Urgent considerations

See Differentials for more details

Coronary artery disease

This should be excluded as the first step in the assessment of dyspepsia. The history is critical, particularly at an unexpected age where congenital coronary abnormality or substance misuse (e.g., amphetamine, cocaine) could be a factor. In making an assessment of dyspepsia, consider that cardiac disorders present with a shorter duration of symptoms (hours, days, or weeks), temporal relationship of symptoms to exertion, and associated features such as dyspnea, weakness, diaphoresis, or altered cardiovascular vital signs. Burning quality of pain and lack of standard risk factors do not exclude cardiac causes.[20][21]​ 

Diagnostic tests include ECG, serum troponin, exercise stress testing, 99mTc-methoxyisobutyl isonitrile scan, and coronary angiography. Patients suspected of having an acute cardiac problem will need to be assessed to determine the need for urgent intervention to protect threatened cardiac muscle. Such interventions include antiplatelet therapy (aspirin or clopidogrel), anticoagulants such as heparin, thrombolytic therapy, or placement of a coronary artery stent.

Other acute cardiovascular problems that could present with symptoms causing confusion with dyspepsia could include dissecting aortic aneurysm, pericarditis, cardiomyopathy, and, rarely, cardiac arrhythmias.

Upper gastrointestinal malignancy

Malignancy is a rare cause of upper gastrointestinal (UGI) symptoms in primary care;[23] however, older patients are far more likely than younger patients to have a neoplasm as the underlying cause for their symptoms. A lower age limit has not been identified that will completely exclude any risk of UGI malignancy; however, the risk of a person <60 years having UGI malignancy is typically very low, even in the presence of an alarm feature.[3]

In the US, endoscopy is suggested for patients ≥60 years to exclude malignancy as the underlying cause of new onset dyspepsia.[3]

In the UK, urgent UGI endoscopy is recommended for those ages 55 years or over with weight loss and dyspepsia.[16]​ Non-urgent UGI endoscopy should be considered for those ages 55 years or over with:[16]

  • treatment-resistant dyspepsia, or

  • dyspepsia with raised platelet count or nausea or vomiting.

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

The standard alarm features of serious UGI disease can be remembered by the acronym VBAD:

V: vomiting

B: bleeding or anemia

A: abdominal mass or unintended weight loss

D: dysphagia.

Of patients (mean age 59 years) with alarm features, 3.8% will have UGI malignancy and 12.8% will have complicated disease (i.e., with bleeding, perforation, ischemia, or obstruction) or severe disease.​[24]

These alarm features (particularly when new in onset, persistent, and progressive) along with abnormal abdominal exam (typical of perforation, ischemia, and obstruction) are used to identify those patients who might require additional investigations or interventions.[25]​ Theoretically, alarm features are very sensitive; nearly all patients who have malignancy will have these features when they present for care.[24]​ However, alarm features have poor positive predictive value; most patients with alarm features will not have malignancy.[26]​ Taken alone, alarm features should not cause undue concern.[24][27]

Special attention is required when assessing older patients (>60 years) with new onset (a few months) of progressive symptoms, particularly in the presence of alarm features. The clinician must assess the need to search for malignancy or complicated UGI disease (i.e., with bleeding, perforation, ischemia, or obstruction);[24]​​[26][27]​​ this will often include prompt endoscopy. When evaluating patients with dyspepsia for malignancy or complicated disease, it is important to consider the need for further investigation using UGI endoscopy (preferred), UGI barium contrast radiography, abdominal computed tomography scan, and abdominal ultrasound for selected patients.[5]​[28][29]​

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