An Approach to Dyspepsia

Introduction
Differential Diagnosis
Evaluation Priorities

Context: OPD

Introduction

Dyspepsia is a broad, generic term used to encompass symptoms the patient and the doctor interpret as originating from the foregut, i.e. typically discomfort centred in the epigastrium, persisting for at least one month.

It is a symptom that usually is associated with functional or benign upper GI conditions, but that can also be the earliest presentation of lethal upper GI cancers- herein is the diagnostic challenge.

This chapter excludes patients who experience severe, debilitating pain requiring hospital evaluation- these will be considered in a separate chapter. In real life, there is often an overlap (“a grey zone”) between dyspepsia and severe epigastric pain- your job as a doctor is always to consider all possibilities and work it out!

It is important to ask if the dyspepsia is constant and progressive or episodic, as the latter is more
suggestive of functional disorders. Try to elicit from the patient is the symptom is predominantly “pain” (typically caused by peptic ulceration), “heartburn” (strongly suggestive of GERD) or “bloating and nausea” (associated with functional GIT disorders, drug-related side effects, or autonomic neuropathy in diabetic patients). In practice, you will notice that there is significant heterogeneity in symptomatology, and patients will often describe sensations that may overlap in each of these categories!

Ask specifically about the use of known GIT irritants, such as smoking, alcohol intake, and recreational and prescribed drugs. It is also essential to take a detailed dietary history and to accurately document weight loss and any change in bowel habit.

On examination pay specific attention to signs of dehydration, weight loss, anaemia, jaundice, and supra-clavicular adenopathy. Patients with an underlying malignancy may have evidence of muscle wasting, loss of subcutaneous fat, and peripheral oedema due to weight loss. Abdominal examination is usually unremarkable, but you may elicit epigastric tenderness or a palpable abdominal mass. Ascites may indicate the presence of peritoneal carcinomatosis.

Most patients (75%) with dyspepsia will not display any demonstrable pathology. They are categorised as “functional dyspepsia” or “non-ulcer dyspesia” (NUD).

The commonest organic pathology noted will be peptic ulceration and GERD. Gastric and pancreatic
cancer will account for less than 1% of all cases.

Differential Diagnosis

Evaluation Priorities

The majority of cases can be managed symptomatically, without any investigations. The use of invasive investigations is limited to new-onset dyspepsia in patients over the age of 60, and in those with convincing alarm symptoms. Most should be investigated as outpatients.

Look for alarm symptoms suggestive of GIT malignancy, and investigate if you have a clinical suspicion. The best initial investigation is an upper gastrointestinal endoscopy.

What other investigations must I consider? Be selective in the investigations, and use common sense.