Dyspepsia is a symptom or a combination of symptoms that alerts a clinician to the presence of an upper GI (UGI) problem. Typical symptoms include epigastric pain or burning, early satiety and post-prandial 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. 
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 gastro-oesophageal reflux disease (GORD) and the under-recognition of H pylori -related disease. Periodic reassessment can add a layer of safety, but the timing and frequency of reassessment needs to be individualised. 
The nomenclature for dyspepsia is confusing. This is largely because some medical organisations include all UGI symptoms in the term dyspepsia, then separate patients with symptoms suggesting GORD for appropriate management, whereas others recognise the overlap in symptoms between the various causes of UGI symptoms but choose to separate the symptoms suggesting GORD before applying the term dyspepsia. Both approaches recommend identifying patients whose symptoms suggest GORD and managing them as having reflux disease.
The Canadian Dyspepsia Working Group (CANDYS)  and the UK National Institute for Health and Care Excellence (NICE)  include GORD symptoms in the term dyspepsia. CANDYS does not require a specific duration for symptoms, whereas NICE requires 4 weeks and the Rome Foundation's ROME III  requires 12 weeks in the previous year to qualify as dyspepsia. The American Gastroenterological Association's (AGA) technical review for the evaluation of dyspepsia  excludes patients with symptoms that suggest GORD and includes only the typical symptoms listed above.
Patients with dyspepsia can be classified based on the type or outcomes of the investigations they have received. Research papers will often refer to different categories of dyspepsia patients, so it is important to understand the descriptions of the most common subgroups of dyspepsia patients that have been described.
Uninvestigated dyspepsia is classified as a condition with characteristic symptoms clinically assessed to be originating in the upper GI (UGI) tract, but which has not been recently investigated by UGI endoscopy.    Symptoms include epigastric pain or burning, early satiety and post-prandial fullness, belching, bloating, nausea, or discomfort in the upper abdomen.
Functional dyspepsia (sometimes called non-ulcer dyspepsia) refers to a situation where UGI endoscopy did not reveal a potential cause for the dyspepsia. It is generally reserved for patients with a normal endoscopy whose symptoms do not suggest GORD. (GORD patients with normal endoscopy are said to have non-erosive reflux disease or NERD.)   
GORD and dyspepsia are related. Patients with troublesome heartburn and/or acid regurgitation can be diagnosed clinically as having GORD.  It is known that many patients with GORD 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 dyspepsia patients. More than half of GORD patients have a normal oesophagus at endoscopy. The difficulty separating GORD from other UGI disorders based on either symptoms or endoscopic findings has led some groups (CANDYS  and NICE  ) to include GORD in the broad group of patients with dyspepsia. This categorisation would include patients with all UGI symptoms under the term uninvestigated dyspepsia. Other groups (AGA  ) prefer to separate UGI symptoms into the two broad categories, GORD and dyspepsia, based on symptom classification. With either categorisation there is now widespread agreement that patients with troublesome heartburn and/or acid regurgitation can generally be diagnosed clinically as having GORD, without the need for endoscopy. 
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.  
Although most people affected by dyspepsia do not seek medical care for their symptoms, roughly one quarter of the population of the developed world suffers from dyspepsia annually. Rates range from 13% to 40% in different countries.  The condition is one of the most common diagnoses in primary care practices.  Dyspepsia remains a common and important diagnosis even into the geriatric age group.  Follow-up of patients over 5 to 7 years shows a benign but recurrent nature of the disease in 50% of cases.  Evidence A There is evidence of special issues relating to dyspepsia in women, particularly in relation to impact on quality of life and history of abuse.  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 abuse appear to be particularly vulnerable to developing dyspepsia symptoms. Work is being done to improve our understanding of brain-to-gut connections that appear to be involved in this association. This work may help shed light on the association between dyspepsia and irritable bowel syndrome (IBS) that is a recurring theme in recent articles. 
Clinical Professor and Chief of Family Medicine
University of Alberta Hospital
NWF is an author of a number of references cited in this monograph.
Professor of Medicine
Chief of GI Endoscopy
Rikshospitalet University Hospital
LA declares that he has no competing interests.
Chief of Service
Hôpital Hôtel-Dieu de Québec
Centre Hospitalier Universitaire de Québec
MB declares that he has no competing interests.
Division of Gastroenterology
Department of Medicine
McMaster University Medical Centre
PM is an author of a number of references cited in this monograph.
Use of this content is subject to our disclaimer