CASE REPORT

“DYSPEPSIA“

Preceptor : dr. Hj. Ihsanil Husna, Sp.PD

Arranged by : Ayu Devita Ashari

 PATIENT’S IDENTITY

• Name : Ms. Ayu

• Age : 20 years old
• Address : Kemayoran
• Religion : Moslem
• Marital Status : Not married
• Date of admission : March 16th 2018
• MR number : 00921843
 ANAMNESIS

• Chief complaint:
epigastric pain since 1 week before entering the hospital.

• Another complaint:
nausea, vomit, fever, cough
 HISTORY OF PRESENT ILLNESS

Patient came to Cempaka Putih Islamic Hospital with epigastric

pain since a week before admission. The pain decreases at rest, but
reappear when patient doing some activity. The pain feels like being
stabbed and there is a burning sensation in the epigastric area. Patient
said the epigastric pain was felt after consuming spicy foods. Patient also
complained fever since approximately two days before admission. Fever is
felt throughout the day. Since one month, patient coughs but not often.
The patient has felt nausea and vomit but not much. Patient doesn’t have
problem with her appetite and also doesn’t have problem with urinating
and defecating.
 HISTORY OF PAST ILLNESS

• Previously patients has experienced the same complaint about

three months ago.
• No history of hypertension
• No history of cardiovascular disease
• No history of asthma
• No history of allergic
• No history of hematologic disease
 HISTORY OF FAMILY

• Patient’s father has history of hypertension

• Patient’s father has history of DM
• No history of allergic
• No history of hematologic disease
 HISTORY OF ALLERGY

• Patient has no allergy to food, drugs and weather.

 HISTORY OF TREATMENT

Patient has already consumed polysilane for her

epigastric pain.
 HABITS

• Patient have a smoking habit about 4 to 5 packs

per day. But has begun to be reduced.
• Patient had a habit of drinking alcohol but it has
stopped a few years ago.
• Patient have a habit of consuming spicy foods.
 PHYSICAL EXAMINATION

Generalis Status • General condition : Moderate ill

• Conciousness : composmentis

• Blood pressure : 120/80 mmHg

Vital Sign • Heart rate : 100 x/minute
• Respiratory rate : 18 x/minute
• Temperature : 38° C
GENERAL PHYSICAL EXAMINATION
 Head : Normocephal, deformity (-)

 Eyes : Anemic conjungtiva (-/-), icteric sclera (-/-)

 Nose : Epistaksis (-/-), septum deviation(-/-)

 Mouth : The oral mucosa moist

 Neck : Mass (-), lymphadenopathy (-)

 Thoraks :
• Inspection : the movement of the chest symmetrical
• Palpation : same vocal fremitus in dextra and sinistra
• Percussion : Sonor in dextra and sinistra
• Auscultacion : vesicular breath sounds + / +, ronkhi - / -, wheezing - / -
GENERAL PHYSICAL EXAMINATION

 Heart:
Inspection : ictus cordis not seen
Palpation : ictus cordis not palpable
Percussion : Right heart margin: sternalis line sinistra ICS-IV
Left heart margin: midclavicula line sinistra ICS-V
Auscultation : Regular 1st & 2nd heart sounds, murmur (-), gallop (-)

 Abdomen :
Inspection : looked flat
Auscultation : bowel (+) sounds, 7x/minutes
Palpation : pressure epigastric pain (+), ascites (-)
Percussion : timpani, shifting dullness (-)
GENERAL PHYSICAL EXAMINATION

 Extremities:
Superior : Edema (- / -), warm akral(+ / +), RCT <2 seconds (+ / +)
Inferior : Edema (-/ -), warm akral (+ / +), RCT <2 seconds (+ / +)
 LABORATORY EXAMINATION
(16 MARCH 2018)

Hematology

Hemoglobin 12.6 g/dL 11,7 - 15,5 g/dL

Leucosite 9.27 x 103/μL 3,60-11,00 x 103/μL

Hematocrite 36 % 35 - 47 %
Trombosite 253 x 103/μL 150 - 440 x 103/μL
Eritrosite 4,48 x 106/μL 3,80 - 5,20 x 106/μL
MCV 81 fL 80 - 100 fL
MCH 28 pg 26 - 34 pg
MCHC 35 g/dL 32 - 36 g/dL
 RESUME

• Ms. A, 20 years old, came to Cempaka Putih Islamic

Hospital with epigastric pain since a week before
admission. The pain decreases at rest, but reappear
when patient doing some activity. The pain feels like
being stabbed and there is a burning sensation in
the epigastric area. Patient said the epigastric pain
was felt after consuming spicy foods.
• Patient also complained fever, cough, nausea and
vomit but not much.
• Patient had a history of the same complaint about
three months ago
• Patient had a habit of smoking, drinking alcohol
and consuming spicy foods.
 RESUME

Physical examination :
• BP: 120/80 mmHg
• HR: 100 x/minute
• RR: 18 x/minute
• Temp: 38° C

General Physical examination:

Pressure epigastric pain (+)

