Question of the Week # 378

378)  A 34  year old caucasian woman comes for re-evaluation of her chronic epigastric pain and burning.  She feels bloated and full even after eating small amounts of food. She denies any chest pain or shortness of breath. She failed several courses of treatment with h2-blockers and proton pump inhibitiors. She has had two endoscopies in the past which were normal, most recent endoscopy was three months ago.  There was no evidence of gastric stasis on endoscopies after overnight fast.  She was tested for H.pylori infection in the past and was negative. She denies dysphagia, weightloss, nausea, vomiting, dark colored stools or rectal bleeding. There is no family history of gastric malignancy. She does not smoke or drink alcohol.   A ultrasound of the abdomen did not reveal any evidence of gall stones. Amylase and Lipase levels have been normal on several occassions. She has been anxious and unable to sleep at night.  On examination, she is slightly under-weight for her age. Abdominal examination does not reveal any tenderness or palpable masses. Stool guaiac is negative. A complete blood count as well as comprehensive metabolic panel are normal. Which of the following  is the most appropriate next step?

A) Antidepressants

B) Repeat Endoscopy

C) Recommend to take Antacid therapy as needed

D) Scintigraphic gastric emptying study

E) Observation

22 Responses

  1. B) Repeat Endoscopy

    but how is this different from E) Endoscopy ?

  2. Ok, now go ahead- what is the definition of functional dyspepsia?

  3. Functional dyspepsia is dyspepsia without evidence of an organic disease

    • Have we excluded all the organic disease? Two endscopies, ultrasound, several PPI trials, no pancreatitis. Did not we exclude it? Do we need more investigations?

      • Its been 3 months since her last endoscopy so we probably need to repeat endoscopy to find out if she has a new pathology

      • Her symptoms have always been the same without any new changes in presentation and no new weightloss or alarming signs

      • Cannot think of anything else we could do so u diagnose it as Functional Dyspepsia and just observe…she’s not even relieved with PPIs
        E) Observation?

      • Doi anti-depressant or anxiolytic trials help in Functional Dyspepsia?

      • Not sure…do they?

      • They help with IBS..may be they do help for functional dyspepsia as well if she has a underlying psychological stressor…we probably need to address that first in that case.

  4. A) Antidepressants – is it then?

  5. I would prefer answer number E) Observation because in my opinion no more investigation could be done, and even it might be the number A) antidepressants because we could think of it after excluding every thing but there is no further information in the case to encourage me to select it

  6. A)

  7. gastric emptying study d, and if it is neg them A…

  8. its E. This patient has nothing but either dyspepsia functional or she is just hychondric . Thats it.

  9. D Gastric emptying study

    Though her metabolic panel is normal excluding Diabetes she can still have idiopathic Gastroparesis; & endoscopy helps to r/o mechanical obstruction only but not gastroperesis;

    if gastroperesis is absent i would go with Antidepressant therapy
    because it could improve patients’ global health status by alleviating
    symptoms of disorders other than dyspepsia, including anxiety, insomnia etc..

    still no response help the patient to cope with their symptoms using psychological therapies like hypnotherapy etc….

  10. dysfunctional dyspepsia and gastroparesis are the DD’S. Apart from Diabetes , Anorexia nervosa can also cause gastroparesis. She is underweight for her age..which probably directs to, we have to do a gastric emptying study to R/O gastroparesis.

  11. She is underweight for her age because she has been eating small meals and then feels full……So most likely she has Functional Dyspepsia,,,,, & since they tried the PPI & H2blocker on her,,,,then we can add antidepressant for her like Venlafaxine ….as from uptodate/ {{{{ Antidepressants — The role of antidepressants in functional dyspepsia is unsettled. A randomized, placebo-controlled trial of venlafaxine (a selective serotonin and norepinephrine reuptake inhibitor) found that it was no more effective than placebo on improving symptoms [64]. Low dose tricyclic antidepressant drugs or trazodone have an uncertain benefit but may improve commonly associated symptoms such as insomnia and fibromyalgia [47,65]. A therapeutic trial should begin with a low dose (eg, amitriptyline or desipramine 10 to 25 mg at night or trazodone 25 to 50 mg at night in women only (due to the risk of priapism in men)), adjusting the dose upward while observing for daytime sedation or other side effects. If the patient responds in a few weeks, we usually continue the drug for a few months before stopping}}}}}

  12. Answers dont give a choice of pancreatic enzyme trial. A small number of patients may have exocrine function deficiency with no blood work abnormality. This would be an empiric therapy and if that doesnt help then non-organic causes should be sought.

  13. what is the answer
    r/o gastroparesis b4 giving antidepressant?

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