Dyspepsia 

1. Definition 

Dyspepsia = Chronic or recurrent pain or discomfort centered in the upper abdomen (epigastrium).

It includes one or more of:

• Epigastric pain
• Epigastric burning
• Early satiety
• Postprandial fullness
• Bloating
• Nausea
  Heartburn alone = GORD, not dyspepsia (though overlap is common).

Differentiating Dyspepsia vs GERD 

2. Pathophysiology

Dyspepsia may be:

A. Organic (structural cause)

• Peptic ulcer disease
• Malignancy
• Pancreatic disease
• Biliary disease
• Drug-induced

B. Functional (most common)

 Functional Dyspepsia (FD)

Defined by Rome IV Criteria

Requires:

• ≥1 symptom:
• Postprandial fullness
• Early satiety
• Epigastric pain
• Epigastric burning
• No structural disease on endoscopy
• Symptoms ≥3 months, onset ≥6 months before diagnosis

Subtypes:

1. Postprandial distress syndrome (PDS)
2. Epigastric pain syndrome (EPS)

 Functional Dyspepsia vs IBS 

3. Causes of Dyspepsia 

— Gastric Causes

• Peptic Ulcer Disease
• Gastritis
• Gastric carcinoma
• Lymphoma

— Infection

• Helicobacter pylori

— Drug-Induced

• NSAIDs
• Steroids
• Bisphosphonates
• Iron
• Metformin

— Reflux Disease

• Gastroesophageal Reflux Disease

— Pancreatic

• Chronic pancreatitis
• Pancreatic carcinoma

— Biliary

• Gallstones
• Biliary colic

— Malignancy Red Flags

• Gastric cancer
• Pancreatic cancer

4.Alarm Features 

Immediate endoscopy if:

• Age ≥55 (UK NICE cutoff; may vary regionally)
• Unintentional weight loss
• Dysphagia
• Persistent vomiting
• GI bleeding
• Iron deficiency anemia
• Epigastric mass
• Family history of upper GI cancer

5. Clinical Assessment

History

Ask about:

• Relation to meals
• NSAID use
• Weight loss
• Vomiting
• Dysphagia
• Alcohol
• Smoking

Pain Patterns

6. Investigation Strateg

Stepwise Approach (NICE-based)

# Age <55, No Alarm Features

➡ Test and treat for H. pylori

Tests:

• Urea breath test (best)
• Stool antigen
• Serology (not preferred)

# Age ≥55 OR Alarm Features

➡ Urgent OGD (endoscopy)

Endoscopy Findings

7. Management 

A. Lifestyle 

• Weight reduction
• Stop smoking
• Reduce alcohol
• Avoid NSAIDs
• Small frequent meals
• Avoid trigger foods

B. H. pylori Eradication

Triple therapy (14 days):

• PPI
• Amoxicillin
• Clarithromycin

OR metronidazole if penicillin allergy

Confirm eradication after 4 weeks.

C. Acid Suppression

First line:PPI for 4–8 weeks

If relapse:

• Long-term lowest effective dose

D. Functional Dyspepsia Management

1. PPI trial
2. H. pylori eradication if positive
3. Prokinetics (limited use)
4. Low-dose TCA (e.g., amitriptyline)
5. Psychological therapy if refractory

8. Complications of Untreated Organic Dyspepsia

• GI bleeding
• Perforation
• Gastric outlet obstruction
• Malignancy progression

9. Specia Scenarios

# NSAID User

Stop NSAID + PPI
Test for H. pylori

# Elderly New-Onset Dyspepsia

Always scope

# Persistent Symptoms After PPI

• Check compliance
• Test H. pylori
• Consider functional dyspepsia
• Consider biliary or pancreatic cause

10. Causes of Epigastric Pain