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For further information, see CMDT Part 15-01: Dyspepsia
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Essentials of Diagnosis
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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
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General Considerations
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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
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Differential Diagnosis
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"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
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Obtain complete blood count, serum electrolytes, liver enzymes, calcium, and thyroid function tests
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Diagnostic Procedures
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In patients younger than 60 years with uncomplicated dyspepsia, initial noninvasive strategies should be pursued
Upper endoscopy
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
Noninvasive testing for H pylori