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For further information, see CMDT Part 15-01: Dyspepsia

Key Features

Essentials of Diagnosis

  • Predominant epigastric pain

  • May be associated with epigastric fullness, nausea, heartburn, or vomiting

  • Endoscopy is warranted in all patients age 60 years or older and selected younger patients with “alarm” features

  • In all other patients, testing for Helicobacter pylori is recommended; if positive, empiric treatment is started

  • Patients who are H pylori-negative or who do not improve after H pylori eradication should be prescribed a trial of empiric proton pump inhibitor therapy

  • Patients with refractory symptoms should be offered a trial of a tricyclic antidepressant, a prokinetic agent, or psychological therapy

General Considerations

  • Functional dyspepsia is the most common cause

Demographics

  • Occurs in 10–20% of the adult population

  • Accounts for 3% of office visits

Clinical Findings

Symptoms and Signs

  • History entails chronicity, location, and quality of the epigastric pain but has limited diagnostic utility

  • Postprandial fullness

  • Heartburn

  • Nausea or vomiting

  • Concomitant weight loss, persistent vomiting, constant or severe pain, progressive dysphagia, hematemesis, or melena warrants endoscopy or abdominal CT imaging

Differential Diagnosis

  • “Indigestion” from overeating, high-fat foods, coffee

  • Drugs

    • Aspirin

    • Nonsteroidal anti-inflammatory drugs (NSAIDs)

    • Antibiotics (eg, macrolides, metronidazole)

    • Dabigatran

    • Diabetes drugs

    • Cholinesterase inhibitors

    • Corticosteroids

    • Digoxin

    • Iron

    • Theophylline

    • Opioids

  • Gastroesophageal reflux (in 20%)

  • Peptic ulcer disease (in 5–15% of cases)

  • Gastroparesis

  • Gastric cancer (in 1%, but extremely rare in those younger than 50 years old with uncomplicated dyspepsia)

  • Helicobacter pylori

  • Chronic pancreatitis or pancreatic cancer

  • Lactase deficiency

  • Malabsorption

  • Parasitic infection, eg, Giardia, Strongyloides, Anisakis

  • Cholelithiasis, choledocholithiasis, or cholangitis

  • Abdominal or paraesophageal hernia

  • Intra-abdominal malignancy

  • Chronic mesenteric ischemia

  • Pregnancy

  • Metabolic conditions

    • Diabetes mellitus

    • Thyroid disease

    • Chronic kidney disease

  • Myocardial ischemia or pericarditis

  • Physical or sexual abuse

Diagnosis

Laboratory Tests

  • Obtain complete blood count, serum electrolytes, liver enzymes, calcium, and thyroid function tests

Imaging Studies

  • Abdominal ultrasonography or CT scanning is indicated if pancreatic or biliary tract disease is suspected

Diagnostic Procedures

  • In patients younger than 60 years with uncomplicated dyspepsia, initial noninvasive strategies should be pursued

  • Upper endoscopy

    • Can be used to diagnose gastroduodenal ulcers, erosive esophagitis, and upper gastrointestinal malignancy

    • However, it is mainly indicated to look for upper gastric or esophageal malignancy in patients over age 60 years with new-onset dyspepsia (in whom there is increased malignancy risk) and in selected younger patients with “alarm” features

    • In patients under age 60, the risk of malignancy is < 1%, even among patients with reported “alarm” features, such as

      • Progressive weight loss

      • Rapidly progressive dysphagia

      • Severe vomiting

      • Evidence of bleeding or anemia

      • Jaundice

  • Noninvasive test for H pylori

    • IgG serology

    • Fecal antigen test

    • Urea breath test

  • Gastric emptying studies indicated for recurrent vomiting

  • In patients with refractory symptoms ...

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