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INTRODUCTIONThe term “dyspepsia” comes from a Greek word

meaning “bad digestion”, or a collection of painful anduncomfortable feelings in the epigastric region.1 In thelatest consensus in 1999 in Rome, dyspepsia expertsaround the world agreed on the definition of dyspepsiaas pain or discomfort in the middle upper abdomen. Theconsequence of this definition is that pain on the left orright hypochondriac region is not considered asdyspepsia.2

Symptoms that often accompany dyspepsia other thanpain or discomfort in the epigastrium are as follows:patients feel quickly satiated, and may complain ofgassiness, nausea, and vomiting.3 Such symptoms areoften found in daily clinical practice, and patientsgenerally recognize it as “maag”. The prevalence ratefor dyspepsia in the United States is almost 26%, whilethe prevalence rate in the United Kingdom almost reaches41%.4

Diagnostic evaluation of patients with dyspepsia iscrucial. Therefore, the terms “uninvestigated dyspepsia”and “investigated dyspepsia” were conceived. By directdefinition, uninvestigated dyspepsia relates to patientswith dyspepsia that have not been further investigatedby endoscopy, while investigated dyspepsia refers topatients with known organic dyspepsia (includinggastric or duodenal ulcer, cancer or gastroesophagealreflux disease) or functional dyspepsia (see Figure 1).

Before we evaluate dyspeptic syndrome, we shouldmake sure we are truly dealing with just dyspepsia. Weshould evaluate whether epigastric discomfort isrelated to heartburn in the chest and regurgitation, whichwould suggest Gastroesophageal reflux disease (GERD).And also we should ask whether the pain is reduced bythe use of antacids. We should find out whether we are

dealing with billiary colic or chest pain due to myo-cardial infarction. We also should to look for about drugsthat the patient often takes. This is important for furtherevaluation in dyspepsia management.

DYSPEPSIA SYMPTOMSSymptoms often found in dyspepsia include:1. Epigastric pain, which is a subjective complaint of

uncomfortable sensations. Certain patients state thatthey feel something wrong in their stomach.

2. Epigastric discomfort: a subjective feeling ofdiscomfort, and not pain.

3. Early satiety: a feeling of fullness at the beginning ofa meal, unrelated to the portion of food intake. Thepatient is usually unable to finish his/her food.

4. Fullness: an unpleasant sensation as if food werewithheld in the stomach, which could occur aftermeals.

5. Gassiness in the upper abdomen, stiffness must bedifferentiated from distention.

6. Nausea: feeling that they are about to vomit.

These complaints could be recent or might havetaken place for several months or years prior toinvestigation. In general, a length of 4 weeks isconsidered to rule out temporary symptoms fromnormal physiologic processes due to an empty stomach.5

CLINICAL APPROACH FOR DYSPEPSIAThe diagnostic approach for dyspepsia requires time

and money. Thus, a precise approach should be taken todetermine dyspepsia cases that require furtherinvestigation, or we could try giving medicationbeforehand. In dealing with dyspepsia cases, there areseveral things that could point to further investigation,such as age, symptoms, and helicobacter pylori status.6

The Patient’s AgeAge is an important factor that requires first hand

attention. The older patients have higher rate of organic

Uninvestigated Dyspepsia versus Investigated DyspepsiaAri Fahrial Syam

Division of Gastroenterology, Department of Internal Medicine,Faculty of medicine, University of Indonesia

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disorder. A study by Rani reported to PEGI-PGI-PPHINational Congress in the year 2001 demonstrated thesame data, where duodenal ulcer and gastric ulcer weremore commonly found in older patients, compared toorganic disorders found in studies of uninvestigateddyspepsia.7

The cut-off age is 45 years old. The nationalconsensus for Helicobacter pylori infection eradicationestablished 45 years as the cut-off age forinvestigation.8 Thus, dyspepsia cases in patients over theage of 45 years with dyspepsia cases require endoscopicexamination to rule out possible organic disorders.

HELICOBACTER PYLORI STATUS AND THE USE OFNON-STEROIDAL ANTI-INFLAMMATORY DRUGS(NSAIDS)

The presence of Helicobacter pylori is closelyassociated with the development of peptic ulcer. Allpatients infected by H. pylori in their gaster will sufferfrom chronic gastritis. This occurs because themicroorganism infiltrates cells of the gastric mucosa. Inseveral patients, this occurs asymptomatically, but thepresence of this microorganism increases the incidenceof peptic ulcer and adenocarcinoma of the gastricanthrum and corpus.10

A case of peptic ulcer with H. pylori was reportedby Syam, et. Al,11 in a 52-year old woman withcomplaints of epigastric pain accompanied by nausea,vomiting, anorexia, and gassiness. Endoscopicevaluation demonstrated a peptic ulcer andhistopathologic evaluation found Helicobacter pylori.11

The latest study, by Japanese experts, on therelationship between H. pylori infection and the incidenceof gastric cancer demonstrate gastric cancer in patientssuffering from H. pylori infection, which did not occur inuninfected patients. In addition, patients with H. pyloriinfection and non-ulcer dyspepsia, gastric ulcer, as wellas hyperplastic polip of the gaster also have a greaterrisk for gastric cancer compared to duodenal ulcer.12

Bearing in mind the complications caused byH. pylori, serologic screening for this infection isrendered necessary. The national consensus onH. pylori infection eradication established H. pyloriserologic testing as the initial step for dyspepsia patientsin the community as well as for dyspepsia patientsundergoing endoscopy (see appendix).

History of the use of drugs that could inducedyspepsia should be inquired about. NSAIDs andaspirin are the main cause for dyspepsia, while steroids,teophyllin and calcium antagonists are less frequentcauses of dyspepsia.

