Dyspepsia

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

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

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 or progressive weight loss, consider obtaining antibodies for celiac disease (IgA tissue transglutaminase [tTG] antibody) or stool testing for ova and parasites or Giardia antigen, fat, or elastase

Medications

• Proton pump inhibitors benefit up to 10%

  • Omeprazole, esomeprazole, or rabeprazole, 20 mg once daily orally

  • Pantoprazole, 40 mg once daily orally

  • Dexlansoprazole or lansoprazole, 30 mg once daily orally

• Antidepressants (eg, desipramine or nortriptyline, 25–50 mg each night at bedtime orally)

• Buspirone

  • Dosage: 10 mg three times daily 15 minutes before meals orally

  • Promotes gastric accommodation

  • Reduces postprandial bloating and fullness in some patients

• Metoclopramide

  • Dosage: 5–10 mg three times daily orally

  • May improve symptoms

  • However, cannot be recommended for long-term use due to the risk of tardive dyskinesia

  • Prucalopride

  • Dosage: 2 mg once daily orally

  • Has demonstrated improvement in gastric emptying and symptoms in patients with gastroparesis

  • However, its efficacy has not been studied in functional dyspepsia, ie, in patients with no demonstrable organic cause

  • It is approved in the United States for treatment of chronic constipation

• H pylori eradication therapy benefits 5–10% (see Helicobacter pylori Gastritis)

Therapeutic Procedures

• Discontinue potentially offending medications if possible

• Reduce or discontinue alcohol and caffeine intake

• Psychotherapy and hypnotherapy beneficial in selected patients

Prognosis

• Up to 75% of affected people have functional dyspepsia; symptoms may be chronic

When to Refer

• Dyspepsia with signs of serious organic disease

• Chronic dyspepsia unresponsive to routine therapies

When to Admit

• Signs of GI bleeding

• Protracted vomiting with dehydration