What is dyspepsia?

What is Dyspepsia?

Dyspepsia is defined as chronic or recurrent pain or discomfort centered in the upper abdomen (epigastrium), which may include symptoms such as postprandial fullness, early satiation, epigastric pain or burning, bloating, belching, and nausea. 1

Definition and Classification

Dyspepsia has evolved from a broad definition to a more specific one that focuses on cardinal symptoms:

• Core symptoms: Epigastric pain or burning, postprandial fullness, and early satiation
• Associated symptoms: Belching, nausea, and upper abdominal bloating may also be present
• Duration requirement: According to Rome IV criteria, symptoms should be present for at least 3 months, with onset at least 6 months before diagnosis 1

Dyspepsia is classified into two main categories:

1. Organic dyspepsia: Has identifiable structural causes
2. Functional dyspepsia (FD): No structural abnormality found after appropriate investigation

Functional dyspepsia is further divided into two subtypes according to Rome IV criteria:

• Epigastric Pain Syndrome (EPS): Characterized by bothersome epigastric pain or burning occurring at least once a week
• Postprandial Distress Syndrome (PDS): Characterized by bothersome postprandial fullness or early satiation occurring at least three times a week 1

Epidemiology

• Annual prevalence in Western countries is approximately 25% 1
• Accounts for 2-5% of all primary care consultations 1
• Approximately 80% of people with dyspepsia in community surveys have functional dyspepsia 1

Causes of Dyspepsia

Organic Causes

• Peptic ulcer disease (approximately 10% of cases)
• Gastroesophageal reflux disease (GERD)
• Gastric or esophageal cancer (less than 0.5%)
• Medication-induced (particularly NSAIDs)
• Helicobacter pylori infection
• Pancreatic or biliary disorders
• Food intolerances

Functional Dyspepsia

Pathophysiological mechanisms include:

• Delayed gastric emptying
• Impaired gastric accommodation to meals
• Hypersensitivity to gastric distension
• Altered duodenal sensitivity to lipids or acids
• Autonomic nervous system dysfunction 2

Distinguishing Dyspepsia from GERD

It's important to differentiate dyspepsia from GERD:

• Patients with predominant or frequent heartburn or acid regurgitation (more than once a week) are considered to have GERD 1
• Heartburn alone is not a symptom of dyspepsia, although it can coexist 1
• In practice, there is considerable symptom overlap between dyspepsia and GERD 1

Diagnostic Approach

For patients with new-onset dyspepsia:

1. Identify alarm features that warrant immediate endoscopy:

   • Age ≥55 years
   • Unexplained weight loss
   • Progressive dysphagia
   • Persistent vomiting
   • GI bleeding
   • Iron deficiency anemia
   • Abdominal mass
   • Family history of upper GI cancer

2. For patients <55 years without alarm features:

   • H. pylori test and treat strategy is recommended
   • Testing is optimally performed by 13C-urea breath test or stool antigen test 1

3. If H. pylori negative or symptoms persist after eradication:

   • Trial of acid suppression with a PPI for 4-8 weeks 1

4. If symptoms persist despite these measures:

   • Consider upper endoscopy to rule out organic causes

Management Implications

Understanding the nature of dyspepsia has important implications for patient outcomes:

• Early identification of organic causes can lead to specific treatments that reduce morbidity and mortality
• Proper diagnosis of functional dyspepsia allows for targeted symptom management
• H. pylori eradication can cure most underlying peptic ulcer disease and may prevent future gastric cancer 1
• Empirical PPI therapy is cost-effective in populations with low H. pylori prevalence (10% or less) 1

Common Pitfalls in Dyspepsia Management

• Failing to distinguish between dyspepsia and GERD
• Not testing for H. pylori in appropriate patients
• Performing unnecessary endoscopies in young patients without alarm features
• Not recognizing the overlap between EPS and PDS subtypes of functional dyspepsia
• Overlooking medication causes, particularly NSAIDs
• Failing to provide adequate reassurance to patients with functional dyspepsia

By understanding what dyspepsia is and following evidence-based diagnostic algorithms, clinicians can provide effective management that improves quality of life while avoiding unnecessary investigations and treatments.