Chapter 039. Nausea, Vomiting, and Indigestion (Part 7)

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Other Causes Alkaline reflux esophagitis produces GERD-like symptoms in patients who have had surgery for peptic ulcer disease. Opportunistic fungal or viral esophageal infections may produce heartburn or chest discomfort but more often cause odynophagia. Other causes of esophageal inflammation include eosinophilic esophagitis and pill esophagitis. Biliary colic is in the differential diagnosis of dyspepsia, but most patients with true biliary colic report discrete episodes of right upper quadrant or epigastric pain rather than chronic burning discomfort, nausea, and bloating. Intestinal lactase deficiency produces gas, bloating, discomfort, and diarrhea after lactose ingestion. ...

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Chapter 039. Nausea, Vomiting, and Indigestion (Part 7) Other Causes Alkaline reflux esophagitis produces GERD-like symptoms in patients who have had surgery for peptic ulcer disease. Opportunistic fungal or viral esophageal infections may produce heartburn or chest discomfort but more often cause odynophagia. Other causes of esophageal inflammation include eosinophilic esophagitis and pill esophagitis. Biliary colic is in the differential diagnosis of dyspepsia, but most patients with true biliary colic report discrete episodes of right upper quadrant or epigastric pain rather than chronic burning discomfort, nausea, and bloating. Intestinal lactase deficiency produces gas, bloating, discomfort, and diarrhea after lactose ingestion. Lactase deficiency occurs in 15–25% of Caucasians of northern European descent but is more common in African
Americans and Asians. Intolerance of other carbohydrates (e.g., fructose, sorbitol) produces similar symptoms. Small-intestinal bacterial overgrowth may produce dyspepsia, often with bowel dysfunction, distention, and malabsorption. Pancreatic disease (chronic pancreatitis and malignancy), hepatocellular carcinoma, celiac disease, Ménétrier's disease, infiltrative diseases (sarcoidosis and eosinophilic gastroenteritis), mesenteric ischemia, thyroid and parathyroid disease, and abdominal wall strain cause dyspepsia. Extraperitoneal etiologies of indigestion include congestive heart failure and tuberculosis. Approach to the Patient: Indigestion History and Physical Examination Care of the patient with indigestion requires a thorough interview. GERD classically produces heartburn, a substernal warmth in the epigastrium that moves toward the neck. Heartburn often is exacerbated by meals and may awaken the patient. Associated symptoms include regurgitation of acid and water brash, the reflex release of salty salivary secretions into the mouth. Atypical symptoms include pharyngitis, asthma, cough, bronchitis, hoarseness, and chest pain that mimics angina. Some patients with acid reflux on esophageal pH testing do not report heartburn and note abdominal pain or other symptoms.
Some individuals with dyspepsia report a predominance of epigastric pain or burning that is intermittent and not generalized or localized to other regions. Others experience a postprandial distress syndrome characterized by fullness occurring after normal-sized meals and early satiety that prevents completion of regular meals several times weekly, with associated bloating, belching, or nausea. Functional dyspepsia overlaps with other functional bowel disorders such as irritable bowel syndrome. The physical exam with GERD and functional dyspepsia usually is normal. In atypical GERD, pharyngeal erythema and wheezing may be noted. Poor dentition may be seen with prolonged acid regurgitation. Functional dyspeptics may exhibit epigastric tenderness or abdominal distention. Discrimination between functional and organic causes of indigestion mandates exclusion of selected historic and examination features. Odynophagia suggests esophageal infection, while dysphagia is worrisome for a benign or malignant esophageal blockage. Other alarming features include unexplained weight loss, recurrent vomiting, occult or gross gastrointestinal bleeding, jaundice, a palpable mass or adenopathy, and a family history of gastrointestinal malignancy. Diagnostic Testing
As indigestion is prevalent and because most cases result from GERD or functional dyspepsia, a general principle is to perform only limited and directed diagnostic testing of selected individuals. Once alarm factors are excluded (Table 39-3), patients with typical GERD do not need further evaluation and are treated empirically. Upper endoscopy is indicated to exclude mucosal injury in cases with atypical symptoms, symptoms unresponsive to acid suppressing drugs, or alarm factors. For heartburn >5 years in duration, especially in patients >50 years old, endoscopy is recommended to screen for Barrett's metaplasia. However, the clinical benefits and cost- effectiveness of this approach have not been validated in controlled studies. Ambulatory esophageal pH testing using a catheter method or an implanted esophageal capsule device is considered for drug-refractory symptoms and atypical symptoms like unexplained chest pain. Esophageal manometry most commonly is ordered when surgical treatment of GERD is considered. A low LES pressure may predict failure of drug therapy and helps select patients who may require surgery. Demonstration of disordered esophageal body peristalsis may affect the decision to operate or modify the type of operation chosen. Manometry with provocative testing may clarify the diagnosis in patients with atypical symptoms. Blind perfusion of saline and then acid into the esophagus, known as the Bernstein test, can delineate whether unexplained chest discomfort results from acid reflux.