Evaluation of dyspepsia

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Last reviewed: 27 Jun 2024

Last updated: 11 Jul 2024

Dyspepsia is a symptom or a combination of symptoms that alerts a clinician to the presence of an upper gastrointestinal (UGI) problem. Typical symptoms include epigastric pain or burning, early satiety and postprandial fullness, belching, bloating, nausea, or discomfort in the upper abdomen. Symptoms are the central focus of this assessment; it is therefore essential that they are described in a manner that is relevant to patients.[1]

Clinicians using symptom-based assessment of UGI symptoms need to be aware of the diagnostic uncertainty inherent in this approach. These assessments can provide functional working diagnoses, but there is always a danger of misclassification. An important consequence of the inability to make a definitive diagnosis based on symptoms alone is an over-diagnosis of GERD and the under-recognition of Helicobacter pylori-related disease. Periodic reassessment can add a layer of safety, but the timing and frequency of reassessment needs to be individualized.[2]

The nomenclature for dyspepsia is confusing. This is largely because some medical organizations include all UGI symptoms in the term dyspepsia, then separate patients with symptoms suggesting GERD for appropriate management, whereas others recognize the overlap in symptoms between the various causes of UGI symptoms but choose to separate the symptoms suggesting GERD before applying the term dyspepsia. Both approaches recommend identifying patients whose symptoms suggest GERD and managing them as having reflux disease.

The American College of Gastroenterology and the Canadian Association of Gastroenterology have published joint guidelines for the management of dyspepsia.[3] The operational definition for dyspepsia used in the guideline is predominant epigastric pain. The authors recognize that patients may present with nausea, vomiting, or fullness but, providing that the patient’s primary concern is epigastric pain, they should be managed as patients with dyspepsia.

A technical review from the American Gastroenterological Association for the evaluation of dyspepsia excludes patients with symptoms that suggest GERD, and includes only those with the typical symptoms.[4] The American College of Gastroenterology have published separate guidance on the diagnosis and management of GERD, which excludes the management of functional heartburn and other functional upper gastrointestinal symptoms.[5] The UK National Institute for Health and Care Excellence guideline on GERD and dyspepsia in adults suggests a discrete algorithm for patients with symptoms typical of GERD.[6]

Classification of dyspepsia

Patients with dyspepsia can be classified based on the type or outcomes of the investigations they have received. Research papers often refer to different categories of patients with dyspepsia, so it is important to understand the descriptions of the most common subgroups that have been described.

Uninvestigated dyspepsia is classified as a condition with characteristic symptoms clinically assessed to be originating in the upper gastrointestinal (UGI) tract, but which has not been recently investigated by UGI endoscopy.[3][4][6] Symptoms include epigastric pain or burning, early satiety and postprandial fullness, belching, bloating, nausea, or discomfort in the upper abdomen.

Functional dyspepsia (sometimes called nonulcer dyspepsia) refers to a situation where investigations have not revealed a potential cause for the dyspepsia.[7] It is generally reserved for patients with a normal endoscopy whose symptoms do not suggest GERD. Patients with GERD with normal endoscopy are said to have nonerosive reflux disease.[3][4][5][8] The American College of Gastroenterology recommends that a diagnosis of nonerosive reflux disease should only be made if endoscopy is performed with the patient off proton pump inhibitors.[5]

The Rome IV classification subdivides functional dyspepsia into 3 categories:[9]

Postprandial distress syndrome (PDS), which is characterized by meal-induced dyspeptic symptoms, such as discomfort, pain, nausea, and fullness
Epigastric pain syndrome (EPS), which refers to epigastric pain, or epigastric burning, that does not occur exclusively postprandially, can occur during fasting, and can even be improved by meal ingestion
Overlapping PDS and EPS, which is characterized by meal-induced dyspeptic symptoms and epigastric pain or burning.

