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Probability diagnosis

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Irritable upper GIT (functional dyspepsia)

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Gastro-oesophageal reflux

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Gastritis

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Oesophageal motility disorder (dysmotility)

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Serious disorders not to be missed

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Cancer:

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  • stomach

  • pancreas

  • oesophagus

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Cardiovascular:

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  • ischaemic heart disease

  • congestive cardiac failure

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Pancreatitis

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Peptic ulcer (PU)

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Pitfalls (often missed)

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Myocardial ischaemia

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Food allergy (e.g. lactose intolerance)

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Pregnancy (early)

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Biliary motility disorder

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Other gall bladder disease

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Post vagotomy

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Duodenitis

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Rarities:

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  • hyperparathyroidism

  • mesenteric ischaemia

  • Zollinger–Ellison syndrome

  • kidney failure

  • scleroderma

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Masquerades checklist

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Depression

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Diabetes (rarely)

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Drugs, esp. NSAIDs, aspirin

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Is the patient trying to tell me something?

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Anxiety and stress are common associations of which patients are often unaware. Consider irritable bowel syndrome.

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Key history

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Clarify the exact nature of the presenting complaint: what the patient means by ‘indigestion’ or ‘heartburn’. Note the relationship of the symptoms to eating. In particular, care should be taken to consider and perhaps exclude ischaemic heart disease. Analyse the presenting symptom according to site and radiation, character of discomfort, aggravating and relieving factors and associated symptoms. Drug history and past history is important, especially NSAID use.

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Key examination

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  • This does not provide the key to the diagnosis, but perform very careful palpation and inspection

  • Look for evidence of anaemia and jaundice

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Key investigations

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Do not overinvestigate.

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  • The investigation of choice is gastroscopy, which is indicated for ‘alarm symptoms’ such as dysphagia, bleeding and unexplained weight loss

  • Test for Helicobacter pylori

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Diagnostic tips

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  • Epigastric pain aggravated by any food and relieved by antacids indicates chronic gastric ulcer.

  • Pain before meals relieved by food indicates chronic duodenal ulcer.

  • Triple loss of appetite, weight and colour is a feature of cancer of the stomach.

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