Dyspepsia

Aka: Dyspepsia, Nonulcer Dyspepsia, Functional Dyspepsia, Gastritis, Duodenitis, Acid-Related Dyspepsia

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II. Definitions

  1. Dyspepsia
    1. Chronic or recurrent Epigastric Pain, burning, early satiety or post-prandial fullness
  2. Functional Dyspepsia
    1. At least 1 month of Dyspepsia without underlying organic cause on upper endoscopy OR
    2. Dyspepsia for at least 3 months of the last 6 months with no signs of organic cause

III. Epidemiology

  1. Dyspepsia overall Prevalence: 30% of adults in U.S (with 70% of cases Functional Dyspepsia)

IV. Pathophysiology: Functional Dyspepsia

  1. Unclear etiology, however may be related to altered gastric motility (present in 70-80% of cases)
  2. Inflammatory and immune factors may also play a role
  3. Helicobacter Pylori often found in patients with Dyspepsia, but causality is not clear

V. Causes

  1. See Dyspepsia Causes
  2. See Medication Causes of Dyspepsia
  3. See Dyspepsia in Pregnancy

VI. Symptoms

  1. Epigastric burning, pain or discomfort
  2. Early satiety
  3. Associated symptoms
    1. Abdominal Bloating (difficult to treat)
    2. Belching and Flatulence
    3. Nausea and Vomiting
    4. Halitosis

VII. Diagnosis: Rome IV Criteria for Functional Dyspepsia

  1. Symptoms for at least 3 months of the last 6 months
  2. No evidence for structural disease (including on upper endoscopy if performed) that could explain symptoms and
  3. Symptom criteria (at least one is present)
    1. Epigastric Pain or epigastric burning on at least 1 day per week
    2. Early satiety on at least 1 day per week
    3. Postprandial fullness on at least 3 days per week
  4. References
    1. Stangnellini (2016) Gastroenterology 150(6): 1380-92 [PubMed]

VIII. Associated Conditions: Functional Dyspepsia

  1. Mood Disorders (e.g. Anxiety Disorder, Major Depression)
  2. Gastroesophageal Reflux disease (up to 50% co-occurrence)
  3. Irritable Bowel Syndrome (up to 35% co-occurrence)

IX. Differential Diagnosis

  1. See Dyspepsia Causes
  2. See Medication Causes of Dyspepsia
  3. Functional Dyspepsia diagnosis assumes exclusion of organic cause

X. Approach: Step 1 - Consider differential Diagnosis

  1. See Dyspepsia Causes
  2. See Medication Causes of Dyspepsia
  3. Most common conditions in differential diagnosis
    1. Idiopathic (functional disorder) in 60% of cases
    2. Gastroesophageal Reflux disease (often comorbid)
    3. Peptic Ulcer Disease
    4. Pancreatitis
    5. Biliary pain (Cholelithiasis)
    6. Irritable Bowel Syndrome
      1. Symptoms relieved by Defecation
      2. Associated with change in stool frequency or form
  4. Consider serious underlying causes (e.g. malignancy, Acute Coronary Syndrome)
    1. See Dyspepsia Red Flags
  5. Symptomatic therapy in the Emergency Department
    1. Antacid monotherapy (e.g. Maalox, Mylanta)
      1. As effective with less side effects than Lidocaine solutions ("GI Cocktail")
      2. Warren (2020) Acad Emerg Med 27(9): 905-9 +PMID: 32602148 [PubMed]
  6. General Measures
    1. Avoid Gastric Irritants
    2. Avoid FODMAPs (Fementable Oligosaccharides, Disaccharides, Monosaccharides and Polyols)
      1. Duncanson (2018) J Hum Nutr Diet 31(3):390-407 [PubMed]

XI. Approach: Step 2 - Upper Endoscopy for high risk patients

  1. See Dyspepsia Red Flags for Indications
  2. Perform early upper endoscopy for those with age >60 years with at least one month of symptoms
  3. Early endoscopy indications at younger ages (<60 years old)
    1. High risk groups (e.g. southeast asian descent)
    2. Use clinical judgment in referral (e.g. multiple red flag symptoms)
    3. Multiple Dyspepsia Red Flags
      1. A single isolated red flag in those under age cut-off only mildly increase risk

