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

Other CausesAlkaline 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) Chapter 039. Nausea, Vomiting, and Indigestion (Part 7) Other Causes Alkaline reflux esophagitis produces GERD-like symptoms in patients whohave had surgery for peptic ulcer disease. Opportunistic fungal or viral esophagealinfections may produce heartburn or chest discomfort but more often causeodynophagia. Other causes of esophageal inflammation include eosinophilicesophagitis and pill esophagitis. Biliary colic is in the differential diagnosis ofdyspepsia, but most patients with true biliary colic report discrete episodes of rightupper quadrant or epigastric pain rather than chronic burning discomfort, nausea,and bloating. Intestinal lactase deficiency produces gas, bloating, discomfort, anddiarrhea after lactose ingestion. Lactase deficiency occurs in 15–25% ofCaucasians of northern European descent but is more common in AfricanAmericans and Asians. Intolerance of other carbohydrates (e.g., fructose, sorbitol)produces similar symptoms. Small-intestinal bacterial overgrowth may producedyspepsia, often with bowel dysfunction, distention, and malabsorption. Pancreaticdisease (chronic pancreatitis and malignancy), hepatocellular carcinoma, celiacdisease, Ménétriers disease, infiltrative diseases (sarcoidosis and eosinophilicgastroenteritis), mesenteric ischemia, thyroid and parathyroid disease, andabdominal wall strain cause dyspepsia. Extraperitoneal etiologies of indigestioninclude congestive heart failure and tuberculosis. Approach to the Patient: Indigestion History and Physical Examination Care of the patient with indigestion requires a thorough interview. GERDclassically produces heartburn, a substernal warmth in the epigastrium that movestoward the neck. Heartburn often is exacerbated by meals and may awaken thepatient. Associated symptoms include regurgitation of acid and water brash, thereflex release of salty salivary secretions into the mouth. Atypical symptomsinclude pharyngitis, asthma, cough, bronchitis, hoarseness, and chest pain thatmimics angina. Some patients with acid reflux on esophageal pH testing do notreport heartburn and note abdominal pain or other symptoms. Some individuals with dyspepsia report a predominance of epigastric painor burning that is intermittent and not generalized or localized to other regions.Others experience a postprandial distress syndrome characterized by fullnessoccurring after normal-sized meals and early satiety that prevents completion ofregular meals several times weekly, with associated bloating, belching, or nausea.Functional dyspepsia overlaps with other functional bowel disorders such asirritable bowel syndrome. The physical exam with GERD and functional dyspepsia usually is normal.In atypical GERD, pharyngeal erythema and wheezing may be noted. Poordentition may be seen with prolonged acid regurgitation. Functional dyspepticsmay exhibit epigastric tenderness or abdominal distention. Discrimination between functional and organic causes of indigestionmandates exclusion of selected historic and examination features. Odynophagiasuggests esophageal infection, while dysphagia is worrisome for a benign ormalignant esophageal blockage. Other alarming features include unexplainedweight loss, recurrent vomiting, occult or gross gastrointestinal bleeding, jaundice,a palpable mass or adenopathy, and a family history of gastrointestinalmalignancy. Diagnostic Testing As indigestion is prevalent and because most cases result from GERD orfunctional dyspepsia, a general principle is to perform only limited and directeddiagnostic testing of selected individuals. Once alarm factors are excluded (Table 39-3), patients with typical GERDdo not need further evaluation and are treated empirically. Upper endoscopy isindicated to exclude mucosal injury in cases with atypical symptoms, symptomsunresponsive to acid suppressing drugs, or alarm factors. For heartburn >5 years induration, especially in patients >50 years old, endoscopy is recommended toscreen for Barretts 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 implantedesophageal capsule device is considered for drug-refractory symptoms andatypical symptoms like unexplained chest pain. Esophageal manometry mostcommonly is ordered when surgical treatment of GERD is considered. A low LESpressure may predict failure of drug therapy and helps select patients who mayrequire surgery. Demonstration of disordered esophageal body peristalsis mayaffect the decision to operate or modify the type of operation chosen. Ma ...