signos y síntomas de tubo digestivo alto

8/9/2019 Signos y Síntomas de Tubo Digestivo Alto

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Symptoms and signs of upper gastrointestinaldiseaseDerek Gillen

Kenneth McColl

Abstract A century ago, Lord Moynihan suggested that the underlying cause of dyspepsia could be discerned by symptoms alone. Subsequent studieshave suggested that, unfortunately, this is not the case since the symptomsassociated with upper gastrointestinal (GI) disease lack both sensitivity andspecicity. ‘Classic’symptomsof reuxdisease (suchas heartburnand regur-gitation), peptic ulcer disease (such as post-prandial epigastric pain) or of functional dyspepsia (such as bloating) have been shown in a number of studies to be poor guides to the underlying diagnosis. However, there isan evidence base to support the use of ‘alarm’ symptoms, such as weightloss and dysphagia, in an effort to target limited investigative resources toserious upper GI pathology. Finally, careful consideration must always begiven to possible extra-luminal causes of apparently upper GI symptoms,of which unrecognized ischaemic heart disease is perhaps the mostimportant.

Keywords alarm symptoms; dyspepsia; gastro-oesophageal reux disease; non-ulcer dyspepsia; peptic ulcer

In 1905, Lord Moynihan suggested that in patients presentingwith dyspepsia the diagnosis could be made solely on the basis of their symptoms. 1 In the modern era, it is accepted that things aresomewhat more complicated. As we shall see, the majority of upper gastrointestinal (GI) symptoms lack specicity and sensi-tivity and therefore correlate poorly with any particular under-lying pathology.

‘Dyspepsia’ is a word that is often used to describe a range of upper GI symptoms. However, there are two different denitionsin clinical use for this term. The rst is as a general umbrellaterm that can essentially encompass the full constellation of upper GI symptoms. The second is much more specic, withdyspepsia correlating solely with pain or discomfort centred inthe epigastrium. This much more restrictive denition is oftenreferred to as ‘Rome III’ dyspepsia, since it was agreed bya working group in functional GI disorders meeting in that cityfor a third time. 2 This more focused denition is required for

clinical researchers. Clearly, the broader umbrella denitionwould make clinical trials almost impossible to interpret, sinceone might be comparing the effects of a treatment on onepatient’s bloating with another patient’s heartburn. However,this evidently means that one must be careful in extrapolating theresults of clinical trials that use this restricted denition to anindividual patient’s symptoms.

In the following article, we shall review the ‘classic’ symp-toms often associated with the main upper GI disease processes.We shall also address the value of these symptoms/symptomclusters in elucidating underlying disease processes.

Gastro-oesophageal reux disease (GORD)

DenitionGastro-oesophageal reux disease (GORD) is dened as symptomsor complications arising from the reux of gastric or duodenalcontents into the oesophagus. 3 It comprises a wide spectrum of disorders. These range from symptoms associated with physiolog-ical amounts of reux, caused by oesophageal hypersensitivity,

through to Barrett’s oesophagus, in which there is usually severereux, but sometimes few or no associated symptoms.

Symptoms of GORDA number of symptoms have been reported more frequently inpatients with GORD versus healthy controls ( Table 1 ). Furtherevidence that these symptoms are caused by underlying acidreux is their resolution in studies in which gastric acid is sup-pressed with effective acid inhibitory therapy.

The symptoms which have been classically associated withGORD include those detailed below.

Heartburn: this is a common symptom, with perhaps 4 e 9% of adults experiencing it on a daily basis andaround 20% on a weeklybasis. 4 Patients usually describe it as a retrosternal sensation of burning discomfort or pain. It is commonly post-prandial andexacerbated by lying at or bending over.

Upper GI symptoms

‘GORD-like’ symptomsC HeartburnC RegurgitationC DysphagiaC OdynophagiaC Waterbrash

‘Ulcer-like’ symptomsC Epigastric pain/discomfort

‘Dysmotility-like’ symptomsC BloatingC Nausea and vomitingC Early satietyC Excessive atus

Table 1

Derek Gillen MD FRCP is a Consultant Gastroenterologist in the University Department of Medicine and Therapeutics of West Glasgow Hospitals,Glasgow, UK and the Lead Clinician for Endoscopy in NHS Greater Glasgow & Clyde. Competing interests: none declared.