XII. Approach: Step 3 - Consider Helicobacter Pylori testing

  1. Indications
    1. Indicated BEFORE acid suppression therapy in patients under age 60 years old
    2. Lack of relief with empiric antisecretory therapy
    3. Undifferentiated Dyspepsia
      1. H. pylori treatment (when testing positive) does appear effective in Functional Dyspepsia
        1. Du (2016) World J Gastroenterol 22(12): 3486-95 [PubMed]
        2. Mazzoleni (2011) Arch Intern Med 171(21): 1929-36 [PubMed]
      2. Test and treat strategy (without endoscopy) is cost effective
        1. Reserve endoscopy for Dyspepsia Red Flags (see Dyspepsia Red Flags)
        2. Dyspepsia Red Flags include age >55 years old, Unexplained Weight Loss, Dysphagia
  2. Testing
    1. See Helicobacter pylori Noninvasive Testing (e.g. H. pylori Stool Antigen, Urea Breath Test)
  3. Protocol
    1. Treat with H. Pylori Management if positive
    2. Retest for cure if symptoms persist after treatment
      1. Urea Breath Test
      2. H. pylori Stool Antigen (HpSA)
      3. Endoscopic Biopsy for H. pylori

XIII. Approach: Step 4 - Consider empiric antisecretory therapy (acid suppression)

  1. Timing
    1. Initial trial for 8 weeks
    2. Longterm antisecretory use is often needed
  2. Antisecretory Agents
    1. Proton Pump Inhibitor (e.g. Omeprazole)
      1. No advantage to high Proton Pump Inhibitor doses (e.g. double doses)
      2. Highly effective agents but at higher cost, and with increased risk
        1. Considered first-line (preferred agents) in Functional Dyspepsia
        2. Risk of C. difficile, Pneumonia, Osteoporosis, Chronic Kidney Disease with PPI use >12 months
      3. Meineche-Schmidt (2004) Am J Gastroenterol 99:1050 [PubMed]
    2. H2 Blocker (e.g. Ranitidine)
      1. Cost effective initial trial
      2. Some protocols recommend as initial agent and switching to Proton Pump Inhibitor if not effective
  3. Adjunctive medication options
    1. Metoclopramide (prokinetic agent)
      1. May offer benefit in Nonulcer Dyspepsia
      2. Risk of tardive diskinesia
  4. Ineffective Medications (avoid)
    1. Sucralfate offers no benefit in Nonulcer Dyspepsia
    2. Misoprostol offers no benefit in Nonulcer Dyspepsia
    3. Bismuth Subsalicylate is not recommended due to toxicity with longerterm use

XIV. Approach: Step 5 - Upper Endoscopy Indications (if not already done above)

  1. Incomplete relief with above management

XV. Approach: Step 6 - Alternative Therapies

  1. Tricyclic Antidepressants
    1. Amitriptyline (Elavil) titrated to 25 mg nightly (may titrate to 75 mg nightly)
    2. Imipramine 50 mg nightly
    3. Ford (2017) Gut 66(3): 411-20 [PubMed]
  2. Other mental health agents and methods have not been shown consistently effective
    1. Selective Serotonin Reuptake Inhibitors (SSRI) have NOT shown benefit in Functional Dyspepsia
    2. Psychotherapy has not shown consistent benefit in Functional Dyspepsia
  3. Complimentary and Alternative Medicine (possibly effective agents in Functional Dyspepsia)
    1. Peppermint plus Caraway Oil
    2. Turmeric (Curcuma longa)
    3. Iberogast (STW 5)
    4. Rikkunshito (per American College Gastroenterology)
    5. Baez (2023) Cochrane Database Syst Rev (6): CD013323 [PubMed]

XVI. References

  1. Bazaldua (1999) Am Fam Physician 60(6):1773-84 [PubMed]
  2. Dickerson (2004) Am Fam Physician 70:107-14 [PubMed]
  3. Fisher (1998) N Engl J Med 339:1376-81 [PubMed]
  4. Laine (2001) An Intern Med 134:361-9 [PubMed]
  5. Loyd (2011) Am Fam Physician 83(5): 547-52 [PubMed]
  6. Moayyedi (2017) Am J Gastroenterol 112(7): 988-1013 [PubMed]
  7. Mounsey (2020) Am Fam Physician 101(2): 84-8 [PubMed]
  8. Richter (1991) Scand J Gastroenterol 182:11-6 [PubMed]
  9. Talley (2005) Am J Gastroenterol 10:2324-37 [PubMed]

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