The assessment of uninvestigated dyspepsia requires consideration of a variety of factors; however, the initial interview will usually unfold in an unstructured fashion. Symptoms are the central focus of the initial assessment; it is therefore essential that enquiries about symptoms are made in a manner that is relevant to patients.[1]Vakil NB, Halling K, Becher A, et al. Systematic review of patient-reported outcome instruments for gastroesophageal reflux disease symptoms. Eur J Gastroenterol Hepatol. 2013 Jan;25(1):2-14.
http://www.ncbi.nlm.nih.gov/pubmed/23202695?tool=bestpractice.com
The assessor must understand precisely what the patient is experiencing.
Careful clinical assessment is needed, particularly for patients aged >60 years, those with alarm features, and those with recent onset (a few months) of worsening or atypical symptoms. A careful clinical assessment outperforms age and alarm features alone in the search for malignancy.[12]National Institute for Health and Care Excellence. Suspected cancer: recognition and referral. 29 January 2021 [internet publication].
http://www.nice.org.uk/guidance/ng12
[18]Kapoor N, Bassi A, Sturgess R, et al. Predictive value of alarm features in a rapid access upper gastrointestinal cancer service. Gut. 2005 Jan;54(1):40-5.
http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=15591502
http://www.ncbi.nlm.nih.gov/pubmed/15591502?tool=bestpractice.com
[19]Talley NJ. What the physician needs to know for correct management of gastro-oesophageal reflux disease and dyspepsia. Aliment Pharmacol Ther. 2004;20(suppl 2):S23-30.
http://www.ncbi.nlm.nih.gov/pubmed/15335410?tool=bestpractice.com
[20]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 Aug;131(2):390-401.
http://www.ncbi.nlm.nih.gov/pubmed/16890592?tool=bestpractice.com
[21]Talley NJ. How to manage the difficult-to-treat dyspeptic patient. Nat Clin Pract Gastroenterol Hepatol. 2007 Jan;4(1):35-42.
http://www.ncbi.nlm.nih.gov/pubmed/17203087?tool=bestpractice.com
[22]Sundar N, Muraleedharan V, Pandit J, et al. Does endoscopy diagnose early gastrointestinal cancer in patients with uncomplicated dyspepsia? Postgrad Med J. 2006 Jan;82(963):52-4.
http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=16397081
http://www.ncbi.nlm.nih.gov/pubmed/16397081?tool=bestpractice.com
The standard alarm features can be remembered by the acronym VBAD:
Assessment of patients with dyspepsia
The initial assessment of a patient with dyspepsia is based on the age of the patient and the probability of serious disease being present. The history and physical examination are designed to identify other medical conditions that can cause dyspeptic symptoms.
The image below illustrates a management pathway, based on the American College of Gastroenterology and the Canadian Association of Gastroenterology guideline on the management of dyspepsia.[3]Moayyedi PM, Lacy BE, Andrews CN, et al. ACG and CAG clinical guideline: management of dyspepsia. Am J Gastroenterol. 2017 Jul;112(7):988-1013.
https://journals.lww.com/ajg/fulltext/2017/07000/ACG_and_CAG_Clinical_Guideline__Management_of.10.aspx
http://www.ncbi.nlm.nih.gov/pubmed/28631728?tool=bestpractice.com
In most developed western countries, patients aged 60 years and older who present with dyspepsia should undergo endoscopy to rule out serious disease, including malignancy.[3]Moayyedi PM, Lacy BE, Andrews CN, et al. ACG and CAG clinical guideline: management of dyspepsia. Am J Gastroenterol. 2017 Jul;112(7):988-1013.
https://journals.lww.com/ajg/fulltext/2017/07000/ACG_and_CAG_Clinical_Guideline__Management_of.10.aspx
http://www.ncbi.nlm.nih.gov/pubmed/28631728?tool=bestpractice.com
In the UK, the National Institute for Health and Care Excellence (NICE) recommends consideration of upper gastrointestinal endoscopy in patients aged 55 or over when dyspepsia has failed to respond to treatment.[3]Moayyedi PM, Lacy BE, Andrews CN, et al. ACG and CAG clinical guideline: management of dyspepsia. Am J Gastroenterol. 2017 Jul;112(7):988-1013.
