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functional dyspepsia — managing the conundrum

Functional Dyspepsia — Managing the Conundrum
George F. Longstreth, M.D. Related article, page 832 amination for tenderness, which is usually nonspecific. However, it is common to find localized tenderness of the abdominal wall that increases with the contraction of abdominal muscles at painful sites in the upper or lowerabdomen. This test (Carmainly in patients with diabetes. Certain worrisome features — such as the onset of dyspepsia after 55 years of age, unintended weight loss, anemia, and progressive dysphagia — increase the likelihood that the cause is an organic disorder. Unfortunately, a medical history and a physical examination cannot distinguish peptic ulcer disease from functional dyspepsia.Ultrasonography of the gallbladder should generally be undertaken only in patients with characteristic biliary pain, since they are the most likely to benefit from cholecystectomy. The measurement of gallbladder emptying with the use of cholecystokinin cholescintigraphy in patients without gallstones is unproven as a predictor of the outcome of cholecystectomy, and “diagnostic cholecystectomy,” which may beincreasing in frequency as laparoscopic surgery becomes more common, should be discouraged. If careful history taking, physical examination, and screening laboratory tests in patients with dyspepsia do not lead to a diagnosis, physicians can follow the management guidelines of the American College of Gastroenterology1 or the American Gastroenterological Association,2 which make similarrecommendations on the basis of data from both cost analyses and randomized, controlled trials of a variety of treatments. Patients who are older than 55 years, who are members of racial or ethnic groups that are predisposed to early gastric

Every day, in countless examination rooms around the world, patients are consulting their doctors about chronic stomach pain. In industrialized countries, medicalevaluation usually uncovers no structural cause for chronic upper abdominal pain or discomfort; the majority of patients have functional, or nonulcer, dyspepsia. Although some general principles are useful in managing functional dyspepsia, the therapies that have been assessed to date provide little hope of a cure for this perplexing disorder. Most patients with dyspepsia are first evaluated by primarycare practitioners, who should elicit a detailed history to identify patients whose symptoms may be attributable to medication use, gastroesophageal reflux disease, gallstones or, if symptoms are associated with constipation or diarrhea, irritable bowel syndrome. Stopping the use of medications (such as nonsteroidal antiinflammatory agents) that have been implicated as potential sources of suchsymptoms may help to mitigate dyspepsia. Symptoms of gastroesophageal reflux disease usually improve after treatment with acid inhibitors, whereas symptoms of irritable bowel syndrome do not. Patients with dyspepsia should be asked about other physical problems, coexisting psychological symptoms, and stressful life events, because these factors influence the severity of the illness and affect itsmanagement. Patients undergo a physical ex-nett’s sign), first described 80 years ago, is an accurate tool for assessing pain from the abdominal wall, and in many patients without weight loss or other worrisome features, no additional investigation is required. However, this test is frequently overlooked, leading to referral to a specialist after fruitless and expensive imaging procedures have beenperformed and drug therapy has proved unsuccessful. Much less often, the examiner palpates a tumor or detects a dermatomal cutaneous sensory abnormality or localized paresis of the abdominal wall, both of which are typical of thoracic polyradiculopathy, which occurs functional dyspepsia — managing the conundrum

Treatments for Functional Dyspepsia. Treatments with limited supporting evidence...