DYSPEPSIA MANAGEMENT IN A RESOURCE POOR SETTING

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A.C. Jemilohun¹ and J.O. Fadare²

1. Department of Medicine, Ladoke Akintola University of Technology, Osogbo, Osun State, Nigeria.
2. Department of Clinical Pharmacology, Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria.

Abstract

Background: Dyspepsia has a significant impact on the quality of life of the sufferer, and results in enormous societal costs, either due to direct medical costs for physician visits, diagnostic tests, medications, or indirect costs from absenteeism or reduced productivity at work. It is therefore important to explore the management options available, especially in a resource poor setting like Nigeria, in the light of the foregoing.

Methods: Extensive internet literature search was made through Google scholar, Pubmed and HINARI. Keywords employed were dyspepsia, prevalence and management.

Result: Several approaches proposed for the management of a newly diagnosed patient with dyspepsia include: empirical trial of acid suppression for 4-8 weeks in regions with low prevalence ofH. pylori ; the “test and treat” approach for H. pylori infection using a validated non-invasive test and; initial use of upper
gastrointestinal endoscopy to determine the nature of the disease before treatment in patients with alarm symptoms and those who are more than 45 years. Helicobacter pylori eradication therapy without initial diagnostic testing can be used as the last result in resource poor regions of the word where diagnostic tests for H. pylori are not available or not cost-effective.

Conclusion: Considering the high cost of upper gastrointestinal endoscopy and the high prevalence of H. pylori infection in developing countries like Nigeria, it seems reasonable that the test and treat’ method will be of immense usefulness in population sub-group who are less than 45 years without alarm symptoms, while those with alarm symptoms and those with onset of symptoms after 45 years will require initial upper gastrointestinal endoscopy.

Keywords: Dyspepsia, Classification, Pathophysiology and Management.

Introduction

Dyspepsia is defined as chronic or recurrent central upper abdominal pain or discomfort which is referable to the upper gastrointestinal tract^1,2. It is usually associated with intake of food or hunger. Discomfort according to the Rome Working Teams refers to a subjective, negative feeling that does not reach the level of pain according to the patient. This can incorporate a variety of symptoms such as upper abdominal fullness, early satiety, bloating, belching or nausea^{1, 2}.

Dyspepsia is a common presentation in clinical practice worldwide^{1, 2}. It has a prevalence of between 20% and 40% in the adult population ^{3, 4}. In a study carried out among the British population it was found to be 38%⁵. It is estimated to account for 2% to 5% of primary care office visits and 30% of consultations by Gastroenterologists^{6, 7}. A prevalence of 26% to 45% was found in some parts of Nigeria^{8, 9}. Dyspepsia has a significant impact on quality of life^10, and results in enormous societal costs, either due to direct medical costs for physician visits, diagnostic tests, medications, or indirect costs from absenteeism or reduced productivity at work^{11, 12}. It is therefore, important to explore the management options available in the light of the foregoing.

CLASSIFICATION OF DYSPEPSIA
Dyspepsia can be broadly classified into two major groups. These include organic dyspepsia and functional dyspepsia.

Organic dyspepsia: This is dyspepsia that results from a structural or anatomical lesion. These structural lesions include chronic gastritis, duodenitis, gastric and duodenal erosions, gastric and duodenal ulcers, gastric adenocarcinoma and mucosal associated lymphoid tissue (MALT) lymphoma.^{13, 14} Helicobacter pylori infection has been noted to be associated with most of the disease entities presenting as dyspepsia.^{13, 14} The particular end result of H. pylori infection is determined by a complex interaction between bacterial, host and other environmental factors.¹³ A detailed description of this interaction is beyond the scope of this review.

Functional dyspepsia: This is dyspepsia in which there is no evidence of organic disease that can adequately explain the symptoms. It is also known as idiopathic or non-ulcer dyspepsia, and is often a diagnosis of exclusion. Many patients with functional dyspepsia (FD) have multiple somatic complaints, as well as symptoms of anxiety and depression.¹⁵ It is further subdivided clinically into ulcer-like, reflux-like, dysmotility-like, and non-specific dyspepsia.¹⁶ This sub-grouping, however, has not been found to be of much practical value in identifying the underlying cause of dyspepsia as the symptoms overlap considerably.

The pathophysiology of functional dyspepsia is poorly understood. There is symptom overlap with those of other functional gastrointestinal disorders, such as functional heartburn, irritable bowel syndrome (IBS), and non-cardiac chest pain.¹⁷ Like other functional gastrointestinal disorders, FD is best understood in the context of the bio-psychosocial model of illness in which symptoms arise out of a complex interaction between abnormal gastrointestinal physiology and psychosocial factors that affect how a person perceives, interprets, and responds to the altered gastrointestinal physiology.¹⁸ Several pathophysiological mechanisms that have been suggested as playing a part in its development include delayed gastric emptying,^18,19 impaired gastric accommodation,^20,21 myoelectric abnormalities,^22,23 altered antro-duodeno-jejunal motility²⁴, visceral hypersensitivity,²⁵ altered vagal function,²⁶ altered duodenal sensitivity to lipids or acid,^{27, 28} and psychological disorders.^29,30