This Sunday, we bring to you from our archives, an article from Dr. Primal Lawate, a noted gastroenterologist. He explains the clinical management of dyspepsia patients, beyond pharmacotherapy.

Functional dyspepsia is amongst the commonest presenting complaints in a Gastroenterology Clinic. It has been objectively defined by Rome IV criteria.

In practice, patients use various terms to describe this symptom complex. Indigestion, bloating, pain, discomfort, burning are reported. Often the patient complains of “acidity” by which they may mean one of the following three symptoms :

• Burning and pain/discomfort in the upper abdomen or chest
• Skin rashes (which actually are urticarial)
• Headaches associated with vomiting (often related to migraine)

It is therefore important to try and have an understanding of the patient’s presenting symptom. In the latest, two editions of the Rome Criteria, GERD has been classified separately although overlap is often seen in patients of functional dyspepsia.

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The next step is to try and assess how the patient’s symptoms fit into current definitions of Functional Dyspepsia.

Four symptoms are now included in the definition:

• Postprandial fullness
• Early satiation
• Epigastric pain
• Epigastric burning

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The first two symptoms are meal-induced (within 30 minutes of a meal) and are clubbed together as Postprandial Distress Syndrome (PDS). The latter two may not be meal related and are clubbed together as Epigastric Pain Syndrome (EPS).

1. The symptoms should be bothersome and should be present at least three times a week for at least 6 months.
2. Having categorised patients by symptoms in these two groups, the physician should assess if the patient has already been evaluated (with tests such as upper gastrointestinal endoscopy, ultrasound, or blood tests). Those who have had these could be considered as investigated patients, while those who have not been investigated are considered as uninvestigated patients.
3. In practice, a decision has to be therefore made in uninvestigated patients as to how much to evaluate and in investigated patients the question is how much further.
4. The decision to evaluate further depends on various factors. Some of these are evidence-based, while others are providence-based.
5. As per standard teaching “alarm”, symptoms such as weight loss, vomiting, nocturnal abdominal pain should warrant evaluation.

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When is the time for individual patient tailored decisions?

In some patients weight loss is due to self imposed dietary restrictions. There are many issues which may not be evidence based. An important factor is the question- how comfortable is the patient and physician with diagnostic uncertainty?

Patients who have recently witnessed some close relative who suddenly got diagnosed with a gastrointestinal malignancy may be wanting to have all sinister diagnoses excluded. Physicians might on their side have had single patient experiences, where a patient thought to have a clearly functional disorder was subsequently diagnosed as malignancy .

These issues are generally not factored in guidelines and algorithms and therefore become individual patient-tailored decisions. In fact, a normal investigation in such patients can itself turn out to be therapeutic.

Certain physical signs are considered to favour functional abdominal pain and these include:

• Closed Eyes sign: Patients with organic pain are more likely to keep their eyes open in anxious anticipation of pain while those with functional disorders often keep their eyes closed with wincing on palpation of specific areas.
• Stethoscope sign: Reduction in pain and a facial expression of satisfaction when the patient perceives with closed eyes that he is being heard and “palpated” with the stethoscope.
• Carnett sign: Where pain decreases when palpated during abdominal contraction and may be helpful in diagnosis of abdominal wall pain.

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Diagnosis likely to be missed when treating these patients empirically includes peptic ulcers, upper GI tumours, pancreatic neoplasms, chronic pancreatitis, eosinophilic enteritis, and lead poisoning– in patients on alternative medications. Atypical cardiac symptoms can also rarely mimic an epigastric pain syndrome.

Postprandial distress syndrome can get misdiagnosed in patients with mechanical obstruction, upper GI / pancratic malignancies, jejunal obstruction, lactose intolerance, celiac disease, non-celiac gluten sensitivity, fructose intolerance.

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Once a decision is made to evaluate one can divide these into invasive and non-invasive evaluation

1. In functional GI disorders, a test is helpful in making alternative diagnoses but there is no documentable objective “sign” or abnormality which is diagnostic of a functional disorder like blood glucose is for diabetes!
2. Tests may guide treatment if an abnormality such as H. pylori infection is found but by and large they may not guide the type of medication used or the duration. Treatment is, therefore, symptom-directed rather than finding directed.

