Today we'll talk about the approach to the
patient with nausea and vomiting.
We'll begin with the definition.
So what is dyspepsia?
Dyspepsia is a clinical term that we use to
refer to a constellation of symptoms that includes
gastric, epigastric pain or burning,
abdominal bloating and nausea and vomiting.
So now let's begin with a case.
We have a 53-year-old woman seen
in clinic for 8 months of epigastric pain.
Her pain is intermittent, described as a
sense of abdominal bloating and discomfort.
Her symptoms tend to occur after meals.
She has nausea, occasional vomiting,
and has lost 5 kg in the last year.
Her mother had a history of stomach cancer.
Her vitals are normal.
On exam, she has mild tenderness in the
epigastric region but no palpable masses.
Her labs show a hemoglobin of 11.5
So what is the best next step in management?
Let's identify some key features of this case
She has chronic abdominal discomfort,
nausea, vomiting and weight loss
and a family history of an upper
GI malignancy which is concerning.
So let's talk a bit more about dyspepsia.
Two-thirds of all cases of dyspepsia are
caused by what is called functional dyspepsia
which is when there is no structural or
obvious etiology for the patient’s symptoms.
However, as with all functional
disorders, this is a diagnosis of exclusion.
So you want to also make sure that you rule out
many of the other causes that can lead to dyspepsia
I'm not gonna go through all of them
here, but they're here for your reference.
Note that anything from
gastroesophageal reflux disease or GERD
to cancer to even medications
can lead to dyspepsia.
So, this brings us to the alarm features that you
should always make sure to elicit for your patients.
If they have the symptoms that onset after
the 50, that could be highly concerning.
They have anemia,
dysphagia or odynophagia - that's difficulty
with swallowing or pain with swallowing,
any unintentional weight loss,
a family or personal history
of an upper GI cancer,
a personal history of
peptic ulcer disease or PUD,
and any prior gastric surgeries.
If any of these risk factors are present, you
should refer this patient for endoscopy
Functional dyspepsia, since this is a diagnosis of
exclusion has a very strict diagnostic criteria.
Symptoms have to be present
consistently for the past 3 months
and they have to have
begun at least 6 months prior.
You must have one or
more of the following features:
Either postprandial fullness, early
satiety, epigastric pain or epigastric burning.
Also, you must make sure there is no
structural disease to explain these symptoms
So we don't know what exactly
causes functional dyspepsia.
It has an unknown mechanism but we
suspect there are contributions for many factors
including abnormal upper GI motor
activity, psychological factors, genetic factors,
disruption in the brain-gut interactions
and disruptions in the gut microbiome.
If you are sure that your
patient has no alarm features,
then basic management consist of testing
and treating for Helicobacter pylori infection,
trialing of proton pump inhibitor or PPI,
and recommending diet
and lifestyle modification.
So in general, telling your patient to keep a food diary
and avoid foods that are known to trigger their symptoms.
So that brings us back to our case.
a 53-year old woman who's been having chronic
abdominal discomfort, nausea, vomiting and weight loss
which indicates dyspepsia
with alarm features
and her family history of GI malignancy.
Because of the presence of all of these
alarm symptoms such as her anemia,
her vomiting, weight loss and
her family history of GI cancer,
the next step should be endoscopy.