstract

2024 update: Mark Fox
2016 version: Mark Fox

Dyspepsia refers to upper abdominal discomfort that can arise from the upper gastrointestinal tract, with symptoms including epigastric pain, bloating, early satiety, belching, nausea, and heartburn. It is commonly caused by functional dyspepsia, gastro-oesophageal reflux disease (GORD), peptic ulcer disease, or malignancy. Endoscopy is not always necessary for diagnosis, and clinical guidelines recommend considering clinical presentation without alarm symptoms. The management of dyspepsia is challenging due to its broad definition, lack of specific treatments, and psychosocial issues. Here, I discuss 10 common mistakes in diagnosis and treatment.

Topics

Neurogastroenterology & Motility

Published

2024

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UEG Standards and Guidelines

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European Guideline on Chronic Nausea and Vomiting—A UEG and ESNM Consensus for Clinical Management

Carolina Malagelada

Summary

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Summary is not available for this content yet.

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Guideline

ABSTRACT

Introduction

Chronic nausea and vomiting are symptoms of a wide range of gastrointestinal and non-gastrointestinal conditions. Diagnosis can be challenging and requires a systematic and well-structured approach. If the initial investigation for structural, toxic and metabolic disorders is negative, digestive motility and gut-brain interaction disorders should be assessed. United European Gastroenterology (UEG) and the European Society for Neurogastroenterology and Motility (ESNM) identified the need for an updated, evidence-based clinical guideline for the management of chronic nausea and vomiting.

Methods

A multidisciplinary team of experts in the field, including European specialists and national societies, participated in the development of the guideline. Relevant questions were addressed through a literature review and statements were developed and voted on according to a Delphi process.

Results

Ninety-eight statements were identified and voted following the Delphi process. Overall agreement was high, although the grade of scientific evidence was low in many areas. Disagreement was more evident for some pharmacological treatment options. A diagnostic algorithm was developed, focussing on the differentiating features between gastrointestinal motility and gut-brain interaction disorders with predominant nausea and vomiting.

Conclusion

These guidelines provide an evidence-based framework for the evaluation and treatment of patients with chronic nausea and vomiting.

Publisher

European Society of Neurogastroenterology and Motility

Guideline

Consensus

Topics

Neurogastroenterology & Motility Paediatrics Primary Care Stomach & H. Pylori

Citation

United European Gastroenterol J.

Published

2025

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Episode 5: UEG Journal September Spotlight

Mohsan Subhani, Djuna L. Cahen

Summary

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Abstract

Published

2025

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This content is part of Gutflix. Log in with your myUEG account, or create one free, to watch it.

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Functional bowel disorders with diarrhoea: Clinical guidelines of the United European Gastroenterology and European Society for Neurogastroenterology and Motility

Edoardo Vincenzo Savarino

Summary

AI Generated

Summary is not available for this content yet.

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Guideline

Abstract

Irritable bowel syndrome with diarrhoea (IBS-D) and functional diarrhoea (FDr) are the two major functional bowel disorders characterized by diarrhoea. In spite of their high prevalence, IBS-D and FDr are associated with major uncertainties, especially regarding their optimal diagnostic work-up and management. A Delphi consensus was performed with experts from 10 European countries who conducted a literature summary and voting process on 31 statements. Quality of evidence was evaluated using the grading of recommendations, assessment, development, and evaluation criteria. Consensus (defined as >80% agreement) was reached for all the statements. The panel agreed with the potential overlapping of IBS-D and FDr. In terms of diagnosis, the consensus supports a symptom-based approach also with the exclusion of alarm symptoms, recommending the evaluation of full blood count, C-reactive protein, serology for coeliac disease, and faecal calprotectin, and consideration of diagnosing bile acid diarrhoea. Colonoscopy with random biopsies in both the right and left colon is recommended in patients older than 50 years and in presence of alarm features. Regarding treatment, a strong consensus was achieved for the use of a diet low fermentable oligo-, di-, monosaccharides and polyols, gut-directed psychological therapies, rifaximin, loperamide, and eluxadoline. A weak or conditional recommendation was achieved for antispasmodics, probiotics, tryciclic antidepressants, bile acid sequestrants, 5-hydroxytryptamine-3 antagonists (i.e. alosetron, ondansetron, or ramosetron). A multinational group of European experts summarized the current state of consensus on the definition, diagnosis, and management of IBS-D and FDr.