Kenneth McColl MD FRCP FMedSci FRSE is the Professor of Gastroenterology at the University of Glasgow, Glasgow, UK. Competing interests: nonedeclared.

SYMPTOMS AND SIGNS

MEDICINE 39:2 67 2010 Elsevier Ltd. All rights reserved.

http://dx.doi.org/10.1016/j.mpmed.2010.11.007




Regurgitation: patients who suffer from this reux-relatedsymptom complain of the effortless return of gastric contents intothe mouth and pharynx. This occurs in the absence of retching,which distinguishes it from vomiting.

Dysphagia: this often manifests itself to the patient as a sensa-tion of food sticking in the retrosternal area. Difculties with

swallowing related to reux disease are often intermittent, whenthey are probably related to reux-related oesophageal spasm/disordered peristalsis. When less intermittent or progressive,they may be related to more structural reux-related damage,such as peptic strictures or cancer.

Odynophagia: this is a sensation of painful swallowing. Thepatient will often describe being uncomfortably aware of thepassage of food boluses or hot liquids from the upper sternumdown to the epigastrium.

Waterbrash: this is the excessive accumulation of saliva in themouth in response to acid reux. Acid regurgitation is sometimes

mistakenly confused with waterbrash, although true waterbrashlacks the bitter taste of acid and accumulates in the mouth, ratherthan entering the mouth/pharynx from below.

Extra-oesophageal manifestations of GORD: Table 2 outlinesa number of extra-oesophageal disorders in which reux may haveeither a direct or indirect causative role. 5,6 Symptoms associatedwith these disorders cover a wide spectrum that includes chroniccough, hoarseness, excessive phlegm and wheeze.

The sensitivity and specicity of symptoms in GORD: Table 3demonstrates the frequency of various dyspeptic symptoms ina study involving 304 patients referred for evaluation of possibleoesophageal symptoms by means of 24-h oesophageal pHmonitoring. 7

There are three possible main conclusions from these results. Symptoms such as heartburn and acid regurgitation appear to

be far from specic for GORD, since many patients with normal24-h oesophageal acid exposure also experience them. None of these symptoms is highly sensitive, since their

occurrence is signicantly less than 100% in the patients withabnormal 24-h acid exposure.

24-h pH monitoring, which has hitherto been regarded asthe ‘gold standard’ for the diagnosis of GORD, may be a relativelypoor method for diagnosing this condition denitively.The truth, in fact, probably contains elements of all three of these.This study, 7 therefore,suggests that individual reux symptoms arerelatively insensitive. Further support for this possibility comesfrom a number of studies that have demonstrated that a signicantproportion of patientswith severe reux-relatedpathology, such as

thehighergradesof oesophagitisor Barrett’s oesophagus, mayhavefew (or indeed no) symptoms. In practical clinical terms, whenthese studies are considered together, this relative insensitivitymeans that a lack of ‘reux’ symptoms does not exclude signicantreux disease.

Another difculty that is clear from these studies is that these‘reux symptoms’ lack specicity. Non-erosive reux disease(NERD; heartburn in association with a normal endoscopy) isprobably the commonest cause of heartburn. However, in NERDpatients, studies suggest that active treatment with powerful acidsuppression for reux symptoms has relatively little benetwhen compared to placebo. Indeed in this situation, the thera-peutic benet of active treatment over placebo is only about

25%. Again in practical terms, reux symptoms are thereforeconsistent with GORD, but far from diagnostic.

Signs of GORDThere are few, if any, signsof GORD. A smallproportion of patientswith severe GORD will havedental erosions from the effects of acidregurgitation on dental enamel. 6 Similarly, some patients withproximal reux have pharyngitis/laryngitis attributed to GORD.However, the majority of patients will have no signs.

Suspected extra-oesophageal manifestations of GORD

Middle ear/eustachian tubeGlue ear Otalgia

Nasal/sinusalChronic sinusitis

OralDental erosionsAphthous ulcersHalitosis

Pharynx/larynx PharyngitisChronic laryngitisLaryngospasmCancer Globus

AirwaysChronic coughAspiration pneumoniaAsthma

Table 2

Symptom frequency in patients with abnormal versusnormal 24-h pH studies

Symptom 24-h pH Abnormal (%) Normal (%)

Heartburn 68 48Acid regurgitation 60 48Odynophagia 10 8Belching 49 40Nausea 38 32Epigastric pain 54 53

Table 3

SYMPTOMS AND SIGNS






at the time of presentation and suggest advanced disease. Simi-larly, rarer associated signs such as a left supraclavicular lymphnode (of Virchow) or inltration of the umbilicus (Sister Joseph’snodule) are suggestive of metastatic disease.

