Stomach problems have become very common in today’s times. Due to changing lifestyles, unbalanced diets, and mental stress, many people suffer from conditions like dyspepsia. When these symptoms persist for a long time, doctors often recommend tests like endoscopy and biopsy.
However, in this case, the doctor has already performed a whole abdomen ultrasound, full body blood tests, an NCCT scan of the KUB region, and a wheat allergy test. No major problems were found in these tests, except for mild anemia, iron deficiency, and a high platelet count. The patient has been taking Rebiprazole and iron tablets for one month but is still experiencing dyspepsia symptoms such as mild pain in the right side of the abdomen after eating, stomach fullness, loose motions, nausea, and occasional acid reflux.
Upper Endoscopy Report Analysis of a Patient with Indigestion (Dyspepsia)
In this article, we will analyze the endoscopy report of such a patient to know what the report says, whether there is any serious disease, whether treatment is required or not, and what things should be kept in mind regarding food.
Clinical Diagnosis: Dyspepsia
The report records dyspepsia as the main symptom. It is a common but disturbing condition in which there are problems like pain, burning sensation, gas, belching, and vomiting in the upper part of the stomach. If these symptoms persist for weeks or months, then it becomes necessary to get an endoscopy done.
Gross Description
The doctor suggested an upper endoscopy, and she reached the hospital lab. In the endoscopy report, the fundus and oesophagus were nil. Grade 2 hiatus, erosions, distal, and proximal body polyps with a 2×2 cm sessile polyp were seen. The report states that tissue was taken for biopsy from 3 different sites inside the stomach:
- Three vials were received, each containing small tissue samples (0.2–0.3 cm).
- Each sample was taken from different areas of your stomach.
And examined under a microscope.
Microscopic Findings
1. Biopsy from erosion in the stomach body:
- The lining of the tissue is partly worn off (denuded).
- Moderate inflammation was seen in the inner lining (lymphocytic infiltrate – mostly immune cells).
- No H. pylori bacteria (a common bacteria linked to ulcers), active inflammation, metaplasia (abnormal cell changes), dysplasia (pre-cancerous condition), or cancer was found.
2. Biopsies from distal and proximal body polyps:
- Both have partially eroded linings.
- Moderate lympho-mononuclear inflammation is seen.
- No obvious polyp is seen.
- No H. pylori infection found and no indication of any serious disease.
What This Means for You:
- You have chronic mild inflammation (gastritis) in your stomach.
- There’s no serious issue like ulcers, H. pylori, or cancer.
- Your symptoms (dyspepsia) are likely due to this mild inflammation.
Final Diagnosis
- Stomach (body erosion): Non-specific changes, mostly inflammation.
- Distal body of stomach: Chronic superficial gastritis (mild, long-standing inflammation of the stomach lining).
- Proximal body of stomach: same chronic superficial gastritis.
Impression
This means that there is mild inflammation on the inner surface of the stomach for a long time, but it is not serious and can usually be treated with medicines and diet.
Do I need further treatment?
The report has not shown any indication of any type of cancer, severe ulcer, H. pylori, or malignant disease. So, no surgery or complex treatment is required at the moment.
But if you are still bothered by indigestion, gas, nausea, or heaviness, you may need to use some common medications prescribed by the doctor, such as:
- PPI (Proton Pump Inhibitors) such as Omeprazole, Pantoprazole
- Anti-acid medications
- Lifestyle changes
for a few weeks.
Dietary advice for a Gastritis & Dyspepsia patient
What you should eat:
- Grains: Plain rice, oats, soft chapati, semolina (suji), khichdi, idli
- Vegetables: Boiled or steamed: carrots, pumpkin, spinach, lauki, tori
- Fruits: Banana, apple (peeled), papaya, pear, watermelon
- Dairy: Low-fat milk, curd/yogurt (not sour), paneer (moderate)
- Drinks: Coconut water, lukewarm water, jeera water, chamomile tea
What you should avoid:
- Spicy, chilly, and fried foods
- Sour foods like lemon, orange, and tomato
- Coffee, tea, cold drinks, and alcohol
- Bakery products, chips, and refined flour
Additional Tips:
- Eat small meals every 3–4 hours instead of 2–3 large ones.
- Chew food slowly and eat calmly.
- Drink water 30 minutes before or after meals, not with meals.
- Avoid eating late at night.
- Don’t lie down immediately after eating (wait at least 2 hours).
- Avoid stress, as mental stress can also aggravate dyspepsia
Next Steps (general advice):
This patient’s endoscopy report has not found any serious disease. This is just a condition of mild chronic inflammation (chronic superficial gastritis), which usually resolves with dietary and lifestyle improvements. The report is completely satisfactory, but if symptoms persist, consult a doctor. You may require further treatment to fully resolve this illness.
