Dyspepsia

GastricEsophageal
Written By Patricia

Diagnosis

Primary concern: epigastric pain for at least one month
Can be associated with other UGI symptoms such as epigastric fullness, nausea, vomiting, and heartburn.


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Who Should Get EGD

60 yo or older presenting with Dyspepsia - EGD to exclude upper GI neoplasia

  • Gastric cancer is 3rd most common cause of cancer death worldwide, often presents with dyspepsia.

  • Esophageal adenocarcinoma

Under the age of 60 with dyspepsia, even with some alarm features - No EGD to exclude UGI neoplasia

  • Alarm features: weight loss, anemia, dysphagia, persistent vomiting

  • Alarm features have limited use in detecting organic pathology such as malignancy, PUD, and esophagitis.

  • The risk of a person < 60 yo having malignancy is typically very low, so even with an alarm feature, the risk is less than 1% and it is very unlikely that endoscopy of young patients even with alarm features is cost-effective.

Initial Assessment for Dyspepsia

Under 60:

Non-invasive H. pylori testing for patients under 60 yo

  • Treat positive H. pylori patients and test for eradication

PPI therapy for patients under 60 yo if H. pylori-negative or if remain symptomatic after H. pylori eradication

  • alternative is H2RA

60 and Over

EGD

Nonresponse to H. pylori eradication or PPI

Prokinetic Therapy: If under the age of 60, and non-responsive to PPI and/or H. pylori eradication therapy

  • Low-quality evidence

  • No randomized studies comparing prokinetic therapy with placebo. Three trials compared PPI with prokinetic therapy and there was a trend for PPI to be more effective, but not statistically significant.

  • The prokinetics that were evaluated in randomized trials (cisapride and mosapride) are not universally available.

  • Given risks of prokinetics, use at lowest effective dose and consistent with country-specific safety recommendations (e.g. ) metoclopramide for less than 12 weeks; domperidone 30mg daily or less)

Tricyclic Antidepressant: if under 60 yo, non-responsive to PPI and/or H. pylori eradication therapy

  • Low-quality evidence

  • TCA in three trials had a significant effect in reducing dyspepsia symptoms

  • TCA unlikely to have a major impact on PUD or GERD

Functional Dyspepsia

  • Treat positive H. pylori patients and test for eradication

  • H. pylori negative, treat with PPI

  • Tricyclic Antidepressants if non-responsive to H. pylori eradication and PPI

  • Prokinetic therapy if non-responsive to H. pylori eradiciation, PPI, and Tricyclic Antidepressants

  • Psychological therapy if non-responsive to drug therapies

  • No recommendations for routine use of complementary and alternative medicines

    • approaches to these studies are too diverse to draw any definitive conclusions

  • No recommendation for routine motility studies for FD

  • Gastroparesis suspected in functional dyspepsia, motility studies in selected patients

Moayyedi, Paul M MB, ChB, PhD, MPH, FACG1; Lacy, Brian E MD, PhD, FACG2; Andrews, Christopher N MD3; Enns, Robert A MD4; Howden, Colin W MD, FACG5; Vakil, Nimish MD, FACG6. ACG and CAG Clinical Guideline: Management of Dyspepsia. American Journal of Gastroenterology 112(7):p 988-1013, July 2017. | DOI: 10.1038/ajg.2017.154

Patricia
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