Make the Diagnosis: Does This Patient With Epigastric Discomfort Have Organic or Functional Dyspepsia?
About 40% of adults experience some sort of upper gastrointestinal symptoms during any 6-month period, but only about half of these patients tell their physicians about the symptoms.1 Clinicians use clinical judgment and/or response to empirical treatment to make the majority of their diagnoses in patients with dyspepsia. Among those who seek care for their symptoms, only about 5% are referred to gastroenterologists where the prevalence of underlying conditions can be determined (Table 69-1).2
Table 69-1Prevalence of Endoscopic Diagnoses in Patients With Dyspepsia2 |Favorite Table|Download (.pdf) Table 69-1 Prevalence of Endoscopic Diagnoses in Patients With Dyspepsia2
|Cause of Dyspepsia ||Prevalence (%)a |
|Normal or minor abnormality ||50 |
|Esophagitis ||20 |
|Endoscopic-negative reflux disease ||20 |
|Peptic ulcer disease ||10 |
|Barrett esophagitis ||2 |
|Malignancy ||<1 |
Population in Whom Organic Dyspepsia Should Be Assessed
Functional dyspepsia refers to epigastric discomfort despite a normal endoscopy. Any patient with dyspepsia could have an organic cause. Experts consider troubling features as dysphagia, weight loss, gastrointestinal, bleeding, anemia, or persistent vomiting.
Assessing the Likelihood of Organic Dyspepsia
Clinicians need to rely on their overall clinical impression rather than individual symptoms. Comparisons can be made between the primary care clinician and gastroenterologist's assessment of the likelihood of organic disease. Computer models incorporate patient demographics, risk factors, history items, and symptoms from patient questionnaires.
A gastroenterologist is slightly better than a primary care clinician in predicting which patients will have abnormal findings, but the differences are small. Computer-derived prediction models are not particularly helpful except perhaps in lowering the likelihood of peptic ulcer disease. See Table 69-2.
Table 69-2Overall Impression for Organic Disease in Patients Referred for Endoscopy |Favorite Table|Download (.pdf) Table 69-2 Overall Impression for Organic Disease in Patients Referred for Endoscopy
|Origin of Presumptive Diagnosis ||LR+ (95% CI) ||LR- (95% CI) |
| ||Organic vs Functional Dyspepsia |
|Primary care ||1.3 (1.2-1.4) ||0.66 (0.55-0.79) |
|Specialists ||1.9 (1.5-2.5) ||0.40 (0.24-0.66) |
|Computer models ||1.6 (1.4-1.9) ||0.45 (0.37-0.55) |
| ||Peptic Ulcer Disease |
|Primary care ||2.2 (1.8-2.5) ||0.63 (0.51-0.79) |
|Specialists ||2.9 (2.1-4.0) ||0.48 (0.43-0.52) |
|Computer models ||1.9 (1.6-2.3) ||0.34 (0.25-0.47) |
| ||Esophagitis |
|Primary care ||2.3 (1.6-3.2) ||0.58 (0.43-0.79) |
|Specialists ||3.0 (2.6-3.5) ||0.48 (0.35-0.65) |
|Computer models ||1.7 (1.5-2.1) ||0.48 (0.36-0.63) |
Endoscopy is the accepted reference standard test for the patient with dyspepsia as it has both a sensitivity and specificity of >95%.3
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