Laboratory examination:
• Normal
 PROBLEM LIST

• Dyspepsia
• Upper Respiratory Tract Infections
 ASSESSMENT

1. DYSPEPSIA
S : Epigastic pain, burning sensation in the
epigastric area, nausea, vomit
O : BP: 120/80 mmHg, HR: 100 x/minute, RR: 18
x/minute, Temp : 38° C.
Pressure epigastric pain (+)
A : Dyspepsia
 ASSESSMENT

PLANNING
• Planning diagnostic
• Endoscopy
• Planning therapy
• Lifestyle modification (by reducing smoke, alcohol and
spicy foods)
• Domperidon 3x10 mg
• Ranitidine injection 2x25 mg
 ASSESSMENT

2. Upper Respiratory Tract Infections

S : Cough, fever
O : BP: 120/80 mmHg, HR: 100 x/minute, RR:
18 x/minute, Temp : 38° C.
A : Upper respiratory tract infections
 ASSESSMENT

PLANNING
• Planning diagnostic
• Sputum for Tuberculosis
• Planning therapy
• Paracetamol 3x500 mg
• Acetylcysteine 2x200 mg
 FOLLOW UP
Date Subject Objective Assessment Planning

17/3/2018 Epigastric pain, BP: 110/80 Dyspepsia Paracetamol 3x500 mg

nausea, cough
HR: 90x Domperidon 3x10 mg
URTI
Ranitidin inj 2x25 mg
RR: 20x
Acetylcysteine 2x200
Temp: 36,50C
mg
Pressure
Epigastric Pain
(+)

18/3/2018 Epigastric pain, BP: 110/70 Dyspepsia Domperidon 3x10 mg

nausea, cough
HR: 88x Ranitidin inj 2x25 mg
URTI
Paracetamol 3x500 mg
RR: 20x
Acetylcystein 2x200
Temp: 360C
mg
Pressure
epigastric pain
(+)
 FOLLOW UP
Date Subject Objective Assessment Planning

19/3/2018 Epigastric pain BP: 120/80 Dyspepsia Domperidon 3x10 mg

HR: 88x Ranitidin inj 2x25 mg

RR: 20x

Temp: 36,30C

Pressure
Epigastric Pain
(+)

20/3/2018 Epigastric pain BP: 110/70 Dyspepsia Domperidon 3x10 mg

HR: 84x Ranitidin inj 2x25 mg

RR: 19x

Temp: 36,10C
 PROGNOSIS

• Quo ad vitam : bonam

• Quo ad functionam : dubia ad bonam
• Quo ad sanationam : dubia ad malam
LITERATURE REVIEW

DYSPEPSIA
 DEFINITION

The British Society of Gastroenterology (BSG) states that the

term 'dyspepsia' is not a diagnosis, but rather a collection
of symptoms that lead to upper gastrointestinal diseases /
disorders. The definition of dyspepsia is upper
gastrointestinal tract infections include pain or discomfort
in the gastro-duodenal (epigastric) area, burning, fullness,
full satiation, nausea or vomiting.
 CLASSIFICATION

Organic
Dyspepsia
Functional
 EPIDEMIOLOGY

It is estimated that about 15-40% of the world's population have

complaints of chronic or recurrent dyspepsia. The highest etiology of
organic dyspepsia is gastric / duodenal peptic ulcer, gastroesophageal
reflux disease, and gastric cancer. However, most of the etiology of
dyspepsia is unknown (functional).
 ETIOLOGY

• Idiopathic / functional dyspepsia (50-70%)

• Peptic ulcer (10%)
• Gastroesophageal reflux disease (GERD) (5-20%)
• Gastric cancer (2%)
• Helicobacter pylori infection
• Non-steroidal anti-inflammatory drugs (NSAIDs)

Dietary factors (burnt food, fast food, fatty, spicy, coffee, tea)
and lifestyle (smoking, alcohol, NSAID / aspirin drugs, lack of
exercise) are believed to contribute to dyspepsia. Cigarettes
are thought to decrease the protective effect of gastric
mucosa, while alcohol and anti-inflammatory drugs play a role
in increasing stomach acid production.
 RISK FACTORS

• Age >50 years

• Family history of gastric cancer
• History of peptic ulcer
• Failure treatment
• History of gastrointestinal bleeding
• Anemia
• Weight loss
• Persistent vomiting
• High or long term use of NSAIDs
• Alcohol consumption
 DIAGNOSTIC

• Distinguishing organic dyspepsia by function

requires an accurate history and physical
examination. Investigations such as blood tests,
endoscopy, and radiology are required in certain
cases. Indication of endoscopy when there are
symptoms or alarm signs.
 SYMPTOMS AND ALARM SIGNS

• Age> 55 years
• Gastrointestinal haemorrhage (hematemesis,
melena)
• Anemia
• Dysphagia
• Weight loss (> 10% normal weight)
• Vomiting over and over
• Lymphadenopathy
• Family history of stomach / esophageal cancer
• Palpable abdominal mass
According to Rome III Criteria, the definition of functional
dyspepsia is the presence of symptoms that are thought
to originate in the upper gastrointestinal tract, in the
absence of organic, systemic, or metabolic diseases.
* Diagnostic criteria should include
• One or more of the following:
• a disruptive post-meal feeling
• fast satiety
• epigastric pain
• burning sensation in the epigastric area
• There is no evidence of structural disease (from
endoscopy) that may explain the symptoms.
 Epigastric
pain type
Functional
dyspepsia
Postprandial
distress type
 PROGNOSIS

