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 of Dyspepsia
Many patients have findings on testing (eg, duodenitis, motility disturbance, Helicobacter pylori gastritis Helicobacter pylori Infection Helicobacter pylori is a common gastric pathogen that causes gastritis, peptic ulcer disease, gastric adenocarcinoma, and low-grade gastric lymphoma. Infection may be asymptomatic or... read more , lactose deficiency, cholelithiasis Cholelithiasis Cholelithiasis is the presence of one or more calculi (gallstones) in the gallbladder. In developed countries, about 10% of adults and 20% of people > 65 years have gallstones. Gallstones tend... read more ) 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 of 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
Nausea or vomiting
Blood in the stool
Dysphagia or odynophagia
Failure to respond to therapy with H2 blockers or proton pump inhibitors (PPIs)
Interpretation of findings
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 Irritable Bowel Syndrome (IBS) Irritable bowel syndrome is characterized by recurrent abdominal discomfort or pain with at least two of the following characteristics: relation to defecation, association with a change in frequency... read more 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 Diagnosis Celiac disease is an immunologically mediated disease in genetically susceptible people caused by intolerance to gluten, resulting in mucosal inflammation and villous atrophy, which causes malabsorption... read more . 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 13C- or 14C-labeled urea breath test or stool assay ( see Noninvasive tests Noninvasive tests Helicobacter pylori is a common gastric pathogen that causes gastritis, peptic ulcer disease, gastric adenocarcinoma, and low-grade gastric lymphoma. Infection may be asymptomatic or... read more ). However, caution is required in using H. pylori or any other nonspecific findings to explain symptoms.
Esophageal manometry Esophageal manometry Manometry is measurement of pressure within various parts of the gastrointestinal tract. It is done by passing a catheter containing solid-state or liquid-filled pressure transducers through... read more and pH studies are indicated if reflux symptoms persist after upper GI endoscopy and a 4- to 8-week trial with a PPI.
Treatment of Dyspepsia
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 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.
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.