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

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
    1. No herbal agent or Acupuncture has been shown to offer significant benefit in Functional Dyspepsia

Images: Related links to external sites (from Bing)

Related Studies

Ontology: Duodenitis (C0013298)

Definition (MSHCZE) Zánět sliznice dvanáctníku (duodena). Mnohdy v souvislosti s infekcí bakterií Helicobacter pylori. (cit. Velký lékařský slovník online, 2013 http://lekarske.slovniky.cz/ )
Definition (NCI) Acute or chronic inflammation of the duodenum. Causes include bacterial and viral infections and gastroesophageal reflux disease. Symptoms include vomiting and abdominal pain.
Definition (NCI_NCI-GLOSS) Inflammation of the duodenum (the first part of the small intestine that connects to the stomach).
Definition (MSH) Inflammation of the DUODENUM section of the small intestine (INTESTINE, SMALL). Erosive duodenitis may cause bleeding in the UPPER GI TRACT and PEPTIC ULCER.
Concepts Disease or Syndrome (T047)
MSH D004382
ICD9 535.6
ICD10 K29.8
SnomedCT 155715004, 72007001
French DUODENITE, Duodénite
English DUODENITIS, duodenitis, duodenitis (diagnosis), Duodenitis [Disease/Finding], Duodenitis, duodenitis nos, Duodenitis (disorder), duodenum; inflammation, inflammation; duodenum, Duodenitis, NOS
Portuguese DUODENITE, Duodenite
Spanish DUODENITIS, duodenitis (trastorno), duodenitis, inflamación del duodeno, Duodenitis
Swedish Tolvfingertarmsinflammation
Japanese ジュウニシチョウエン, 十二指腸炎, 十二指腸カタル
Czech duodenitida, zánět sliznice dvanáctníku, Duodenitida
Finnish Duodeniitti
Korean 십이지장염
Polish Zapalenie dwunastnicy
Hungarian Duodenitis
Norwegian Inflammasjon i tolvfingertarmen, Duodenitt, Betennelse i tolvfingertarmen
Dutch duodenum; ontsteking, ontsteking; duodenum, duodenitis, Duodenitis
Italian Duodenite

Ontology: Dyspepsia (C0013395)

Definition (MEDLINEPLUS)

Nearly everyone has had indigestion at one time. It's a feeling of discomfort or a burning feeling in your upper abdomen. You may have heartburn or belch and feel bloated. You may also feel nauseated, or even throw up.

You might get indigestion from eating too much or too fast, eating high-fat foods, or eating when you're stressed. Smoking, drinking too much alcohol, using some medicines, being tired, and having ongoing stress can also cause indigestion or make it worse. Sometimes the cause is a problem with the digestive tract, like an ulcer or GERD.

Avoiding foods and situations that seem to cause it may help. Because indigestion can be a sign of a more serious problem, see your health care provider if it lasts for more than two weeks or if you have severe pain or other symptoms. Your health care provider may use x-rays, lab tests, and an upper endoscopy to diagnose the cause. You may need medicines to treat the symptoms.

