Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 15-01: Dyspepsia + Key Features Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ +++ 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 + Treatment Download Section PDF Listen +++ +++ 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 + Outcome Download Section PDF Listen +++ +++ 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 + References Download Section PDF Listen +++ + +Bharucha AE et al. Common functional gastroenterological disorders associated with abdominal pain. Mayo Clin Proc. 2016 Aug;91(8):1118–32. [PubMed: 27492916] + +Carbone F et al. Prucalopride in gastroparesis: a randomized placebo-controlled crossover study. Am J Gastroenterol. 2019 Aug;114(8):1265–74. [PubMed: 31295161] + +Gharibans AA et al. Spacial patterns from high-resolution electrogastrography correlate with severity of symptoms in patients with functional dyspepsia and gastroparesis. Clin Gastroenterol Hepatol. 2019 Dec;17(13):2668–77. [PubMed: 31009794] + +Koduru P et al. Definition, pathogenesis, and management of that cursed dyspepsia. Clin Gastroenterol Hepatol. 2018 Apr;16(4):467–79. [PubMed: 28899670] + +Masuy I et al. Review article: treatment options for functional dyspepsia. Aliment Pharmacol Ther. 2019 May;49(9):1134–72. [PubMed: 30924176] + +Moayyedi PM et al. ACG and CAG Clinical Guideline: management of dyspepsia. Am J Gastroenterol. 2017 Jul;112(7):988–1013. [PubMed: 28631728] + +Pittayanon R et al. Prokinetics for functional dyspepsia: a systematic review and meta-analysis of randomized control trials. Am J Gastroenterol. 2019 Feb;114(2):233–43. [PubMed: 30337705] + +Vakil NB et al. White Paper AGA: functional dyspepsia. Clin Gastroenterol Hepatol. 2017 Aug;15(8):1191–4. [PubMed: 28529164]