Dyspepsia Overview

Contents

Overview
Assessment
Specialist Referral
Clinical Decision
Non-Ulcer Dyspepsia or Functional Dyspepsia
Follow-Up
Evaluation of Alarm Symptoms
Empiric Therapy
Patient Education
Guideline References

OVERVIEW

Assessment

Dyspepsia
  • Refers to pain or discomfort centered in the upper abdomen
    • Discomfort refers to a subjective sensation that the patient does not interpret as pain which may be characterized by or associated w/ upper abdominal fullness, early satiety, bloating, belching, nausea & vomiting (N/V)
    • Centered refers to pain or discomfort in or around the midline
  • Dyspepsia is considered a symptom complex rather than a specific diagnosis
Signs & Symptoms
  • Ulcer-like
    • Recurrent epigastric pain or discomfort
  • Reflux-like
    • Acid regurgitation
    • Heartburn
  • Dysmotility-like
    • Bloating in upper abdomen not accompanied by visible distension
    • Early satiety
    • N/V
    • Postprandial fullness
    • Upper abdominal discomfort often aggravated by food
History
  • A detailed medical & family history reduces the differential diagnoses
  • Review medications for possible causes of dyspepsia eg Ca antagonists, nitrates, theophyllines, bisphosphonates, steroids & nonsteroidal anti-inflammatory drugs (NSAIDs), Acarbose, Orlistat, potassium supplements
Physical Examination
  • Often normal except for epigastric tenderness
  • Other PE findings may help diagnose or exclude other diseases eg right upper quadrant pain w/ cholelithiasis, palpable abdominal mass in hepatoma, lymphadenopathy in gastric malignancy
Laboratory Tests
  • Complete blood counts & chemistries (eg LFTs) may be performed to identify alarm features or metabolic diseases causing dyspepsia or to investigate patients who have been unresponsive to treatment
Differential Diagnoses
  • Chronic peptic ulcer disease (PUD)
  • Gastroesophageal reflux disease (GERD)
  • Gastroesophageal malignancy
  • Irritable bowel syndrome (IBS)
    • Link w/ pain & bowel movement is indicative of IBS
  • Consider the possibility of cardiac or biliary disease
    • Biliary pain is characterized by acute & severe upper abdominal pain that is episodic & not colicky, lasting for an hour or more

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Specialist Referral

  • Specialist investigation is necessary for patients >55 yr (>40 yr in areas w/ high prevalence of gastric cancer), patients w/ alarm symptoms, patients who did not respond to empiric therapy & have persistent symptoms, & for further evaluation of an alternate diagnosis
Endoscopy
  • Upper GI endoscopy is the investigation of choice when further evaluation is warranted
  • Endoscopy allows a clinician to view the GIT &, if necessary, perform diagnostic & therapeutic procedures, eg biopsy
  • Routine endoscopic investigation of patients at any age, presenting w/ dyspepsia & w/o alarm signs, is not necessary
  • Should be reserved for patients who have little or no response to therapy after 7-10 days or for patients whose symptoms have not resolved after 6-8 wk
    • If upper GI endoscopy is unremarkable, patients w/ persistent symptoms or alarm features should be evaluated further for other diagnosis
  • Depending on local protocol: For patients >55 yr (>40 yr in areas w/ high prevalence of gastric cancer), consider endoscopy when symptoms persist despite H pylori testing/treatment & acid suppression therapy, & when patient has one or more of:
    • Previous gastric ulcer or surgery
    • Continuing need for NSAID treatment
    • Raised risk of gastric cancer
    • Anxiety about cancer
  • Patients undergoing endoscopy should be free from medication w/ either a PPI or H2RA for a minimum of 2 wk

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Clinical Decision

  • Patients <40 yo w/o alarm features & prior dyspepsia workup can be treated either by:
    • Empiric therapy w/ antisecretory agents if local H pylori prevalence is <5%
    • Testing &, if positive, treating for H pylori if local prevalence is >10%
    • If local prevalence rate is 5-10%, treatment choice will depend on length of symptoms, comorbidities, NSAID use, risk factors for gastric or esophageal malignancy, testing availability & cost, & patient preference
  • H pylori testing & treating are effective as initial therapeutic strategy at reducing dyspeptic symptoms in trials of patients w/ uninvestigated dyspepsia
    • Recommended as initial therapy by some experts

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Non-Ulcer Dyspepsia Or Functional Dyspepsia

