**4. Diagnostic investigations of dyspepsia**

Functional dyspepsia is usually a diagnosis of exclusion; the diagnosis is made after eliminat‐ ing organic disease or a structural basis for symptoms. The physician must decide how many investigations to order before deciding that the patient has a functional disorder (Table 4). The heterogeneity of presentation and the extensive differential diagnosis including significant organic disease mandates rapid exclusion of pathologies like peptic ulcer disease, reflux esophagitis and malignancy of the stomach or esophagus. Another perspective is the test-andtreat approach that includes acid suppression, treatment of *H.pylori* infection and early endoscopy. Patients with "alarm features" (Fig 1), or those older than 40-50 years (depending on ethnicity) require a more aggressive strategy such as early endoscopy. It must also be understood that there are many patients who can have both organic as well as functional components of dyspepsia.

Initial investigations may include blood counts, electrolytes, fasting blood sugar, renal function tests and thyroid function tests. Testing for celiac disease and stool examination for occult blood or parasites may also be considered. *H.pylori* infection can be diagnosed by serology, breath or stool testing.

Gastric accommodation can be assessed by gastric barotest. The barotest measures gastric tone and comprises of a bag that can be maintained at a constant pressure by feedback mechanisms (termed a barostat). Volume changes in the bag thus represent variation in gut - the bag becomes bigger with gut relaxation and smaller with contraction. "Barotesting" is the "gold standard" for visceral hypersensitivity, but is invasive and uncomfortable, so non-invasive means have been developed that include SPECT (Single Photon Emission Tomography) imaging and 3-D ultrasound.

SPECT can be used to assess intragastric volume although correlation with barotest has not been consistently established and the volumes determined do not reflect muscle activity of the stomach. 3D ultrasound can also be used for volume determination of the stomach but this remains a highly operator dependent technique and there is limited data available in the literature.

Chemical hypersensitivity tests can be done by a duodenal infusion of lipid to provoke early symptoms of gastric distension in patients with functional dyspepsia and relief by adminis‐ tering a cholecystokinin receptor antagonist (loxiglumide). CCK-8 (cholecystokinin octapep‐ tide) intravenously can be used instead of the lipid infusion to provoke symptoms in patients with functional dyspepsia, but this does not affect normal individuals.

**Figure 2.** Position of patient and camera during acquisition of images for scintigraphic evaluation of gastric emptying

• Contraindicated in acid peptic disease and

Diagnostic Testing for Functional Dyspepsia http://dx.doi.org/10.5772/57088 7

• Relatively time consuming as it requires repeated and prolonged observations

partial intestinal obstruction • Can cause barium appendicitis

• Operator dependent

• Invasive procedure

• Ionizing radiation used • Time consuming

• Equipment widely available

correlate well with symptomatology

• Variability similar to other tests

• Needs special equipment (mass

been developed (NDIRS\* and LARA\*\*)

• Good reproducibility

• Degree of delayed gastric emptying does not

spectrophotometer) but cheaper alternates have

• Not well accepted by patients • Requires trained personnel • Limited availability of equipment

**Test Strengths Weaknesses**

• Does not involve ionizing radiation • Equipment used is available in most of the

gastric and duodenal mucosa

• Simple and non-invasive • Physiological meal used • No reaction to pharmaceutical • No documented complication

meal

• Non invasive

alarm features

• Non invasive • No radiation involved

acid for solids)

\*NDIRS Non-dispersive isotope-selective infrared spectroscopy

hospitals

• Gastroparesis can be diagnosed with barium

• Permits direct visualization of the oesophagus,

• First-line diagnostic procedure for patients with

• Can be adapted for solid or liquid emptying (C-13 sodium acetate for liquid and C-13 octanoic

**Table 4.** Investigations for the work-up of functional dyspepsia with their strengths and weaknesses

times.

Radiological method (Barium meal)

Ultrasonography

Endoscopy

Gastric emptying scintigraphy

C-13 Acetate breath test

\*\*LARA Laser-assisted ratio analysis

Scintigraphic imaging lends itself elegantly to the evaluation of functional-dyspepsia due to the inherent strength of dynamic imaging and generating physiological data. Currently, it remains the only method to quantitatively measure the rate of gastric emptying.

