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Invited review
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INVITED REVIEW NON-ULCER CHARLES
DYSPEPSIA MORRIS
Abstract-This paper dlacusses the definition of non-ulcer dyspepsia and ita relationship to other functional bowel disorders. The research on the prevalence, outcome, aetiology and management of this condition ix reviewed with particular emphasis on its multifactorial nature. Future research will need to concentrate on the inter-relationship of physical and psychosocial factors including the health beliefs of the individual patient.
INTRODUCTION
symptoms and complaints are very common amongst the general population [1, 21. In fact they are so common that it has been suggested that there is little to be gained by surveys of unselected populations I31 and that these symptoms should be regarded as an expected part of normal everyday life. However, a proportion of patients develop such symptoms as part of a life threatening physical illness while many others are considerably and persistently troubled by symptoms for which they are given no definite explanation. These unexplained symptoms are very varied. Chronic lower abdominal complaints associated with disturbed bowel habit are often diagnosed as irritable bowel syndrome. Acute abdominal pain frequently results in hospital admission but only a proportion, even of those who undergo surgery, have serious organic pathology [4-61. Dyspepsia and indigestionlike symptoms are very common complaints in the genera1 population, in genera1 practice attenders and in hospital out-patients [ 1, 71. Gastroenterological clinics contain a high proportion of patients whose upper abdominal symptoms cannot be attributed to organic pathology [7-91, some of whom may experience chronic symptoms which are unpleasant and disruptive to their lives [3, 10, 111. Little is known about their long-term outcome but what evidence there is suggests that a significant minority suffer chronic difficulties. Much of the research has been by gastroenterologists who have concentrated on two main questions-first, how do physicians identify those patients with organic disease and, secondly, to what can one attribute the symptoms of those without clearly demonstrable gastrointestinal disease? There are well described organic causes of upper abdominal symptoms, including frank peptic disease, and in a minority, pathology outside the proximal gut such as heart disease producing atypical symptoms. However, in a significant proportion of investigated patients no macroscopic organic pathology is identified and the term GASTROENTEROLOGICAL
senior
Registrar
in Psychiatry,
Warneford
Hospital.
Oxford
OX3
7JX,
U.K.
CHARLES MORRIS
130
non-ulcer
dyspepsia
has
been
used.
Some
patients
with
this
diagnosis
have
their
symptoms provisionally ascribed to a variety of minor physical causes (such as microscopic gastritis, smooth muscle disorder or gastro-oesophageal reflux) whereas others have no apparent cause for their symptoms and are considered to have a functional The role is unclear of patients of those (mainly
disorder. of psychosocial factors in the onset and development of these problems and there is a striking lack of research in this area. Varying proportions have been reported as having psychiatric illness but it is evident that most
with persistent ‘non-organic’ dyspeptic from general practice) have commented
but there has been little interest who have persistent dyspeptic demonstrable.
in the management and outcome of those patients symptoms but in whom no organic pathology is
DEFINITIONS
Abdominal symptoms (acute or chronic, focal
symptoms do not. Other researchers on consulting and illness behaviour
OF SYNDROMES
take many forms and may be divided either or generalized, upper or lower) or aetiologically
functional). Functional bowel disorder may irritable bowel syndrome, in acute symptoms
result in chronic symptoms diagnosed as non-specific
descriptively (organic or typical of abdominal
pain or in symptoms indicative of non-ulcer dyspepsia. There is considerable overlap between these sub-groups as well as between them and other indistinct syndromes such as atypical chest pain. Attempts have relied symptoms loose stools mucus with
to clearly delineate irritable bowel syndrome from other functional illnesses upon efforts to define core symptoms. Manning et (11. [ I21 suggested six (i.e. pain eased by defaecation. more frequent stools at onset of pain. at onset of pain. visible distension, feelings of incomplete evacuation and stools) which largely reflect lower bowel function. However, it is not
always possible to separate the groups clearly [ I31 and some have considered that the underlying pathology in many cases of irritable bowel syndrome and non-ulcer dyspepsia is the same. It has been suggested that a diffuse smooth muscle disorder atfecting the whole of the GI tract may bc responsible both disorders I l4- 181. Non-specific abdominal pain (NSAP) is a condition
for the varied well
recognized
symptoms
of
by surgeons
as being responsible for many acute hospital admissions. It tends to lead to acute presentation after a short duration of illness, has a number of different causes and in general has a good prognosis with the majority of patients experiencing no further episodes 14. 5, 61. Attempts at accurate diagnosis of NSAP range from the oversimplified [ I91 to the highly sophisticated [201. but a clear description of the syndrome is still lacking. Dyspepsia is intended to refer to all upper abdominal and indigestion-like symptoms thought to arise from the proximal alimentary tract including upper abdominal and retrosternal pain or discomfort, nausea, heartburn. vomiting and difficulty swallowing. However, the precise definition used varies 12 I , 22, 151. An international working party 12.31 sub-divided dyspepsia into orgafiic i.c. ‘dyspepsia due to specific lesions which could be readily identified on routine investigation’ and non-ulcer i.c. ‘dyspepsia lasting for more than four months, unrelated to exercise and for which
Invited Review
131
no focal lesion or systemic disease can be found responsible’. Non-ulcer dyspepsia (NUD) appears to be the latest in a number of similar diagnoses (such as ‘pseudo‘pyloro-duodenal irritability’, ‘functional dyspepsia’, ‘nervous ulcer syndrome’, ‘X-ray negative dyspepsia’) and, not surprisingly, there is confusion in dyspepsia’, the current use of the term. Talley and Piper t 131have suggested an alternative term ‘essential dyspepsia’ to mean dyspepsia with ‘no ascertainable cause’ whereas others have sub-divided NUD in other ways e.g. histological criteria [241. There is unavoidable overlap between the sub-groups of dyspepsia but it is reasonable in the present state of knowledge to use the general term non-ulcer dyspepsia to describe those symptoms which, in the absence of physical disease, are largely attributed to the proximal alimentary tract. It must be acknowledged, however, that the syndrome may have aetiological similarities to other functional categories. The simple broad definition proposed by the International Working Party seems as useful as any currently available, but makes no attempt to incorporate the complex interplay between physical and psychological factors which exists in the aetiology and maintainance of the condition. PREVALENCE
It is almost 40 years since Doll er al. demonstrated the high frequency of dyspepsia in the community 1251. Further studies have confirmed their findings. Of physically healthy people 20-25 % experience significant abdominal pain at least six times a year and a further lo-15% have painless bowel dysfunction. The reported prevalence of dyspepsia varies from 7% per year to 38% over six months [2, 26, 271. A recent community survey [II found a 41% six-month period prevalence for dyspepsia with a similar frequency present in the five geographical areas of the UK studied-unlike peptic disease which shows a marked regional variation. They also found that 56% of sufferers reported both heartburn and upper abdominal pain. Abdominal symptoms, including dyspepsia. are a frequent cause of consultation in general practice-up to one quarter of dyspepsia sufferers consult their general practitioner [ 11 and dyspepsia accounts for 3-4% of all general practitioner consultations [271. Abdominal pain is largely managed within general practice and the most common treatments are advice and reassurance [6, 281. Pain, chronicity of symptoms and concern over symptoms seem important determinants of consultation whereas symptom frequency, symptom severity and effect on daily life are poor predictors of help-seeking behaviour [27, 291. Acute and acute-on-chronic abdominal pain are frequent causes of admission to hospital and up to one half of such admissions are attributed to ‘non-organic’ or ‘nonspecific’ abdominal pain [30, 311. Similarly, about one half of hospital gastroenterology out-patients may have functional disorders of the GI tract [91. Two thirds of these were reported as having irritable bowel syndrome and 10% ‘endoscopy negative dyspepsia’. Others have reported similar high levels of ‘functional complaints’ both for gastroenterological symptoms in general [261 and dyspepsia in particular [7, 81. It has been suggested that abdominal symptoms may commonly be present as part of a broadly-based syndrome of somatization which would apply to nearly 5% of the community [321.
