Resident Editor: Ashley McMullen, M.D.

Faculty Editor: Aparajita Singh, M.D., MPH

Background

• Definition: Predominant epigastric pain lasting at least 1 month. It can be associated with any other upper gastrointestinal symptoms including epigastric fullness, nausea, vomiting, or heartburn, provided epigastric pain is the primary complaint
• Epidemiology: Present in about 20% of adult population  
• Heart burn or regurgitation can be part of symptom complex in dyspepsia patients but if these are predominant symptoms then those patients should be classified as having GERD.
• There is strong overlap between GERD, Dyspepsia and IBS

Etiology/Differential Diagnosis:

• Idiopathic: 60-75% of patients have functional (idiopathic) dyspepsia with no underlying cause found on evaluation or endoscopy. There is no evidence that functional dyspepsia decreases survival
• Organic: 25% may have an underlying organic cause due to following structural or biochemical diseases

Organic Causes

• PUD: epigastric pain, melena, h/o NSAID use, relieved by food/antacids, H. pylori positive
• GERD: heartburn, regurgitation, worse in supine position or after large meal, cough, hoarseness
• Gastroparesis:  history of diabetes; bloating, nausea, early satiety
• Biliary disease: worse with fatty meals, acholic stool, dark urine, RUQ/epigastric pain, jaundice
• Medications: NSAIDs, antibiotics, iron, metformin, potassium, steroids, acarbose
• Others: pancreatitis, gastric cancer, pancreatic cancer, Crohn disease, sarcoidosis, parasitic infection (Giardia, Strongyloides), carbohydrate malabsorption, abdominal wall pain ( + carnett sign), hepatoma,  ischemic bowel

Evaluation/Treatment:

• Age ≥  60 or clinically indicated based on individual risk* :  EGD to rule out organic pathology
  • Most patients with normal EGD and normal routine laboratory tests have Functional Dyspepsia. Additional evaluation (e.g. abdominal imaging) may be done selectively based on type of ongoing symptoms
• *Consider EGD at age <60 if clinically significant weight loss, overt GI bleeding, greater than 2 alarm symptoms, or rapidly progressive symptomsAge <60 : Test and treat for H. Pylori
  • Treat empirically with PPI for 8-week trial if H. pylori negative, or if patient remains symptomatic after H. Pylori eradictation therapy
  • If symptoms persist despite PPI, consider neuromodulator (TCA, SSRI, etc.) or prokinetic therapy. Consider referring for EGD (if not already done) and/or psychotherapy for patients not responding to drug treatment.

H. Pylori test and treat: (refer to H. Pylori chapter for details)

• No clear significant difference between various PPIs; choice should be based upon cost and individual patient response. Observational studies suggest that hip fracture, community acquired pneumonia, C diff, CKD,  are more common in PPI users, these associations were extremely modest, and direct causation cannot be assumed from these data.
• Advise discontinuation of NSAIDs, smoking, alcohol
• Some evidence of benefit with alternative therapies for functional dyspepsia with acupuncture, iberogast, peppermint oil, caraway oil. ACG does not recommend routine use of alternative therapy for dyspepsia

When to Refer

• If the patient is > 60 years old with new onset dyspepsia <60 years old on a case-by-case basis, or patients with persistent symptoms despite adequate trials of drug therapy

References

ASGE Standards of Practice Committee. The role of endoscopy in dyspepsia. Gastrointestinal Endoscopy 2007. 66(6) 1071-1075. Ford AC, Moayyedi P. Dyspepsia. BMJ. 2013;347:f5059.

Maggio M, Corsonello A, Ceda GP, et al. Proton pump inhibitors and risk of 1-year mortality and rehospitalization in older patients discharged from acute care hospitals. JAMA Intern Med. 2013;173(7):518-23.

Moayyedi PM, Lacy BE, Andrews CN, et al. ACG and CAG Clinical Guideline: Management of Dyspepsia. Am J Gastroenterol 2017; 112:988

Vakil N , Moayyedi P , Fennerty MB et al. Limited value of alarm features in the diagnosis of upper gastrointestinal malignancy: systematic review and meta-analysis . Gastroenterology 2006 ; 131 : 390 – 401.