Gastric scintigraphy employs a radiolabeled meal to measure emptying [24]. Gastric scintig‐ raphy has evolved to include an evaluation of compartmental or antral motility, and more recently to SPECT to evaluate postprandial gastric accommodation. As a physiologic, quanti‐ tative, and non-invasive test, gastric emptying scintigraphy is well suited for evaluating patients before and after medical or surgical treatment. This procedure is now widely consid‐ ered the gold standard for evaluating gastric emptying. The advantages of radionuclide imaging are:


**Figure 2.** Position of patient and camera during acquisition of images for scintigraphic evaluation of gastric emptying times.


\*NDIRS Non-dispersive isotope-selective infrared spectroscopy

\*\*LARA Laser-assisted ratio analysis

becomes bigger with gut relaxation and smaller with contraction. "Barotesting" is the "gold standard" for visceral hypersensitivity, but is invasive and uncomfortable, so non-invasive means have been developed that include SPECT (Single Photon Emission Tomography)

SPECT can be used to assess intragastric volume although correlation with barotest has not been consistently established and the volumes determined do not reflect muscle activity of the stomach. 3D ultrasound can also be used for volume determination of the stomach but this remains a highly operator dependent technique and there is limited data available in the

Chemical hypersensitivity tests can be done by a duodenal infusion of lipid to provoke early symptoms of gastric distension in patients with functional dyspepsia and relief by adminis‐ tering a cholecystokinin receptor antagonist (loxiglumide). CCK-8 (cholecystokinin octapep‐ tide) intravenously can be used instead of the lipid infusion to provoke symptoms in patients

Scintigraphic imaging lends itself elegantly to the evaluation of functional-dyspepsia due to the inherent strength of dynamic imaging and generating physiological data. Currently, it

Gastric scintigraphy employs a radiolabeled meal to measure emptying [24]. Gastric scintig‐ raphy has evolved to include an evaluation of compartmental or antral motility, and more recently to SPECT to evaluate postprandial gastric accommodation. As a physiologic, quanti‐ tative, and non-invasive test, gastric emptying scintigraphy is well suited for evaluating patients before and after medical or surgical treatment. This procedure is now widely consid‐ ered the gold standard for evaluating gastric emptying. The advantages of radionuclide

**1.** The method is simple and non-invasive from the patient's point of view, requiring a single

**2.** The meal used in this method is physiological and does not alter the normal physiology

**4.** Both solid and liquid meals can be studied and the gastric emptying can be quantified. **5.** The radiation dose is very low so that repeated studies can be done to follow the progress of the disease or the response to treatment and the method can therefore be used as a

**6.** This method can be used to assess the amount of original meal in the stomach irrespective

**7.** There is no documented complication reported as the result of the gastric emptying

**8.** There are different protocols with a 2, 3 or 4 hour end points (3 and 4 hour end points are

with functional dyspepsia, but this does not affect normal individuals.

oral administration of the radionuclide.

**3.** Reaction to the radiopharmaceutical is rare.

of the gastric secretions or the duodenal reflux.

emerging as more diagnostic).

remains the only method to quantitatively measure the rate of gastric emptying.

imaging and 3-D ultrasound.

6 Dyspepsia - Advances in Understanding and Management

literature.

imaging are:

of the gut.

research tool.

studies.

**Table 4.** Investigations for the work-up of functional dyspepsia with their strengths and weaknesses

**Figure 4.** Dynamic images and time–activity curves of a patient with impaired gastric emptying.

Diagnostic Testing for Functional Dyspepsia http://dx.doi.org/10.5772/57088 9

**Figure 3.** Figure Dynamic images and time–activity curves of a normal person.

**Figure 4.** Dynamic images and time–activity curves of a patient with impaired gastric emptying.

**Figure 3.** Figure Dynamic images and time–activity curves of a normal person.

8 Dyspepsia - Advances in Understanding and Management

### **5. Conclusion**

Functional dyspepsia is a common problem with a significant impact on individuals and society. A variety of diagnostic tests are available to exclude organic disease and characterize underlying pathophysiologic abnormalities. Further work is needed to validate existing diagnostic tests in different populations. The goal of having an objective test that correlates with the symptom severity remains elusive. Physicians must remain cognisant that functional disorders create the same or perhaps even more distress in the patient when compared to conditions that can yield evidence of organic pathology.

