Assessment of dyspepsia - Diagnosis Approach

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] 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][18][19][20][21][22] The standard alarm features can be remembered by the acronym VBAD:

V: vomiting
B: bleeding or anaemia
A: abdominal mass or unintended weight loss
D: dysphagia.

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] 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] 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] In other regions of the world, an earlier age cut-off may be appropriate.[4]

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] 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] [ ] 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.

com.bmj.content.model.assessment.Caption@33919b39 [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][25][26] 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] [ ]

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] 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] 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][5] Complicated UGI disease is identified by any of the following:

Alarm features (V: vomiting; B: bleeding or anaemia; A: abdominal mass or unintended weight loss; D: dysphagia)
Fever
Abdominal rigidity
Low haemoglobin.

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][4][12] This age recommendation reflects American College of Gastroenterology and Canadian Association of Gastroenterology guidance on the management of dyspepsia.[3]

In the UK, NICE recommends urgent gastrointestinal endoscopy for those aged 55 or over with weight loss and dyspepsia.[3] 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]

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]

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] 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.

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