  • Non-ulcer dyspepsia or functional dyspepsia is defined as dyspepsia of at least 3 mth duration starting at least 6 mth prior the diagnosis of which no focal or structural lesions can be found after endoscopy (Rome III criteria), & which cannot be explained by any other obvious structural or biochemical abnormalities on ultrasound exam or screening blood tests
  • Patients w/ dyspepsia symptoms (eg epigastric pain or burning, early satiety, postprandial fullness) & a normal endoscopy are known to have non-ulcer dyspepsia
  • Patients w/ this diagnosis should be treated similarly as those w/ uninvestigated dyspepsia provided they meet the following criteria:
    • No heartburn
    • No NSAID use
    • Normal blood tests
    • No evidence of an abnormality

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Follow-Up

  • Offer low-dose treatment w/ limited number of prescriptions or stopping treatment
    • Dyspepsia is a remitting & relapsing disease & continuous medication is not necessary after eradication of symptoms unless there is an underlying condition requiring treatment
  • May consider treatment w/ antacids when necessary
  • Continue to avoid known precipitants of dyspepsia including smoking, alcohol, coffee, chocolate, fatty foods & being overweight
  • Monitor for appearance of alarm signs & symptoms

Below is the overview of disease management of Dyspepsia:

overview of management of dyspepsia Dyspepsia1

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 empiric therapy of dyspepsia Dyspepsia2

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 endoscopy in dyspepsia Dyspepsia3

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Dyspepsia Symptoms▶

Version: 6 Aug 2015

Guideline References:

  1. Delaney BC, Moayyedi P, Forman D. Initial management strategies for dyspepsia [abstract]. Cochrane Database Syst Rev. 2003(2):CD001961. PMID: 12804417
  2. Longstreth GF, Lacy BE. Approach to the adult with dyspepsia. UpToDate. http://www.uptodate.com/contents/approach-to-the-adult-with-dyspepsia#H63380126. 28 Aug 2013. Accessed 20 Jan 2014
  3. Loyd RA, McClellan DA. Update on the evaluation and management of functional dyspepsia. Am Fam Physician. 2011;83(5):547-552. http://www.aafp.org/afp/2011/0301/p547.pdf. Accessed 20 Jan 2014. PMID: 21391521
  4. Moayyedi P, Soo S, Deeks L, et al. Pharmacological interventions for non-ulcer dyspepsia [abstract]. Cochrane Database Syst Rev. 2003(1):CD001960. PMID: 12535421
  5. National Institute for Health and Care Excellence. Dyspepsia: Managing dyspepsia in adults in primary care. NICE. http://www.nice.org.uk. Aug 2004
  6. New Zealand Guidelines Group. Management of dyspepsia and heartburn: evidence-based practice guideline. http://www.health.govt.nz/publication/management-dyspepsia-and-heartburn. Jun 2004
  7. North of England Dyspepsia Guideline Development Group. Dyspepsia: managing dyspepsia in adults in primary care: evidence-based clinical practice guideline. http://www.nice.org.uk/nicemedia/pdf/cg017fullguideline.pdf. Aug 2004
  8. Schroeder BM. Evaluation of epigastric discomfort and management of dyspepsia and GERD. Am Fam Physician. 2003 Sep;68(6):1215-1220. PMID: 14524407
  9. Scottish Intercollegiate Guidelines Network. Dyspepsia. A national clinical guideline. SIGN. http://www.guideline.gov/content.aspx?id=3723. Mar 2003
  10. Simren M, Tack J. Functional dyspepsia: evaluation and treatment. Gastroenterol Clin North Am. 2003 Jun;32(2):577-599. PMID: 12858607
  11. Soll AH, Graham DY. Approach to the patient with dyspepsia and peptic ulcer disease. In: Yamada T, Alpers DH, Kalloo AN, eds. Principles of clinical gastroenterology. 1st ed. West Sussex; 2008
  12. Talley NJ, Silverstein MD, Agréus L, Nyrén O, Sonnenberg A, Holtmann G. AGA technical review: evaluation of dyspepsia. Gastroenterology. 1998 Mar;114(3):582-595. PMID: 9496950
  13. Talley NJ, Vakil N; Practice Parameters Committee of the American College of Gastroenterology. Guidelines for the management of dyspepsia. Am J Gastroenterol. 2005 Oct;100(10):2324-2337. PMID: 16181387
  14. Talley NJ. Dyspepsia: management guidelines for the millennium. Gut. 2002 May;50(Suppl 4):iv72-78. PMID: 11953354
  15. Talley NJ. Update on the role of drug therapy in non-ulcer dyspepsia. Rev Gastroenterol Disord. 2003;3(1):25-30. PMID: 12684590
  16. Veldhuyzen van Zanten SJ, Flook N, Chiba N, et al. An evidence-based approach to the management of uninvestigated dyspepsia in the era of Helicobacter pylori. CMAJ. 2000 Jun;162(12 Suppl):S3-S23. PMID: 10870511