2. •Nature, frequency, and chronicity of the symptoms.
•Degree of weight loss.
•Assessment of symptoms or signs of a systemic disorder
and of the patient’s family and personal history.
History and Physical Examination
3. •Specific attention should be given to a history of
heartburn.
•Burning pain confined to the epigastrium is a cardinal
symptom of dyspepsia and not considered heartburn
unless it radiates retrosternally.
•The presence of frequent and typical reflux symptoms
should lead to a provisional diagnosis of GERD rather
than dyspepsia.
•The possible presence of overlapping IBS should also be
assessed.
Johnsson F, Roth Y, Damgaard Pedersen NE, Joelsson B. Cimetidine improves GERD symptoms
in patients selected by a validated GERD questionnaire. Aliment Pharmacol Ther 1993; 7:81-6
4. Laboratory Testing
•Most clinicians will consider routine tests after the age
of 45 to 55.
•Serum amylase level, antibodies for celiac disease, stool
testing for ova and parasites and for Giardia antigen.
5. Initial Management Strategies
•Most guidelines and recommendations advocate prompt
endoscopy when risk factors for an organic cause of
dyspepsia (e.g., NSAID use, age at least 45 to 55, alarm
symptoms) are present.
•Majority of patients who do not have a risk factor for an
organic cause of dyspepsia remains a matter of debate.
Talley NJ, Vakil NB, Moayyedi P. American Gastroenterological Association technical
review on the evaluation of dyspepsia. Gastroenterology 2005; 129:1756-80.
6. Available options include-
(1) prompt diagnostic endoscopy followed by targeted
medical therapy.
(2) noninvasive testing for Hp infection, followed by
treatment based on the result (“test and-treat”
strategy).
(3) empirical antisecretory drug therapy
7. Prompt Endoscopy and Directed Treatment
•Diagnostic upper GI endoscopy allows direct detection of
organic causes of dyspepsia, such as peptic ulcer, erosive
esophagitis, or malignancy.
•Peptic ulcer or erosive esophagitis will receive
antisecretory drug therapy, and in those with a negative
upper endoscopy result, functional dyspepsia and
nonerosive GERD are empirically treated with
antisecretory drug therapy.
Mitchell RM, Collins JS, Watson RG, Tham TC. Differences in the diagnostic yield of upper gastrointestinal
endoscopy in dyspeptic patients receiving proton-pump inhibitors and H2-receptor antagonists. Endoscopy
2002; 34:524-6.
8. •Endoscopy has been claimed to detect gastric cancer at
an early curable stage.
•Functional dyspepsia and GERD recur after treatment
will be referred for endoscopy.
•Guidelines advocate initial endoscopy in all patients
having age (usually age 45 to 55) to detect a potentially
curable upper GI malignancy.
Dyspepsia: Managing dyspepsia in adults in primary care. North of England Dyspepsia Guideline
Development Group (UK). Newcastle upon Tyne (UK): University of Newcastle upon Tyne; 2004 Aug 01
9. Test and Treat for Hp Infection
•Majority of peptic ulcers is the most important risk factor for
gastric cancer.
•Hp in PUD advocates noninvasive testing for Hp in young
patients (<45 to 55 years of age) with uncomplicated
dyspepsia.
•Positive test result should receive eradication therapy, Negative
test result should be treated empirically, with a PPI.
•Eradication of Hp eliminate chronic gastritis lead to a reduction
in the risk of Hp–associated gastric cancer.
Malfertheiner P, Megraud F, O’Morain C, et al. Currentvconcepts in the management of
Helicobacter pylori infection: The Maastricht III Consensus Report. Gut 2007; 56:772-81.
10. •Whether eradication of Hp causes or worsens GERD has
long been debated, but a 2013 RCT eradication in Hp–
positive patients with GERD failed to demonstrate any
worsening of GERD.
•Antibiotic use-inducing resistance .
•Serologic tests are cheaper but least accurate.
•If the prevalence of Hp in a population is less than 60%,
the fecal antigen test and urea breath test for Hp are
preferred.
Vakil N, Rhew D, Soll A, Ofman J. The cost-effectiveness of diagnostic testing strategies
for Helicobacter pylori. Am J Gastroenterol 2000; 95:1691-8.
11. •A meta-analysis of studies comparing a test-and-
treat strategy with empirical antisecretory drug
therapy of dyspepsia found little difference.
•The test and- treat strategy as an initial approach
to uninvestigated dyspepsia is most likely to be
beneficial in areas where the Hp infection rate is
high, where the hp infection rate is high.
Ford AC, Moayyedi P, Jarbol DE, et al. Meta-analysis: Helicobacter pylori “test and treat”
compared with empirical acid suppression for managing dyspepsia. Aliment Pharmacol Ther
2008; 28:534-44.
12. Empirical Antisecretory Drug Therapy
• Widely used in uninvestigated dyspepsia.
• It controls symptoms and heals lesions in most patients with
underlying GERD or PUD and may be beneficial in up to 1/3rd of
patients with functional dyspepsia.
• PPIs > H2RAs, and response occurs within 2 weeks.
• Disadvantages of empirical PPI therapy are rapid symptomatic relapse
and rebound gastric hypersecretion.
• A meta-analysis of studies that compared a test and- treat approach in
dyspepsia found little difference in symptom resolution.
Delaney B, Ford AC, Forman D, et al. Initial management strategies for dyspepsia.
Cochrane Database Syst Rev 2005; CD001961.
13. Recommendations
•(<age 45 to 55)- initial endoscopy cannot be
recommended
•But can be reconsidered if the patient has a family
history of cancer, or has emigrated from an area with a
high incidence of gastric or esophageal cancer.
•high prevalence (>20%) of Hp infection, the test-and-
treat approach remains attractive.
14. •Tests of choice are the urea breath test or the fecal
antigen test for Hp.
•Hp–positive patients should be given a 7- to 14-day
course of Hp eradication therapy.
•In those who are Hp–negative, a PPI can be
prescribed for 1 to 2 months.
15. •In populations where the prevalence of Hp infection is
low, empirical antisecretory drug therapy (PPI for 1 to 2
months) appears to be the preferred option.
•Patients who fail to respond to these initial approaches,
should undergo endoscopy.
•In patients older than age 45 to 55 without alarm
features, most guidelines recommend initial diagnostic
endoscopy.
16. Additional Investigations
•Testing for celiac disease and Giardia infection in patients
with refractory symptoms, like weight loss.
•In patients with severe pain or weight loss, abdominal
US or CT can be used to rule out pancreaticobiliary
disease and screen for mesenteric ischemia.
•In cases of severe postprandial fullness, and especially
in cases of refractory nausea and vomiting, a gastric
emptying test using scintigraphy or a breath test can be
considered.
17. •When a severe delay in gastric emptying is detected, a
small bowel x-ray can rule out mechanical obstruction.
•In cases of refractory intermittent epigastric pain or
burning, esophageal pH with impedance monitoring
is useful for diagnosing atypical manifestations of
GERD not responding sufficiently to empirical
antisecretory drug therapy.
•Electrogastrography, barostat studies, or simple
nutrient challenge tests have been used as research
tools but have no established role in the clinical
management of patients with dyspepsia.
