Dyspepsia Overview

OVERVIEW

Assessment

• 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

• 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

• 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

• 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

• 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

• 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

• 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:

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Dyspepsia Symptoms▶

Version: 6 Aug 2015

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