Dyspepsia is a complex of symptoms that includes epigastric pain or burning, abdominal fullness after meals (an unpleasant sensation of food retention in the stomach), and early satiety (feeling full that is disproportionate to the amount of consumed food and prevents the patient from finishing the meal). Dyspepsia does not include heartburn (a retrosternal burning sensation); although heartburn is often present in addition to dyspeptic symptoms, it cannot be the dominant problem.
Causes and PathogenesisTop
1. Undiagnosed dyspepsia: Patients presenting with dyspepsia symptoms that have not had investigations to determine whether the cause is organic or functional.
2. Organic dyspepsia: Gastroesophageal reflux disease (GERD); drug-induced gastric, duodenal, or esophageal mucosal injury (acetylsalicylic acid and other nonsteroidal anti-inflammatory drugs [NSAIDs], certain oral antibiotics [mainly doxycycline, erythromycin, ampicillin], digitalis, theophylline, iron or potassium salts, calcium channel blockers, nitrates, glucocorticoids, bisphosphonates); peptic ulcer disease; diseases of the biliary system; hepatitis; pancreatitis; pancreatic pseudocysts; malignancy (gastric, pancreatic, colorectal); intestinal ischemia; and abdominal aortic aneurysm.
3. Functional dyspepsia: Dyspepsia lasting ≥3 months (with onset of symptoms ≥6 months prior to diagnosis) with no organic cause identified on upper gastrointestinal endoscopy. Symptoms do not resolve on bowel movement and are not associated with changes in the frequency of bowel movements or the appearance of stool (features of irritable bowel syndrome).
1. History and physical examination: Determine:
1) How long the symptoms have been present.
2) Whether they are accompanied by bloating (this may suggest irritable bowel syndrome) or heartburn and regurgitation of acid (suggestive of GERD).
3) Whether the frequency of bowel movements and stool consistency are normal (any abnormalities and resolution of pain after bowel movements are suggestive of irritable bowel syndrome).
4) What medications the patient is taking (identify drugs that cause dyspepsia, particularly NSAIDs).
5) Whether there are any alarming symptoms, or red flags (unintended weight loss, abdominal pain waking the patient, jaundice, gastrointestinal bleeding, dysphagia, recurrent vomiting, epigastric mass).
2. Diagnostic studies: Perform the following to confirm or exclude an organic cause:
1) Complete blood count (CBC) (iron deficiency anemia is a red flag suggestive of an organic cause).
2) Abdominal ultrasonography (to be performed in patients with red flags).
3) Upper gastrointestinal endoscopy (not always necessary but usually warranted in patients aged ≥60 years in areas of low risk of gastric cancer and younger ages in countries where gastric cancer is more common. Red flags may prompt endoscopy in younger age groups but this depends on the concern regarding cancer. For example, a 5-kg weight loss may not be of a major concern in a 20-year-old patient with dyspepsia but it may prompt endoscopy in a 55-year-old person.
1. Undiagnosed dyspepsia: A noninvasive test for Helicobacter pylori followed by treatment if infected (see Peptic Ulcer Disease) is the recommended approach for young patients with dyspepsia. If the patient is H pylori–negative or does not respond to successful eradication therapy, then empiric proton pump inhibitor (PPI) therapy should be offered. Endoscopy should not be done routinely in young patients with dyspepsia. The definition of “young” will vary by country according to gastric cancer risk. In low-risk countries endoscopy is not necessary in those <60 years of age.
2. Organic dyspepsia: Treat the underlying condition and, if possible, discontinue the drugs that cause dyspepsia. In patients with coexisting heartburn and dyspepsia, the preliminary diagnosis is GERD, and empiric treatment with PPIs is started (agents and dosage: see Peptic Ulcer Disease). If dyspepsia persists despite appropriate treatment, GERD is an unlikely diagnosis. Of note, some European experts include a positive H pylori status among causes of organic dyspepsia.
3. Functional dyspepsia: By definition, if the patient has had an endoscopy and histology, they should have H pylori testing. If the test result is positive, start eradication therapy (see Peptic Ulcer Disease). If the test is negative or eradication therapy fails, treat the patient with a PPI. You may try amitriptyline 10 to 25 mg taken at bedtime for 8 to 12 weeks (if effective, continue for ~6 months). Instruct the patient to stop smoking, avoid foods and drinks that cause or worsen the symptoms, and eat frequent small meals. Prokinetic therapy, such as domperidone, may be tried if available in the country of practice. Psychotherapy may also be useful.