Esophagogastroduodenoscopy and Helicobacter Pylori
Although most dyspepsia in clinical practice is functional, the diagnosis of functional dyspepsia is a diagnosis of exclusion. A search for organic etiologies should be undertaken, because therapy for many organic causes is more satisfying than therapies for functional disorders. Age, symptoms and practical concerns of the patient and physician should guide investigation of the patient’s symptoms.
Endoscopy is essential in making the diagnosis of nonulcer dyspepsia. In a gastroenterology practice, essentially all patients referred for evaluation of dyspepsia will have already been tested and treated for Helicobacter pylori. Empiric determination of H. pylori status in patients with uninvestigated dyspepsia is an arguable strategy that is heavily dependent upon the prevalence of H. pylori infection and peptic ulcer disease in the population being served. Although opinions remain divided, eradication of H. pylori in patients with nonulcer dyspepsia offers a net therapeutic gain of about 9% beyond placebo.
Ultrasonography is commonly employed in the evaluation of dyspepsia. In general, pancreaticobiliary disease can be distinguished clinically from dyspepsia. Findings need to be carefully weighed against symptoms prior to undertaking further diagnostic or therapeutic interventions that often have associated morbidity and mortality. Scintigraphic measures of gastric emptying are also commonly performed but of limited value. An abnormal gastric emptying test is neither diagnostic nor predictive of a response to prokinetic agents.
A similar and even more robust case can be made for electrogastrography. Gastroduodenal manometry is generally helpful only if pseudo-obstruction or a partial small bowel obstruction is clinically suspected. Finally, gastric sensory testing does not yet have an established clinical role and the concept of visceral hypersensitivity has not fully distinguished itself from hypervigilence.
Although not generally regarded as the realm of the gastroenterologist, psychometric testing is often clinically rewarding as it provides an objective, nonjudgemental measurement of certain behaviors and attitudes. From a practical standpoint, in the patient with refractory dyspeptic symptoms and an extensive negative evaluation, more diagnostic information will be obtained by ascertaining the patient’s tendency towards somatization or their illness behavior than will be gained by performing more invasive and obscure tests of digestive anatomy or function. Several simple self-administered measures are available in this setting. Perhaps the most widely used instrument is the Symptom Checklist-90-R (SCL-90-R). The SCL-90-R is a self-reporting, clinical symptom rating scale consisting of 90 questions.
Responses indicate symptoms associated with nine psychiatric constructs. These constructs are somatization, obsessive-compulsive behavior, feelings of inadequacy or inferiority (interpersonal sensitivity), depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. SCL-90-R scores for a group of 73 controls and 92 patients with nonulcer dyspepsia. There are significant differences for all scales and profound differences for the somatization and depression. It should be kept in mind that these measures are not diagnostic of any psychiatric disorder and responses must be considered within the context of the clinical scenario and psychosocial history.