DYSPEPSIA
PRESENTATION & SURGICAL MANAGEMENT
Blanket term for symptoms implying indigestion.
Includes a combination of following symptoms:
• Epigastric pain
• Reflux & waterbrash
• Eructations
• Heartburn
• Bloating/Distension
• Flatulence
Most often --- Upper GI pathology
Especially associated with following disorders:
• Acid-peptic disease
• Gastroesophageal Reflux Disease
• Reflux esophagitis
• Hiatus hernia (sliding vs. paraesophageal)
• Cholelithiasis
Rarely a manifestation of malignant/other sinister pathology:
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CARCINOMA STOMACH
CARCINOMA GALL BLADDER
CHRONIC LIVER DISEASE
May also present as a manifestation of distal GI pathology:
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FUNCTIONAL COLONIC DISEASE
MALABSORPTION SYNDROMES
RELEVANT HISTORY
• Duration of symptoms ---- new-onset vs. long standing
• Progressive vs. static
• Weight loss and anorexia
• Meal timings and meal content (e.g. binges & junk foods)
• Addictions --- esp. alcohol & tobacco
Body habitus ---- morbid obesity!
Complete general physical examination --- pallor, jaundice, lymphadenopathy etc.
RELEVANT EXAMINATION
Complete abdominal examination:
• Tenderness
• Distension
• Organomegaly
• Mass
INVESTIGATING THE CAUSE OF DYSPEPSIA
Mandatory diagnostic tools:
• Ultrasound scan of abdomen
• Esophagogastroduodenoscopy
Second-line modalities:
• Upper GI contrast series
• 24 Hr pH monitoring
• Esophageal manometry
ULTRASOUND SCAN ABDOMEN
Cheap, least invasive, sensitive screening tool to rule out:
• Gall stones
• Liver disease
Abdominal mass/organomegaly
• Observer-dependent ; not highly specific
• Flexible scope can reach upto duodenum
• Excellent diagnostic value for:
ESOPHAGOGASTRODUODENOSCOPY
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Reflux esophagitis
Hiatus hernia
Gastric ulcer
Duodenal ulcer
Motility disorders
Can obtain biopsy of suspicious lesions
BARIUM / GASTROGRAFFIN SWALLOW
24 HR PH MONITORING
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GOLD STANDARD TEST FOR DIAGNOSIS OF
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GASTROESOPHAGEAL REFLUX DISEASE (GERD)
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INVASIVE TEST --- requires ambulatory monitoring
MANAGING A PATIENT WITH DYSPEPSIA
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CHOLELITHIASIS: Cholecystectomy indicated in all symptomatic cases.
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Operation can be performed with minimally invasive technique with minimum morbidity and
mortality
HIATUS HERNIA: if early and sliding --- conservative treatment first
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If para-esophageal or large ---- warrants surgical repair
GASTRO-ESOPHAGEAL REFLUX ---- always a trial of conservative treatment first:
• Weight reduction
• Lifestyle changes
• PPIs
IF FAILS : Anti-refluxprocedure e.g Nissen fundoplication
• ACID-PEPTIC DISEASE: Conservative management first:
• PPIs
• Lifestyle changes
• Eradication of H pylori .
• IF ULCER PERFORATES --- peritonitis --- emergent laparotomy
• MALIGNANT ULCER ---- radical surgery if operable
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MOTILITY DISORDERS: Endoscopic vs. surgical treatment
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MALIGNANCY: Radical surgery if operable; Palliation if inoperable
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Malabsorption & functional colonic disease: non-surgical treatment