• Most patients with chronic and recurrent functional

dyspepsia, with asymptomatic periods followed by
episodes of relapse.
• Based on population study of functional dyspepsia
patients, 15-20% had persistent symptoms, 50% had
symptom improvement, and 30-35% had fluctuating
symptoms. Although functional dyspepsia is chronic
and affects the quality of life, it is not proven to
decrease life expectancy.
 CONCLUSION

• Dyspepsia many experienced and disrupt the

quality of life of patients. Classification based on the
presence or absence of organic lesions from
physical and supporting examinations (laboratory,
endoscopy). Consideration of possible non-
gastrointestinal causes should be considered.
Recommended avoidance of risk factors for triggers
and pharmacological therapy.
 REFERENCES
• 1. Schellack N, Schellack G, Sandt N, Masuku B. Gastric pain. S Afr Fam Pract. 2015;
57(4):13-9.
• 2. Otero W, Zuleta MG, Otero L. Update on approaches to patients with dyspepsia and
functional dyspepsia. Rev Col Gastroenterol. 2014;29(2):129-34.
• 3. Lee SW, Lien HC, Lee TY, Yang SS, Yeh HZ, Chang CS. Etiologies of dyspepsia among
a Chinese population: One hospital-based study. Open Journal of Gastroenterology
2014;4:249-54.
• 4. Basandra S, Bajaj D. Epidemiology of dyspepsia and irritable bowel syndrome in
medical students of Northern India. Journal of Clinical and Diagnostic Research 2014;
8(12):13-6.
• 5. Jaber N, Oudah M, Kowatli A, Jibril J, Baig I, Mathew E, et al. Dietary and lifestyle
factors associated with dyspepsia among pre-clinical medical students in Ajman,
United Arab Emirates. Central Asian Journal of Global Health 2016;5(1):1-16.
• 6. National Institute of Health and Care Excellence. Dyspepsia and gastro-
oesophageal reflux disease. In: Investigation and management of dyspepsia,
symptoms suggestive of gastro-oesophageal reflux disease, or both. London: NICE;
2014.
• 7. Talley NJ, Ford AC. Functional dyspepsia. New England Journal of Medicine 2015;
373(19):1853-63.
• 8. Phavichitr N, Koosiriwichian K, Tantibhaedhyangkul R. Prevalence and risk factors of
dyspepsia in Thai schoolchildren. J Med Assoc Thai 2012;95(5):42-7.
• 9. Chen Y, Wang C, Wang J, Zheng L, Liu W, Li H, et al. Association of psychological
characteristics and functional dyspepsia treatment outcome: A case-control study.
Gastroenterology Research and Practice 2016;2016:5.
• 10. Jamil O, Sarwar S, Hussain Z, Fiaz RO, Chaudary RD. Association between functional
dyspepsia and severity of depression. JCPSP. 2016;26(6):513-6.
• 11. Syam AF, Miftahussurur M, Makmun D, Nusi IA, Zain LH, Zulkhairi, et al.
Risk factors and prevalence of Helicobacter pylori in five largest islands of
Indonesia: A preliminary study. PLoS ONE 2015;10(11):e0140186.
• 12. Fujiwara Y, Arakawa T. Overlap in patients with dyspepsia/functional
dyspepsia. J Neurogastroenterol Motil 2014;20(4):447-57.
• 13. Appendix A: Rome III diagnostic criteria for functional gastrointestinal
disorders. In: Drossman DA, editor. Rome III: The functional gastrointestinal
disorders. Raleigh, NC: Rome Foundation; 2006 .p. 885-97.
• 14. Wannmacher L. Review of the evidence for H. Pylori treatment
regimens. 18th Expert Committee on the Selection and Use of Essential
Medicines (Antacids and other antiulcer medicines) - Adults and children
2011 Section 17.1.
• 15. Lu Y CM, Huang Z, Tang C. Antidepressants in the treatment of
functional dyspepsia: A systematic review and meta-analysis. PLoS ONE
2016;11(6):e0157798.
• 16. Talley NJ. Functional dyspepsia: New insights into pathogenesis and
therapy. The Korean journal of internal medicine 2016;31(3):444-56.
 Endoscopic appearance
of PHG and GAVE.
(a)The mosaic or ‘snake-
skin’ appearance of
gastric body mucosa
without red spots,
characteristic of mild
PHG.
(b)Congested mosaic
appearing mucosa with
(c) Background ‘snake-skin’ mucosa in the red spots, characteristic
cardia and fundus with red and brown spots with of moderate PHG.
active oozing characteristic of moderate-to-
severe PHG.
(d) GAVE with the classic watermelon stomach
of the antrum, with columns of tortuous ectactic
vessels converging on the pylorus without active
bleeding.