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Clinical Crossroads | Clinician's Corner

A 32-Year-Old Woman With Chronic Abdominal Pain

Brian E. Lacy, PhD, MD; Brooks D. Cash, MD
JAMA. 2008;299(5):555-565. doi:10.1001/jama.2007.51-a.
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Functional dyspepsia is a highly prevalent disorder that accounts for 5% of visits to primary care clinicians. It frequently coexists with other gastrointestinal tract disorders, including irritable bowel syndrome and gastroesophageal reflux disease. Symptoms of functional dyspepsia, including epigastric pain, early satiety, and postprandial nausea, are nonspecific, making its diagnosis difficult. Functional dyspepsia is a heterogeneous disorder involving a number of different pathophysiologic processes, culminating in both gastrointestinal sensory and motor dysfunction. Although functional dyspepsia does not impart any increased risks to long-term health, it significantly affects both individuals and society. The economic burden of evaluating and treating functional dyspepsia is estimated to be at least $1 billion per year, and patients with functional dyspepsia experience a markedly reduced quality of life. Using the case of Ms C, we apply an evidence-based approach to highlight current knowledge in the diagnosis, evaluation, and treatment of functional dyspepsia.

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Is functional dyspepsia really the right diagnosis?
Posted on January 30, 2008
Lorenzo Fuccio, MD
University of Bologna, Italy
Conflict of Interest: None Declared
How should functional dyspepsia be evaluated and what is the yield of diagnostic testing? The patient is a 32-year-old without alarm symptoms. The initial management strategy should include a “test and treat” strategy for H. pylori infection; although serologic testing is inexpensive, in low H. pylori prevalence populations its performance characteristics as a test are poor and it is not helpful in confirming eradication. In this case urea breath test or stool antigen test should be performed before treating the infection. In areas of low H. pylori prevalence (less than 20%), proton pump inhibitor (PPI) empirical treatment is considered equivalent option to a test-and-treat strategy. At this age, endoscopy has the lowest diagnostic yield and should be considered when both “test and treat” and “PPI empirical therapy” have failed. [1,2] What is the evidence that nonpharmacological or pharmacological treatment is effective? H. pylori eradication therapy has a small but statistically significant effect in H. pylori-positive non-ulcer dyspepsia (NUD), with a number needed to treat (NNT) of 14 (95% CI = 10 to 25).[3] Similarly, PPI therapy when compared with placebo, provides significant beneficial effects on symptoms of NUD with a RR of 0.86 (95% CI 0.78-0.95) and a NNT of 9 (95% CI, 5-25).[4] There is insufficient evidence from systematic reviews to confirm the efficacy of prokinetic therapy, since the results could be due to publication bias, therefore more large randomized controlled trials are needed. Undoubtedly, antacids and sucralfate have not showed any significantly better effect than placebo.[5] No firm conclusion can be drawn on the efficacy of psychological intervention in NUD, due to the lack of well-performed randomized trials.[6]
What do you recommend for Ms C? In this case, I would recommend re-evaluating her symptoms and diagnosis and consider other sources of abdominal pain.[7] She presented with symptoms of lower abdominal discomfort, constipation (straining and feelings of incomplete evacuation), and bloating and a family history of irritable bowel syndrome (IBS), therefore a diagnosis of IBS should be considered.[8] Furthermore, abdominal pain and constipation represent less common but well-known presentations of celiac disease and serologic testing is advisable.[9] Finally, intolerance foods other than gluten and psychological and panic disorders should be carefully addressed.[7,9]
References
1. Malfertheiner P, Megraud F, O'Morain C, Bazzoli F, El-Omar E, Graham D, Hunt R, Rokkas T, Vakil N, Kuipers EJ. Current concepts in the management of Helicobacter pylori infection: the Maastricht III Consensus Report. Gut. 2007 Jun;56(6):772-81. 2. Delaney B, Ford AC, Forman D, Moayyedi P, Qume M. Initial management strategies for dyspepsia. Cochrane Database Syst Rev. 2005 Oct 19;(4). 3. Moayyedi P, Soo S, Deeks J, Delaney B, Harris A, Innes M, Oakes R, Wilson S, Roalfe A, Bennett C, Forman D. Eradication of Helicobacter pylori for non-ulcer dyspepsia. Cochrane Database Syst Rev. 2006 Apr 19;(2). 4. Moayyedi P, Delaney BC, Vakil N, Forman D, Talley NJ. The efficacy of proton pump inhibitors in nonulcer dyspepsia: a systematic review and economic analysis. Gastroenterology. 2004 Nov;127(5):1329-37. 5. Moayyedi P, Soo S, Deeks J, Delaney B, Innes M, Forman D. Pharmacological interventions for non-ulcer dyspepsia. Cochrane Database Syst Rev. 2006 Apr 18;(4). 6. Soo S, Moayyedi P, Deeks J, Delaney B, Lewis M, Forman D. Psychological interventions for non-ulcer dyspepsia. Cochrane Database Syst Rev. 2005 Apr 18;(2). 7. Talley NJ, Vakil NB, Moayyedi P. American gastroenterological association technical review on the evaluation of dyspepsia. Gastroenterology. 2005;129(5):1756-80. 8. Spiller R, Aziz Q, Creed F, Emmanuel A, Houghton L, Hungin P, Jones R, Kumar D, Rubin G, Trudgill N, Whorwell P; Clinical Services Committee of The British Society of Gastroenterology. Guidelines on the irritable bowel syndrome: mechanisms and practical management. Gut. 2007 Dec;56(12):1770- 98. 9. Green PH, Cellier C. Celiac disease. N Engl J Med. 2007 Oct 25;357(17):1731-43.
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