NIH: National Institute of Diabetes and Digestive and Kidney Diseases

Definition (NCI_CTCAE) A disorder characterized by an uncomfortable, often painful feeling in the stomach, resulting from impaired digestion. Symptoms include burning stomach, bloating, heartburn, nausea and vomiting.
Definition (NCI_NCI-GLOSS) Upset stomach.
Definition (NCI) An uncomfortable, often painful feeling in the stomach, resulting from impaired digestion. Symptoms include burning stomach pain, bloating, heartburn, nausea, and vomiting. Causes include gastritis, gastric ulcer, gastroesophageal reflux disease, pancreatic disease, and gallbladder disease.
Definition (MSH) Impaired digestion, especially after eating.
Concepts Sign or Symptom (T184)
MSH D004415
ICD10 K30 , R10.13
SnomedCT 266505001, 139299007, 249510006, 87548005, 155722007, 196752002, 162031009
English Indigestion, Dyspepsia, Dyspepsias, DYSPEPSIA, INDIGESTION, Indigestion NOS, dyspepsia (diagnosis), dyspepsia, Indigestions, Dyspepsia [Disease/Finding], indigestion, Dyspepsia/indigestion NOS, Indigestion NOS (finding), Dyspepsia (disorder), Dyspepsia, indigestion NOS, Indigestion (finding), Dyspepsia/indigestion, Dyspepsia, NOS, Indigestion, NOS, Dyspepsia (disorder) [Ambiguous]
French DYSPEPSIE, INDIGESTION, Dyspepsie, Indigestion
Portuguese DISPEPSIA, Indisgestão, INDIGESTAO, Dispepsia, Indigestão
Spanish DISPEPSIA, INDIGESTION, indigestión, SAI (hallazgo), indigestión, SAI, dispepsia (trastorno), dispepsia (concepto no activo), dispepsia, indigestión (hallazgo), indigestión, Dispepsia, Indigestión
German DYSPEPSIE, VERDAUUNGSBESCHWERDEN, Dyspepsie, Indigestion, Magenverstimmung, Verdorbener Magen, Verdauungsstörung
Dutch indigestie, Indigestie/dyspepsie, dyspepsie, Dyspepsia, Dyspepsie, Indigestie
Swedish Dyspepsi
Japanese ショウカショウガイ, ショウカフリョウ, 消化不良, 消化障害, 不消化, 消化不良症
Czech dyspepsie, Dyspepsie, Porucha trávení
Finnish Dyspepsia
Italian Indigestione, Dispepsia
Korean 소화불량
Polish Zaburzenia trawienia, Dyspepsja, Niestrawność
Hungarian Dyspepsia, Indigestio
Norwegian Fordøyelsesbesvær, Dyspepsi

Ontology: Gastritis (C0017152)

