Dyspepsia: A Merck Manual of Patient Symptoms podcast

Dyspepsia is a sensation of pain or discomfort in the upper abdomen; it often is recurrent. It may be described as indigestion, gassiness, early satiety, postprandial fullness, gnawing, or burning.

Etiology

There are several common causes of dyspepsia (see Table 2: Approach to the Patient with Upper GI Complaints: Some Causes of Dyspepsia).

Table 2
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Some Causes of Dyspepsia Cause Suggestive Findings Diagnostic Approach Achalasia Slowly progressive dysphagia, sometimes nocturnal regurgitation of undigested food, chest discomfort Barium swallow Esophageal manometry Endoscopy Cancer (eg, esophageal, gastric) Chronic, vague discomfort Later, dysphagia (esophageal) or early satiety (gastric) Weight loss Upper endoscopy Coronary ischemia Symptoms described as “gas” or “indigestion” rather than chest pain by some patients with coronary ischemia May have exertional component, cardiac risk factors ECG Serum cardiac markers Sometimes stress testing Delayed gastric emptying (caused by diabetes, viral illness, drugs) Nausea, bloating, fullness Scintigraphic test of gastric emptying Drugs (eg, bisphosphonates, erythromycinSome Trade Names ERY-TAB ERYTHROCIN Click for Drug Monograph and other macrolide antibiotics, estrogensSome Trade Names PREMARIN Click for Drug Monograph , iron, NSAIDs, potassium) Use apparent on history, symptoms coincident with use Clinical evaluation Esophageal spasm Substernal chest pain with or without dysphagia for liquids and solids Barium swallow Esophageal manometry Gastroesophageal reflux disease Heartburn, sometimes reflux of acid or stomach contents into mouth Symptoms sometimes triggered by lying down Relief with antacids Clinical evaluation Sometimes endoscopy Sometimes 24-h pH testing Peptic ulcer disease Burning or gnawing pain relieved by food, antacids Upper endoscopy

Many patients have findings on testing (eg, duodenitis, pyloric dysfunction, motility disturbance, Helicobacter pylori gastritis, lactose deficiency, cholelithiasis) that correlate poorly with symptoms (ie, correction of the condition does not alleviate dyspepsia).

Nonulcer (functional) dyspepsia is defined as dyspeptic symptoms in a patient who has no abnormalities on physical examination and upper GI endoscopy.

Evaluation

History: History of present illness should elicit a clear description of the symptoms, including whether they are acute or chronic and recurrent. Other elements include timing and frequency of recurrence, any difficulty swallowing, and relationship of symptoms to eating or taking drugs. Factors that worsen symptoms (particularly exertion, certain foods or alcohol) or relieve them (particularly eating or taking antacids) are noted.

Review of systems seeks concomitant GI symptoms such as anorexia, nausea, vomiting, hematemesis, weight loss, and bloody or black (melanotic) stools. Other symptoms include dyspnea and diaphoresis.

Past medical history should include known GI and cardiac diagnoses, cardiac risk factors (eg, hypertension, hypercholesterolemia), and the results of previous tests that have been done and treatments that have been tried. Drug history should include prescription and illicit drug use as well as alcohol.

Physical examination: Review of vital signs should note presence of tachycardia or irregular pulse.

General examination should note presence of pallor or diaphoresis, cachexia, or jaundice. Abdomen is palpated for tenderness, masses, and organomegaly. Rectal examination is done to detect gross or occult blood.

Red flags: The following findings are of particular concern:

• Acute episode with dyspnea, diaphoresis, or tachycardia
• Anorexia
• Nausea or vomiting
• Weight loss
• Blood in the stool
• Dysphagia or odynophagia
• Failure to respond to therapy with H₂ blockers or proton pump inhibitors (PPIs)

Interpretation of findings: Some findings are helpful (see Table 2: Approach to the Patient with Upper GI Complaints: Some Causes of Dyspepsia).

A patient presenting with a single, acute episode of dyspepsia is of concern, particularly if symptoms are accompanied by dyspnea, diaphoresis, or tachycardia; such patients may have acute coronary ischemia. Chronic symptoms that occur with exertion and are relieved by rest may represent angina.

GI causes are most likely to manifest as chronic complaints. Symptoms are sometimes classified as ulcer-like, dysmotility-like, or reflux-like; these classifications suggest but do not confirm an etiology. Ulcer-like symptoms consist of pain that is localized in the epigastrium, frequently occurs before meals, and is partially relieved by food, antacids, or H₂ blockers. Dysmotility-like symptoms consist of discomfort rather than pain, along with early satiety, postprandial fullness, nausea, vomiting, bloating, and symptoms that are worsened by food. Reflux-like symptoms consist of heartburn or acid regurgitation. However, symptoms often overlap.