The Role of Endoscopy in DyspepsiaAs an investigative tool for dyspepsia, endoscopy is

still the gold standard instrument and is superior toradiologic imaging. Endoscopy allows us to see themacroscopic structure of the gastrointestinal tract. Ifabnormality is found, biopsy can be performed forhistopathologic evaluation. In addition, biopsy allows usto obtain samples for rapid urease testing (CLO),Helicobacter pylori culture, and PCR.8 Technologicaldevelopments of endoscopy allow us to take moreoptimal therapeutic action.

Figure 1. The Relationship Between Dyspepsia and FunctionalDyspepsia, Investigated and Uninvestigated Dyspepsia

2

SYMPTOMSSymptoms that warn us of the presence of an

organic disorder include: dyspepsia symptomsaccompanied by weight loss, bleeding in the form ofhematemesis or melena, dysphagia and continuousvomiting. Other literature suggest alarm symptoms areas follows: weight loss, anemia, vomiting, jaundice, andepigastric mass.9 Additional symptoms indicate furtherexamination. Ulcer-like or dysmotility-like symptoms donot indicate further investigation.10

Upper GI symptoms Lower GI symptoms

GERD Dyspepsia IBS

Functional

Investigated

Oranic disease

Uninvestigated

Ulcer like Dysmotility like

GERD: Gastroesophageal reflux disease IBS: Irritable bowel syndrome

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A study on a large number of cases had beenconducted, where study subjects with and withoutdyspepsia symptoms were examined. Study resultsconfirmed that only cases with duodenitis and peptic ulcerwere clearly associated with symptoms of dyspepsia.13

In a study conducted by Rani at CiptoMangunkusumo Hospital, 44 cases of uninvestigateddyspepsia were evaluated. Endoscopy of these casesdemonstrated almost 15% suffered from organicabnormality (peptic ulcer and gastroduodenitis).7

Another study conducted by Syam, et al in CiptoMangunkusumo Hospital found esophageal abnormalityin 32% out of 1017 upper gastrointestinal endoscopy.Out of that number, 81.1% were found in the gaster,while 11.9% were in the duodenum. Duodenal andpeptic ulcers were found in approximately 10% of thecases.

CONCLUSIONDyspepsia is a common disorder with variety of

symptoms. Which often found in daily clinical practice.As we know, an organic cause is found in 20-30 % ofpatients with dyspepsia. Diagnostic evaluation of patientswith dyspepsia is crucial. Therefore, the terms“uninvestigated dyspepsia” and “investigated dyspepsia”were conceived. Before we evaluate dyspepticsyndrome, we should make sure we are truly dealingwith just dyspepsia. In dealing with dyspepsia cases,there are several things that could point to furtherinvestigation, such as age, symptoms, and helicobacterpylori status. And also are there some alarmsymptoms such as weight loss, bleeding in the form ofhematemesis or melena, dysphagia, continuous vomitingand also epigastric mass. If so, an endoscopic should beperformed promptly to determine whether the patienthas an organic dyspepsia or not.

REFERENCES1. Talley NJ, Philips SE. Non ulcer dyspepsia: potential cause and

pathophysiology. Ann Intern Med 1988;108:856-79.2. Talley NJ, Stanghellini V, Heading RC, Koch KL, Malagelada

JR, Tytgat GNJ. Functional gastroduodenal disorders. Gut1999;45(Suppl II):1137-42.

3. Barbara L, Camilleri M, Corinaldesi R, et al. Definition andinvestigation of dyspepsia: consensus of international ad hocworking party. Dig Dis Sci 1989;34:1272-6.

4. Jones R, Lydeard S. Prevalence of symptomps of dyspepsia inthe community. BMJ 1989; 298:30-2.

5. Rani AA. Sindrom dispepsia. Dalam: Rani AA, SumodihardjoS, Setiati S, Simadibrata M, Mansjoer A, editor. Sindromdispepsia diagnosis dan penatalaksanaan dalam praktek sehari-hari. Jakarta PIP 1999; 1-4.

6. Talley NJ, Holtmann G. Approach to the patient withdyspepsia and related functional gastrointestinal complaints.In: Yamada T, Alpers DH, Laine L, Owyang C, Powell DH,editors. Textbook of Gastroenterology. 3rd ed. LippincotsWilliam Wilkins

7. Rani AA. Metode non-invasive deteksi infeksi Helicobacterpylori: Helicobacter pylori antigen in stool (HpSA). Kumpulanabstrak KONAS PGI-PEGI X. Medan 2001.

8. Konsensus Nasional Penanggulangan Infeksi Helicobacterpylori. Jakarta 21 Desember 1996.

9. Delaney BC. 10-minute consultation: dyspepsia. BMJ2001;322:776.

10. Blaser MJ. Helicobacter pylori and gastric diseases. BMJ1998; 316:1507-10.

11. Syam AF, Kolopaking MS, Manan C. The success oferadicating Helicobacter pylori in patients with duodenal ulcer.AMI 2001:33;74.

12. Uemura N, Okamoto S, Yamaoto S et al. Helicobacter pyloriinfection and the development of gastric cancer. NEJM2001:345;784-9.

13. Johnsen R, Bennersen B, Sraume B, et al. Prevalence ofendoscopics and histologic findings in subject with and withoutdyspepsia. BMJ 1991;302:749.

14. Syam AF, Abdullah M, Makmun D, dkk. Kelainan salurancerna bagian atas per endoskopi di RSUPN CiptoMangunkusumo. Kumpulan abstrak KONAS PGI-PEGI X.Medan 2001.