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Dyspepsia is a frequent reason for consultation in primary care and gastrointestinal practice. Dyspepsia is characterized by abdominal pain or discomfort centered in the upper abdomen.

What is dyspepsia?

The term is not a diagnosis in its own right. It has been used to refer to various symptoms including upper abdominal fullness, feeling full after a small amount of food, abdominal bloating, loss of appetite, nausea or vomiting. 

Dyspepsia is a common problem in the general population, with an estimated prevalence of 23–41% in most industrialized countries. Only about a quarter of those who experience dyspeptic symptoms seek medical attention. As many as 40% of the people in the United States have dyspepsia, but only about 5% go to a doctor to treat it. The reason for consultation is probably related to the symptom severity or frequency, fear of malignant diagnosis, underlying anxiety or other psychosocial factors. It accounts for 2-5% of primary care office visits and 30% of consultations by gastroenterologists.

There is no precise definition of dyspepsia. Dyspepsia is defined as persistent or recurrent pain or discomfort centered in the upper abdomen. Dyspepsia literally means bad digestion (In Greek ‘dys’ means bad and ‘peptein’ means digestion). Although it may improve in many patients, up to 50% of the affected individuals have chronic symptoms. Dyspepsia has a negative impact on health related quality of life, interferes with daily activities, work, sleep, socializing, eating and drinking and contributes to emotional stress.

Organic versus functional dyspepsia

Thorough investigation of dyspepsia usually results in the diagnosis of conditions like:

  • Acid reflux
  • Peptic ulcer disease
  • Pancreatic disorders
  • Biliary disorders like gallstone disease
  • Intolerance to medications
  • Parasitic infections
  • Food intolerance
  • Gastric  and other upper abdominal cancers

Dyspepsia due to some underlying medical conditions as above is called as organic dyspepsia. It accounts for 40% of the cases of dyspepsia. There are many pointers for organic dyspepsia which include:

  • Unintentional weight loss
  • Iron deficiency anemia
  • Gastrointestinal bleeding
  • Difficulty in swallowing
  • Pain during swallowing
  • Previous gastric surgery
  • Previous gastric ulcer
  • Treatment with NSAIDs (painkillers)
  • Persistent vomiting
  • Mass in the abdomen

If any of these are present then organic cause of dyspepsia should be suspected and the evaluation should be done to find the underlying cause. The commonly identified causes are peptic ulcer and acid reflux.
In more than 50% of the cases of dyspepsia no obvious cause is found. Individuals in whom recurrent or persistent dyspepsia occurs and none of the diagnostic tests including endoscopy are able to find any underlying cause are said to be suffering from functional dyspepsia. It is also called as nonulcer dyspepsia.  Patients with functional dyspepsia are a difficult group to manage.

Functional dyspepsia is a poorly understood disease. The possible causes that have been implicated in functional dyspepsia are Helicobacter pylori infection and psychological factors. The high prevalence of H.pylori infection and chronic dyspepsia has lead to the speculation that it might be the cause in most of the individuals with functional dyspepsia.  But many subsequent studies done have proved otherwise. Moreover treatment of H.pylori infection rarely leads to any improvement in symptoms. But still eradication of H.pylori infection is done as part of treatment of functional dyspepsia as about 15% respond to it.  Individuals with functional dyspepsia have increased prevalence of psychological disorders like anxiety, depression and hysteria. Acute life stresses may play a role in provoking dyspepsia.

Most of the affected individuals also have other functional disorders like irritable bowel syndrome. Studies have shown that nearly two thirds of the patients with functional dyspepsia also suffer from irritable bowel syndrome.
Functional dyspepsia is again divided in to three groups based on the predominant symptom it causes.

  • Ulcer like dyspepsia – pain is the predominant symptom
  • Dysmotility type or dyspepsia – abdominal bloating is the predominant symptom
  • Unspecified dyspepsia – When symptoms do not fit in to any of the above

Symptoms of dyspepsia

In addition to the symptoms that may be indicative of organic dyspepsia which are mentioned above, the common symptoms with which patients seek medical care are:

  • Abdominal pain above the belly-button
  • Abdominal discomfort – Discomfort is a negative feeling in the upper abdomen that does not reach the level of pain and may be characterized by one or more of the following symptoms
  • Early satiety - feeling full after a small amount of food
  • Fullness of stomach
  • Belching
  • Nausea and vomiting
  • Heartburn - If heartburn is the predominant symptom, then a diagnosis of gastroesophageal reflux disease is made and not called as dyspepsia.

Diagnosis of Dyspepsia

Physicians determine the cause of the dyspepsia by taking a careful medical history, performing a physical examination of the patient and ordering appropriate tests. If the alarm symptoms or the pointers for organic dyspepsia are present, then the following tests are done:

  • Upper gastrointestinal endoscopy - Any patient over the age of 45 with new-onset dyspepsia should undergo an endoscopy
  • Ultrasound scan of the abdomen
  • Upper GI and small bowel series
  • Breath tests for H.pylori and bacterial overgrowth - Patients with dyspepsia, below the age of 45 and with no alarm signs should have a blood test for H. pylori.
  • Gastric emptying study
  • 24 hours pH monitoring
  • Liver function test
  • Thyroid function test

Treatment of dyspepsia

If the symptoms and the tests done point towards organic dyspepsia, then the treatment should directed towards the specific cause.  If the tests are inconclusive, then it is considered functional dyspepsia and treatment is directed towards relief of symptoms.

After the diagnosis of functional dyspepsia, subsequent investigation should be avoided as it implies diagnostic uncertainty and may worsen the outcome. Minimum treatment required should be adopted with simple antacids. Because it is a functional disorder rather than an organic disease, functional dyspepsia can be difficult to treat.

General measures

  • Reassurance
  • Lifestyle advice:
  1. Stopping smoking
  2. Weight reduction
  3. Avoiding coffee, chocolates and excessive alcohol
  4. Avoiding medication associated with dyspepsia if possible (e.g. theophylline, NSAIDs. etc)
  5. Eating regular meals

Drug treatment

Scientific evidence for specific treatments is lacking and treatment is mainly for the relief of symptoms.

  • Antacids – Magnesium hydroxide, aluminum hydroxide
  • H2 receptor antagonists – Cimetidine, Ranitidine, Famotidine and Nizatidine
  • Proton pump inhibitors – Omeprazole, Lansoprazole, Rabeprazole, Pantoprazole and Esomeprazole
  • Prokinetics –Metaclopromide, Cisapride and Domperidone

Treatment of specific types of functional dyspepsia

  • For ulcer type of dyspepsia- Antacids or H2 receptor antagonists or proton pump inhibitors
  • For  dysmotility type of dyspepsia – Prokinetics
  • For unspecified type of dyspepsia – Proton pump inhibitors along with prokinetics

Since treatment of H.pylori infection is effective in about 15% of cases it may be tried.  Since psychological factors do play a role in functional dyspepsia, psychotherapy and antidepressants may be given.

  • Evidence-based Gastroenterology and Hepatology- 2nd Edition
  • The Encyclopedia of the Digestive System and Digestive Disorders
  • ABC of the Upper Gastrointestinal Tract
  • Clinic Handbook of Gastroenterology - John L.H.Wong
  • Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 8th edition
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