There are certain upcoming non invasive alternatives to Upper GI Endoscopy. One of them is a breath test to assess for H. pylori infection ( this is now available more widely) and the other is a panel of blood tests called as “Gastrolab”. The latter has been tested extensively in Italy at the primary care level to decide on treatment and to decide which patients could be further evaluated. It needs to be further validated in clinical studies but seems to be a promising diagnostic option.

In India, the cost of an upper GI endoscopy has been reasonable at most centres and many patients, therefore, get evaluated with endoscopy despite its “invasive” nature.

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Treatment for functional dyspepsia

The treatments for Functional dyspepsia have traditionally fallen into those that affect the psyche and those that affect the soma (as in all psychosomatic disorders). The emphasis on a strong patient-physician relationship is pertinent when physicians have very little time allotted to individual patients.

Lifestyle management is important. The following factors are important and may often need modification.

Diet

1. Three aspects of diet need attention: Content, timing, and variation (in individuals whose jobs necessitate travel) Diet can induce GI Symptoms through various mechanisms such as foodborne infection, food intolerances (Lactose, Gluten, Fructose), food-induced symptoms– colic as seen with spicy food (which is an overlooked factor in dietary history as well), food-induced allergies, specific symptoms related to certain components such as Monosodium Glutamate (MSG).
2. Writing a list of dietary components which can be excluded is easier and less time consuming for physicians than writing a day’s diet plan which needs the help of a registered dietician.

Stress

1. A simplistic classification of stress would include stress related to circumstances (financial, interpersonal, workplace), self-induced stress (unrealistic deadlines and unrealistic expectations from colleagues and family), stress-prone personality (where day to day routine induces stress), and stress related to chronic symptoms, with negative results on multiple evaluations.
2. The patient may find it easier to identify himself/herself into one of these groups and corrective measures can be taken with medications, dialogue and involvement of family members, counsellors, and psychiatrists.

Habits and Polypharmacy

These also have become important issues in patient management and enlisting all drugs can help to identify if a drug could be a cause for the patient’s symptoms. Some examples include metformin, aspirin, NSAIDs as inducers of GI symptoms.

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Managing difficult patients

It is difficult to define what is meant by a “difficult patient”. In a busy practice, a patient who deserves or demands more time can also be considered a difficult patient. There have been some attempts at “classifying” these patients into groups:

• Dependent Clinger: A patient who calls or “WhatsApp” regularly, and visits the clinic multiple times a week
• Entitled Demander: A patient who angers the doctor, induces a sense of guilt in the doctor and devalues his opinion; adds negative experiences on social media
• Help Rejecter: Opens his statement with “I do not tolerate any medicine”; medicines make me worse
• Google-Educated Millennial: Tries to test your knowledge on basis of what is available on google with insistence on admission and evaluation (through entitled insurance)
• Perpetual Consultant Changer: With negative comments on the earlier doctors that he consulted (as a doctor one has to be careful with these patients and follow the rule of remaining non-committal about earlier opinions and treatments, because if you are this patient's treating doctor it is likely that you would be the next doctor “eligible” for criticism
• The List Writer: Brings a detailed list of questions about diet and many other issues. Osler’s Aphorism 309 categorises these patients as neurasthenia (this was a subject of an article in the New England Journal Of Medicine, in September 1985, where the author tends to suggest otherwise as a list can make your job easier and the physician should probably look at it as a list of focussed points that need to be addressed)

There can be many more categories which can be added to this classification and a physician in clinical practice for many years may have more categories added to this list.

Over the years the current practice of medicine has evolved to define diseases based on objective parameters defined by laboratory or imaging abnormalities with definitive endpoints of treatment defined by improvement in these parameters.

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Unfortunately, the majority of patients with functional dyspepsia will not fall into this category. Treatment endpoints are therefore symptom-directed rather than being directed by demonstrable abnormalities and endpoints.

Many trials for drugs used for treatment of functional dyspepsia have used Quality of Life Questionnaires and there have been attempts at defining objective endpoints at least in the short term. Evaluation of literature on functional needs consideration of these factors when the results are applied in clinical practice.

Re-emphasising the need for a strong physician-patient relationship is essential. For non-responders, the options can be

• change with the diagnosis,
• change the medicines,
• change the doctor!

A good patient-physician relationship can definitely eliminate the third option!

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This article was originally published on March 1, 2019.

Disclaimer-The information and views set out in this article are those of the author(s) and do not necessarily reflect the official opinion of M3 India. Neither M3 India nor any person acting on their behalf may be held responsible for the use which may be made of the information contained therein.