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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, antibacterial treatment is given.
Patients who are H pylori negative or 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 tricyclic antidepressant, prokinetic agent, or psychological therapy.
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GENERAL CONSIDERATIONS
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Dyspepsia refers to acute, chronic, or recurrent pain or discomfort centered in the upper abdomen. Predominant epigastric pain that is present for at least 1 month is clinically relevant. The epigastric pain may be associated with other symptoms of heartburn, nausea, fullness, or vomiting. Heartburn (retrosternal burning) should be distinguished from dyspepsia. When heartburn is the dominant complaint, gastroesophageal reflux is nearly always present. Dyspepsia occurs in 10–20% of the adult population and accounts for 3% of general medical office visits.
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A. Food or Drug Intolerance
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Acute, self-limited “indigestion” may be caused by overeating, eating too quickly, eating high-fat foods, eating during stressful situations, or drinking too much alcohol or coffee. Prescription and nonprescription medications should be carefully reviewed since many may cause dyspepsia. Common offenders include aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), antibiotics (metronidazole, macrolides), dabigatran, diabetes drugs (metformin, alpha-glucosidase inhibitors, amylin analogs, GLP-1 receptor antagonists), antihypertensive medications (angiotensin-converting enzyme [ACE] inhibitors, angiotensin receptor blockers), cholesterol-lowering agents (niacin, fibrates), neuropsychiatric medications (cholinesterase inhibitors [donepezil, rivastigmine]), selective serotonin reuptake inhibitors (SSRIs) (fluoxetine, sertraline), serotonin-norepinephrine reuptake inhibitors (venlafaxine, duloxetine), Parkinson drugs (dopamine agonists, monoamine oxidase [MAO]-B inhibitors), corticosteroids, estrogens, digoxin, iron, and opioids.
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B. Functional Dyspepsia
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Functional dyspepsia refers to dyspepsia for which no organic etiology has been determined by endoscopy or other testing. This is the most common cause of chronic dyspepsia, accounting for the majority of patients. Symptoms may arise from a complex interaction of increased visceral afferent sensitivity, gastric delayed emptying or impaired accommodation to food or psychosocial stressors or may develop de novo following an enteric infection. Although benign, these symptoms may be chronic and difficult to treat.
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C. Luminal Gastrointestinal Tract Dysfunction
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Peptic ulcer disease is present in 5–15% of patients with dyspepsia. Gastroesophageal reflux disease (GERD) is present in up to 20% of patients with dyspepsia, even without significant heartburn. Gastric or esophageal cancer is identified in less than 1% but is extremely rare in persons under age 60 years with uncomplicated dyspepsia. Other causes include gastroparesis (especially in diabetes mellitus) and parasitic infection (Giardia, Strongyloides, Anisakis).
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D. Helicobacter pylori Infection
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Chronic gastric infection with H pylori is an important cause ...