CHARLES
132
MORRIS
OUTCOME
Talley
et (I/. [ 111 assert
that
‘there
is no evidence
that symptom
burn-out
occurs
in non-ulcer dyspepsia’. However. there is little evidence relating outcome to the difierent sub-groups of NUD and none demonstrating relief of dyspeptic symptoms when social dysfunction is ameliorated or apparent psychiatric disorder treated. There are no conclusive research studies but the available information contirms the clinical impression that non-ulcer dyspepsia is a chronic problem of disabling severity for a significant proportion of subjects. Bonnevie 131 reports a 13-year follow-up of X-ray negative dyspepsia and claims and Gregory rt al. [ 101 show that. of a similar
that 34% have a ‘severe outcome’ group, 15% have ‘no change’ in
symptoms at 6 years. Our own follow-up study of almost 100 consecutively endoscoped patients with non-ulcer dyspepsia confirms a significant level of both physical symptoms and psychological distress one year after diagnosis 1331. Psychosocial factors and low pain tolerance have been identifed as predictors of chronic symptoms 1341. It is likely that such chronic as repeated attendance
symptoms at general
lead to further significant social handicap as well practice surgeries and hospital out-patients. AETIOlAY3Y
The evidence shows that a large proportion of gastroenterology believed by clinicians to have ‘functional’ disorders and that many tigated for dyspeptic symptoms How. then. can the symptoms
A number
of physical
do not have ulcerative of NUD be explained?
explanations
have
been
or other
put
symptoms between irritable bowel syndrome and non-ulcer cussed above; other possible causes for dyspeptic symptoms disease) include the following. (a) Gtr.stro-o~so~~~~(~~~~~~l rdlm (GOR). This is a difficult certainty burning induced
rcfcrrals are of those inves-
macroscopic
forward.
The
change.
overlap
in
dyspepsia has been dis(other than frank peptic diagnosis
to make
with
on clinical grounds alone [361. but some dyspeptic symptoms. particularly anterior chest pain, have been shown to be due to GOR [351. Such symptoms by exertion may be misdiagnosed as being of cardiac origin [371 and
oesophageal acid perfusion is the most useful diagnostic test. Tally and Piper II31 suggest that about a quarter of dyspeptic patients with normal endoscopic findings have GOR. (b) Ml~st.uloskel~t~~l pcCn. Chest-wall syndrome presents as acute or chronic pain and may lead to diagnostic difficulties. Cervical spine disease has also been implicated in the aetiology 1381. (c) Cilr,ll)~lobu(.tt~r ir~fiction. Microscopic gastritis induced by C. p)lori has only recently been implicated in the causation of dyspepsia F391. The exact role of C. pyfori in producing symptoms is uncertain [40, 41 I but treatment with colloidal Bismuth appears successful in eradicating C. plori and reducing symptoms in some cases [42, 431. (d) ~::\-cYs.vgastric trcki secwtim. In the absence of peptic disease and GOR. excess gastric acid secretion in response to stress has been suggested as a sole cause for
Invited
Review
133
dyspepsia [441, but this is unlikely and evidence is scanty [7, 221. The role of ‘stress’ in non-ulcer dyspepsia is considered later. (e) Abnormal gut motility. Functional dyspepsia has been attributed to abnormalities in gastric tone, gastric motility, small intestinal motility and oesophageal motility [7, 4.51. Antral motor dysfunction leading to post-prandial gastric stasis has been specifically implicated [ 171 and small intestinal dysmotility may be associated with irritable bowel syndrome [ 181. Painful sensations from the oesophagus may give rise to a number of symptoms including heartburn and angina-like pain [461. Others have claimed that abnormal gut motility may be detected throughout the bowel in functional disorders [ 161 and that diffuse smooth muscle disorders leading to oesophageal spasm may be a major cause of upper abdominal pain and other dyspeptic symptoms [47, 141. Not surprisingly pain caused by abnormal gut motility may be confused with cardiac pain t35, 48, 491. Four possible levels for the mechanisms causing abnormal gut motility may be the central nervous system, intermediate pathways (i.e. autonomic nervous and hormonal systems), the intrinsic (enteric) nervous system and the gut smooth muscle cells [7]. Abnormal peptide secretion has been implicated in gut dysmotility [221 and a comprehensive neurohumoural explanation is predicted by some researchers 171. (ii) Relationship
to psychiatric
disorder
Half of those with recently diagnosed functional abdominal pain of all types may have a psychiatric disorder. For example, Gomez and Dally 1501 found that only 15 of 96 patients presenting at surgical or gastroenterological out-patients with recurrent or persistent abdominal pain had an organic disorder. However, 31 were depressed, 21 had ‘chronic tension’ and in 17 ‘hysterical mechanisms were prominent’. Others have reported similar results [511. but not all [521, have found a high incidence of Similarly, most researchers, psychiatric disorder amongst those with localized functional upper abdominal pain 181. Harvey et al. 191 described 1% of their gastroenterology out-patients as ‘mad and incurable’ whilst only a further 3% received the more conventional diagnoses of depression and anxiety. This is likely to be a significant underestimate. There are few studies of note for non-ulcer dyspepsia alone. Non-ulcer dyspepsia has been found to be associated with a variety of factors. including high neuroticism, ‘mood swings’ and childhood emotional deprivation a family history of dyspepsia, [53, 541. Talley et al. [551 have described one of the few studies of subjects with ‘essential dyspepsia’. They compared 76 of these with an equal number of matched asymptomatic controls and 66 patients with duodenal ulcer. Using a variety of selfreport questionnaires, they found that the essential dyspepsia and duodenal ulcer groups were both more neurotic, more anxious and more depressed than community controls but not different to each other. Interestingly, the high scores persisted in the essential dyspepsia group at 3 months (unfortunately the duodenal ulcer group was not retested). No explanation was offered for the similarity between the ‘functional’ and ‘organic’ groups. More recently others have confirmed the high association of NUD with psychiatric disorder and some have suggested it may be more specifically linked to anxiety disorders 156, 571. Psychological factors have been linked to oesophageal motility disorders by a number of authors. Patients with abnormal distal oesophageal contractions score
CHARLES
I.34
highly
on measures
ceptibility’) 1601. Also, have
a higher
[58,
on anxiety,
depression
591 and are more
patients
with
incidence
MORRIS
and
sensitive
somatization
(‘gastrointestinal
to intraoesophageal
oesophageal
disorders
of psychiatric
disorder
presenting than
those
with with
balloon atypical cardiac
sus-
distension chest
pain
dysfunction
[611. There is therefore some evidence, even if not conclusive, that a proportion of patients have a psychiatric disorder (usually anxiety or depression) or personality traits which are influential in their presentation with dyspeptic symptoms. In patients with psychiatric disorder, their dyspeptic symptoms may arise simultaneously with, and as part of, this disorder to increased bowel concerns appear to have no psychiatric
Psychosocial
factors
or it may be that their psychological disturbance leads and hence symptoms [Sl I. However, some patients disorder, no physical illness and ‘normal’ personalities.