Gastroenterology Surveillance Study (DIGEST). Scand J Gastroenterol 1999; 231

Diagnostic Testing for Functional Dyspepsia http://dx.doi.org/10.5772/57088 11

[7] Moayyedi P, Mason J. Clinical and economic consequences of dyspepsia in the com‐

[8] Chang L. Review article: epidemiology and quality of life in functional gastrointesti‐

[9] Tack J, Nicholas J.T,Camilleri M, Holtmann G, Hu P,Malagelada JR, Stanghellini V et al Functional. Functional Gastroduodenal disorders. Gastroenterology 2006;

[10] nepeel P, Geypens B, Janssens J, Tack J. Symptoms associated with impaired gastric emptying of solids and liquids in functional dyspepsia. Am J Gastroenterol 2003; 98:

[11] Waldron B, Cullen PT, Kumar R, et al. Evidence for hypomotility in functional dys‐

[12] Ricci R, Bontempo I, La Bella A, De Tschudy A, Corazziari E. Dyspeptic symptoms and gastric antrum distribution. An ultrasonographic study. Ital J Gastroenterol 1987;

[13] Gilja OH, Hausken T, Wilhelmsen I, Berstad A. Impaired accommodation of proxi‐ mal stomach to a meal in functional dyspepsia. Dig Dis Sci 1996; 41:689–696.

[14] Camilleri M, Coulie B, Tack J. Visceral hypersensitivity: facts, speculations and chal‐

[15] Boeckxstaens GE, Hirsch DP, Kuiken SD, Heisterkamp SH, Tytgat GN. The proximal stomach and postprandial symptoms in functional dyspeptics. Am J Gastroenterol

[16] Tack J, Bisschops R, Caenepeel P, Vos R, Janssens J. Pathophysiological relevance of fasting versus postprandial sensitivity testing in functional dyspepsia (abstr). Gastro‐

[17] Thumshirn M, Camilleri M, Saslow SB, Williams DE, Burton DD, Hanson RB. Gastric accommodation in functional dyspepsia and the roles of Helicobacter pylori infection

[18] Rhee PL, Kim YH, Son HJ, et al. Lack of association of Helicobacter pylori infection with gastric hypersensitivity or delayed gastric emptying in functional dyspepsia.

[19] Sarnelli G, Janssens J, Tack J. Helicobacter pylori is not associated with symptoms and pathophysiological mechanisms of functional dyspepsia. Dig Dis Sci 2003;

nal disorders. Aliment Pharmacol Ther 2004; 20 Suppl 7: 31-39

pepsia: a prospective multifactorial study. Gut 1991; 32:246–251.

Suppl: 38-47

130:1466-1469.

783−788.

19:215–217.

2002; 97:40−48.

48:2229–36.

enterol 2002; 122; A34.

and vagal function. Gut 1999; 44:55–64.

Am J Gastroenterol 1999; 94: 316–569.

lenges. Gut 2001; 48:125–131.

munity. Gut 2002; 50 Suppl 4: iv10-iv12

## **Author details**

Durre Sabih1 and Muhammad Kashif Rahim2

\*Address all correspondence to: dsabih@yahoo.com

1 Multan Institute of Nuclear Medicine and Radiotherapy (MINAR), Nishtar Medical College and Hospital, Multan, Pakistan

2 Multan Institute of Nuclear Medicine and Radiotherapy (MINAR), Nishtar Medical College and Hospital, Multan, Pakistan

#### **References**


Gastroenterology Surveillance Study (DIGEST). Scand J Gastroenterol 1999; 231 Suppl: 38-47

[7] Moayyedi P, Mason J. Clinical and economic consequences of dyspepsia in the com‐ munity. Gut 2002; 50 Suppl 4: iv10-iv12

**5. Conclusion**

10 Dyspepsia - Advances in Understanding and Management

**Author details**

and Hospital, Multan, Pakistan

and Hospital, Multan, Pakistan

Durre Sabih1

**References**

4:145−160.

