Workup for Dyspepsia in an Elderly Female with Epigastric Tenderness, Early Satiety, and Limited Appetite
This elderly patient requires urgent upper endoscopy given her age (≥55 years), early satiety, and limited appetite, which constitute alarm features warranting prompt investigation to exclude gastro-oesophageal malignancy. 1
Immediate Investigations
Blood Work
- Full blood count - mandatory in all patients ≥55 years with dyspepsia to assess for anemia and evaluate platelet count (thrombocytosis associated with gastro-oesophageal cancer) 1
- Coeliac serology - only if overlapping IBS-type symptoms are present 1
Urgent Endoscopy Indications (This Patient Meets Criteria)
- Age ≥55 years with dyspepsia PLUS early satiety/limited appetite qualifies as an alarm symptom requiring urgent 2-week wait endoscopy 1
- Early satiety and limited appetite suggest possible gastric pathology including malignancy 1
- Epigastric tenderness with these features increases concern for organic disease 1
Additional Urgent Imaging if Indicated
- Urgent abdominal CT scan - consider if patient is ≥60 years with abdominal pain and weight loss to exclude pancreatic cancer 1
- Obtain objective evidence of any reported weight loss 1
During Endoscopy
Biopsy Protocol
- Gastric biopsies for H. pylori testing - document infection status during endoscopy 1
- Evaluate for structural disease: peptic ulcer, erosive oesophagitis, malignancy 1
- Assess for low-grade mucosal inflammation, particularly in duodenum 2
If Endoscopy is Normal (Functional Dyspepsia Diagnosis)
H. pylori Testing and Management
- Non-invasive H. pylori testing (carbon-13 urea breath test or stool antigen test) if not done at endoscopy 1
- Eradication therapy if positive - this is first-line treatment for H. pylori-positive functional dyspepsia 1, 3
- Confirmation of eradication only needed in patients at increased risk of gastric cancer 1
Empirical Treatment if H. pylori Negative
- Full-dose PPI therapy (e.g., omeprazole 20 mg once daily) for 4-8 weeks, particularly given epigastric tenderness suggesting acid-related symptoms 1, 3
- Trial of withdrawal after symptom control, with on-demand therapy for recurrence 1, 3
Important Clinical Pitfalls
Do NOT Delay Endoscopy in This Patient
- The combination of age ≥55 years with early satiety/limited appetite is an alarm feature 1
- Empirical PPI therapy should NOT precede endoscopy in elderly patients with alarm symptoms, as symptomatic response does not exclude gastric malignancy 4
- Approximately 80% of dyspepsia patients have functional dyspepsia, but the 20% with organic disease (including malignancy) must be identified, especially in elderly patients 1, 5
Age-Specific Considerations
- Gastric cancer incidence rises rapidly after age 55 in Western populations 1
- Symptoms are often atypical in elderly patients with peptic ulceration and gastro-oesophageal reflux disease 6
- Prompt investigation is more appropriate than empirical treatment in elderly patients due to higher proportion of organic disease 6
Additional Testing NOT Routinely Recommended
- Gastric emptying studies and 24-hour pH monitoring should not be performed routinely in typical functional dyspepsia 1
- These may be considered in specialist settings for refractory cases 1
Post-Investigation Management Pathway
If Organic Disease Found
- Treat appropriately based on endoscopic findings (peptic ulcer, erosive oesophagitis, malignancy) 1
- H. pylori eradication for peptic ulcer disease is highly efficacious 1
If Functional Dyspepsia Confirmed
- Lifestyle modifications: regular aerobic exercise, avoid trigger foods including coffee 1, 2
- Symptom-based pharmacotherapy: PPI for epigastric pain/burning; consider prokinetics for early satiety/fullness if PPI fails 1, 3
- Low-dose tricyclic antidepressants as second-line for refractory symptoms 3
- Referral to specialist gastroenterology clinic if severe, refractory, or diagnostic doubt 1