https://journals.lww.com/ajg/fulltext/2017/07000/ACG_and_CAG_Clinical_Guideline__Management_of.10.aspx
http://www.ncbi.nlm.nih.gov/pubmed/28631728?tool=bestpractice.com
In other regions of the world, an earlier age cut-off may be appropriate.[4]Talley NJ, Vakil NB, Moayyedi P. AGA technical review: evaluation of dyspepsia. Gastroenterology. 2005 Nov;129(5):1756-80.
http://www.gastrojournal.org/article/S0016-5085%2805%2901818-4/fulltext
http://www.ncbi.nlm.nih.gov/pubmed/16285971?tool=bestpractice.com
In patients aged younger than 60 years, the history and physical examination is also directed at determining whether a serious underlying condition is present. Alarm features such as unintentional weight loss, progressive dysphagia, odynophagia, unexplained iron deficiency anaemia, persistent vomiting, palpable mass in the abdomen, or a family history of upper gastrointestinal cancer should prompt consideration for endoscopy, regardless of patient age.
Patients with no alarm symptoms should initially receive a non-invasive test for Helicobacter pylori. Tests that detect active infection with H pylori, such as the stool antigen test or the urea breath test, are preferred as the reliability of serology has declined significantly in recent years.[23]Best LM, Takwoingi Y, Siddique S, et al. Non-invasive diagnostic tests for Helicobacter pylori infection. Cochrane Database Syst Rev. 2018 Mar 15;(3):CD012080.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012080.pub2/full
http://www.ncbi.nlm.nih.gov/pubmed/29543326?tool=bestpractice.com
Patients who test negative for H pylori, or those who are still symptomatic after H pylori eradication, should be given a short trial (4-8 weeks) of proton pump inhibitor therapy. Patients who are still symptomatic after this trial may benefit from a tricyclic antidepressant (an 8-12-week trial) or prokinetic therapy (a 4-8 week trial).[3]Moayyedi PM, Lacy BE, Andrews CN, et al. ACG and CAG clinical guideline: management of dyspepsia. Am J Gastroenterol. 2017 Jul;112(7):988-1013.
https://journals.lww.com/ajg/fulltext/2017/07000/ACG_and_CAG_Clinical_Guideline__Management_of.10.aspx
http://www.ncbi.nlm.nih.gov/pubmed/28631728?tool=bestpractice.com
[
]
How do prokinetics compare with placebo for people with functional dyspepsia?/cca.html?targetUrl=https://www.cochranelibrary.com/cca/doi/10.1002/cca.2450/fullShow me the answer Non-responders should be re-evaluated in case new symptoms or findings drive further investigation. Investigation for motility disorders such as gastroparesis should also be considered at this time, along with psychotherapy if appropriate.
[Figure caption and citation for the preceding image starts]: Pathway for the management of dyspepsiaCreated by the BMJ Knowledge Centre based on information in the ACG and CAG guideline. [Citation ends].
Therapeutic trial of proton pump inhibitors
Initially proposed as a diagnostic test for GORD, a trial of proton pump inhibitors (PPI) therapy is now part of the algorithm for uninvestigated dyspepsia. A therapeutic trial of PPI for 1-2 months can be used to predict response to treatment for uninvestigated dyspepsia.[24]Talley NJ, Vakil N, Lauritsen K, et al. Randomized-controlled trial of esomeprazole in functional dyspepsia patients with epigastric pain or burning: does a 1-week trial of acid suppression predict symptom response? Aliment Pharmacol Ther. 2007 Sep 1;26(5):673-82.