Functional dyspepsia is a common problem with a significant impact on individuals and society. A variety of diagnostic tests are available to exclude organic disease and characterize underlying pathophysiologic abnormalities. Further work is needed to validate existing diagnostic tests in different populations. The goal of having an objective test that correlates with the symptom severity remains elusive. Physicians must remain cognisant that functional disorders create the same or perhaps even more distress in the patient when compared to

1 Multan Institute of Nuclear Medicine and Radiotherapy (MINAR), Nishtar Medical College

2 Multan Institute of Nuclear Medicine and Radiotherapy (MINAR), Nishtar Medical College

[1] Talley NJ, Colin-Jones D, Koch KL, Koch M, Nyren O, et al. Functional dyspepsia: a classification with guidelines of diagnosis and management. Gastroenterol Int 1991;

[2] Tack J, Bisschops R, Sarnelli G. Pathophysiology and treatment of functional dyspep‐

[3] Talley NJ, Vakil NB, Moayyedi P. American gastroenterological association technical review on the evaluation of dyspepsia. Gastroenterology 2005; 129: 1756-1780

[4] Talley NJ, Stanghellini V, Heading RC, Koch KL, Malagelada JR, et al. Functional

[5] Baker G, Fraser RJ, Young G. Subtypes of functional dyspepsia. World J Gastroenter‐

[6] Haycox A, Einarson T, Eggleston A. The health economic impact of upper gastroin‐ testinal symptoms in the general population: results from the Domestic/International

conditions that can yield evidence of organic pathology.

and Muhammad Kashif Rahim2

sia. Gastroenterology 2004; 127: 1239-1255

gastroduodenal disorders. Gut 1999; 45:37−42.

ol 2006; 12(17): 2667-2671

\*Address all correspondence to: dsabih@yahoo.com


[20] Houghton LA, Mangnall YF, Dwivedi A, Read N. Increased nutrient sensitivity in a subgroup of patients with nonulcer dyspepsia. Gut 1990; 31:1185 (abstract).

**Chapter 2**

**Is Functional Dyspepsia Idiopathic?**

Additional information is available at the end of the chapter

ing and belching in the definition of dyspepsia [2]

endoscopy, and were found to be normal [5].

Dyspepsia is currently defined by Rome III criteria for the diagnosis of functional gastroin‐ testinal disorders (FGIDs), as the presence of one or more of the following symptoms: both‐ ersome postprandial fullness, early satiation, epigastric pain and epigastric burning [1] These are symptoms thought to originate from the gastroduodenal region. Bloating and nausea often coexist with dyspepsia but are considered nonspecific and are thus not included in the Rome III criteria. However, there have been attempts by some researchers to broaden this definition to include more symptoms. The Asian consensus guideline includes bloating, nausea, vomit‐

Dyspeptic patients who have not undergone any investigations are defined as having unin‐ vestigated dyspepsia. An organic cause is found in only a minority who seek medical care [3, 4]. The remaining group is labeled as having functional dyspepsia (FD). Organic dyspepsia means there is a clear anatomic or pathophysiologic reason for the dyspeptic complaints, such as peptic ulcer or cancer. In contrast, when a diagnosis of functional dyspepsia has been made, it means that a number of investigations were performed including upper gastrointestinal

The need for more systematic description of FGIDs gave rise to the Rome process, which has evolved from Rome I in 1991 [6], Rome II in 1999 [7], to the most recent, which is Rome III [1]. According to Rome I and Rome II definitions, FD was defined as the presence of pain or discomfort centered in the upper abdomen, in the absence of organic disease that readily explained the symptoms [7]. While the meaning of pain is readily understood, the lack of an accurate definition for discomfort was a major limitation of Rome I. Rome I also included reflux symptoms in FD, and recognized a subgroup called "reflux-like dyspepsia". Rome II tried to correct this by excluding patients with predominant heartburn from the definition of FD. Rome

> © 2013 Nwokediuko; licensee InTech. This is a paper distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Sylvester Chuks Nwokediuko

http://dx.doi.org/10.5772/56620

**1. Introduction**