may play a role both
in the development
of symptoms
their presentation to the primary care or hospital physician. There evidence for patients with non-ulcer dyspepsia but paraliels may studies of patients with all types of functional abdominal pain.
and in
is little specific be drawn with
(a) Strcssfil lifk evet~ts. Severe threatening life events may precede presentation with abdominal pain leading to surgical removal of a non-inflamed appendix. Such presentation is not necessarily mediated by development of psychiatric disorder [621 although the severity of life events may be similar to that seen in depressed patients [63. 641. However, Canton ct a/. [641 found that appendicectomy patients were more convinced of a physical cause for their symptoms and showed less emotional disturbance than depressed patients. Life events were not implicated in the aetiology of non-ulcer dyspepsia by Talley and Piper 1651 although this study has striking methodological flaws [661. Life events may precede consultation with the general practitioner
in dyspepsia sufferers [671. Acute stress experiments may induce proximal and distal oesophageal muscle contraction [68. 691. However. some sufferers of functional dyspepsia abnormal oesophageal motor function even in the absence of stress whereas
(b) Stress. smooth exhibit
others have normal baseline motility. It has been proposed [701 that this latter group have an abnormal perception of normal stress-induced motor changes which results in the development of symptoms. These authors suggest that ‘alternative strategies need to be developed to alter perception of luminal stimuli in those patients when no quantitative disorder of gut motility is found’. (c) Hrtrlth belie@. Attitudes to health and health beliefs are an important determinant of care-seeking behaviour. In a community survey Lydeard and Jones [671 identified patients with dyspepsia and compared those who had consulted their general practitioner with those who had not done so. There were no significant differences in the reported severity or frequency of symptoms. or in the degree of associated symptoms. However. the consulters were more concerned about the seriousness of their symptoms and were more worried about the possibility of cancer and heart disease. (d) fl/r~.s.s hrhu~~iour. This refers to ‘the ways in which given symptoms may be differently perceived, evaluated and acted (or not acted) upon by different kinds of persons’ 17 I I ‘Abnormal illness behaviour’ has been shown to be more frequent in
Invited
Review
13.5
patients with non-organic abdominal pain [8, 311 and in those with irritable bowel syndrome I721 when compared to those with organic diagnoses. However, it is not clear which components of the behaviour are more frequent and how these relate to symptom formation and consultation. Consultation with GPs for dyspepsia is more common in social class 4 than social class 1, although the prevalence of dyspepsia is unrelated to class. In addition, the use of investigations by general practitioners and the diagnosis of peptic ulcer were also more frequent in social class 5 than social class 1 111. (e) Childhood abdominal pain. There is some evidence that complaints of abdominal pain in childhood may persist into adult life [731. The determinants of this are unclear but may be relevant in some patients. A MULTICAUSAL
EXPLANATION
There has been in recent years an increasing awareness that the aetiology of functional somatic symptoms is multicausal [74, 751. Similarly, some studies have shown an association between organic gastroenterological disease and psychosocial factors-for example, MacDonald and Bouchier t761 found that 20% of their sample with an organic cause of abdominal symptoms received a psychiatric diagnosis, and Craig and Brown 1631 demonstrated that life events involving ‘goal frustration’ were significantly associated with onset of peptic disease (being far more common than in those with functional disorder). Thus, the diagnosis of organic disease does not preclude the relevance of psychosocial factors. Similarly, evidence suggests that, although some of those with non-ulcer dyspepsia will have a physical basis for their symptoms (e.g. oesophageal spasm, gastrooesophageal rcflux), this abnormality will not completely explain the symptoms presented to the physician. Health beliefs, stressful life events, learned behaviour from childhood and personality traits will contribute to severity and chronicity of symptoms and hence determine consultation and investigation. Minor digestive complaints are common symptoms of anxiety and other emotional disorders and in a proportion of cases it is likely that symptoms may be attributed entirely to a psychological cause. In many cases, however, it will be uncertain to what extent each of the physical and psychological factors will be playing a part in determining symptoms. However, as it is the interaction of these various factors which determine the patient’s presentation. this uncertainty need not be an obstacle to treatment. Indeed, it may often be turned to therapeutic advantage, as will be discussed later. It is only when all aetiological factors are considered that the individual patient can be understood and treated. MANAGEMENT
Warndorlf et al. [28] conclude that dyspepsia is largely well managed by general practitioners in the U.K. and that it is rarely associated (at least in general practice) with major lesions. However, multiple associated symptoms often make diagnosis difficult 167, 771. Referral to hospital has been recommended for older patients and for those with ominous symptoms [79, 801. If the patient is young and has no symptoms suggestive of serious occult organic disease or psychiatric disorder, a trial
CHAKLES
136
MVKKIS
of empirical symptomatic treatment coupled with appropriate sufficient. Treatment of non-ulcer dyspepsia with H1-blockers unlikely to bc successful [78l but in some cases Bismuth salts
reassurance may be such as Ranitidine is may be effective [42,
431. It is important, of course, for all physicians to consider psychological factors at all stages of assessment [ 15, 26, 211 and to diagnose psychogenic abdominal pain only on positive grounds rather than by exclusion of organic pathology [811. The general practitioner is well placed to appraise psychosocial and discussion of these in a way acceptable to the patients physical investigations.
factors at an early stage may obviate unnecessary
Similarly, the hospital physician will wish to limit further physical investigations to those with specific indications. Once the physician is sufficiently confident that there is no significant organic disease investigations should cease and the reasons explained to the patient. In the majority of cases specialist psychiatric treatment will not be required even when psychological factors are prominent. Most patients will respond to a simple explanation of their symptoms provided that it takes account of the individual beliefs and concerns. Jones [821 reported that consulting and prescribing rates of gastroenterological problems fell significantly after patients with upper abdominal pain received a normal endoscopy and claims that ‘negative endoscopies may have positive outcomes’. However, the limitation of reassurance must be recognized 1831. It may be particularly important in a sub-group of patients with chronic persistent symptoms to control further medical investigations in order to break the cycle of complaint-normal investigation-temporary reassurancecomplaint-investigation. The management of the persistent attender without organic pathology is clearly more difhcult. Hypnotherapy and behaviour therapy have been tried with some success in patients with irritable bowel syndrome 184. 851 and could be considered in NUD. An interested physician could co-ordinate this in conjunction with the appropriate specialist e.g. psychologist, social worker. alternative therapist etc. In casts where more claboratc psychological treatments are indicated, the treatment must vary according to the patient’s needs. Overt psychiatric illness such as depressive illness and anxiety disorders should respond to conventional physical and psychological
treatments.
In other
cases
where
maintainance
of symptoms
is more
directly related to longstanding abnormal health beliefs or preoccupation with bodily symptoms, a cognitive behavioural approach rnay be indicated. This type of treatment has been used for children with chronic abdominal pain 1861 and is being developed for a wide range of somatic and hypochondriacal complaints 187. 881. The uncertainty over the aetiology of a patient’s symptoms would be well suited to the behavioural experiments and re-evaluations inherent in this type of treatment. Brief dynamic psychotherapy may lead to symptom reduction in patients with irritable bowel syndrome [891. However. the availability of these types of psychotherapy is limited and their effectiveness has not been studied in patients with non-ulcer dyspepsia.
