Non-ulcer dyspepsia

About non-ulcer dyspepsia 

Dyspepsia is the medical term for indigestion. Dyspepsia is upper abdominal (epigastric) or lower chest discomfort or pain which is related to food or eating. Dyspepsia is often accompanied by other gastrointestinal symptoms such as loss of appetite (anorexia), nausea, vomiting, belching or distension and bloating. Non-ulcer dyspepsia refers to those cases of indigestion or dyspepsia where no ulcer or other medical cause, such as gallstones or gastro-esophageal reflux disease is found.

Prior to the advent of medical investigations such as upper gastrointestinal endoscopy (gastroscopy) it was not possible for doctors to make a definitive diagnosis of non-ulcer dyspepsia. Advances in clinical investigation have allowed patients who are thought to have non-ulcer dyspepsia to be diagnosed and treated appropriately. For example, esophageal pH studies may well change the diagnosis to endoscpy-negative gastro-esophageal reflux disease. Some patients may elude diagnosis because they are not investigated thoroughly.

The diagnosis of non-ulcer dyspepsia may sound vague, and is not intellectually satisfying to doctors, but it is an important diagnosis to make. Firstly the patient is able to be reassured that he or she has a recognised medical diagnosis. Secondly serious disease or pathology has been excluded and the patient can be accordingly reassured and treated.

Epidemiology or origins of non-ulcer dyspepsia

Non-ulcer dyspepsia is extremely common. For example in one medical study which was carried out in the South West of England, 38% of the entire adult population had symptoms of dyspepsia during a six-month period. A further 25% of the population surveyed gave a past history of symptoms of dyspepsia. The researchers found that nearly all of these individuals had non-ulcer dyspepsia.

Symptoms of non-ulcer dyspepsia

Non-ulcer dyspepsia patients report a variety of symptoms. Medical research has revealed a number of abnormalities of physiological function. The symptoms and the corresponding causes or pathophysiology are described below. In practice doctors report that the relationship between symptoms and disorders of function remain ill-defined, and it is to be noted that many patients have more than one symptom.

Gastroenterologists who specialise in this area speculate that a common theme in these patients is that mild injury, irritation or anxiety reduces the threshold for perception of pain and discomfort in the upper gastrointestinal tract. Symptoms include:

Burning sensation 

It is common for patients with dyspepsia to complain or report the symptom of burning in the upper abdomen (epigastric area) or lower chest. These symptoms are similar to those experienced by patients with gastric esophageal reflux disease.

Distension symptom

Many patients with non-ulcer dyspepsia report that their abdomen feels distended. This is a symptom that also occurs in irritable bowel syndrome. In non-ulcer dyspepsia distension is mainly felt in the upper abdomen and after meals. In addition there is often a sensation of feeling full (early satiety) after meals, and a proportion of patients with non-ulcer dyspepsia have delayed gastric emptying when investigated with scintigraphy (a form of diagnostic test which is used in nuclear medicine where radio-isotopes are injected or taken internally and the emitted radiation is captured by external detectors to form two-dimensional pictures). The cause of delayed gastric emptying is not known, although sometimes anxiety is a factor. It is also been found that reflux of duodenal contents back into the stomach, from the duodenum also occurs more frequently in non-ulcer dyspeptic sufferers. The other medical conditions which cause distension, that are considered by doctors, include: ascites (fluid within the abdominal cavity), irritable bowel syndrome, bowel cancer, ovarian cysts, ovarian cancer, obesity, pregnancy and other rarer causes.

Pain in non-ulcer dyspepsia

Pain felt in the upper abdomen, is a frequent symptom in non-ulcer dyspepsia, although its origin may be difficult to establish. The pain may be due to muscular spasm. The differential diagnosis considered by doctors includes oesophageal spasm, achalasia, peptic ulcer, gallstone disease and pancreatitis.

Nausea, vomiting and satiety (The condition of being full or gratified beyond the point of satisfaction)

If nausea and vomiting continue without an organic cause being found on investigation of the upper gastrointestinal tract, then it is important to ensure that this nausea and vomiting is not caused by other problems. Other causes of nausea and vomiting include: drugs, metabolic disease (such as renal failure, liver disease or diabetes), vertigo and problems of the middle ear and central nervous system, bulimia, anorexia nervosa and psychogenic vomiting.

Diagnosis

When doctors examine patients with non-ulcer dyspepsia, they usually find no abnormality apart from mild tenderness in the upper abdomen (epigastrium). Medical investigation aims to exclude other diseases. This is to enable reassurance of the patient and to enable appropriate and effective treatment. The problem that doctors have is that the condition is so common that it can be difficult and impractical to investigate all patients fully. Doctors therefore need to use their clinical judgement. Upper gastrointestinal endoscopy is needed and indicated if the symptoms or clinical picture suggest organic disease or if symptoms are persistent or recurrent. Ultrasound scanning of the upper abdomen is a useful investigation, and indicated if gallstones are suspected. It is debated by gastroenterologists whether it is necessary to test all patients with dyspepsia for Helicobacter pylori. This decision remains controversial. Medical studies have shown that infection with Helicobacter pylori is no more prevalent or common in patients with non-ulcer dyspepsia than in the general population.

Treatment

The first aspect of treatment by gastroenterologists is to explain the diagnosis and provide reassurance to the patient. This helps to reduce anxiety and may in itself reduce the symptoms.

The remaining symptoms can then usually be treated with antacids without the need for further medical attention. If more potent treatment is required, then proton pump inhibitors (PPI's) such as omeprazole (Losec) or esomeprazole (Nexium) are the most effective, but also the most expensive. There are other treatments which are often helpful and less expensive. These include histamine H2-receptor antagonists such as cimetidine and ranitidine and pro-kinetics such as domperidone or metoclopramide. With regard to treatment or eradication of Helicobacter pylori, most large, double-blind, randomised, controlled studies have shown that eradication of Helicobacter pylori has not resulted in an improvement in symptoms in patients with non-ulcer dyspepsia.

Prognosis

Non-ulcer dyspepsia is known to be a benign condition with no complications and a good prognosis. Medical studies have shown that only a small number of patients require long-term maintenance treatment. The problem that doctors have, is that a few of the many dyspeptic sufferers in the community will go on to develop serious organic disease. In the case of those patients who have gastro-oesophageal reflux disease, there is an increased risk of Barrett's oesophagus which has an increased risk of cancer of the oesophagus. Therefore doctors need to monitor patients with symptoms of non-ulcer dyspepsia that persists, and have a low threshold for investigating them again if they develop red flag or worrying symptoms.

If you are suffering from indigestion or dyspepsia, then it is important to seek medical advice if your symptoms persist.