Wallach's Interpretation of Diagnostic Tests: Pathways to Arriving at a Clinical Diagnosis (131 page)

   Recommended Tests

   Laboratory investigation may not be necessary in young patients (<45 years of age) who have a normal examination and no indicators for organic disease. The etiology of dyspepsia is presented in Table
5-2
.

   In older patients at increased risk, the minimal laboratory workup should include a CBC, electrolytes, calcium, and liver chemistries.

   Thyroid tests, hCG, amylase, and stool studies should be ordered if specific features of the history or examination are suggestive.

   
Additional studies

   
Upper endoscopy
(i.e., esophagogastroduodenoscopy [EGD]): In the majority of cases, this is the study of first choice when further evaluation of dyspepsia is required, including the ability to obtain biopsies. As many as two thirds of endoscopies are completely normal in younger patients (i.e., <45 years of age). Therefore, it is best applied to older patients and to younger patients with classic symptoms.

   
Upper GI radiography
: This test is less accurate than upper endoscopy and cannot provide tissue diagnosis. It is best reserved for situations where endoscopy expertise is unavailable, for patients who refuse endoscopy or have low pretest probability of disease, and in situations where endoscopy might be considered unsafe.

   
Helicobacter pylori testing

   
Gastric emptying studies
: Gastric scintigraphy and gastroduodenal manometry studies generally do not influence medical management and are reserved for patients with normal laboratory tests and a normal EGD, yet who continue to have frequent or protracted vomiting suggestive of a motility disorder. Even in these cases, empiric treatment with prokinetic agents should probably be tried first. Disorders of the gallbladder (see Biliary Extrahepatic Obstruction, Complete).

TABLE 5–2. Differential Diagnosis of Dyspepsia

*Nonulcerative dyspepsia occurs in up to 60% of cases, but the diagnosis requires the exclusion of other diagnostic entities.

Suggested Readings

Dominguez-Munoz JE, Malfertheiner P. Optimized serum pancreolauryl test for differentiating patients with and without chronic pancreatitis.
Clin Chem.
1998;44:869.

Ferry GD. Causes of acute abdominal pain in children.
www.uptodate.com
, May 2009.

Khan F, Sachs H, Pechet L, et al.
Guide to Diagnostic Testing
. Philadelphia, PA: Lippincott Williams & Wilkins; 2002.

Penner RM, Majumdar SR. Diagnostic approach to abdominal pain in adults.
www.uptodate.com
, May 2009.

ASCITES

   Definition