What is dyspepsia?

What is Dyspepsia?

Dyspepsia is chronic or recurrent pain or discomfort centered in the upper abdomen (epigastrium), specifically excluding patients whose predominant symptom is heartburn or acid regurgitation occurring more than once weekly, as these patients have GERD until proven otherwise. 1

Core Definition and Cardinal Symptoms

The most current guidelines define dyspepsia by the following cardinal symptoms 1:

• Epigastric pain or burning (pain centered in the upper central abdomen)
• Postprandial fullness (feeling excessively full after meals)
• Early satiation (inability to finish a regular-sized meal due to fullness)

Additional symptoms that can be present but are not defining features include 1:

• Upper abdominal bloating
• Belching
• Nausea (but persistent vomiting suggests another disorder)

Critical Distinction from GERD

The key to proper diagnosis is identifying the patient's predominant symptom. 1, 2

• If heartburn or acid regurgitation is predominant and occurs more than once weekly → diagnose and treat as GERD 1, 2
• If epigastric pain, burning, or discomfort is predominant → diagnose and treat as dyspepsia 1, 2

This distinction matters because approximately 63-66% of patients have overlapping symptoms, and 19% cannot identify their predominant symptom, making clinical assessment challenging. 2

Functional vs. Organic Dyspepsia

After investigation (typically upper endoscopy), dyspepsia is classified as 1, 3:

Functional Dyspepsia (80% of cases):

• No structural abnormality found on endoscopy to explain symptoms 1, 3
• Caused by disorders of gut-brain interaction, not psychological factors alone 3
• Divided into two subtypes 1:
  • Epigastric Pain Syndrome (EPS): Bothersome epigastric pain or burning at least 1 day per week
  • Postprandial Distress Syndrome (PDS): Bothersome postprandial fullness or early satiation at least 3 days per week

Organic Dyspepsia (20% of cases): 3

• Peptic ulcer disease (8-10% of all dyspepsia cases) 1, 3
• Erosive esophagitis (13% of endoscoped patients) 3
• Gastric or esophageal malignancy (<0.5%, but critical to exclude) 3
• Medication-induced (particularly NSAIDs) 1, 3

Epidemiology and Risk Factors

• Annual prevalence in Western populations is approximately 25-30% using broad definitions, but only 7% using strict Rome IV criteria 1
• Risk factors include female sex, smoking, NSAID use, and H. pylori infection (though associations are modest) 1, 3

Common Diagnostic Pitfalls to Avoid

1. Failing to ask about the predominant symptom leads to misclassification between dyspepsia and GERD 2
2. Assuming heartburn always means GERD when heartburn can coexist with dyspepsia 2
3. Over-relying on endoscopy when most GERD patients have normal endoscopy and most dyspepsia patients have functional disease 2
4. Failing to test for H. pylori in all dyspeptic patients, as eradication cures underlying peptic ulcer disease and prevents future gastric adenocarcinoma 3

Rome IV Diagnostic Criteria Controversy

The Rome IV criteria require symptoms to be present for the last 3 months with onset at least 6 months before diagnosis, and symptoms must be "bothersome" (severe enough to interfere with daily activities). 1

However, the Rome Foundation has acknowledged these restrictive criteria limit applicability in routine clinical practice and could delay diagnosis and treatment. 1 Global epidemiological studies demonstrate much lower prevalence using Rome IV compared to broader definitions, suggesting these criteria may be too restrictive for real-world use. 1