INDIGESTION

INDIGESTION: Excerpt from Differential Diagnosis in Primary Care

This is a vague term, and if the patient is put on the spot, he or she will usually describe the problem as heartburn, regurgitation of water brash, fullness in the stomach, or frequent belching following meals. Usually the patient’s appetite is not affected nor is there any weight loss. The causes are easy to arrive at by merely asking the question, “Why would food cause these symptoms?” Obviously, the food or drink ingested may be the source of irritation: spicy foods, coffee, alcohol, excessive fried food (which actually suppresses the secretion of gastric juice and slows gastric emptying), and insufficiently masticated food. The patient may sometimes be allergic to a particular food. The upper gastrointestinal (GI) tract may be already irritated with reflux esophagitis from a hiatal hernia, gastritis, or gastric or duodenal ulcer, or it may be partially obstructed by a carcinoma of the esophagus or stomach or by a pyloric ulcer. Chronic appendicitis and regional ileitis may cause partial obstruction or paralytic ileus. There may be diminished secretion of GI juices in pernicious anemia, cholecystitis, cholelithiasis, hepatitis, chronic pancreatitis, or pancreatic carcinoma or in patients with previous gastrectomies. There may be a systemic illness that is associated with GI irritation or paralytic ileus. In this category, one must consider congestive heart failure (CHF), electrolyte disturbances such as hypokalemia (diuretics) or hyperkalemia (Addison disease), abdominal angina, migraine, and epilepsy. Anemia and diabetic acidosis may produce similar symptoms. Is there another way of recalling these conditions that may be simpler? Yes, the application of the “target" method to the anatomy of the internal organs. In the “bullseye," one would think of the esophagus and stomach (esophagitis, esophageal carcinoma, gastritis, gastric ulcer, and gastric carcinoma); in the next circle one would consider gallbladder, pancreatic, liver, and heart diseases; and, in the final circle, kidney, central nervous system (CNS), and other systemic diseases and hormonal alterations. A third approach is simply to apply the mnemonic MINT to the organs of the upper abdomen. It is recommended that the reader apply this method as an exercise. Table 41 applies the mnemonic VINDICATE to the same organs.

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INDIGESTION

	V	I	N	D
	Vascular	Inflammatory	Neoplasm	Degenerative
Esophagus	Varices	Esophagitis	Esophageal carcinoma	Plummer-Vinson syndrome
Stomach		Gastritis Ulcer	Carcinoma	Atrophic gastritis Pernicious anemia
Duodenum and Small Intestines	Abdominal angina	Duodenitis Ulcer	Polyp
Gallbladder		Cholecystitis	Cholangiocarcinoma
Liver	Congestive heart failure	Infectious hepatitis	Hepatoma Metastatic carcinoma	Cirrhosis
Pancreas		Pancreatitis	Pancreatic carcinoma
Kidney		Pyelonephritis

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INDIGESTION

	I	C	A	T	E
	Intoxication	Congenital	Autoimmune	Trauma	Endocrine
	Idiopathic		Allergic
	Lye stricture	Hiatal hernia Diverticulitis Barrett esophagitis	Scleroderma
	Aspirin Steroids Reserpine Alcohol Coffee	Cascade stomach		Gastrectomy	Zollinger–Ellison syndrome
		Diverticuli	Scleroderma	Gastrectomy with afferent loop obstruction	Zollinger–Ellison syndrome Uremic ulcer
		Stones from sickle cell anemia		Calculus
	Alcoholic cirrhosis
		Fibrocystic disease			Hyperparathyroidism
	Uremia			Calculus

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Approach to the Diagnosis

The association of other symptoms and signs is important. If there is relief by antacids, esophagitis, gastritis, or an ulcer may be present. If there is blood in the stool, one should suspect an ulcer or carcinoma. Radiographic studies in the form of an upper GI series, esophagram, cholecystogram, and barium enema are usually indicated. A gastric analysis, esophagoscopy, and gastroscopy often need to be done. Awareness that a systemic disease such as an electrolyte disturbance or uremia may be the cause will suggest the need for other studies, especially if there are systemic symptoms, fever, or shortness of breath.

Other Useful Tests

1. Esophageal motility studies (cardiospasm, reflux esophagitis)
2. Ambulatory pH monitoring (reflux esophagitis)
3. Bernstein test (reflux esophagitis)
4. Gallbladder sonogram (cholecystitis)
5. CT scan of the abdomen (neoplasm abscess, pancreatitis)
6. Serial electrocardiogram (ECGs) and cardiac enzymes (myocardial infarction)
7. Circulation time (CHF)
8. Breath test and Helicobacter pylori antibody test (peptic ulcer)
9. Serum gastrin (gastrinoma)

Pictures

Book Source Details

• Book Title: Differential Diagnosis in Primary Care
• Author(s): R. Douglas Collins MD, FACP
• Year of Publication: 2007
• Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Differential Diagnosis in Primary Care Authors: R. Douglas Collins MD, FACP Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8

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