7 Stomach disorders

Questions

What are the causes of dyspepsia?

What is gastro-oesophageal reflux disease and how is it treated?

What are the complications of peptic ulcers?

Dyspepsia

Dyspepsia is a broad term encompassing a range of symptoms: pain (epigastric or retrosternal), heartburn, acid regurgitation and bloating. Fig. 3.7.1 shows the causes of dyspepsia.

Fig. 3.7.1 Causes of dyspepsia.

Management depends on the age and the presentation:

new-onset dyspepsia in anyone over 45 years of age should be investigated with endoscopy within 2 weeks to exclude cancer

a patient of any age with alarm symptoms (weight loss, haematemesis, malaena, dysphagia, anaemia) should be investigated with endoscopy promptly

those under 45 years of age should be tested and treated for Helicobacter pylori (see below) for 2 weeks; endoscopy is indicated if symptoms persist.

Gastro-oesophageal reflux disease

GORD is the most common upper gastrointestinal diagnosis. Reflux occurs when the lower oesophageal sphincter temporarily relaxes, and acid refluxes up the oesophagus. This in itself is a normal physiological mechanism but when inflammation of the oesophagus occurs (oesphagitis) it is known as GORD. It affects 7% of the population and obesity is a risk factor. A hiatus hernia may be present and contributing to symptoms.

Clinical features

Heartburn may be intermittent and is the most common presentation. Other presentations include dysphagia, dyspepsia, chest pain (mimicking angina), globus sensation (feeling a lump in the throat), wheezing and bronchitis (from aspiration) or odynophagia (painful swallowing).

Investigation

Endoscopy is the investigation of choice in those over 45 years (to exclude carcinoma and ulcer); it may identify a hiatus hernia. Barrett’s oesophagus or syndrome (Ch. 9) may be found. Diagnosis of GORD is made objectively with pH studies (pH is < 4 for > 4% of a 24-hour period) and oesophageal mamometry (showing a hypotonic lower oesophageal sphincter).

Management

Management can be conservative (stop smoking, avoid alcohol and eating late, lose weight, raise head of bed (gravity)), medical (proton pump inhibitors (omeprazole) as first-line treatment) or surgical: fundoplication performed laparoscopically (part of the stomach is wrapped around the lower oesophagus) is effective in > 95% of patients. Surgery is used when medical therapies have failed or for patients who prefer not to take long-term medication.

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