Dyspepsia

Michael Camilleri, M.D.
Mayo Medical School

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

Definition/Key Clinical Features

• Functional GI disorder that causes upper abdominal symptoms in postprandial period
  • Nausea
  • Vomiting
  • Pain
  • Bloating
  • Anorexia
  • Early satiety
• Pathogenetic features shared with other functional GI disorders
  • Abnormal motility
  • Heightened visceral sensation
  • Psychosocial distress
• Frequent psychological comorbidity
  • Anxiety
  • Depression
  • Obsessive-compulsive disorder

Differential Diagnosis

• Esophagitis
• Peptic ulcer disease
• Helicobacter pylori gastritis
• Cancer of esophagus or stomach

Best Tests

• History and physical exam are usually normal and nondiscriminatory
• Perform endoscopy and test for H. pylori infection in new-onset cases
• 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
• Refer for further evaluation or begin therapeutic trials

Red Flags

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

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, tegaserod) indicated when gastric emptying is delayed
• Antidepressants at low dose (tricyclic agents) or standard dose (SSRIs) may be beneficial in the long term; formal trials are needed

Best References

Bramble, et al: Gut 46:464, 2000

Delaney, et al: Cochrane Database Syst Rev (3):CD001961, 2001

Danesh, et al: Arch Intern Med 160:1192, 2000

July 2004