CONCl.USION
The aetiology of dyspepsia is still unclear. A number of possible physical explanations exist but a considerable proportion of patients still go undiagnosed. Research suggests that some of these patients will have psychological disturbance or
Invited
Review
137
health concerns. There is also evidence that psychosocial factors are relevant in the aetiology (and hence management) of those with proven or likely organic pathology. There are still many unanswered questions about non-ulcer dyspepsia. For example, is it a chronic condition? Are there discrete sub-groups? Is there a difference between those patients referred to hospital and those seen only by their GP? Are chronic physical symptoms associated with abnormal health beliefs or over-concern about bodily symptoms, and if so, is this the case for those with physical diagnoses as well as for those without? How does non-ulcer dyspepsia relate to other forms of functional bowel disease? Which treatments are most effective. and for which patients? It is an obvious conclusion that understanding is still at a relatively unsophisticated level and more collaborative research is necessary. Meanwhile, it is essential that all patients presenting with dyspepsia receive from their physicians an assessment which includes consideration of the psychological factors discussed above. exaggerated
Ackno~~led~rmmrs.--I should like to thank Dr Richard Mayou for his encouragement and helpful comments on previous drafts of the manuscript, and Mrs Lisa Cox for her invaluable secretarial assistance. REFERENCES
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38 39. 40. 41. 42.
43. 44. 4s. 46. 47. 48. 49. 50. 51.
WARNI~ORFF DK. KNOTINERVS JA, HUIJNEN LGJ, S~ARMRANS R. How well do general practitioners manage dyspepsia? J R Co/i Gen Pruc-r 1989; 39: 499-502. Jolts R. Dyspeptic symptoms in the community. Cur 1989; 30: 893-898. RAHEJA SK. MCDONALD PJ. TAYLOR I. Non-specific abdominal pain-an expensive mystery. JR Sot Med 1990; 83: 10-l 1 JOYCX PR, BUSHNELI. JA. WAI.SH EJWB, MORTON JB. Abnormal illness behaviour and anxiety in acute non-organic abdominal pain. Br J Psychiur 1986; 149: 57-62. EXOBAR JI, B~JRNAM MA. KARNO M. FORSYTHE A, GOLDINC JM. Somatiration in the community. Arch Gen Psychicrtr~ 1987; 44: J 13-7 18. MORRIS CH, CHAPMAN R. MAYOR RA. A questionnaire follow-up study of patients wtth dyspepsia of unknown cause (m prep.). SI OTH H. JORGENSEN LG. Predictors for the course of chronic non-organic upper abdominal pain. Scumi J Gasrroenrrrol 1989: 24: 440-444. DAVILS HA. JONFS DB, RHODES J. ‘Esophageal Angina’ a\ the cause of chest pain. JAMA 1982; 248: 2274~2278. KI AUSER AC. SCHINULBE~K NE, MULL~R-LISSNICR S4. Symptoms in gastro-oesophageal retlux diseasc. k~ncer 1990: 335: 205-208. S~HOI~IF~.D PM, BENN~II DH. WHORWELL PJ, BROOKS NH, BRAY CL, WARD C. JONES PE. Excrtional gaatro-oesophageal reflux: a mechamsm for symptoms in patients with angina pectoris and normal coronary angiograma. Br Med J 1987; 294: 1459-1461. EPSTIYIN SE. GERBER LH, BORER JS. Chest wall syndrome. JAMA 1979; 241: 2793-2797. MARSHALL BJ. MCGIX.HE DB, ROGERS PA, GI.ANCY RJ. Pyloric campylobacter infection and gastroduodenal disease. Med J Ausf 1985; 142: 439-444. VAIRA D. HOLTON J, OSBORN J. DOWSETT J, MCNEIL I. HATP1Et.D A. Use ofendoscopy in patients with dyspepsia. Er Mcd J 1989: 299: 237. LOFP~I.D RJLF. Porrt~s HUJP, STOHBERINCIHE, FLENDRW JA, VAN SPRE~VW~L JP. ARENDS JW. Campylobacter associated gastritis in patients with non-ulcer dyspepsia. Gur 1989; 30: 1206-12 12. H~~~~P!IREYS H. BOURKF S, DOOLEY C, MCKENNA D, POWER B, KEANE CT, SWEENEY EC, O‘Morain C. Effects of treatment on cump?,lohuc~tor plot-i in peptic disease: a randomised prospective trial. Girt 1988; 29: 279-283 ROKKAS T, PURSEY C. UZOECHINA E. DORRIN~ITON L, SIMMONS NA, FILIPE MI. SI.AT)EN GE. Nonulcer dyspepsia and short-term De Nol therapy. Gut 1988; 29: 1386-1391. SHAY H. Emotional stress and parietal zell mass. Am J Dig Dis 1959: 4: 846-870. YOLI CH. LEEK Y. CH~Y WY, MENCINY R. Electrogastrographic study of patients with unexplained nausea, bloating and vomiting. Gosfrornterology 1980; 79: 31 I-314. VAN I KAPPEN G, JANSSLNS J. Angina and oesophageal pain-a gastroenterologist’a point of view. Eurr, Heurr J 1986: 7: X28-834. KINGHAM JGL, DAWSON AM. Origin of chronic right upper quadrant pain. Gut 1985; 26: 783-788. LAN~XI (Editorial). Angina and Oesophageal Disease. ~IIZ(.E~, 1986: I: 191- 192. RI(.H~EK JE, BRADLEY LA, CASTF,I.I. DO. Esophageal chest pain: current controversies m pathogenesis. diagnosis and therapy. Ann lnt Med 1989; 110: 66-78. GOMET J. DALLY P. Psychologically mediated abdominal pain in surgical and medical out-patient clinics. Br Med J 1977; 1: 1451-1453. CREED F. GUTHRIE E. Psychological factors in the irritable bowel syndrome. Cur 1987; 28: 1307-1318.
