Dyspepsia - Challenges in Primary Care

Introduction

Dyspepsia and Helicobacter pylori infection are common digestive-related problems. However, sometimes dyspepsia is confused and misdiagnosed or remains underdiagnosed. Primary health care physicians require adequate knowledge to care for patients suffering from dyspepsia. The role of primary health care is essential, and they need to identify the alarming feature of dyspepsia. The test and treat strategy is the first step toward managing the condition. Dyspepsia affects up to 80 percent of the population at some time in life, and most patients have no severe underlying disease. However, patients who present with new dyspepsia at the age of more than 55 years and younger, unresponsive, and those who can receive empirical treatment require investigation to exclude serious disease. In addition, the ratio of men to women suffering from dyspepsia is more for women. This article aims to encounter the challenges primary care faces in diagnosing and referring to higher centers and focuses on the appropriate treatment for patients with dyspepsia.

What Is the Role of Primary Care?

The Public Health Center looks over the prevention and control of locally endemic diseases. Primary Health Care came to be instituted following a joint World Health Organization-United Nations International Children's Fund International Conference at Alma-At on 12th September 1978.

Primary Health Care is essential health care accessible to all rural and urban areas and affordable to all people for their healthy development. The following are the roles of primary care:

• Primary health care should be shared equally by all people.

• Primary health services are independent of people's ability to pay. Therefore, all rich, poor, urban, and rural citizens must have access to health services.

• An essential ingredient of primary health care is the involvement of families, individuals, and communities in promoting their health and welfare.

• Primary health care uses scientifically sound technology that is acceptable to local needs.

• Primary health care focuses on the prevention of diseases.

• Illness should be treated under primary health care services, and rehabilitation should be carried out.

• Primary health care focuses on exemplary treatment service.

• Health services should not be curative but should instill health and a healthy lifestyle and emphasize prevention.

• Primary healthcare provides medical care along with education about health.

• The public health center provides a safe water supply and basic sanitation.

What Is Dyspepsia?

Dyspepsia is a condition that is described by symptoms such as discomfort, bloating, and nausea, which are thought to originate from the upper gastrointestinal tract. However, it can occur due to various causes. In addition, it can happen in the absence of organic disease, known as functional dyspepsia, which is chronic. Soreness and motility-dysfunction-type subgroups are seen, but there is an overlap between these and irritable bowel syndrome. It is very similar to H. pylori infection, and thus dyspepsia is misdiagnosed. The exact cause of dyspepsia is poorly understood but probably covers the spectrum of mucosal, motility, and psychiatric disorders.

What Are the Causes of Dyspepsia?

There are many causes of dyspepsia, including some outside the digestive system. For example, heartburn and other reflux symptoms are separate entities and considered elsewhere.

The following are the main factors that cause dyspepsia:

Upper Gastrointestinal Disorders -

• Peptic ulcer disease.

• Acute gastritis.

• Gallstones.

• Esophageal spasm.

• Non-ulcer dyspepsia.

• Irritable bowel syndrome.

Other Gastrointestinal Disorders -

• Pancreatic disease (cancer, chronic pancreatitis).

• Colonic carcinoma.

• Hepatic disease (hepatitis).

Systemic Disease -

• Renal failure.

• Hypercalcemia (an abnormal increase in blood calcium levels).

Drugs-

• Glucocorticoids (Beclomethasone).

• Non-steroidal anti-inflammatory drugs (Ibuprofen).

• Iron and potassium supplements (multivitamins).

• Digoxin.

Other Factors Causing Dyspepsia-

• Psychological factors (anxiety, depression).

• Alcohol.

What Are the Symptoms of Dyspepsia?

The following are the symptoms of dyspepsia:

• Patients are usually young (< 40 years).

• Abdominal pain.

• Nausea.

• Bloating after a meal.

• Morning symptoms are characteristic of dyspepsia and include pain or sickness that may occur on waking.

• Anxiety.

• Heartburn.

Alarm Features in Dyspepsia

• Weight loss.

• Anemia.

• Vomiting.

• Dysphagia (difficulty in swallowing).

• Palpable abdominal mass.

• Melaena (dark and tarry stool).

• Hematemesis (vomiting blood).

How Can Dyspepsia Be Diagnosed?

Dyspepsia and H. pylori infections are often confused and are common digestive-related problems. Patients with H. pylori infection are referred to a gastroenterologist for adequate treatment. It is classified as a high-priority infectious disease that needs to be resolved soon; otherwise, patients may suffer from other complications.

Patient history is an important aspect of diagnosis, and it is essential to detect the alarming features of dyspepsia; that is why a basic investigation algorithm is followed to make the appropriate diagnosis, as shown below.

What Are Challenges Faced by Primary Care?

As discussed above, dyspepsia and Helicobacter pylori infection are common digestion-related problems. Primary health care face problems in the diagnosis and treatment of dyspepsia. The symptoms often correlate poorly with the underlying diagnosis; a careful history is essential to detect the ‘alarm’ feature requiring urgent investigation and to detect atypical symptoms that may originate other than the gastrointestinal tract.

• A direct inquiry may elicit symptoms suggestive of irritable bowel syndrome.

• Peptic ulcer disease must be considered, while intra-abdominal malignancy is a prime concern in older people.

• There is no diagnostic sign apart from abdominal pain on palpation.

• The patient often appears anxious.

• Primary healthcare can follow the investigation algorithm as mentioned above.

What Measures Can Be Taken to Overcome the Challenges in Diagnosing Dyspepsia?

• It is essential to detect ‘alarm’ signs of dyspepsia.

• The history will provide a clue to the diagnosis.

• A proper drug history should be taken, and depression or mental illness should be considered.

• Pregnancy should be considered in young women before the radiological investigation is performed.

• Alcohol misuse should be considered when nausea and vomiting are prominent in the morning.

• All patients above 55 years should be checked for Helicobacter pylori infection, as they should undergo endoscopy to eliminate the mucosal disease.

• While gallstones are diagnosed by ultrasound, they are not responsible for dyspeptic symptoms.

• Up to 10 percent of patients benefit from Helicobacter pylori eradication therapy, which should be offered to the infected individual.

What Are the Treatment Options for Dyspepsia?

The most crucial aspect is clarifying their condition to patients and clearing their doubts and fear. In addition, possible psychological and emotional issues should be asked about and considered, and the psychological influences on gut function should be explained. The following are the treatment options for dyspepsia:

Changing Lifestyle - Lifestyles and restrictive diets are of little benefit, but having smaller meals and restricting fat consumption may help.

Helicobacter Pylori Eradication - Helicobacter pylori eradication therapy benefits the patient and removes a significant risk factor for peptic ulcer and gastric cancer.

Medication -

1. Over-the-counter drugs can be used, such as antacids, which are sometimes helpful.

2. Prokinetic drugs such as Metoclopramide or Domperidone may be used when nausea and vomiting are noticed.

3. H2 receptor antagonist drugs may be tried if night pain or heartburn is troublesome.

4. Low-dose tricyclic agents, such as Amitriptyline, can be used.

Symptoms associated with an identifiable cause of stress should be resolved with appropriate counseling and intervention.

Some patients with major mental illnesses or emotional issues need behavioral therapy and proper counseling.

Conclusion

Proper diagnosis and treatment after diagnosing dyspepsia is a challenge for primary care. The critical step is to identify an alarming feature of dyspepsia. A careful history is essential to detect bad symptoms requiring urgent investigation. It is a therapeutic challenge for primary care to diagnose and treat patients with dyspepsia. Patients with dyspepsia should be interpreted appropriately and treated adequately.