https://onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2036.2007.03410.x
http://www.ncbi.nlm.nih.gov/pubmed/17697201?tool=bestpractice.com
[25]van Zanten SV, Flook N, Talley NJ, et al. One-week acid suppression trial in uninvestigated dyspepsia patients with epigastric pain or burning to predict response to 8 weeks' treatment with esomeprazole: a randomized, placebo-controlled study. Aliment Pharmacol Ther. 2007 Sep 1;26(5):665-72.
https://onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2036.2007.03409.x
http://www.ncbi.nlm.nih.gov/pubmed/17697200?tool=bestpractice.com
[26]van Zanten SV, Armstrong D, Chiba N, et al. Esomeprazole 40 mg once a day in patients with functional dyspepsia: the randomized, placebo-controlled "ENTER" trial. Am J Gastroenterol. 2006 Sep;101(9):2096-106.
http://www.ncbi.nlm.nih.gov/pubmed/16817845?tool=bestpractice.com
Symptom resolution at 1-2 months means a positive trial, and continuation of symptoms at 1-2 months means a negative trial. A Cochrane review concluded that PPIs are effective in the treatment of functional dyspepsia.[27]Pinto-Sanchez MI, Yuan Y, Hassan A, et al. Proton pump inhibitors for functional dyspepsia. Cochrane Database Syst Rev. 2017 Nov 21;11(11):CD011194.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011194.pub3/full
http://www.ncbi.nlm.nih.gov/pubmed/29161458?tool=bestpractice.com
[
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What are the effects of proton pump inhibitors for people with functional dyspepsia?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.1945/fullShow me the answer
Imaging
Upper gastrointestinal (UGI) radiography is not recommended as an initial investigation for patients presenting with uninvestigated dyspepsia, due to sub-optimal performance and potentially misleading results. It is limited to a subset of selected patients for whom endoscopic assessment is indicated but is unavailable.[3]Moayyedi PM, Lacy BE, Andrews CN, et al. ACG and CAG clinical guideline: management of dyspepsia. Am J Gastroenterol. 2017 Jul;112(7):988-1013.
https://journals.lww.com/ajg/fulltext/2017/07000/ACG_and_CAG_Clinical_Guideline__Management_of.10.aspx
http://www.ncbi.nlm.nih.gov/pubmed/28631728?tool=bestpractice.com
Radiological assessment should generally be reserved for patients who have symptoms suggesting UGI motility disturbances or suspected UGI obstruction, when other investigations are not readily available.
Abdominal ultrasound is not recommended as a routine investigation for patients presenting with uninvestigated dyspepsia because the results can be misleading.[3]Moayyedi PM, Lacy BE, Andrews CN, et al. ACG and CAG clinical guideline: management of dyspepsia. Am J Gastroenterol. 2017 Jul;112(7):988-1013.
https://journals.lww.com/ajg/fulltext/2017/07000/ACG_and_CAG_Clinical_Guideline__Management_of.10.aspx
http://www.ncbi.nlm.nih.gov/pubmed/28631728?tool=bestpractice.com
Abdominal ultrasound can be considered when the presentation suggests a hepatobiliary cause for symptoms. The finding of cholelithiasis does not indicate this is the cause of symptoms as asymptomatic gallstones are often found in the general population.
Endoscopy
UGI endoscopic examination is recommended when the presentation suggests complicated UGI disease (obstruction, perforation, and haemorrhage) or a serious underlying cause for the symptoms.[3]Moayyedi PM, Lacy BE, Andrews CN, et al. ACG and CAG clinical guideline: management of dyspepsia. Am J Gastroenterol. 2017 Jul;112(7):988-1013.
https://journals.lww.com/ajg/fulltext/2017/07000/ACG_and_CAG_Clinical_Guideline__Management_of.10.aspx
http://www.ncbi.nlm.nih.gov/pubmed/28631728?tool=bestpractice.com
[5]National Institute for Health and Care Excellence. Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management. Oct 2019 [internet publication].