GERD and dyspepsia are related and may overlap. There is no gold standard for the diagnosis of GERD. The diagnosis is based on a combination of symptom presentation, endoscopic evaluation of esophageal mucosa, reflux monitoring, and response to therapeutic intervention.[5] It is known that many patients with GERD will have atypical presentations such as epigastric burning or pain, and therefore their symptoms will cause them to be placed into the group of uninvestigated patients with dyspepsia. Among those undergoing endoscopy for typical GERD symptoms, normal mucosa is the most common finding.[5]

The extent or severity of the patient's dyspepsia is measured by the patient's report of the impact of symptoms on quality of life and function. The patient's assessment of the severity of dyspepsia usually relates to the degree to which it affects work, sleep, diet, or leisure.[4][6]

Epidemiology

One meta-analysis of studies evaluating the prevalence of uninvestigated dyspepsia according to the Rome criteria found that the prevalence varied between countries, suggesting that environmental, cultural, ethnic, dietary, or genetic influences play a role.[10] The pooled prevalence of uninvestigated dyspepsia was 6.9% (95% CI 5.7% to 8.2%) in those studies defining uninvestigated dyspepsia according to Rome IV criteria, and 17.6% (95% CI 9.8% to 27.1%) in those studies using Rome I criteria. The prevalence of uninvestigated dyspepsia was 1.5 fold higher in women.[10]

An internet-based cross-sectional health survey found that Rome IV functional dyspepsia is significantly more prevalent in the US (232 [12%] of 1949 responses) than in Canada (167 [8%] of 1988 responses) and the UK (152 [8%] of 1994 responses; p<0·0001).[11] The subtype distribution was 61% postprandial distress syndrome, 18% epigastric pain syndrome, and 21% overlapping variant with both syndromes; this pattern was similar across countries.

There is evidence of particular concerns relating to functional dyspepsia in women.[12] Dyspepsia has been shown to have a significant negative impact on quality of life. The impact relates to changes in sleep, diet, and interference with work and leisure activities. Women who have experienced emotional or physical abuse appear to be particularly vulnerable to developing functional dyspepsia and irritable bowel syndrome (IBS).

There is much overlap between functional dyspepsia and IBS. Patients who have both disorders have a substantially greater symptom burden and are more likely to consult a physician.[13]

Differentials

Common

Functional dyspepsia
Helicobacter pylori infection
GERD and esophagitis
Peptic ulcer disease
Gastroparesis
Gastritis and duodenitis with and without erosions
Lactose intolerance
Cholelithiasis
Cholecystitis
Drug-induced dyspepsia
Celiac disease

Full details

Uncommon

Upper gastrointestinal malignancy
Intestinal parasites: Giardia, Cryptosporidium
Coronary artery disease
Chronic pancreatitis
Acute pancreatitis
Pancreatic tumors/cancers
Obstruction of the hepatobiliary tract from stricture or tumor
Hypercalcemia
Abdominal wall pain

Full details

Contributors

Authors

Nimish Vakil, MD, FACP, AGAF, FASGE, FACG

Clinical Adjunct Professor

School of Medicine and Public Health

University of Wisconsin

Madison

Disclosures

NV is a consultant for Phathom Pharmaceuticals and Redhill Pharmaceuticals, and is an author of several references cited in this topic.

Acknowledgements

Dr Nimish Vakil would like to gratefully acknowledge Dr Nigel W. Flook, a previous contributor to this topic.

Disclosures

NWF declares that he has no conflicting interests.

Peer reviewers

Lars Aabakken, MD

Professor of Medicine

Chief of GI Endoscopy

Rikshospitalet University Hospital

Oslo

Norway

Disclosures

LA declares that he has no competing interests.

Marc Bradette, MD, FRCP(C)

Gastroenterologist

Chief of Service

Hôpital Hôtel-Dieu de Québec

Centre Hospitalier Universitaire de Québec

Québec City

Québec

Canada

Disclosures

MB declares that he has no competing interests.

Paul Moayyedi, BSc, MB ChB, PhD, MPH, FRCP (London), FRCPC, FACG, AGAF

Director

Division of Gastroenterology

Professor

Department of Medicine

McMaster University Medical Centre

Hamilton

Ontario

Canada

Disclosures

PM is an author of a number of references cited in this topic.

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Evaluation of dyspepsia

Summary

Classification of dyspepsia

Epidemiology

Differentials

Common

Uncommon

Contributors

Authors

Nimish Vakil, MD, FACP, AGAF, FASGE, FACG

Disclosures

Acknowledgements

Disclosures

Peer reviewers

Lars Aabakken, MD

Disclosures

Marc Bradette, MD, FRCP(C)

Disclosures

Paul Moayyedi, BSc, MB ChB, PhD, MPH, FRCP (London), FRCPC, FACG, AGAF

Disclosures

Patient information

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