Given the nonspecific nature of dyspeptic symptoms, the history has limited diagnostic utility. It should clarify the chronicity, location, and quality of the epigastric pain, and its relationship to meals. The pain may be accompanied by one or more upper abdominal symptoms including 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. Potentially offending medications and excessive alcohol use should be identified and discontinued if possible. The patient’s reason for seeking care should be determined. Recent changes in employment, marital discord, physical and sexual abuse, anxiety, depression, and fear of serious disease may all contribute to the development and reporting of symptoms. Patients with functional dyspepsia often are younger, report a variety of abdominal and extragastrointestinal complaints, show signs of anxiety or depression, or have a history of use of psychotropic medications.
The symptom profile alone does not differentiate between functional dyspepsia and organic gastrointestinal disorders. Based on the clinical history alone, primary care clinicians misdiagnose nearly half of patients with peptic ulcers or gastroesophageal reflux.
The physical examination is rarely helpful. Signs of serious organic disease such as weight loss, organomegaly, abdominal mass, or fecal occult blood are to be further evaluated.
In patients younger than age 60 with uncomplicated dyspepsia (in whom gastric cancer is rare), initial noninvasive strategies should be pursued. In patients older than age 60 years, initial laboratory work should include a blood count, electrolytes, liver enzymes, calcium, and thyroid function tests. The cost-effectiveness of routine laboratory studies is uncertain. In most patients younger than age 60, a noninvasive test for H pylori (urea breath test, fecal antigen test) should be performed first. Although serologic tests are inexpensive, performance characteristics are poor in low-prevalence populations, whereas breath and fecal antigen tests have 95% accuracy. If H pylori breath test or fecal antigen test results are negative in a patient not taking NSAIDs, peptic ulcer disease is virtually excluded.
Upper endoscopy is the study of choice to diagnose gastroduodenal ulcers, erosive esophagitis, and upper gastrointestinal malignancy. However, gastroduodenal ulcers and erosive esophagitis can be treated empirically with H pylori eradication or empiric proton pump inhibitor therapy or both. Therefore, upper endoscopy 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 less than 1%—even among patients with reported “alarm” features. Recent guidelines therefore recommend against routine endoscopy for younger patients—even those with “alarm” features. However, endoscopy should be performed in patients with prominent “alarm” features, such as progressive weight loss, rapidly progressive dysphagia, severe vomiting, evidence of bleeding or anemia, or jaundice. It is also helpful for selected patients who are excessively concerned about serious underlying disease. For patients born in regions in which there is a higher incidence of gastric cancer, such as Central or South America, China and Southeast Asia, or Africa, an age threshold of 45 years may be more appropriate.
Endoscopic evaluation may also be warranted when symptoms fail to respond to initial empiric management strategies or when frequent symptom relapse occurs after discontinuation of empiric therapy.
In patients with refractory symptoms or progressive weight loss, antibodies for celiac disease or stool testing for ova and parasites or Giardia antigen, fat, or elastase may be considered. Abdominal imaging (ultrasonography or CT scanning) is performed only when pancreatic, biliary tract, vascular disease, or volvulus is suspected. Gastric emptying studies may be useful in patients with recurrent nausea and vomiting who have not responded to empiric therapies.