http://www.nice.org.uk/guidance/cg184
Complicated UGI disease is identified by any of the following:
Endoscopic examination should be considered for older patients (>60 years old) with new onset (within a few months) of progressively worsening symptoms, particularly if alarm features (VBAD) are present.[3]Moayyedi PM, Lacy BE, Andrews CN, et al. ACG and CAG clinical guideline: management of dyspepsia. Am J Gastroenterol. 2017 Jul;112(7):988-1013.
https://journals.lww.com/ajg/fulltext/2017/07000/ACG_and_CAG_Clinical_Guideline__Management_of.10.aspx
http://www.ncbi.nlm.nih.gov/pubmed/28631728?tool=bestpractice.com
[4]Talley NJ, Vakil NB, Moayyedi P. AGA technical review: evaluation of dyspepsia. Gastroenterology. 2005 Nov;129(5):1756-80.
http://www.gastrojournal.org/article/S0016-5085%2805%2901818-4/fulltext
http://www.ncbi.nlm.nih.gov/pubmed/16285971?tool=bestpractice.com
[12]National Institute for Health and Care Excellence. Suspected cancer: recognition and referral. 29 January 2021 [internet publication].
http://www.nice.org.uk/guidance/ng12
This age recommendation reflects American College of Gastroenterology and Canadian Association of Gastroenterology guidance on the management of dyspepsia.[3]Moayyedi PM, Lacy BE, Andrews CN, et al. ACG and CAG clinical guideline: management of dyspepsia. Am J Gastroenterol. 2017 Jul;112(7):988-1013.
https://journals.lww.com/ajg/fulltext/2017/07000/ACG_and_CAG_Clinical_Guideline__Management_of.10.aspx
http://www.ncbi.nlm.nih.gov/pubmed/28631728?tool=bestpractice.com
In the UK, NICE recommends urgent gastrointestinal endoscopy for those aged 55 or over with weight loss and dyspepsia.[3]Moayyedi PM, Lacy BE, Andrews CN, et al. ACG and CAG clinical guideline: management of dyspepsia. Am J Gastroenterol. 2017 Jul;112(7):988-1013.
https://journals.lww.com/ajg/fulltext/2017/07000/ACG_and_CAG_Clinical_Guideline__Management_of.10.aspx
http://www.ncbi.nlm.nih.gov/pubmed/28631728?tool=bestpractice.com
Other patients who might benefit from endoscopy include those with dyspepsia that fails to respond to treatment; NICE recommends consideration of endoscopy in patients aged 55 or over with treatment-resistant dyspepsia.[3]Moayyedi PM, Lacy BE, Andrews CN, et al. ACG and CAG clinical guideline: management of dyspepsia. Am J Gastroenterol. 2017 Jul;112(7):988-1013.
https://journals.lww.com/ajg/fulltext/2017/07000/ACG_and_CAG_Clinical_Guideline__Management_of.10.aspx
http://www.ncbi.nlm.nih.gov/pubmed/28631728?tool=bestpractice.com
In some populations and regions, for example Asia and parts of eastern Europe, UGI malignancies are an important consideration in younger people; therefore, the threshold for investigation should be tailored to local protocols.[4]Talley NJ, Vakil NB, Moayyedi P. AGA technical review: evaluation of dyspepsia. Gastroenterology. 2005 Nov;129(5):1756-80.
http://www.gastrojournal.org/article/S0016-5085%2805%2901818-4/fulltext
http://www.ncbi.nlm.nih.gov/pubmed/16285971?tool=bestpractice.com
Other patients who might benefit from endoscopy include those with ongoing symptoms after 1 to 2 months of treatment using PPI or H pylori eradication treatment.[12]National Institute for Health and Care Excellence. Suspected cancer: recognition and referral. 29 January 2021 [internet publication].
http://www.nice.org.uk/guidance/ng12
Endoscopy may also benefit patients with unusual case presentations or significant comorbid conditions, as well as those who are unable to be reassured in the absence of an endoscopic examination.