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Stem
A 38-year-old woman presents with eight months of bothersome postprandial fullness after ordinary-sized meals and early satiety that prevents her finishing a normal meal, present on at least three days per week. She also describes intermittent epigastric burning. There is no weight loss, no dysphagia, no vomiting, no bleeding, and no anaemia. She takes no regular medication. OGD is normal (no ulcer, no oesophagitis, no malignancy); H. pylori stool antigen is negative; coeliac serology, FBC, LFTs and amylase are normal. She is anxious about the possibility of cancer.
Questions
a) What is the most likely diagnosis, and state the diagnostic criteria that support it? (2 marks)
Functional dyspepsia — postprandial distress subtype (with overlap epigastric pain syndrome). Rome IV requires one or more of the four cardinal symptoms (epigastric pain, epigastric burning, bothersome postprandial fullness, early satiety), with onset at least 6 months before diagnosis, present for at least 3 months, and no structural disease including at upper endoscopy. This patient meets PDS (fullness and early satiety, 3+ days/week) and EPS (epigastric burning); her normal OGD and absence of alarm features complete the diagnosis.
b) Outline the pathophysiology in this disorder. (3 marks)
Functional dyspepsia is a disorder of gut-brain interaction operating on a structurally normal stomach and duodenum. Four converging mechanisms:
- Impaired gastric accommodation (defective vagally-mediated fundal relaxation, ~40%) — causes early satiety
- Delayed gastric emptying (~25-35%) — causes postprandial fullness
- Visceral hypersensitivity with abnormal central processing (insula, ACC) — lowered pain threshold
- Duodenal low-grade inflammation with eosinophil/mast-cell infiltrate, acid hypersensitivity, barrier disruption
Contributors: H. pylori, post-infectious, psychological stress (HPA axis), dysbiosis, genetics. PDS maps to accommodation/emptying defects; EPS to hypersensitivity.
c) Describe your stepwise management, with named drugs and doses. (3 marks)
- Explanation, reassurance and lifestyle — explain the benign gut-brain diagnosis; small frequent low-fat meals; avoid triggers (fat, coffee, alcohol, NSAIDs, smoking); stress management
- PPI trial — omeprazole 20 mg od for 4-8 weeks (for the epigastric burning/EPS component)
- Prokinetic/accommodation-enhancer for PDS — acotiamide 100 mg tds (where available) or itopride 50 mg tds; short-course domperidone 10-20 mg tds (max 7 days, ECG) or metoclopramide 10 mg tds (max 5 days)
- If refractory — low-dose amitriptyline 10-25 mg nocte (titrate to 50-75 mg); consider CBT; address comorbid anxiety
d) List five alarm features that would mandate urgent OGD. (2 marks)
Any of: (1) age 55 or over at onset; (2) weight loss; (3) dysphagia/odynophagia; (4) recurrent vomiting; (5) gastrointestinal bleeding (haematemesis/melaena) or iron-deficiency anaemia; (6) palpable epigastric mass; (7) family history of upper-GI cancer. Any one mandates urgent OGD under the suspected-cancer pathway.