What investigations should be sent for a patient presenting with dyspepsia?

Investigations for Dyspepsia

For patients presenting with dyspepsia, the recommended investigations include H. pylori testing via breath or stool antigen testing, full blood count in patients aged ≥55 years, and endoscopy in patients with alarm features or age ≥60 years. 1, 2

Initial Risk Assessment and Triage

Endoscopy Indications (Urgent/2-week wait):

• Age ≥60 years with dyspepsia and weight loss 2, 3
• Dyspepsia with weight loss if age ≥25 years 1
• Age >40 years from areas with increased risk of gastric cancer 1
• Family history of gastro-oesophageal malignancy 1
• Presence of dysphagia (any age) 2

Consider Non-urgent Endoscopy:

• Treatment-resistant dyspepsia if age ≥25 years 1
• Patients with persistent symptoms despite appropriate empirical treatment 2

Consider Urgent CT Scan:

• Abdominal pain and weight loss if age ≥60 years (to exclude pancreatic cancer) 1, 2

Consider Abdominal Ultrasound:

• Epigastric pain <1 year with characteristics of biliary colic 1

Baseline Investigations for All Dyspeptic Patients

1. H. pylori Testing:

   • Urea breath test or stool antigen test (preferred over serology due to higher specificity) 1, 2
   • Testing should be done before initiating PPI therapy as it can lead to false-negative results 2

2. Blood Tests:

   • Full blood count in patients aged ≥55 years to identify anemia which may suggest GI bleeding 1, 2
   • Coeliac serology in patients with overlapping IBS-type symptoms 1, 2

Important Considerations

Avoid Unnecessary Testing:

• Routine laboratory testing is not recommended for all dyspeptic patients 1
• Gastric emptying testing and 24-hour pH monitoring should not be routinely performed 2
• Repeated endoscopies in patients with typical functional dyspepsia symptoms and no new alarm features are not recommended 2

Diagnostic Yield:

• Endoscopy in dyspeptic patients without alarm features has a low yield for detecting malignancy (<0.5%) 1
• Approximately 80% of dyspeptic patients will have a normal endoscopy, suggesting functional dyspepsia 1

Common Pitfalls:

• Overreliance on individual alarm symptoms in patients <60 years (poor predictors of malignancy) 2
• Failing to test for H. pylori before initiating empiric acid suppression therapy 2
• Not considering overlapping conditions such as IBS and GERD which may require different management approaches 2
• H. pylori serology is not recommended due to lower specificity compared to breath or stool testing 1

Algorithmic Approach to Dyspepsia Investigations

1. Initial assessment: Evaluate for alarm features and age
2. If alarm features present or age ≥60: Proceed directly to endoscopy
3. If no alarm features and age <60:
   • Test for H. pylori (breath or stool test)
   • Obtain full blood count if age ≥55 years
   • Test for coeliac disease if IBS-type symptoms present
4. If H. pylori positive: Treat with eradication therapy
5. If symptoms persist or H. pylori negative: Trial of PPI therapy
6. If symptoms persist despite treatment: Consider non-urgent endoscopy

This approach balances the need to detect serious pathology while avoiding unnecessary invasive procedures, reducing healthcare costs, and providing appropriate treatment for the majority of patients with functional dyspepsia.