1. Approch to dyspepsia Vossoughinia H Associate professor of medicine Mashad university of medical sceinces

2. Definition Postprandial fullness (classified as postprandial distress syndrome) Early satiation (inability to finish a normal sized meal, also classified as postprandial distress syndrome) Epigastric pain or burning (classified as epigastric pain syndrome)

3. Classification Functional dyspepsia Secondary dyspepsia

4. Functional dyspepsia Presence of one or more of the following: postprandial fullness, early satiation, epigastric pain or burning, and no evidence of structural disease to explain the symptoms These criteria should be fulfilled for the last three months with symptom onset at least six months before diagnosis.

5. Main causes Peptic ulcer disease Gastroesophageal reflux Gastric malignancy NSAID-induced dyspepsia

6. Drugs Nonsteroidal antiinflammatory drugs (NSAIDs) COX-2 selective inhibitors Calcium channel blockers Methylxanthines Alendronate Orlistat Potassium supplements Certain antibiotics including erythromycin Corticosteroids Niacin Gemfibrozil Narcotics Colchicine Quinidine Estrogens Levodopa Acarbose

7. Seconary dyspepsia: others Biliary pain Chronic abdominal wall pain Gastroparesis Pancreatitis Carbohydrate malabsorption Infiltrative diseases of the stomach Metabolic disturbances Hepatoma Ischemic bowel disease Systemic disorders Intestinal parasites Abdominal cancer Celiac disease steatohepatitis

8. Initial evaluation History Physical examination Laboratory evaluation

11. Approach to dyspepsia Presence or absence of alarm features Patient age Local prevalence of Helicobacter pylori (H. pylori) infection

13. Patient with alarm features or age >55 years Early upper endoscopy If the upper endoscopy is normal, patients with alarm features or persistent symptoms of dyspepsia should undergo further evaluation to exclude other etiologies. Most patients with a normal upper endoscopy and routine laboratory tests have functional dyspepsia.

14. Patient without alarm features and age ≤55 years Test and treat for H. pylori Antisecretory therapy

16. Persistent dyspepsia Patients with continued symptoms of dyspepsia fall into the following categories: 1.Patients with persistent H. pylori infection 2.Patients with an alternate diagnosis 3.Patients with functional dyspepsia

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23. History A dominant history of heartburn, regurgitation, or cough is suggestive of GERD NSAID use raises the possibility of NSAID dyspepsia and peptic ulcer disease. Radiation of the pain to the back, a personal or family history of pancreatitis may be indicative of underlying chronic pancreatitis Significant weight loss, anorexia, vomiting, dysphagia, odynophagia, and a family history of gastrointestinal cancers suggest the presence of an underlying malignancy The presence of severe episodic epigastric or right upper quadrant abdominal pain lasting more than an hour or pain that occurs at any time is suggestive of symptomatic cholelithiasis.

24. Physical examination Carnett’s sign A palpable abdominal mass (eg, hepatoma) Lymphadenopathy (eg, left supraclavicular or periumbilical in gastric cancer) Jaundice (eg, secondary to liver metastasis) Pallor secondary to anemia Ascites may indicate the presence of peritoneal carcinomatosis. Muscle wasting, loss of subcutaneous fat, and peripheral edema due to weight loss.

25. Laboratory tests Routine blood counts and blood chemistry including liver function tests should be performed