Mistakes in dyspepsia and how to avoid them

Expert knowledge at your fingertips!

Dyspepsia refers to upper abdominal discomfort that is thought to arise from the upper gastrointestinal tract. Symptoms include epigastric pain or discomfort, bloating, early satiety and/or fullness after meals, repeated belching or regurgitation (often rumination), nausea and heartburn.1 The symptoms of dyspepsia are nonspecific, but most commonly result from one of four underlying disorders: functional (nonulcer) dyspepsia, gastro-oesophageal reflux disease (GORD; 10–20% erosive esophagitis), peptic ulcer disease (5–15%) and malignancy (~1%).2 Dyspeptic symptoms may also result from other problems, such as medication intolerance, pancreatitis, biliary tract disease or motility disorders (e.g. gastroparesis or gastric dumping).

Clinical guidelines recommend that endoscopy is not always required for diagnosis; a positive diagnosis of GORD and functional dyspepsia can be based on clinical presentation in the absence of alarm symptoms or features (see below).3,4 In many cases symptoms are increased after meal ingestion (postprandial distress syndrome), being triggered by impaired gastric accommodation and visceral hypersensitivity to gastric distension.5 Other patients have an epigastric pain syndrome in which discomfort is independent of food intake and gastrointestinal function.6 There is an important overlap between functional dyspepsia and other functional gastrointestinal diseases (e.g. irritable bowel syndrome [IBS]) and chronic pain syndromes (e.g. fibromyalgia).7 Psychological disease (e.g. anxiety or somatization disorder) and/or psychosocial stress are also present in a significant proportion of patients who seek medical attention.8,9 Notwithstanding the constructive advice provided by published reviews and guidelines, the broad definition of dyspepsia, lack of diagnostic investigations, uncertain cause of disease, psychosocial issues and paucity of specific treatments make the management of dyspepsia challenging. Here, I discuss 10 common and/or high-impact mistakes that are made in the diagnosis and treatment of patients with dyspeptic symptoms: five related to diagnosis, five related to treatment.

Mistakes in coeliac disease diagnosis and how to avoid them

Learn from leaders in the field!

Coeliac disease is regarded as an autoimmune disorder triggered by gluten, which activates an immune reaction against the autoantigen tissue transglutaminase (transglutaminase 2; TG2) in genetically predisposed subjects. Genetic susceptibility to coeliac disease has been proven by its close linkage with major histocompatibility complex (MHC) class II human leukocyte antigen (HLA) DQ2 and DQ8 haplotypes. The identification of biomarkers for coeliac disease (e.g. endomysial antibodies [EmA] and antibodies to TG2 [anti-TG2]) has changed the epidemiology of coeliac disease from being a rare to a frequent condition, with an expected prevalence of 1% in the worldwide population.1 Nonetheless, the majority of patients who have coeliac disease remain undiagnosed, leaving the coeliac ‘iceberg’ mostly submerged. Coeliac disease can be difficult to diagnose because symptoms vary from patient to patient. Indeed, the heterogeneity among the clinical signs and the lack of specificity of many of the presenting symptoms means that the diagnosis of coeliac disease can be a challenge even for experts.

Despite substantial differences in the mode of presentation and the availability of new diagnostic tools, small intestinal biopsy, which shows different grades of mucosal damage, remains the gold standard for coeliac disease diagnosis. A delayed diagnosis of coeliac disease in the elderly can be considered a risk factor for complications including refractory coeliac disease, ulcerative jejunoileitis, collagenous sprue, small bowel carcinoma and enteropathy-associated T-cell lymphoma (EATL). Complicated coeliac disease is not so frequent, being found only in about 1–2% of the total number of coeliac disease patients, but for those who have it the prognosis is very poor, with a low rate of survival after 5 years.2 Here we discuss the major mistakes that are made when diagnosing coeliac disease and how to avoid them. The list of mistakes and the discussion that follows is evidence based and integrated with our clinical experience of more than 30 years in this field.
<1 2 3