Dyspepsia

History of present illness should elicit a clear description of the symptoms, including whether they are acute or chronic and recurrent. Other elements include timing and frequency of recurrence, any difficulty swallowing, and relationship of symptoms to eating or taking drugs. Factors that worsen symptoms (particularly exertion, certain foods, or alcohol) or relieve them (particularly eating or taking antacids) are noted.

Review of systems seeks concomitant GI symptoms such as anorexia, nausea, vomiting, hematemesis, weight loss, and bloody or black (melanotic) stools. Other symptoms include dyspnea and diaphoresis.

Past medical history should include known GI and cardiac diagnoses, cardiac risk factors (eg, hypertension, hypercholesterolemia), and the results of previous tests that have been done and treatments that have been tried. Drug history should include prescription and illicit drug use as well as alcohol.

Review of vital signs should note presence of tachycardia or irregular pulse.

General examination should note presence of pallor or diaphoresis, cachexia, or jaundice. Abdomen is palpated for tenderness, masses, and organomegaly. Rectal examination is done to detect gross or occult blood.

The following findings are of particular concern:

• Acute episode with dyspnea, diaphoresis, or tachycardia

• Anorexia

• Nausea or vomiting

• Weight loss

• Blood in the stool

• Dysphagia or odynophagia

• Failure to respond to therapy with H2 blockers or proton pump inhibitors (PPIs)

Some findings are helpful ( see Table: Some Causes of Dyspepsia).

A patient presenting with a single, acute episode of dyspepsia is of concern, particularly if symptoms are accompanied by dyspnea, diaphoresis, or tachycardia; such patients may have acute coronary ischemia. Chronic symptoms that occur with exertion and are relieved by rest may represent angina.

GI causes are most likely to manifest as chronic complaints. Symptoms are sometimes classified as ulcer-like, dysmotility-like, or reflux-like; these classifications suggest but do not confirm an etiology. Ulcer-like symptoms consist of pain that is localized in the epigastrium, frequently occurs before meals, and is partially relieved by food, antacids, or H2 blockers. Dysmotility-like symptoms consist of early satiety, postprandial fullness, nausea, vomiting, bloating, and symptoms that are worsened by food and typically not pain. Reflux-like symptoms consist of heartburn or acid regurgitation. However, symptoms often overlap.

Alternating constipation and diarrhea with dyspepsia suggests irritable bowel syndrome or excessive use of over-the-counter laxatives or antidiarrheals.

Patients in whom symptoms suggest acute coronary ischemia, particularly those with risk factors, should be sent to the emergency department for urgent evaluation, including ECG and serum cardiac markers. Tests for cardiac disorders should precede tests for GI disorders such as endoscopy.

For patients with chronic, nonspecific symptoms, routine tests include complete blood count (to exclude anemia caused by GI blood loss), routine blood chemistries, and possibly testing for celiac disease. If results are abnormal, additional tests (eg, imaging studies, endoscopy) should be considered. Because of the risk of cancer, patients > 60 and those with new-onset red flag findings should undergo upper GI endoscopy. For patients < 60 with no red flag findings, some authorities recommend empiric therapy for 4 to 8 weeks with antisecretory agents (eg, PPIs) followed by endoscopy in treatment failures. Others recommend screening for H. pylori see Noninvasive tests). However, caution is required in using H. pylori or any other nonspecific findings to explain symptoms.

Esophageal manometry and pH studies are indicated if reflux symptoms persist after upper GI endoscopy and a 4- to 8-week trial with a PPI.