Alternating constipation and diarrhea with dyspepsia suggests irritable bowel syndrome or excessive use of OTC laxatives or antidiarrheals.

Testing: Patients in whom symptoms suggest acute coronary ischemia, particularly those with risk factors, should be sent to the emergency department for urgent evaluation, including ECG and serum cardiac markers.

For patients with chronic, nonspecific symptoms, routine tests include CBC (to exclude anemia caused by GI blood loss) and routine blood chemistries. If results are abnormal, additional tests (eg, imaging studies, endoscopy) should be considered. Because of the risk of cancer, patients > 45 and those with new-onset red flag findings should undergo upper GI endoscopy. For patients < 45 with no red flag findings, some authorities recommend empiric therapy for 2 to 4 wk with antisecretory agents followed by endoscopy in treatment failures. Others recommend screening for H. pylori infection with a C₁₄-urea breath test or stool assay (see Gastritis and Peptic Ulcer Disease: Noninvasive tests). However, caution is required in using H. pylori or any other nonspecific findings to explain symptoms.

Esophageal manometry and pH studies are indicated if reflux symptoms persist after upper GI endoscopy and a 2- to 4-wk trial with a PPI.

Treatment

Specific conditions are treated. Patients without identifiable conditions are observed over time and reassured. Symptoms are treated with PPIs, H₂ blockers, or a cytoprotective agent (see Table 3: Approach to the Patient with Upper GI Complaints: Some Oral Drugs for Dyspepsia). Prokinetic drugs (eg, metoclopramideSome Trade Names
REGLAN
Click for Drug Monograph
, erythromycinSome Trade Names
ERY-TAB
ERYTHROCIN
Click for Drug Monograph
) given as a liquid suspension also may be tried in patients with dysmotility-like dyspepsia. However, there is no clear evidence that matching the drug class to the specific symptoms (eg, reflux vs dysmotility) makes a difference. MisoprostolSome Trade Names
CYTOTEC
Click for Drug Monograph
and anticholinergics are not effective in functional dyspepsia. Drugs that alter sensory perception (eg, tricyclic antidepressants) may be helpful.

Table 3
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Some Oral Drugs for Dyspepsia Drug Usual Dose* Comments Proton pump inhibitors EsomeprazoleSome Trade Names NEXIUM Click for Drug Monograph LansoprazoleSome Trade Names PREVACID Click for Drug Monograph OmeprazoleSome Trade Names PRILOSEC Click for Drug Monograph PantoprazoleSome Trade Names PROTONIX Click for Drug Monograph RabeprazoleSome Trade Names ACIPHEX Click for Drug Monograph 40 mg once/day 30 mg once/day 20 mg once/day 40 mg once/day 20 mg once/day With long-term use, elevated gastrin levels, but no evidence that this causes dysplasia or cancer May cause abdominal pain and/or diarrhea H2 blockers CimetidineSome Trade Names TAGAMET Click for Drug Monograph FamotidineSome Trade Names PEPCID Click for Drug Monograph NizatidineSome Trade Names AXID Click for Drug Monograph RanitidineSome Trade Names ZANTAC Click for Drug Monograph 800 mg once/day 40 mg once/day 300 mg once/day 300 mg once/day or 150 mg bid Doses reduced in elderly patients With cimetidineSome Trade Names TAGAMET Click for Drug Monograph and to a lesser extent other drugs, minor antiandrogen effects and, less commonly, erectile dysfunction Also, delayed metabolism of drugs eliminated by cytochrome P-450 enzyme system (eg, phenytoinSome Trade Names DILANTIN Click for Drug Monograph , warfarinSome Trade Names COUMADIN Click for Drug Monograph , diazepamSome Trade Names VALIUM Click for Drug Monograph ) May cause constipation or diarrhea Cytoprotective agent SucralfateSome Trade Names CARAFATE Click for Drug Monograph 1 g po qid Rarely, constipation May bind to other drugs and interfere with absorption CimetidineSome Trade Names TAGAMET Click for Drug Monograph , ciprofloxacinSome Trade Names CILOXAN CIPRO Click for Drug Monograph , digoxinSome Trade Names DIGITEK LANOXIN Click for Drug Monograph , norfloxacinSome Trade Names NOROXIN Click for Drug Monograph , ofloxacinSome Trade Names FLOXIN Click for Drug Monograph , and ranitidineSome Trade Names ZANTAC Click for Drug Monograph avoided 2 h before or after taking sucralfateSome Trade Names CARAFATE Click for Drug Monograph

Key Points

• Coronary ischemia is possible in a patient with acute “gas.”
• Endoscopy is indicated for patients > 45 or with red flag findings.
• Empiric treatment with an acid blocker is reasonable for patients < 45 without red flag findings. Those who do not respond in 2 to 4 wk require further evaluation.

Last full review/revision March 2008 by Norton J. Greenberger, MD

Content last modified March 2008