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Dyspepsia
Diagnosis/Definition
Episodic or persistent abdominal symptoms, often related to meals, which patients or physicians believe to be due to disorders of the proximal digestive tract. This usually manifests as an epigastric discomfort, accompanied by fullness, burning, belching, bloating, nausea, vomiting, fatty food intolerance or difficulty completing a meal; bowel habits usually remain unaltered.
Initial Diagnosis and Management
A history and physical exam, noting in particular NSAID use, past history of PUD, and an attempt to distinguish GERD, irritable bowel syndrome, biliary colic, aerophagia from dyspepsia.
Ongoing Management and Objectives
- If on NSAIDs, attempt to stop (consider Tylenol +/- codeine for analgesia).
- If patient is <45 yrs and has no alarm features (e.g., weight loss, recurrent vomiting, dysphagia, evidence of bleeding, or iron deficiency anemia), then H. pylori testing (Breath H2, fecal antigen preferable to serology) and treat if positive (click here for prescribing guideline). * If H. pylori is negative, give an empiric trial of H2-blockers (such as cimetidine 400 mg bid for 4 weeks).
- If treatment fails with either option, refer for endoscopy.
- In patients previously diagnosed with NON-ULCER DYSPEPSIA (NUD) (dyspepsia with normal endoscopy or showing only gastritis): Antacids or H2-blockers can be tried for “acid” type pain.
- Reglan can be tried for patients with nausea, vomiting, or bloating.
Indications for Specialty Care Referral
New onset dyspepsia in any patient is >45 yrs or with alarm features (unexplained weight loss, recurrent vomiting, dysphagia, evidence of bleeding, or iron deficiency anemia associated with dyspepsia).
No response to empiric H2-blockers.
Patients treated for H. pylori, but with persistent or recurrent dyspepsia.
Patients with a prior course of H2-blocker therapy who have not had prior endoscopy for the same problem (i.e. relapsing patients).
Criteria for Return to Primary Care
Completed GI evaluation that outlines further care.
Diagnosis of non-ulcer dyspepsia (NUD). Patients with the diagnosis of NUD do NOT need repetitive EGDs or evaluation if their symptoms are stable and they have no alarm features.
