Laboratory Tests and Ancillaries
Diagnostic Tests
Dyspepsia_Diagnostics 1
In Asian countries with high incidences of gastric cancer (eg China, Japan and Korea) and peptic ulcer (eg Bangladesh and parts of India), diagnostic tests are crucial to exclude organic causes, and depending on local resources and epidemiology, these may include complete blood count (CBC), blood chemistries, stool examination, Helicobacter pylori (H pylori) test, abdominal ultrasound or computed tomography (CT) scan and endoscopy before functional dyspepsia is diagnosed. CBCs and blood chemistries (eg liver function tests [LFTs], pancreatic amylase and lipase, thyroid function, celiac disease serology, inflammatory markers) may be performed to identify alarm features or metabolic diseases causing dyspepsia or to investigate patients who have been unresponsive to treatment.
Imaging
Certain upper GI disorders can increase a patient’s risk of cardiovascular (CV) disease; thus, an electrocardiogram (ECG) may be performed. Abdominal ultrasound may be considered in patients with epigastric pain of <1 year with features of biliary colic. An abdominal computed tomography (CT) scan may be considered to exclude pancreatic cancer in patients ≥60 years old with new-onset abdominal pain and weight loss. Endoscopy should be performed when alarm symptoms are present and should be considered in populations with a high prevalence of upper GI malignancies or organic GI diseases. Although endoscopy can aid in diagnosing functional dyspepsia, its primary purpose is to exclude organic pathology.
Endoscopy
Upper gastrointestinal (GI) endoscopy is the investigation of choice when further evaluation is warranted, including testing for H pylori and consideration for endoscopy should be on a case-by-case basis per the physician’s clinical judgment. Endoscopy allows a clinician to view the GIT and, if necessary, perform diagnostic and therapeutic procedures (eg biopsy). This should be reserved for patients who have little or no response to therapy after 7-10 days or for patients whose symptoms have not resolved after 4-8 weeks of therapeutic trial with acid suppression. If upper GI endoscopy is unremarkable, patients with persistent symptoms or alarm features should be evaluated further for other diagnoses using other appropriate work-up (eg ultrasound, blood chemistries). Minor findings such as mildly elevated liver enzymes, esophagitis, hiatus hernia or mild gastritis should not preclude a diagnosis of functional dyspepsia. The American College of Gastroenterology (ACG) advises routine upper endoscopy for patients ≥60 years old regardless of alarm symptoms and for those <60 years old with alarm symptoms.
Dyspepsia_Diagnostics 2Depending on local protocol: For patients ≥60 years old (younger in areas with high prevalence of gastric cancer), consider endoscopy when symptoms persist despite H pylori testing or treatment and acid suppression therapy, and when the patient has one or more of the following: Previous gastric ulcer or surgery; continuing need for NSAID treatment; raised risk of gastric cancer; and anxiety about cancer.