Dyspepsia Đánh giá ban đầu

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 nonsteroidal anti-inflammatory drugs [NSAIDs], Aspirin, Acarbose, Orlistat, potassium supplements, opioids).

Functional dyspepsia has been reported to be significantly associated with depression, anxiety and other psychopathological factors. 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 when no evidence is documented on routine evaluation (including imaging or upper endoscopy) of organic, 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: Postprandial distress syndrome (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. EPS-PDS overlap subtype may occur in up to 20% of patients based on the Rome IV criteria. The Rome IV Diagnostic Questionnaires were created as a standardized tool to screen for disorders of gut-brain interaction (DGBI), including functional dyspepsia, and have been proven to be valid worldwide, though their complexity has limited their widespread use in clinical settings.

Rome IV 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 disease (including at upper endoscopy) that could explain the symptoms.

Postprandial distress syndrome (PDS) includes one or both of the following symptoms for at least 3 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). Supportive criteria include the following: Postprandial epigastric pain or burning, epigastric bloating, excessive belching and nausea can also be present; vomiting warrants consideration of another disorder; heartburn is not a dyspeptic symptom but may often coexist; symptoms relieved by evacuation of feces or gas should generally not be considered as part of dyspepsia; and other digestive symptoms (eg GERD and IBS) that may coexist with PDS.

Epigastric pain syndrome (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 burning. Supportive criteria include the following: Pain may be induced or relieved by ingestion of a meal, or may occur while fasting; postprandial epigastric bloating, belching and nausea can also be present; persistent vomiting is likely to suggest another disorder; heartburn is not a dyspeptic symptom but may often coexist; pain does not meet criteria for biliary pain; symptoms relieved by evacuation of feces or gas generally should not be considered as part of dyspepsia; and other digestive symptoms (eg GERD and IBS) that may coexist with EPS.

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.