Definition (MSHCZE) Zánět žaludku. Akutní g. vzniká většinou jako součást infekce nebo následkem dietní chyby. Často je spojena i se střevními projevy (gastroenteritida). Bývá značná nevolnost, zvracení, průjmy. Jde o běžné onemocnění, někdy se však za podobnými příznaky mohou skrývat závažnější stavy. Srov. dyspepsie. Chronická g. je onemocnění, které lze zjistit jen histologicky (biopsie při gastroskopii). Nemá typické příznaky a může probíhat i zcela bezpříznakově. U chronické g. se rozlišuje několik typů. Typ A je autoimunitní g. spojená s achlorhydrií a ev. perniciózní anemií, uvádí se vyšší riziko vzniku nádoru. Typ B je antrální g. vznikající v souvislosti s infekcí H. pylori. Typ C se někdy uvádí jako chemická g. (cit. Velký lékařský slovník online, 2013 http://lekarske.slovniky.cz/ )
Definition (NCI) Inflammation of the stomach.
Definition (NCI_NCI-GLOSS) Inflammation of the lining of the stomach.
Definition (NCI_CTCAE) A disorder characterized by inflammation of the stomach.
Definition (CSP) inflammation of the stomach.
Definition (MSH) Inflammation of the GASTRIC MUCOSA, a lesion observed in a number of unrelated disorders.
Concepts Disease or Syndrome (T047)
MSH D005756
ICD10 K29.7
SnomedCT 155711008, 235653009, 266503008, 196743006, 4556007
English Gastritides, Gastritis, GASTRIC INFLAMMATION, STOMACH INFLAMMATION, Gastritis unspecified, Gastritis, unspecified, gastritis, gastritis (diagnosis), Gastritis NOS, Inflammation stomach, Stomach inflammation, Gastritis [Disease/Finding], stomach inflammation, Inflammation;stomach, gastric inflammation, Gastritis unspecified (disorder), Already mapped above AAHA ID #: 832, Gastric inflammation, Stomach inflamed, Catarrhal gastritis, GASTRITIS, Gastric catarrh, Gastritis (disorder), Gastritis, NOS, Gastritis [Ambiguous], inflammation of the stomach
French GASTRITE, Inflammation gastrique, Inflammation de l'estomac, Gastrite SAI, INFLAMMATION DE L'ESTOMAC, INFLAMMATION GASTRIQUE, Gastrite
Portuguese GASTRITE, Inflamação gástrica, Inflamação do estômago, Gastrite NE, INFLAMACAO DO ESTOMAGO, INFLAMACAO GASTRICA, Gastrite
Spanish GASTRITIS, Gastritis NEOM, Inflamación de estómago, Inflamación gástrica, Inflamación estomacal, ESTOMAGO INFLAMADO, GASTRICA, INFLAMACION, gastritis no especificada (trastorno), gastritis no especificada, catarro gástrico, gastritis (trastorno), gastritis, Gastritis
German GASTRITIS, Magenentzuendung, Gastritis NNB, Entzuendung, Magen, Gastritis, nicht naeher bezeichnet, MAGENENTZUENDUNG, MAGENSCHLEIMHAUTENTZUENDUNG, Gastritis, Magenschleimhautentzündung
Dutch gastritis NAO, maagontsteking, gastrische ontsteking, ontsteking maag, Gastritis, niet gespecificeerd, gastritis, Gastritis
Italian Gastrite NAS, Infiammazione gastrica, Infiammazione dello stomaco, Gastrite
Japanese 胃炎NOS, 胃炎, 胃の炎症, イノエンショウ, イエン, イエンNOS
Swedish Magkatarr
Czech gastritida, zánět žaludeční sliznice, Zánět žaludku, Gastritida NOS, Gastritida
Finnish Mahatulehdus
Korean 상세불명의 위염
Polish Zapalenie żołądka, Nieżyt żołądka
Hungarian Gastritis k.m.n., Gyomor gyulladása, Gastritis, Gastrikus gyulladás, Gyomorgyulladás
Norwegian Gastritt, Magekatarr

Ontology: Nonulcer dyspepsia (C0267167)

Concepts Finding (T033)
ICD10 K30
SnomedCT 3696007
English FUNCTIONAL DYSPEPSIA, NUD (nonulcer dyspepsia), functional dyspepsia, gastric irritation, non ulcer dyspepsia, non-ulcer dyspepsia, nonulcer dyspepsia, dyspepsia functional, Nonulcer dyspepsia, Non ulcer dyspepsia, Functional dyspepsia, Non-ulcer dyspepsia, Nonulcer dyspepsia (disorder)
Dutch dyspepsie niet ten gevolge van ulcus, functionele dyspepsie
French Dyspepsie sans ulcère, Dyspepsie fonctionnelle
German funktionelle Dyspepsie, Funktionelle Dyspepsie
Italian Dispepsia non ulcerosa, Dispepsia funzionale
Portuguese Dispepsia não ulcerosa, Dispepsia funcional
Spanish Dispepsia funcional, Dispepsia no-ulcerosa, dispepsia funcional, dispepsia no ulcerosa (trastorno), dispepsia no ulcerosa
Japanese 非潰瘍性消化不良, ヒカイヨウセイショウカフリョウ, 機能性ディスペプシア, キノウセイディスペプシア
Czech Nevředovitá dyspepsie, Funkční dyspepsie
Hungarian Nem-fekélyes dyspepsia, Funkcionális dyspepsia

Ontology: Acid dyspepsia (C0857034)

Concepts Disease or Syndrome (T047)
Dutch zure dyspepsie
French Dyspepsie acide
German saure Dyspepsie
Italian Dispepsia acida
Portuguese Dispepsia ácida
Spanish Dispepsia ácida
Japanese 胃酸過多性消化不良, イサンカタセイショウカフリョウ
English Acid dyspepsia
Czech Dyspepsie
Hungarian Sav dyspepsia