Dyspepsia Diagnosis

• A detailed medical, social (eg smoking and alcohol intake) and family history reduces the differential diagnoses
• Review medications for possible causes of dyspepsia eg calcium antagonists, nitrates, theophyllines, bisphosphonates, steroids and nonsteroidal anti-inflammatory drugs (NSAIDs), Aspirin, Acarbose, Orlistat, potassium supplements

• Often normal except for epigastric tenderness
• Other physical exam findings may help diagnose or exclude other diseases eg right upper quadrant pain with cholelithiasis, palpable abdominal mass in hepatoma, lymphadenopathy in gastric malignancy

• Complete blood counts and chemistries (eg liver function tests, pancreatic amylase) may be performed to identify alarm features or metabolic diseases causing dyspepsia or to investigate patients who have been unresponsive to treatment

Alarm Symptoms 

• Symptoms that suggest complicated disease must be recognized and patients referred immediately for further diagnostic testing:
  • GI bleeding
  • Epigastric mass
  • Iron-deficiency anemia
  • Persistent vomiting
  • Progressive dysphagia
  • Suspicious barium meal
  • Unintentional weight loss
  • Persistent nocturnal symptoms
  • Family history of upper GI cancer
  • Lymphadenopathy
  • Jaundice
  • Painful swallowing
  • Recent use of antiplatelet, anticoagulant or NSAIDs

• Patients have ≥1 bothersome dyspepsia symptoms (eg epigastric pain or burning, early satiety, postprandial fullness) and without evidence of structural disease, including a normal upper endoscopy, that can explain the symptoms
• Includes subcategories that can overlap: 
  • Postprandial distress syndrome (dyspepsia symptoms caused by meals): Includes 1 or both of the following for at least 3 days/week: Bothersome postprandial fullness or early satiety 
  • Epigastric pain syndrome (dyspepsia symptoms that do not occur exclusively postprandially and can be improved by meals): Includes at least 1 of the following for at least 1 day/week: Bothersome epigastric pain and/or burning   
• Criteria must be fulfilled for postprandial distress syndrome and/or epigastric pain syndrome and fulfilled for the last 3 months with symptoms starting at least 6 months prior to diagnosis (Rome IV criteria)
• No evidence is documented on routine evaluation (including upper endoscopy) of organic, systemic or metabolic disease that can explain the symptoms
• Patients with this diagnosis should be treated similarly as those with uninvestigated dyspepsia provided they meet the following criteria:
  
  • No heartburn
  • No NSAID or low-dose Aspirin use
  • Normal blood tests
  • No evidence of an abnormality
• H pylori eradication therapy is effective for patients with H pylori-positive functional dyspepsia 
  • Patients without symptoms 6-12 months following H pylori eradication therapy can be classified as H pylori-associated functional dyspepsia 

Refractory Functional Dyspepsia

• Persistence of symptoms for ≥8 weeks despite ≥2 medications after excluding other diseases or organic causes
• Patients are unresponsive to initial acid suppression therapy, prokinetics, antidepressants, and H pylori eradication therapy