Dyspepsia

Key Features

Essentials of Diagnosis

• Predominant epigastric pain or discomfort

• May be associated with heartburn, nausea, postprandial fullness, 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 persistent symptoms should be offered a trial of a tricyclic antidepressant,

General Considerations

• Predominant epigastric pain that is present for at least 1 month

• Functional dyspepsia is the most common cause of chronic dyspepsia

Demographics

• Occurs in 10–20% of the adult population

• Accounts for 3% of office visits

Clinical Findings

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, eating too quickly, high-fat foods, coffee, alcohol

• Drugs

  • Aspirin

  • Nonsteroidal anti-inflammatory drugs (NSAIDs)

  • Antibiotics (eg, macrolides, metronidazole)

  • Antihypertensive medications

  • Dabigatran

  • Diabetes drugs

  • Cholesterol-lowering agents

  • Corticosteroids

  • Digoxin

  • Iron

  • Opioids

  • Selective serotonin reuptake inhibitors

• 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

Laboratory Tests

• Age >60: 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

  • 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

    • Persistent vomiting

    • Evidence of bleeding or iron ...