Keywords: abdominal pain, clinical practice guidelines, diarrhea, FDr, functional bowel disorders, functional diarrhea, IBS-D, irritable bowel syndrome

Publisher

European Society of Neurogastroenterology and Motility

Guideline

Clinical Practice Guideline

Topics

Neurogastroenterology & Motility

Citation

United European Gastroenterol J.2022;10:556–584

Published

2022

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Guideline for the diagnosis and treatment of Faecal Incontinence—A UEG/ESCP/ESNM/ESPCG collaboration

Sadé L Assmann

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Guideline

Abstract

Introduction
The goal of this project was to create an up-to-date joint European clinical practice guideline for the diagnosis and treatment of faecal incontinence (FI), using the best available evidence. These guidelines are intended to help guide all medical professionals treating adult patients with FI (e.g., general practitioners, surgeons, gastroenterologists, other healthcare workers) and any patients who are interested in information regarding the diagnosis and management of FI.

Methods
These guidelines have been created in cooperation with members from the United European Gastroenterology (UEG), European Society of Coloproctology (ESCP), European Society of Neurogastroenterology and Motility (ESNM) and the European Society for Primary Care Gastroenterology (ESPCG). These members made up the guideline development group (GDG). Additionally, a patient advisory board (PAB) was created to reflect and comment on the draft guidelines from a patient perspective. Relevant review questions were established by the GDG along with a set of outcomes most important for decision making. A systematic literature search was performed using these review questions and outcomes as a framework. For each predefined review question, the study or studies with the highest level of study design were included. If evidence of a higher-level study design was available, no lower level of evidence was sought or included. Data from the studies were extracted by two reviewers for each predefined important outcome within each review question. Where possible, forest plots were created. After summarising the results for each review question, a systematic quality assessment using the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) approach was performed. For each review question, we assessed the quality of evidence for every predetermined important outcome. After evidence review and quality assessment were completed, recommendations could be formulated. The wording used for each recommendation was dependent on the level of quality of evidence. Lower levels of evidence resulted in weaker recommendations and higher levels of evidence resulted in stronger recommendations. Recommendations were discussed within the GDG to reach consensus.

Results
These guidelines contain 45 recommendations on the classification, diagnosis and management of FI in adult patients.

Conclusion
These multidisciplinary European guidelines provide an up-to-date comprehensive evidence-based framework with recommendations on the diagnosis and management of adult patients who suffer from FI.

Keywords: clinical guidelines, diagnosis, faecal incontinence, fecal incontinence, GRADE, guidelines, ptns, treatment, Sacral neuromodulation, unwanted loss of feces

Publishers

European Society of Neurogastroenterology and Motility, European Society for Coloproctology

Guideline

Clinical Practice Guideline

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Citation

United European Gastroenterol J.2022;10:251–286

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2022

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Summary

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References

Mistakes

References

Mistake 1 Mistake 2 Mistake 3 Mistake 4 Mistake 5 Mistake 6 Mistake 7 Mistake 8 Mistake 9 Mistake 10

Tack J, Talley N. Functional dyspepsia: symptoms, definitions and validity of the Rome III criteria. Nat Rev Gastroenterol Hepatol 2013; 10: 134–141.

Talley N, Vakil N. Guidelines for the management of dyspepsia. Am J Gastroenterol 2005; 100: 2324–2337.

Farré R, Vanheel H, Vanuytsel T. In functional dyspepsia, hypersensitivity to postprandial distention correlates with meal-related symptom severity. Gastroenterology 2013; 145: 566–573.

Vanheel H, Vanuytsel T, Oudenhove L. Postprandial symptoms originating from the stomach in functional dyspepsia. Neurogastroenterol Motil 2013; 25: 911–703.

Ford AC, Marwaha A, Lim A. Systematic review and meta-analysis of the prevalence of irritable bowel syndrome in individuals with dyspepsia. Clin Gastroenterol Hepatol 2010; 8: 401–409.

Hungin AP, C H, Raghunath A. Systematic review: frequency and reasons for consultation for gastro-oesophageal reflux disease and dyspepsia. Aliment Pharmacol Ther 2009; 30: 331–342.

Ford AC, Forman D, Bailey AG. Initial poor quality of life and new onset of dyspepsia: results from a longitudinal 10-year follow-up study. Gut 2007; 56: 321–327.

10.

11.

Melzer J, Rösch W, Reichling J, et al. Meta-analysis: phytotherapy of functional dyspepsia with the herbal drug preparation STW 5 (Iberogast). Aliment Pharmacol Ther 2004; 20: 1279–1287.

12.

13.

Pinto‐Sanchez MI, Yuan Y, Hassan A, et al. Proton pump inhibitors for functional dyspepsia. Cochrane Database Syst Rev 2017; 2017: CD011194.

14.

Pittayanon R, Yuan Y, Bollegala NP, et al. Prokinetics for functional dyspepsia. Cochrane Database Syst Rev 2018; 2018: CD009431.

15.

