Dyspepsia Initial Assessment

The symptoms alone are not reliable in distinguishing organic causes of dyspepsia from functional dyspepsia; thus, patients have to undergo investigation to exclude organic, systemic or metabolic disease to diagnose functional dyspepsia. Dyspepsia in patients who have not yet undergone endoscopic evaluation to identify a specific underlying cause is referred to as uninvestigated dyspepsia.

Signs and Symptoms

Ulcer-like symptoms are chronic or recurrent epigastric pain or discomfort for at least 2-4 weeks. The pain improves with food or acid-reducing medications, occurs before meals or when hungry, may wake the patient from sleep, and tends to follow a pattern of remission and relapse. Reflux-like symptoms are characterized by acid regurgitation and heartburn. Dysmotility-like symptoms include bloating in the upper abdomen not accompanied by visible distension, early satiety, nausea and vomiting; postprandial fullness, and upper abdominal discomfort often aggravated by food. Western patients more often exhibit ulcer-like and reflux-like symptoms, while Eastern patients predominantly experience dysmotility-type or postprandial distress syndrome (PDS) symptoms, including early satiety, bloating and belching. 

Inquire regarding the onset, severity and duration of symptoms and any progressive symptoms should be considered in the alternative diagnoses. Detailed medical, surgical, social (eg smoking and alcohol intake, stress, psychological trauma), family and dietary histories reduce the alternative diagnoses. Review medications for possible causes of dyspepsia (eg calcium antagonists, nitrates, theophyllines, bisphosphonates, steroids and NSAIDs, Aspirin, Acarbose, Orlistat, potassium supplements, opioids).

Functional dyspepsia has been reported to be significantly associated with depression, anxiety and other psychopathological factors. Sleep, trauma, eating restriction, and health anxiety are included as part of biopsychosocial assessment. Screen for anxiety and depression using the Generalized Anxiety Disorder-7 (GAD-7) and Patient Health Questionnaire-9 (PHQ-9) screening tools, respectively. Consider early specialist referral for patients identified with significant psychological symptoms to enable concurrent treatment of underlying psychiatric conditions, rather than delaying referral until after multiple medical therapies have failed.

The physical exam should include the patient’s vital signs, body mass index (BMI) and abdominal, rectal and pelvic (for women) exams. This is often normal except for epigastric tenderness. Other physical exam findings may help diagnose or exclude other diseases including right upper quadrant tenderness for cholecystitis, palpable abdominal mass in hepatoma, and lymphadenopathy in gastric malignancy.

Functional Dyspepsia or Non-Ulcer Dyspepsia

Functional dyspepsia or non-ulcer dyspepsia is diagnosed when no evidence is documented on routine evaluation (including imaging or upper endoscopy) of structural, systemic or metabolic disease that can explain the chronic dyspeptic symptoms which may be severe enough to impair daily functioning.

Functional dyspepsia includes subtypes that can overlap: PDS, which is dyspepsia symptoms caused by meals; and epigastric pain syndrome (EPS) which is dyspepsia symptoms that do not occur exclusively postprandially and can be improved by meals. 

Rome V Diagnostic Criteria for Functional Dyspepsia and Its Subtypes

Functional dyspepsia is diagnosed in patients who, for the past 3 months with symptom onset for at least 6 months prior to diagnosis, and experience ≥1 bothersome symptoms (eg epigastric pain or burning, early satiety or postprandial fullness) in the absence of structural, systemic or metabolic disease that could explain the symptoms; must fulfill criteria for PDS or EPS, or both.

PDS includes one or both of the following symptoms for at least 2 days/week: Bothersome postprandial fullness (severe enough to affect usual activities) or bothersome early satiety (severe enough to hinder completion of a regular-sized meal). In the presence of either or both symptoms, other bothersome symptoms (ie postprandial epigastric pain or burning, postprandial nausea, postprandial upper abdominal bloating or postprandial excessive belching) that are elicited or worsened by food ingestion are part of PDS. Predominant nausea and/or persistent vomiting rules out the diagnosis of PDS. Heartburn is not a gastroduodenal symptom but often coexists. There is also absence of structural, systemic, or metabolic disease that could likely explain the symptoms on routine investigations.

EPS includes one or both of the following symptoms for at least 1 day/week which are severe enough to affect usual activities: Bothersome epigastric pain or epigastric burning. Both symptoms can be induced or worsened postprandially or occur independently from meal ingestion. Postprandial EPS is epigastric pain or epigastric burning that starts or gets worse after meals in ≥50% of the times, while meal-unrelated EPS is epigastric pain or epigastric burning that starts or gets worse after meals in <50% of the times. In EPS, PDS criteria are not fulfilled. Predominant nausea or persistent vomiting or both, rules out the diagnosis of EPS. Also, heartburn is not a gastroduodenal symptom but may often coexist. Lastly, the absence of structural, systemic or metabolic disease that could likely explain the symptoms on routine investigations is also noted. 

Refractory Functional Dyspepsia

Refractory functional dyspepsia is the persistence of symptoms for ≥8 weeks despite ≥2 medications after excluding other diseases or organic causes. Patients are unresponsive to initial acid suppression therapy, prokinetics, antidepressants, and Helicobacter pylori eradication therapy.

Postinfection Functional Dyspepsia

Postinfection functional dyspepsia is a distinct medical condition that develops following acute gastroenteritis. Pathogens associated with postinfectious functional dyspepsia symptoms include Salmonella spp, Escherichia coli, Campylobacter jejuni, Giardia lamblia and norovirus. Emerging evidence points to a potential relationship between coronavirus disease 2019 (COVID-19) and the development of functional dyspepsia.