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
There are several common causes of dyspepsia (see table Some Causes of Dyspepsia).
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 |
Change in bowel habits (eg, diarrhea, steatorrhea, bloating) Unexplained iron deficiency anemia | Serologic testing Small bowel biopsy | |
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 medications) | Nausea, bloating, fullness | Scintigraphic test of gastric emptying |
Medications (eg, bisphosphonates, erythromycin and other macrolide antibiotics, estrogens, iron,NSAIDs, opioids, potassium) | Use apparent on history Symptoms coincident with use | Clinical evaluation |
Reflux symptoms do not respond to acid-suppression therapy | Upper endoscopy with biopsy | |
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 Sometimes esophageal pH monitoring | |
Burning or gnawing pain, may be relieved by food or antacids Risk factors: NSAID use, smoking, alcohol use, Helicobacter pylori infection | Upper endoscopy with H. pylori testing Trial of NSAID avoidance | |
NSAID = nonsteroidal anti-inflammatory drug. | ||
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 of Dyspepsia
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 medications. 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. Medication/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.
The 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 symptoms. 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 who have symptoms that 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 and for H. pylori. If results are abnormal, additional tests (eg, imaging studies, endoscopy) should be considered. Because of the risk of cancer, patients > 60 should undergo upper GI endoscopy. For patients < 60, the need for endoscopy needs to be evaluated on a case-by-case basis using clinical judgment (1). For patients < 60, some authorities recommend screening for H. pylori infection with a 13C- or 14C-labeled urea breath test or stool assay (see Noninvasive tests) (1). If they are H. pylori-negative or remain symptomatic after H. pylori eradication therapy, empiric therapy for 4 to 8 weeks with antisecretory agents (eg, PPIs) is recommended (1). However, caution is required in using H. pylori or any other nonspecific findings to explain symptoms.
Diagnosis reference
1. Moayyedi P, Lacy BE, Andrews CN, Enns RA, Howden CW, Vakil N. ACG and CAG Clinical Guideline: Management of Dyspepsia [published correction appears in Am J Gastroenterol. 2017 Sep;112(9):1484]. Am J Gastroenterol. 2017;112(7):988-1013. doi:10.1038/ajg.2017.154
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 (1) (see table Some Oral Medications for Dyspepsia
Some Oral Medications for Dyspepsia
Medication* | Comments |
|---|---|
Proton pump inhibitors | |
With long-term use, elevated gastrin levels, but no evidence that this finding causes dysplasia or cancer May cause abdominal pain or diarrhea | |
H2 blockers | |
Doses reduced in older adults May cause constipation or diarrhea | |
Cytoprotective agent | |
Rarely constipation May bind to other medications and interfere with absorption | |
† Ranitidine (oral, IV, and over the counter) has been removed from the market in the United States and in many other countries because of unacceptable concentrations of N | |
Treatment reference
1. Moayyedi P, Lacy BE, Andrews CN, Enns RA, Howden CW, Vakil N. ACG and CAG Clinical Guideline: Management of Dyspepsia [published correction appears in Am J Gastroenterol. 2017 Sep;112(9):1484]. Am J Gastroenterol. 2017;112(7):988-1013. doi:10.1038/ajg.2017.154
Key Points
Coronary ischemia is possible in a patient with acute “gas.”
Endoscopy is indicated for patients > 60.
For patients < 60, the need for endoscopy needs to be evaluated on a case-by-case basis using clinical judgment.
For patients who are H. pylori-negative or remain symptomatic after H. pylori eradication therapy, empiric therapy for 4 to 8 weeks with antisecretory agents (eg, PPIs) is recommended.