Extra-luminal diseases

For any patient with symptoms that appear to be referable to theupper GI tract, it is sensible for clinicians to consider alternative

possible sources of their symptoms in the differential diagnosis.Possible alternative diagnoses fall into two main categories:GI- and non-GI-related ( Table 5 ).

Pancreatic pain is characteristically a constant epigastric pain. Itis often said to be eased by leaning forward. In both acute andchronic forms, a history of excessive alcohol ingestion will raise thediagnostician’s index of suspicion. However, the absence of a history of signicant alcohol ingestion does not exclude thisdiagnosis.

Although the pain and discomfort of cholecystitis are often feltto be classically located in the right upper quadrant, observa-tional series suggests that pain that is maximal in the epigastriumis probably more common than this ‘classic’ presentation. Other

sites, such as the left upper quadrant, chest and lower abdomenare less frequent, but are still recognized sites of maximum painin these case series. The differentiation of cholecystitis fromother sources of upper abdominal pain is often difcult andrequires a high index of clinical suspicion.

Chronic mesenteric ischaemia characteristically presents asupper/mid abdominal pain that occurs within 30 min of eating,

Management algorithm for dyspepsia

‘Indigestion’

Dyspepsia* Predominant heartburn

Manage as gastroesophagealreflux disease (GORD)

Consider:• Heart• Liver• Gall bladder

• Pancreas• Bowel• NSAIDs etc. Alarm features:

• Dysphagia• Evidence of GI blood loss• Persistent vomiting• Unexplained weight loss• Upper abdominal mass

Uncomplicated dyspepsiaConsider:• Lifestyle• Antacids/H 2RA

Hp test − veHelicobacter pylori (Hp) test

No

Refer to hospitalspecialist

Age

Hp test + ve

YesNo

Yes

Persistent/recurrent symptomsEradicate Hp

Consider referral to

hospital specialist

Manage as functional

dyspepsia

< 55 > 55Asymptomatic

*Rome II definition

Reproduced from the SIGN dyspepsia guideline. 23

Persistent/recurrent symptoms

Figure 1

Alternative extra-luminal sources of apparently upper GI symptoms

GI-relatedC Acute and chronic pancreatitisC Acute and chronic cholecystitisC Mesenteric ischaemia

Non-GI-relatedC Ischaemic heart disease

Table 5

SYMPTOMS AND SIGNS






gradually increasing to a plateau, then remits over several hours.Initially patients often notice it only with large meals, but it tendsgradually to increase in frequency.

Ischaemic heart disease can be very difcult to distinguishfrom heartburn for both patients and clinicians. Furthermore,angina can present with epigastric pain, which may be indistin-guishable from dyspepsia. Although angina may be exercise-

related, there are reports suggesting the triggering of GORD byexercise, even during exercise testing. 28 In addition, oesophagealacid stimulation in patients with co-existing coronary arterydisease can lead to ECG changes. 29 Responsiveness to antacidsand acid suppression may be of some help. However, since upperGI symptoms and ischaemic heart disease are both common andtherefore may co-exist ultimately, symptoms may be an insuf-cient guide if doubt remains. In that situation, more formalinvestigation to exclude ischaemic heart disease may berequired.

Summary

The upper GI tract is a common source of symptoms in humans,but an uncommon source of signs. Although ‘classical’ patternsof dyspeptic symptoms that were felt to correlate with specicunderlying upper GI disease processes were described in thepast, modern studies suggest that many of these symptoms lacksensitivity and specicity. Alarm symptoms are an importantelement in a history related to the upper GI tract. Although alsolacking in specicity, there is an evidence base for their use in anattempt to target urgent investigation for possible sinister upperGI disease. Finally, some consideration must be given to alter-native possible differential diagnoses, with ischaemic heartdisease perhaps being the most frequent and important non-GIdiagnosis to consider. A

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