Invited
Review
139
52. STOCKTON M, WEINMAN J, MCCOLL I. An investigation of psychological factors in patients with upper abdominal pam. J Psychosom Res 1985; 29: 191-198. 53. WII.SON KCM, WHITEOAK R, DEWEY M, WATSON JP. Aspects of personality of soldiers presenting to an endoscopy clinic. J Psvchosom Res 1989; 33: 85-91. 54. ROBERTS DM. The psychiatric basis of dyspepsia in the absence of orgariic disease. J R Arm Med Corps 1978; 124: 13-18. 55. TALLEY NJ, FUNC LH, GII.LIGAN IJ, MCNEIL D. PIPER DW. Association of anxiety, neuroticism and depression with dyspepsia of unknown cause. Gasrroentrrology 1986; 90: 886-892. 56. MAGNI G. DI MARIO F, BERNASCONI G, MASTROPAOLO G. DSM-III diagnoses associated with dyspepsia of unknown cause. Am J Psychiar 1987; 144: 1222-1223. 57. LAN(JEI.UDDECKE P. GOULSTON K, TENNANT C. Psychological factors in dyspepsia of unknown cause: A comparison with peptic ulcer disease. J Psychosom Res 1990; 34: 215-222. 58. CLOUSE RE, LUSTMAN PJ. Psychiatric illness and contraction abnormalities of the esophagus. N Enx/ J Med 1983; 309: 1337-1342. 59. RICHTER JE, OBRECH~ F, BRADLEY LA. YOUNG LD, ANDERSON K. Psychological comparison of patients with Nutcracker Esophagus and irritable bowel syndrome. Dig Dis Sci 1986; 31: 131-138. 60. RICHTER JE, BARISH CF. CASTELL DO. Abnormal sensory perception in patients with oesophageal chest pain. Gasrroenrerofogy 1986; 91: 845-852. 61. COL.C~ANSM. SCHOPIELD PM, WHORWELL PJ, BENNETT DH, BROOKS NH, JONES PE. Angina-like chest pain: a joint medical and psychiatric investigation. Postgrad Med J 1988; 64: 743-746. 62. CREED F. CRAIG T, FARMER R. Functional abdominal pain, psychiatric illness and life events. Gut 1988; 29: 235-242. 63. CRAIG TKJ. BROWN GW. Goal frustration and life events in the aetiology of painful gastrointestinal disorder. J Psychosom Res 1984; 28: 41 I-421. 64. CANTON G, SANTONASTASO P, FRACCON IG. Life events, abnormal illness behaviour and appendectomy. Gerr Hc>.sp Psychiar 1984; 6: 191-195. 65. TAI.LEY NJ, PIPER DW. Major life event stress and dyspepsia of unknown cause: a case control study. Cur 1986; 27: 127-134. 66. BASS C. Life events and gastrointestinal symptoms. Cur 1986; 27: 123-126. 67. LYDEARD S, JONES R. Factors affecting the decision to consult with dyspepsia: comparison of conxulters and non consulters. J R Coil Gen Pratt 1989; 39: 495-498. 68. C~oust RE. Anxiety and gastrointestinal mucus. Psycho/ Cfin N Am 1988; 11: 399-417. 69. ANDERSON KO, DALTON CB. LAURENCE PAC, BRADLEY LA, RICHTER JE. Stress induces alteration of esophageal pressures in healthy volunteers and non-cardiac chest pain patients. Dig Dis Sci 1989; 34: 83-91. 70. CAMIL.I.ERI M, NERI M. Motility disorders and stress. Dig Dis Sci 1989; 34: 1777-1786. 71. MECHANIC D. The concept of illness behaviour. J. Chron Dis 1961; 15: 189-194. 72. WHIIEHEAD WE. WINGET MA, FEDORAVICIUS ALS, WOOLLEY S. BLACKWELL B. Learned
73. 74. 75. 76. 77.
78.
79. 80. 81. 82.
83. 84.
illness behaviour in patients with irritable bowel syndrome and peptic ulcer. Dig Dis Sri 1982; 27: 202-208. CHRISTENSEN MF, MORTENSEN 0. Long-term prognosis in children with recurrent abdominal pain. Arch Dis Child 1975; 50: 110-I 14. BARSKY AJ, KL~RMAN GL. Overview: Hypochondriasis, bodily complaints and somatic styles. Am J Psychiur 1983; 140: 273-283. KELLNER R. Hypochondriasis and somatisation. JAMA 1987; 258: 2718-2722. MACDONALD AJ. BOUCHIER IAD. Non-organic gastrointestinal illness: A medical and psychiatric study. Br J Psychiur 1980; 136: 276-283. HORKOC.KSJC. DE DOMBAL FT. Clinical presentation of patients with ‘dyspepsia’. Cur 1978; 19: 19-26. NYREN 0, ADARI HO, BATES S, BERGSTROM R. GUSTAVSSON S, LOOF L, NYBCRG A. Absence of therapeutic benefits from antacids or cimetidine in non-ulcer dyspepsia. N Eql J Med 1986; 314: 399-403. BROWN C, REES WDW. Dyspepsia in general practice. Br Med J 1990; 300: 829-830. COIIN-JONES DG. Practical guidelines for the management of dyspepsia. Luncet 1990; 336: 30 I-302. EISENDRATH SJ, WAY LW, OSTROFF JW, JOHANSON CA. Identification of psychogenic abdominal pain. Psychosomarics 1986; 27: 705-7 12. JONES R. What happens to patients with non-ulcer dyspepsia after endoscopy? Practitioner 1988; 232: 75-78. WARWICK HMC, SALKOVSKIS PM. Reassurance. Er Med J 1985; 290: 1028. WHORWEI.I. PJ, PRIOR A. COLGAN SM. Hypnotherapy in severe irritable bowel syndrome: further experience. GUI 1987; 28: 423-425.
CHARLES
140
MORRIS
85. BENNETT P, WILI~INSON S. A comparison of psychological and medical treatment of the irritable bowel syndrome. Br J C/in Psychiat 1985; 24: 215-216. 86. SANDFRS MR. REBGETZ M, MORRISON M, BOR W, GORDON A. DADDS M, SHEPHERD R. Cognitive-behavioural treatment of recurrent non-specific abdominal pain in children. J Cons C/in Psychoi 87.
1989;
57:
294-300.
KLIMES I,MAYOU RA, PEARCE MJ, COLES L, FAW JR. Psychological treatment for atypical noncardiac chest pain: a controlled evaluation. Psycho1 Med 1990; 20: 605-611. 88. SALKOVSKIS PM, WARWICK HM. Morbid preoccupations, health anxiety and reassurance: a cognitive-behavioural approach to hypochondriasis. Behuv Res Ther 1986; 24: 597-602. 89. SVEDLL~ND J. SYODIN I, OLLOSON JO ef rrl. Controlled study of psychotherapy in irritable bowel syndrome. Luncer 1983; ii: 589-602.
INVITED REVIEW NON-ULCER CHARLES
DYSPEPSIA MORRIS
Abstract-This paper dlacusses the definition of non-ulcer dyspepsia and ita relationship to other functional bowel disorders. The research on the prevalence, outcome, aetiology and management of this condition ix reviewed with particular emphasis on its multifactorial nature. Future research will need to concentrate on the inter-relationship of physical and psychosocial factors including the health beliefs of the individual patient.
INTRODUCTION
symptoms and complaints are very common amongst the general population [1, 21. In fact they are so common that it has been suggested that there is little to be gained by surveys of unselected populations I31 and that these symptoms should be regarded as an expected part of normal everyday life. However, a proportion of patients develop such symptoms as part of a life threatening physical illness while many others are considerably and persistently troubled by symptoms for which they are given no definite explanation. These unexplained symptoms are very varied. Chronic lower abdominal complaints associated with disturbed bowel habit are often diagnosed as irritable bowel syndrome. Acute abdominal pain frequently results in hospital admission but only a proportion, even of those who undergo surgery, have serious organic pathology [4-61. Dyspepsia and indigestionlike symptoms are very common complaints in the genera1 population, in genera1 practice attenders and in hospital out-patients [ 1, 71. Gastroenterological clinics contain a high proportion of patients whose upper abdominal symptoms cannot be attributed to organic pathology [7-91, some of whom may experience chronic symptoms which are unpleasant and disruptive to their lives [3, 10, 111. Little is known about their long-term outcome but what evidence there is suggests that a significant minority suffer chronic difficulties. Much of the research has been by gastroenterologists who have concentrated on two main questions-first, how do physicians identify those patients with organic disease and, secondly, to what can one attribute the symptoms of those without clearly demonstrable gastrointestinal disease? There are well described organic causes of upper abdominal symptoms, including frank peptic disease, and in a minority, pathology outside the proximal gut such as heart disease producing atypical symptoms. However, in a significant proportion of investigated patients no macroscopic organic pathology is identified and the term GASTROENTEROLOGICAL
senior
Registrar
in Psychiatry,
Warneford
Hospital.
