GIT GUT - Indigestion

Question 1

Differential diagnoses of Indigestion /Dyspepsia

Answer 1

1. Indigestion - Esophageal Cancer
2. Dyspepsia - Gastritis vs GORD vs PUD
3. Dyspepsia - Liver metastasis

Probability diagnosis
Irritable upper GIT (functional dyspepsia)
Gastro-oesophageal reflux
Gastritis
Oesophageal motility disorder (dysmotility)

Serious disorders not to be missed  
Cancer:
•stomach
•pancreas
•oesophagus

Cardiovascular:
•ischaemic heart disease
•congestive cardiac failure 
Pancreatitis
Peptic ulcer (PU)

Pitfalls (often missed) 
Myocardial ischaemia
Food allergy (e.g. lactose intolerance)
Pregnancy (early)
Biliary motility disorder

Other
gall bladder disease

Postvagotomy
Duodenitis

Rarities:
•hyperparathyroidism
•mesenteric ischaemia
•Zollinger–Ellison syndrome
•kidney failure
•scleroderma

Masquerades checklist

Depression
Diabetes (rarely)
Drugs, esp. NSAIDs, aspirin

Is the patient trying to tell me something?
Anxiety and stress are common associations of which patients are often unaware.
Consider irritable bowel syndrome.

Question 2

Indigestion/Dyspepsia - Key History

Answer 2

Key history

Clarify the exact nature of the presenting complaint: what the patient means by ‘indigestion’ or ‘heartburn’. Note the relationship of the symptoms to eating. In particular, care should be taken to consider and perhaps exclude ischaemic heart disease. Analyse the presenting symptom according to site and radiation, character of discomfort, aggravating and relieving factors and associated symptoms.
Drug history and past history is important, especially NSAID use.

Question 3

Indigestion/ Dyspepsia - Key PE

Answer 3

Key examination

• This does not provide the key to the diagnosis, but perform very careful palpation and inspection
• Look for evidence of anaemia and jaundice

Question 4

Indigestion/Dyspepsia - Key Investigations

Answer 4

Key investigations
Do not overinvestigate.

• The investigation of choice is gastroscopy, which is indicated for ‘alarm symptoms’ such as dysphagia, bleeding and unexplained weight loss
• Test for Helicobacter pylori

Question 5

Indigestion/Dyspepsia - Diagnostic tips

Answer 5

Diagnostic tips

• Epigastric pain aggravated by any food and relieved by antacids indicates chronic gastric ulcer.
• Pain before meals relieved by food indicates chronic duodenal ulcer.
• Triple loss of appetite, weight and colour is a feature of cancer of the stomach.