Dyspepsia

Henry P. Parkman, M.D.
Temple University School of Medicine

Definition/Key Clinical Features
Differential Diagnosis
Best Tests
Best Therapy
Best References

Definition/Key Clinical Features

• Functional Dyspepsia is a GI disorder that causes upper abdominal symptoms, generally in postprandial period
  • epigastric pain or burning
  • postprandial fullness
  • early satiation
• Functional dyspepsia has been recently divided into
  • postprandial distress syndrome
  • epigastric pain syndrome
• Pathogenetic features shared with other functional GI disorders
  • Abnormal motility
  • Heightened visceral sensation
  • Psychosocial distress
• Frequent psychological comorbidity
  • Anxiety
  • Depression
  • Obsessive-compulsive disorder

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Differential Diagnosis

• Gastroesophageal Reflux Disease (Esophagitis)
• Peptic ulcer disease
• Helicobacter pylori gastritis
• Cancer of esophagus or stomach

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Best Tests

• History and physical exam are usually normal and nondiscriminatory
• Perform upper endoscopy and test for H. pylori infection in new-onset cases
• Begin therapeutic trial
• proton pump inhibitor
• prokinetic agent
• If no response, consider further evaluation:
• Gastric emptying test (scintigraphy, breath test or wireless capsule motility)
• Water or nutrient beverage tests: evaluate response to drinking 30 ml of Ensure per minute: maximum tolerated volume and fullness, satiety, bloating, nausea, and pain

Red Flags

• Following are indications for endoscopy in patients with dyspepsia
  • Dysphagia
  • Bleeding
  • Weight loss > 5 kg
  • Epigastric mass
  • Hepatomegaly
  • Supraclavicular lymphadenopathy

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Best Therapy

• Therapy is often difficult; antacids, H₂ blockers, and proton pump inhibitors are often ineffective
• Eradication of H. pylori not indicated, although it may be treated because of concern with development of atrophy or gastric cancer
• Reassurance: there is no mortality from dyspepsia once malignancy is excluded
• Prokinetic agents (e.g., metoclopramide) indicated when gastric emptying is delayed
• Antidepressants at low dose (tricyclic agents) may be beneficial; formal trials are needed

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Best References

Bramble, et al: Gut 46:464, 2000 [PMID 10716673]

Delaney, et al: Cochrane Database Syst Rev (3):CD001961, 2001 [PMID 11687004]

Danesh, et al: Arch Intern Med 160:1192, 2000 [PMID 10789614]

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The authors and editors gratefully acknowledge the contributions of the previous author, Michael Camilleri, MD, to the development and writing of this module.

February 2009