Oxford
OX3
7JX,
U.K.
CHARLES MORRIS
130
non-ulcer
dyspepsia
has
been
used.
Some
patients
with
this
diagnosis
have
their
symptoms provisionally ascribed to a variety of minor physical causes (such as microscopic gastritis, smooth muscle disorder or gastro-oesophageal reflux) whereas others have no apparent cause for their symptoms and are considered to have a functional The role is unclear of patients of those (mainly
disorder. of psychosocial factors in the onset and development of these problems and there is a striking lack of research in this area. Varying proportions have been reported as having psychiatric illness but it is evident that most
with persistent ‘non-organic’ dyspeptic from general practice) have commented
but there has been little interest who have persistent dyspeptic demonstrable.
in the management and outcome of those patients symptoms but in whom no organic pathology is
DEFINITIONS
Abdominal symptoms (acute or chronic, focal
symptoms do not. Other researchers on consulting and illness behaviour
OF SYNDROMES
take many forms and may be divided either or generalized, upper or lower) or aetiologically
functional). Functional bowel disorder may irritable bowel syndrome, in acute symptoms
result in chronic symptoms diagnosed as non-specific
descriptively (organic or typical of abdominal
pain or in symptoms indicative of non-ulcer dyspepsia. There is considerable overlap between these sub-groups as well as between them and other indistinct syndromes such as atypical chest pain. Attempts have relied symptoms loose stools mucus with
to clearly delineate irritable bowel syndrome from other functional illnesses upon efforts to define core symptoms. Manning et (11. [ I21 suggested six (i.e. pain eased by defaecation. more frequent stools at onset of pain. at onset of pain. visible distension, feelings of incomplete evacuation and stools) which largely reflect lower bowel function. However, it is not
always possible to separate the groups clearly [ I31 and some have considered that the underlying pathology in many cases of irritable bowel syndrome and non-ulcer dyspepsia is the same. It has been suggested that a diffuse smooth muscle disorder atfecting the whole of the GI tract may bc responsible both disorders I l4- 181. Non-specific abdominal pain (NSAP) is a condition
for the varied well
recognized
symptoms
of
by surgeons
as being responsible for many acute hospital admissions. It tends to lead to acute presentation after a short duration of illness, has a number of different causes and in general has a good prognosis with the majority of patients experiencing no further episodes 14. 5, 61. Attempts at accurate diagnosis of NSAP range from the oversimplified [ I91 to the highly sophisticated [201. but a clear description of the syndrome is still lacking. Dyspepsia is intended to refer to all upper abdominal and indigestion-like symptoms thought to arise from the proximal alimentary tract including upper abdominal and retrosternal pain or discomfort, nausea, heartburn. vomiting and difficulty swallowing. However, the precise definition used varies 12 I , 22, 151. An international working party 12.31 sub-divided dyspepsia into orgafiic i.c. ‘dyspepsia due to specific lesions which could be readily identified on routine investigation’ and non-ulcer i.c. ‘dyspepsia lasting for more than four months, unrelated to exercise and for which
Invited Review
131
no focal lesion or systemic disease can be found responsible’. Non-ulcer dyspepsia (NUD) appears to be the latest in a number of similar diagnoses (such as ‘pseudo‘pyloro-duodenal irritability’, ‘functional dyspepsia’, ‘nervous ulcer syndrome’, ‘X-ray negative dyspepsia’) and, not surprisingly, there is confusion in dyspepsia’, the current use of the term. Talley and Piper t 131have suggested an alternative term ‘essential dyspepsia’ to mean dyspepsia with ‘no ascertainable cause’ whereas others have sub-divided NUD in other ways e.g. histological criteria [241. There is unavoidable overlap between the sub-groups of dyspepsia but it is reasonable in the present state of knowledge to use the general term non-ulcer dyspepsia to describe those symptoms which, in the absence of physical disease, are largely attributed to the proximal alimentary tract. It must be acknowledged, however, that the syndrome may have aetiological similarities to other functional categories. The simple broad definition proposed by the International Working Party seems as useful as any currently available, but makes no attempt to incorporate the complex interplay between physical and psychological factors which exists in the aetiology and maintainance of the condition. PREVALENCE
It is almost 40 years since Doll er al. demonstrated the high frequency of dyspepsia in the community 1251. Further studies have confirmed their findings. Of physically healthy people 20-25 % experience significant abdominal pain at least six times a year and a further lo-15% have painless bowel dysfunction. The reported prevalence of dyspepsia varies from 7% per year to 38% over six months [2, 26, 271. A recent community survey [II found a 41% six-month period prevalence for dyspepsia with a similar frequency present in the five geographical areas of the UK studied-unlike peptic disease which shows a marked regional variation. They also found that 56% of sufferers reported both heartburn and upper abdominal pain. Abdominal symptoms, including dyspepsia. are a frequent cause of consultation in general practice-up to one quarter of dyspepsia sufferers consult their general practitioner [ 11 and dyspepsia accounts for 3-4% of all general practitioner consultations [271. Abdominal pain is largely managed within general practice and the most common treatments are advice and reassurance [6, 281. Pain, chronicity of symptoms and concern over symptoms seem important determinants of consultation whereas symptom frequency, symptom severity and effect on daily life are poor predictors of help-seeking behaviour [27, 291. Acute and acute-on-chronic abdominal pain are frequent causes of admission to hospital and up to one half of such admissions are attributed to ‘non-organic’ or ‘nonspecific’ abdominal pain [30, 311. Similarly, about one half of hospital gastroenterology out-patients may have functional disorders of the GI tract [91. Two thirds of these were reported as having irritable bowel syndrome and 10% ‘endoscopy negative dyspepsia’. Others have reported similar high levels of ‘functional complaints’ both for gastroenterological symptoms in general [261 and dyspepsia in particular [7, 81. It has been suggested that abdominal symptoms may commonly be present as part of a broadly-based syndrome of somatization which would apply to nearly 5% of the community [321.
CHARLES
132
MORRIS
OUTCOME
Talley
et (I/. [ 111 assert
that
‘there
is no evidence
that symptom
burn-out
occurs
in non-ulcer dyspepsia’. However. there is little evidence relating outcome to the difierent sub-groups of NUD and none demonstrating relief of dyspeptic symptoms when social dysfunction is ameliorated or apparent psychiatric disorder treated. There are no conclusive research studies but the available information contirms the clinical impression that non-ulcer dyspepsia is a chronic problem of disabling severity for a significant proportion of subjects. Bonnevie 131 reports a 13-year follow-up of X-ray negative dyspepsia and claims and Gregory rt al. [ 101 show that. of a similar
that 34% have a ‘severe outcome’ group, 15% have ‘no change’ in
symptoms at 6 years. Our own follow-up study of almost 100 consecutively endoscoped patients with non-ulcer dyspepsia confirms a significant level of both physical symptoms and psychological distress one year after diagnosis 1331. Psychosocial factors and low pain tolerance have been identifed as predictors of chronic symptoms 1341. It is likely that such chronic as repeated attendance
symptoms at general
lead to further significant social handicap as well practice surgeries and hospital out-patients. AETIOlAY3Y
The evidence shows that a large proportion of gastroenterology believed by clinicians to have ‘functional’ disorders and that many tigated for dyspeptic symptoms How. then. can the symptoms
A number
of physical
do not have ulcerative of NUD be explained?
explanations
have
been
or other
put
symptoms between irritable bowel syndrome and non-ulcer cussed above; other possible causes for dyspeptic symptoms disease) include the following. (a) Gtr.stro-o~so~~~~(~~~~~~l rdlm (GOR). This is a difficult certainty burning induced
rcfcrrals are of those inves-
macroscopic
forward.
