Evaluation of the Patient with Dyspepsia

Journal of Family Practice, June, 2001 by John Smucny

KEY POINTS

* Functional dyspepsia is the most common diagnosis for the dyspeptic patient in the primary care setting, occurring in approximately 3 out of 4 patients.

* The history and physical examination are not very helpful for distinguishing functional dyspepsia from organic dyspepsia.

* Endoscopy is more accurate than upper gastrointestinal series, particularly for detecting small ulcers and cancers.

* Evidence supports a "test and treat" approach for the initial management of patients younger than 45 years who do not have alarm symptoms for malignancy or complicated disease and immediate endoscopy for patients older than 45 years or who have alarm symptoms.

An international consensus conference has defined dyspepsia as chronic or recurrent pain or discomfort that is centered in the upper abdomen.[1] This discomfort includes such symptoms as early satiety, fullness, bloating, and nausea. Up to 50% of people in community surveys in the United States and Europe report having dyspepsia.[2] Although only a minority of people with dyspepsia seek care,[3,4] this complaint still accounts for 2% to 3% of visits to family physicians.[5] Patients with dyspepsia report lower quality of life than asymptomatic people; in one report, they had a quality of life similar to patients with angina.[6] This review discusses the evaluation of dyspepsia and will be followed next month by a review of the treatment of dyspepsia.

DIFFERENTIAL DIAGNOSIS

Information about the differential diagnosis of this condition largely comes from studies in which patients with dyspepsia were referred for upper endoscopy (Table 1).[7] The most common identifiable conditions were esophagitis, gastric ulcer, and duodenal ulcer. Most patients in these studies did not have any abnormalities on endoscopy and were considered to have functional dyspepsia. The patho-physiology of functional dyspepsia is not well understood and is likely to be multifactorial. Gastroduodenal dysmotility, increased gastric acid secretion, increased visceral sensation to distention and/or gastric acid, psychological distress, and environmental factors such as smoking and Helicobacter pylori infection all may play a role.[8]

TABLE 1
ENDOSCOPIC FINDINGS IN PATIENTS WITH DYSPEPSIA[7]

                                                 Patients Presenting
                         Patients Referred            to General
                           for Endoscopy             Practitioners
Endoscopic diagnosis   (9 Studies, N=7658), %   (3 Studies, N=2922), %

Esophagitis                     5-18                     0-10
Gastric ulcer                   2-8                      4-6
Duodenal ulcer                  4-13                     9-10
Gastric cancer                  1-3                      1-2
No abnormality noted           65-85                    75-80

When dyspeptic patients undergo more extensive evaluations and/or are followed up for longer periods of time, a large variety of other conditions have been identified. These include gastroesophageal reflux without esophagitis, lactose intolerance, cholelithiasis, gastroparesis, chronic pancreatitis, pancreatic cancer, celiac disease, giardiasis, and ischemic heart disease.[9-11] However, it is not always clear that these diagnoses are completely responsible for a patient's dyspeptic symptoms. Finally, a variety of medications or other ingestions (such as alcohol) can lead to dyspepsia.[12]

USING THE HISTORY AND PHYSICAL EXAMINATION

The history and physical examination are important in detecting red flags for potentially fatal conditions, such as cancer or complicated ulcers. Alarm symptoms include dysphagia, gastrointestinal bleeding, acute abdominal pain, jaundice, or an abdominal mass. The presence of 1 or more of these symptoms should trigger a consultation with a surgeon or a gastroenterologist and possible endoscopy.

A patient's age is of some help in diagnosis; older patients are more likely to have identifiable causes for dyspepsia than those who are younger.[7,9] This is particularly true for gastric cancer, which is rare in people younger than 45 years in Europe and North America. In 1 study that identified all cases of gastric cancer in a population of 280,500, only 25 of 319 gastric cancers occurred in patients younger than 55 years. Of these patients, 24 of 25 had symptoms or signs of gastric cancer: weight loss (14), dysphagia (8), anemia (7), gastrointestinal bleed (3), previous gastric surgery (3), palpable mass (3), gastrointestinal perforation (1), and cerebral metastases (1).[13] Historical and demographic factors that are more likely to be seen in patients with ulcers than in those with functional dyspepsia are male sex, smoking, and nonsteroidal anti-inflammatory drug (NSAID) use.[14]

Table 2 shows the results of 3 large prospective studies of patients with dyspepsia who were referred for endoscopy.[12,15,16] Although certain symptoms are more likely to occur in some conditions than in others, no single item from the history and physical examination clearly establishes a diagnosis. Compared with patients with normal endoscopic examinations, those with ulcers are more likely to have relief of pain with food or antacids; those with gastric cancer are more likely to have lost weight; and those with esophagitis are more likely to have heartburn and pain relief with antacids. Symptoms such as nausea, distinct localization of pain, and nocturnal pain overlap to a large degree among patients with different diagnoses and are therefore not helpful.