Dyspepsia

Introduction

Dyspepsia, commonly referred to as indigestion, is a clinical syndrome characterised by upper abdominal discomfort or pain. It may be accompanied by bloating, early satiety, nausea, belching, and sometimes heartburn. It is typically benign but may be the presenting symptom of peptic ulcer disease, gastro-oesophageal reflux disease (GORD), or gastric malignancy.

Peak Incidence

• Most common in adults aged 20–60 years, with a slight female predominance.

Pathophysiology

• Dyspepsia may arise from various underlying conditions, or it may be functional (non-ulcer dyspepsia).
• Common causes include:
  • Functional dyspepsia (most frequent)
  • GORD
  • Peptic ulcer disease
  • Gastritis
  • Helicobacter pylori infection
  • Medication-induced mucosal irritation (e.g. NSAIDs, aspirin)

Symptoms

• Epigastric pain or discomfort
• Postprandial fullness
• Early satiety
• Bloating
• Nausea (± occasional vomiting)
• Belching
• Heartburn and acid regurgitation (if overlapping with GORD)

Signs

• Often no abnormal findings on examination
• May have epigastric tenderness
• Red flag signs requiring urgent investigation:
  • Unintentional weight loss
  • Iron-deficiency anaemia
  • Dysphagia
  • Haematemesis or melaena
  • Palpable upper abdominal mass
  • Lymphadenopathy

Diagnosis

Clinical Assessment

• History is key. Classify as:
  • Epigastric pain syndrome
  • Postprandial distress syndrome
• Assess for red flag symptoms (see above)

NICE Referral Criteria (Urgent Endoscopy Within 2 Weeks)

• All patients with:
  • Dysphagia
  • Upper abdominal mass suggestive of gastric cancer
  • Haematemesis
• Patients aged ≥55 years with weight loss and one of:
  • Upper abdominal pain
  • Dyspepsia
  • Reflux
• Patients aged ≥55 years with any of the following:
  • Treatment-resistant dyspepsia
  • Low haemoglobin with upper abdominal pain
  • Raised platelet count with any of: dyspepsia, nausea, vomiting, weight loss, or upper abdominal pain
  • Nausea or vomiting with any of: weight loss, reflux, dyspepsia, or upper abdominal pain

Investigations

• Test for H. pylori:
  • Urea breath test (preferred)
  • Stool antigen test (alternative)
  • Avoid PPIs and antibiotics for 2 weeks prior to testing
• FBC – to check for anaemia
• Further investigations (e.g. LFTs, U&Es) if clinical suspicion of alternative diagnoses

Complications

• Peptic ulcer disease
• Gastrointestinal bleeding
• Gastric or oesophageal perforation
• Gastric outlet obstruction
• Oesophageal strictures (if associated with chronic GORD)

Management

General Approach

• Review medications that may contribute to dyspepsia (e.g. NSAIDs, bisphosphonates, SSRIs).
• Lifestyle modifications:
  • Reduce portion sizes
  • Avoid meals within 3 hours of lying down
  • Identify and avoid trigger foods (e.g. spicy, fatty, acidic)
  • Weight loss if overweight
  • Avoid smoking, alcohol, caffeine, and stress

Medical Therapy

• First-line:

  • Test and treat for H. pylori or
  • Trial of full-dose PPI for 4 weeks (e.g. omeprazole, esomeprazole, lansoprazole, pantoprazole)

• If symptoms persist after PPI trial:

  • Switch to H2-receptor antagonist (e.g. famotidine, cimetidine)
  • Consider upper GI endoscopy if not already done

• Antacids and alginates:

  • Used for short-term symptom relief (e.g. calcium carbonate, magnesium hydroxide)