The
change.
overlap
in
dyspepsia has been dis(other than frank peptic diagnosis
to make
with
on clinical grounds alone [361. but some dyspeptic symptoms. particularly anterior chest pain, have been shown to be due to GOR [351. Such symptoms by exertion may be misdiagnosed as being of cardiac origin [371 and
oesophageal acid perfusion is the most useful diagnostic test. Tally and Piper II31 suggest that about a quarter of dyspeptic patients with normal endoscopic findings have GOR. (b) Ml~st.uloskel~t~~l pcCn. Chest-wall syndrome presents as acute or chronic pain and may lead to diagnostic difficulties. Cervical spine disease has also been implicated in the aetiology 1381. (c) Cilr,ll)~lobu(.tt~r ir~fiction. Microscopic gastritis induced by C. p)lori has only recently been implicated in the causation of dyspepsia F391. The exact role of C. pyfori in producing symptoms is uncertain [40, 41 I but treatment with colloidal Bismuth appears successful in eradicating C. plori and reducing symptoms in some cases [42, 431. (d) ~::\-cYs.vgastric trcki secwtim. In the absence of peptic disease and GOR. excess gastric acid secretion in response to stress has been suggested as a sole cause for
Invited
Review
133
dyspepsia [441, but this is unlikely and evidence is scanty [7, 221. The role of ‘stress’ in non-ulcer dyspepsia is considered later. (e) Abnormal gut motility. Functional dyspepsia has been attributed to abnormalities in gastric tone, gastric motility, small intestinal motility and oesophageal motility [7, 4.51. Antral motor dysfunction leading to post-prandial gastric stasis has been specifically implicated [ 171 and small intestinal dysmotility may be associated with irritable bowel syndrome [ 181. Painful sensations from the oesophagus may give rise to a number of symptoms including heartburn and angina-like pain [461. Others have claimed that abnormal gut motility may be detected throughout the bowel in functional disorders [ 161 and that diffuse smooth muscle disorders leading to oesophageal spasm may be a major cause of upper abdominal pain and other dyspeptic symptoms [47, 141. Not surprisingly pain caused by abnormal gut motility may be confused with cardiac pain t35, 48, 491. Four possible levels for the mechanisms causing abnormal gut motility may be the central nervous system, intermediate pathways (i.e. autonomic nervous and hormonal systems), the intrinsic (enteric) nervous system and the gut smooth muscle cells [7]. Abnormal peptide secretion has been implicated in gut dysmotility [221 and a comprehensive neurohumoural explanation is predicted by some researchers 171. (ii) Relationship
to psychiatric
disorder
Half of those with recently diagnosed functional abdominal pain of all types may have a psychiatric disorder. For example, Gomez and Dally 1501 found that only 15 of 96 patients presenting at surgical or gastroenterological out-patients with recurrent or persistent abdominal pain had an organic disorder. However, 31 were depressed, 21 had ‘chronic tension’ and in 17 ‘hysterical mechanisms were prominent’. Others have reported similar results [511. but not all [521, have found a high incidence of Similarly, most researchers, psychiatric disorder amongst those with localized functional upper abdominal pain 181. Harvey et al. 191 described 1% of their gastroenterology out-patients as ‘mad and incurable’ whilst only a further 3% received the more conventional diagnoses of depression and anxiety. This is likely to be a significant underestimate. There are few studies of note for non-ulcer dyspepsia alone. Non-ulcer dyspepsia has been found to be associated with a variety of factors. including high neuroticism, ‘mood swings’ and childhood emotional deprivation a family history of dyspepsia, [53, 541. Talley et al. [551 have described one of the few studies of subjects with ‘essential dyspepsia’. They compared 76 of these with an equal number of matched asymptomatic controls and 66 patients with duodenal ulcer. Using a variety of selfreport questionnaires, they found that the essential dyspepsia and duodenal ulcer groups were both more neurotic, more anxious and more depressed than community controls but not different to each other. Interestingly, the high scores persisted in the essential dyspepsia group at 3 months (unfortunately the duodenal ulcer group was not retested). No explanation was offered for the similarity between the ‘functional’ and ‘organic’ groups. More recently others have confirmed the high association of NUD with psychiatric disorder and some have suggested it may be more specifically linked to anxiety disorders 156, 571. Psychological factors have been linked to oesophageal motility disorders by a number of authors. Patients with abnormal distal oesophageal contractions score
CHARLES
I.34
highly
on measures
ceptibility’) 1601. Also, have
a higher
[58,
on anxiety,
depression
591 and are more
patients
with
incidence
MORRIS
and
sensitive
somatization
(‘gastrointestinal
to intraoesophageal
oesophageal
disorders
of psychiatric
disorder
presenting than
those
with with
balloon atypical cardiac
sus-
distension chest
pain
dysfunction
[611. There is therefore some evidence, even if not conclusive, that a proportion of patients have a psychiatric disorder (usually anxiety or depression) or personality traits which are influential in their presentation with dyspeptic symptoms. In patients with psychiatric disorder, their dyspeptic symptoms may arise simultaneously with, and as part of, this disorder to increased bowel concerns appear to have no psychiatric
Psychosocial
factors
or it may be that their psychological disturbance leads and hence symptoms [Sl I. However, some patients disorder, no physical illness and ‘normal’ personalities.
may play a role both
in the development
of symptoms
their presentation to the primary care or hospital physician. There evidence for patients with non-ulcer dyspepsia but paraliels may studies of patients with all types of functional abdominal pain.
