Approach

The assessment of uninvestigated dyspepsia requires consideration of a variety of factors; however, the initial interview will usually unfold in an unstructured fashion. Symptoms are the central focus of the initial assessment; it is therefore essential that enquiries about symptoms are made in a manner that is relevant to patients.[1] The assessor must understand precisely what the patient is experiencing.

Careful clinical assessment is needed, particularly for patients aged >60 years, those with alarm features, and those with recent onset (a few months) of worsening or atypical symptoms. A careful clinical assessment outperforms age and alarm features alone in the search for malignancy.​[24]​​[26][27]​​[30][31] The standard alarm features can be remembered by the acronym VBAD:

  • V: vomiting

  • B: bleeding or anaemia

  • A: abdominal mass or unintended weight loss

  • D: dysphagia.

Assessment of patients with dyspepsia

The initial assessment of a patient with dyspepsia is based on the age of the patient and the probability of serious disease being present. The history and physical examination are designed to identify other medical conditions that can cause dyspeptic symptoms.

The image below illustrates a management pathway, based on the American College of Gastroenterology / Canadian Association of Gastroenterology (ACG/CAG) guideline on the management of dyspepsia.[3]​​[Evidence A]​ ACG/CAG guidance recommends that patients ≥60 years who present with new onset dyspepsia should undergo endoscopy to rule out serious disease, including malignancy.[3]

Alarm features such as unintentional weight loss, progressive dysphagia, odynophagia, unexplained iron deficiency anaemia, persistent vomiting, palpable mass in the abdomen, or a family history of upper gastrointestinal cancer should prompt consideration for endoscopy, regardless of patient age.

Patients with no alarm symptoms should initially receive a non-invasive test for Helicobacter pylori. Tests that detect active infection with H pylori, such as the stool antigen test or the urea breath test, are preferred over serology.[32] Patients who test negative for H pylori, or those who are still symptomatic after H pylori eradication, should be given a short trial (4-8 weeks) of proton pump inhibitor therapy. Patients who are still symptomatic after this trial may benefit from a tricyclic antidepressant (an 8-12-week trial) or prokinetic therapy (a 4-8 week trial).[3]​​ [ Cochrane Clinical Answers logo ] ​ Non-responders should be re-evaluated in case new symptoms or findings drive further investigation. Investigation for motility disorders such as gastroparesis should also be considered at this time, along with psychotherapy if appropriate.[Figure caption and citation for the preceding image starts]: Pathway for the management of dyspepsiaCreated by the BMJ Knowledge Centre based on information in the ACG and CAG guideline. [Citation ends].com.bmj.content.model.assessment.Caption@730f2e2a

Patients with functional dyspepsia may require referral to a consultant for further assessment if there is diagnostic doubt; symptoms are severe, or refractory to first-line treatments; or the patient requests a consultant opinion.[7]

Therapeutic trial of proton pump inhibitors

Initially proposed as a diagnostic test for GORD, a trial of proton pump inhibitor (PPI) therapy is now part of the algorithm for uninvestigated dyspepsia. A therapeutic trial of PPI for 1-2 months can be used to predict response to treatment for uninvestigated dyspepsia.[33][34][35]​ Symptom resolution at 1-2 months means a positive trial, and continuation of symptoms at 1-2 months means a negative trial. The United European Gastroenterology and European Society for Neurogastroenterology and Motility recommend PPI therapy as an effective therapy for functional dyspepsia.[14]​ A Cochrane review concluded that PPIs are effective in the treatment of functional dyspepsia.[36] [ Cochrane Clinical Answers logo ]

Imaging

Upper gastrointestinal (UGI) radiography is not recommended as an initial investigation for patients presenting with uninvestigated dyspepsia, due to sub-optimal performance and potentially misleading results.[4] Radiological assessment should generally be reserved for patients who have symptoms suggesting UGI motility disturbances or suspected UGI obstruction, when other investigations are not readily available. 

Abdominal ultrasound is not recommended as a routine investigation for patients presenting with uninvestigated dyspepsia because the diagnostic yield is low.[4]​ Abdominal ultrasound can be considered when the presentation suggests a hepatobiliary cause for symptoms. The finding of cholelithiasis does not indicate this is the cause of symptoms as asymptomatic gallstones are often found in the general population.

Endoscopy

UGI endoscopic examination is recommended when the presentation suggests complicated UGI disease (obstruction, perforation, and haemorrhage) or a serious underlying cause for the symptoms.[3]​​[6]​ Complicated UGI disease is identified by any of the following:

  • Alarm features (V: vomiting; B: bleeding or anaemia; A: abdominal mass or unintended weight loss; D: dysphagia)

  • Fever

  • Abdominal rigidity

  • Low haemoglobin.

ACG/CAG guidance on the management of dyspepsia suggests endoscopy to exclude malignancy as the underlying cause of new onset dyspepsia in older patients (≥60 years old), particularly if alarm features (VBAD) are present.[3]

In the UK, the National Institute for Health and Care Excellence (NICE) recommends urgent UGI endoscopy for those aged 55 years or over with weight loss and dyspepsia.[16] Non-urgent UGI endoscopy should be considered for those aged 55 years or over with:[16]

  • treatment-resistant dyspepsia, or

  • dyspepsia with raised platelet count or nausea or vomiting.

The British Society of Gastroenterology also recommends that non-urgent endoscopy should be considered in patients aged 55 years or over with dyspepsia and either a raised platelet count or nausea or vomiting.[7]

The threshold for investigation should be tailored to local protocols.[3][4]

Endoscopy may also benefit patients with unusual case presentations or significant comorbid conditions, as well as those who are unable to be reassured in the absence of an endoscopic examination.

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