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Dyspepsia

By

Jonathan Gotfried

, MD, Lewis Katz School of Medicine at Temple University

Last full review/revision Mar 2020| Content last modified Mar 2020
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NOTE: This is the Professional Version. CONSUMERS: Click here for the Consumer Version
Topic Resources

Dyspepsia is a sensation of pain or discomfort in the upper abdomen; it often is recurrent. It may be described as indigestion, gassiness, early satiety, postprandial fullness, gnawing, or burning.

Etiology

There are several common causes of dyspepsia (see Table: Some Causes of Dyspepsia).

Table
icon

Some Causes of Dyspepsia

Cause

Suggestive Findings

Diagnostic Approach

Cancer (eg, esophageal, gastric)

Chronic, vague discomfort

Later, dysphagia (esophageal) or early satiety (gastric)

Weight loss

Upper endoscopy

Abdominal CT

Symptoms described as gas or indigestion rather than chest pain by some patients

May have exertional component

Cardiac risk factors

ECG

Serum cardiac markers

Sometimes stress testing

Delayed gastric emptying (caused by diabetes, viral illness, or drugs)

Nausea, bloating, fullness

Scintigraphic test of gastric emptying

Drugs (eg, bisphosphonates, erythromycin and other macrolide antibiotics, estrogens, iron, nonsteroidal anti-inflammatory drugs, opioids, potassium)

Use apparent on history

Symptoms coincident with use

Clinical evaluation

Substernal chest pain with or without dysphagia for liquids and solids

Barium swallow

Esophageal manometry

Heartburn

Sometimes reflux of acid or stomach contents into mouth

Symptoms sometimes triggered by lying down

Relief with antacids

Clinical evaluation

Sometimes endoscopy

Burning or gnawing pain, may be relieved by food or antacids

Risk factors: Nonsteroidal anti-inflammatory drug use, smoking, alcohol use, Helicobacter pylori infection

Upper endoscopy

Many patients have findings on testing (eg, duodenitis, motility disturbance, Helicobacter pylori gastritis, lactose deficiency, cholelithiasis) that correlate poorly with symptoms (ie, correction of the condition does not alleviate dyspepsia).

Nonulcer dyspepsia (functional dyspepsia) is defined as dyspeptic symptoms in a patient who has no abnormalities on physical examination and upper gastrointestinal (GI) endoscopy and/or other evaluation (eg, laboratory tests, imaging).

Evaluation

History

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.

Physical examination

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.

Red flags

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)

Interpretation of findings

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.

Testing

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) and routine blood chemistries. 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 infection with a 14C-urea breath test or stool assay (see Helicobacter pylori Infection : 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.

Treatment

Specific conditions are treated. Patients without identifiable conditions are observed over time and reassured. Symptoms are treated with PPIs, H2 blockers, or a cytoprotective agent (see Table: Some Oral Drugs for Dyspepsia). Prokinetic drugs (eg, metoclopramide, erythromycin) given as a liquid suspension also may be tried in patients with dysmotility-like dyspepsia. However, there is no clear evidence that matching the drug class to the specific symptoms (eg, reflux vs dysmotility) makes a difference. Misoprostol and anticholinergics are not effective in functional dyspepsia. Drugs that alter sensory perception (eg, tricyclic antidepressants) may be helpful.

Table
icon

Some Oral Drugs for Dyspepsia

Drug*

Usual Dose

Comments

Proton pump inhibitors

Dexlansoprazole

30 mg once/day

With long-term use, elevated gastrin levels, but no evidence that this finding causes dysplasia or cancer

May cause abdominal pain or diarrhea

Esomeprazole

40 mg once/day

Lansoprazole

30 mg once/day

Omeprazole

20 mg once/day

Pantoprazole

40 mg once/day

Rabeprazole

20 mg once/day

H2 blockers

Cimetidine

800 mg once/day

Doses reduced in elderly patients

With cimetidine and to a lesser extent with other drugs, minor antiandrogen effects and, less commonly, erectile dysfunction

Delayed metabolism of drugs eliminated by cytochrome P-450 enzyme system (eg, phenytoin, warfarin, diazepam)

May cause constipation or diarrhea

Famotidine

40 mg once/day

Nizatidine

300 mg once/day

Ranitidine

300 mg once/day or 150 mg 2 times a day

Cytoprotective agent

Sucralfate

1 g 4 times a day

Rarely constipation

May bind to other drugs and interfere with absorption

Cimetidine, ciprofloxacin, digoxin, norfloxacin, ofloxacin, and ranitidine avoided 2 hours before or after taking sucralfate

* Tricyclic antidepressants may help. Metoclopramide or erythromycin given as a liquid suspension also may be tried in patients with dysmotility-like dyspepsia.

Ranitidine (oral, IV, and over the counter) has been removed from the market in the US and in many other countries because of unacceptable concentrations of N-nitrosodimethylamine (NDMA), a probable human carcinogen. Cimetidine and famotidine are alternatives and do not contain NDMA, nor do proton pump inhibitors.

Key Points

  • Coronary ischemia is possible in a patient with acute “gas.”

  • Endoscopy is indicated for patients > 60 or with red flag findings.

  • Empiric treatment with an acid blocker is reasonable for patients < 60 without red flag findings; patients who do not respond in 4 to 8 weeks require further evaluation.

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NOTE: This is the Professional Version. CONSUMERS: Click here for the Consumer Version
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