and in
is little specific be drawn with
(a) Strcssfil lifk evet~ts. Severe threatening life events may precede presentation with abdominal pain leading to surgical removal of a non-inflamed appendix. Such presentation is not necessarily mediated by development of psychiatric disorder [621 although the severity of life events may be similar to that seen in depressed patients [63. 641. However, Canton ct a/. [641 found that appendicectomy patients were more convinced of a physical cause for their symptoms and showed less emotional disturbance than depressed patients. Life events were not implicated in the aetiology of non-ulcer dyspepsia by Talley and Piper 1651 although this study has striking methodological flaws [661. Life events may precede consultation with the general practitioner
in dyspepsia sufferers [671. Acute stress experiments may induce proximal and distal oesophageal muscle contraction [68. 691. However. some sufferers of functional dyspepsia abnormal oesophageal motor function even in the absence of stress whereas
(b) Stress. smooth exhibit
others have normal baseline motility. It has been proposed [701 that this latter group have an abnormal perception of normal stress-induced motor changes which results in the development of symptoms. These authors suggest that ‘alternative strategies need to be developed to alter perception of luminal stimuli in those patients when no quantitative disorder of gut motility is found’. (c) Hrtrlth belie@. Attitudes to health and health beliefs are an important determinant of care-seeking behaviour. In a community survey Lydeard and Jones [671 identified patients with dyspepsia and compared those who had consulted their general practitioner with those who had not done so. There were no significant differences in the reported severity or frequency of symptoms. or in the degree of associated symptoms. However. the consulters were more concerned about the seriousness of their symptoms and were more worried about the possibility of cancer and heart disease. (d) fl/r~.s.s hrhu~~iour. This refers to ‘the ways in which given symptoms may be differently perceived, evaluated and acted (or not acted) upon by different kinds of persons’ 17 I I ‘Abnormal illness behaviour’ has been shown to be more frequent in
Invited
Review
13.5
patients with non-organic abdominal pain [8, 311 and in those with irritable bowel syndrome I721 when compared to those with organic diagnoses. However, it is not clear which components of the behaviour are more frequent and how these relate to symptom formation and consultation. Consultation with GPs for dyspepsia is more common in social class 4 than social class 1, although the prevalence of dyspepsia is unrelated to class. In addition, the use of investigations by general practitioners and the diagnosis of peptic ulcer were also more frequent in social class 5 than social class 1 111. (e) Childhood abdominal pain. There is some evidence that complaints of abdominal pain in childhood may persist into adult life [731. The determinants of this are unclear but may be relevant in some patients. A MULTICAUSAL
EXPLANATION
There has been in recent years an increasing awareness that the aetiology of functional somatic symptoms is multicausal [74, 751. Similarly, some studies have shown an association between organic gastroenterological disease and psychosocial factors-for example, MacDonald and Bouchier t761 found that 20% of their sample with an organic cause of abdominal symptoms received a psychiatric diagnosis, and Craig and Brown 1631 demonstrated that life events involving ‘goal frustration’ were significantly associated with onset of peptic disease (being far more common than in those with functional disorder). Thus, the diagnosis of organic disease does not preclude the relevance of psychosocial factors. Similarly, evidence suggests that, although some of those with non-ulcer dyspepsia will have a physical basis for their symptoms (e.g. oesophageal spasm, gastrooesophageal rcflux), this abnormality will not completely explain the symptoms presented to the physician. Health beliefs, stressful life events, learned behaviour from childhood and personality traits will contribute to severity and chronicity of symptoms and hence determine consultation and investigation. Minor digestive complaints are common symptoms of anxiety and other emotional disorders and in a proportion of cases it is likely that symptoms may be attributed entirely to a psychological cause. In many cases, however, it will be uncertain to what extent each of the physical and psychological factors will be playing a part in determining symptoms. However, as it is the interaction of these various factors which determine the patient’s presentation. this uncertainty need not be an obstacle to treatment. Indeed, it may often be turned to therapeutic advantage, as will be discussed later. It is only when all aetiological factors are considered that the individual patient can be understood and treated. MANAGEMENT
Warndorlf et al. [28] conclude that dyspepsia is largely well managed by general practitioners in the U.K. and that it is rarely associated (at least in general practice) with major lesions. However, multiple associated symptoms often make diagnosis difficult 167, 771. Referral to hospital has been recommended for older patients and for those with ominous symptoms [79, 801. If the patient is young and has no symptoms suggestive of serious occult organic disease or psychiatric disorder, a trial
CHAKLES
136
MVKKIS
of empirical symptomatic treatment coupled with appropriate sufficient. Treatment of non-ulcer dyspepsia with H1-blockers unlikely to bc successful [78l but in some cases Bismuth salts
reassurance may be such as Ranitidine is may be effective [42,
431. It is important, of course, for all physicians to consider psychological factors at all stages of assessment [ 15, 26, 211 and to diagnose psychogenic abdominal pain only on positive grounds rather than by exclusion of organic pathology [811. The general practitioner is well placed to appraise psychosocial and discussion of these in a way acceptable to the patients physical investigations.
factors at an early stage may obviate unnecessary
Similarly, the hospital physician will wish to limit further physical investigations to those with specific indications. Once the physician is sufficiently confident that there is no significant organic disease investigations should cease and the reasons explained to the patient. In the majority of cases specialist psychiatric treatment will not be required even when psychological factors are prominent. Most patients will respond to a simple explanation of their symptoms provided that it takes account of the individual beliefs and concerns. Jones [821 reported that consulting and prescribing rates of gastroenterological problems fell significantly after patients with upper abdominal pain received a normal endoscopy and claims that ‘negative endoscopies may have positive outcomes’. However, the limitation of reassurance must be recognized 1831. It may be particularly important in a sub-group of patients with chronic persistent symptoms to control further medical investigations in order to break the cycle of complaint-normal investigation-temporary reassurancecomplaint-investigation. The management of the persistent attender without organic pathology is clearly more difhcult. Hypnotherapy and behaviour therapy have been tried with some success in patients with irritable bowel syndrome 184. 851 and could be considered in NUD. An interested physician could co-ordinate this in conjunction with the appropriate specialist e.g. psychologist, social worker. alternative therapist etc. In casts where more claboratc psychological treatments are indicated, the treatment must vary according to the patient’s needs. Overt psychiatric illness such as depressive illness and anxiety disorders should respond to conventional physical and psychological
treatments.
In other
cases
where
maintainance
of symptoms
is more
directly related to longstanding abnormal health beliefs or preoccupation with bodily symptoms, a cognitive behavioural approach rnay be indicated. This type of treatment has been used for children with chronic abdominal pain 1861 and is being developed for a wide range of somatic and hypochondriacal complaints 187. 881. The uncertainty over the aetiology of a patient’s symptoms would be well suited to the behavioural experiments and re-evaluations inherent in this type of treatment. Brief dynamic psychotherapy may lead to symptom reduction in patients with irritable bowel syndrome [891. However. the availability of these types of psychotherapy is limited and their effectiveness has not been studied in patients with non-ulcer dyspepsia.
CONCl.USION
The aetiology of dyspepsia is still unclear. A number of possible physical explanations exist but a considerable proportion of patients still go undiagnosed. Research suggests that some of these patients will have psychological disturbance or
Invited
Review
137
health concerns. There is also evidence that psychosocial factors are relevant in the aetiology (and hence management) of those with proven or likely organic pathology. There are still many unanswered questions about non-ulcer dyspepsia. For example, is it a chronic condition? Are there discrete sub-groups? Is there a difference between those patients referred to hospital and those seen only by their GP? Are chronic physical symptoms associated with abnormal health beliefs or over-concern about bodily symptoms, and if so, is this the case for those with physical diagnoses as well as for those without? How does non-ulcer dyspepsia relate to other forms of functional bowel disease? Which treatments are most effective. and for which patients? It is an obvious conclusion that understanding is still at a relatively unsophisticated level and more collaborative research is necessary. Meanwhile, it is essential that all patients presenting with dyspepsia receive from their physicians an assessment which includes consideration of the psychological factors discussed above. exaggerated
Ackno~~led~rmmrs.--I should like to thank Dr Richard Mayou for his encouragement and helpful comments on previous drafts of the manuscript, and Mrs Lisa Cox for her invaluable secretarial assistance. REFERENCES
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