Kapoor N, Bassi A, Sturgess R. Predictive value of alarm features in a rapid access upper gastrointestinal cancer service. Gut 2005; 54: 40–45.

16.

17.

Heikkinen M, Pikkarainen P, Takala J. Etiology of dyspepsia: four hundred unselected consecutive patients in general practice. Scand J Gastroenterol 1995; 30: 519–523.

18.

Spiegel BM, Gralnek IM, Bolus R. Is a negative colonoscopy associated with reassurance or improved health-related quality of life in irritable bowel syndrome? Gastrointest Endosc 2005; 62: 892–899.

19.

Soo S, Forman D, Delaney BC. A systematic review of psychological therapies for nonulcer dyspepsia. Am J Gastroenterol 2004; 99: 1817–1822.

20.

Drossman DA, Whitehead WE, Toner BB. What determines severity among patients with painful functional bowel disorders? Am J Gastroenterol 2000; 95: 974–980.

21.

Santonicola A, Siniscalchi M, Capone P. Prevalence of functional dyspepsia and its subgroups in patients with eating disorders. World J Gastroenterol 2012; 18: 4379–4385.

22.

23.

24.

Delaney B, Ford AC, Forman D. Initial management strategies for dyspepsia. Cochrane Database Syst Rev 2005; 4: 001961.

25.

26.

Wang WH, Huang JQ, Zheng GF. Effects of proton-pump inhibitors on functional dyspepsia: a meta-analysis of randomized placebo-controlled trials. Clin Gastroenterol Hepatol 2007; 5: 178–185.

27.

Reimer C, Søndergaard B, Hilsted L. Proton-pump inhibitor therapy induces acid-related symptoms in healthy volunteers after withdrawal of therapy. Gastroenterology 2009; 137: 80–87.

28.

29.

Fox M, Forgacs I. Gastro-oesophageal reflux disease. BMJ 2006; 332: 88–93.

30.

Stanghellini V, Tack J. Gastroparesis: separate entity or just a part of dyspepsia? Gut 2014; 63: 1972–1978.

31.

Boeckxstaens GE, Hirsch DP, Den Elzen BDJ. Impaired drinking capacity in patients with functional dyspepsia: relationship with proximal stomach function. Gastroenterology 2001; 121: 1054–1063.

32.

Vijayvargiya P, Camilleri M, Chedid V, et al. Effects of Promotility Agents on Gastric Emptying and Symptoms: A Systematic Review and Meta-analysis. Gastroenterology 2019; 156: 1650–1660.

33.

34.

35.

Talley NJ, Locke GR, Saito Y. Effect of amitriptyline and escitalopram on functional dyspepsia: A multicenter, randomized controlled study. Gastroenterology 2015; 149: 340-349 2.

36.

Mertens MC, Vries J, Scholtes VP. Prospective 6 weeks follow-up post-cholecystectomy: the predictive value of pre-operative symptoms. J Gastrointest Surg 2009; 13: 304–311.

37.

Luman W, Adams WH, Nixon SN. Incidence of persistent symptoms after laparoscopic cholecystectomy: a prospective study. Gut 1996; 39: 863–866.

38.

Fenster LF, Lonborg R, Thirlby RC. What symptoms does cholecystectomy cure? Insights from an outcomes measurement project and review of the literature. Am J Surg 1995; 169: 533–538.

39.

Sperber AD, Morris CB, Greemberg L. Development of abdominal pain and IBS following gynecological surgery: a prospective, controlled study. Gastroenterology 2008; 134: 75–84.

40.

Lacy BE, Weiser KT, Kennedy AT. Functional dyspepsia: the economic impact to patients. Aliment Pharmacol Ther 2013; 38: 170–177.

41.

42.

Barba E, Burri E, Accarino A. Abdominothoracic mechanisms of functional abdominal distension and correction by biofeedback. Gastroenterology 2015; 148: 732–739.

43.

Ward BW, Wu WC, Richter JE. Long-term follow-up of symptomatic status of patients with noncardiac chest pain: is diagnosis of esophageal etiology helpful? Am J Gastroenterol 1987; 82: 215–218.

Abstract

Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) is a subclassification of steatotic liver disease (SLD), defined as the presence of excess triglyceride storage in the liver in conjunction with at least one cardiometabolic risk factor and no other discernible cause.1 Cirrhosis secondary to MASH is the most common cause of liver disease in the world and is the fastest-growing indication for liver transplantation, but it also has a >50% recurrence rate post-transplantation.

Topics

Hepatobiliary

Citation

Townsend SA and Newsome PN. Mistakes in nonalcoholic fatty liver disease and how to avoid them. UEG Education 2017; 17: 39–41.

Published

2024

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