AGA technical review: Evaluation of dyspepsia

doi:10.1016/S0016-5085(98)70542-6

Gastroenterology

Volume 114, Issue 3, March 1998, Pages 582-595

https://doi.org/10.1016/S0016-5085(98)70542-6 Get rights and content

Abstract

This literature review and the recommendations therein were prepared for the American Gastroenterological Association Clinical Practice and Practice Economics Committee. Following external review, the paper was approved by the Committee on September 6, 1997.

GASTROENTEROLOGY 1998;114:582-595

Section snippets

Definitions and epidemiology

Upper abdominal pain or discomfort is remarkably common in the general population. The annual prevalence of recurrent upper abdominal pain or discomfort in the United States and other Western countries is approximately 25%; if frequent heartburn (defined as retrosternal burning pain or discomfort once a week or more often) is also considered, the prevalence approaches 40%.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 When classic heartburn or acid regurgitation are the dominant symptoms, objective evidence

The problem: What is the optimal management of dyspepsia?

For many persons, the symptoms of dyspepsia are of short duration or mild severity²¹ and are therefore self-managed. Less than half of dyspepsia sufferers seek medical care for their complaints in the United States and Europe.7, 9, 10, 22, 23 Despite this, the management of dyspepsia represents a major issue in clinical practice; 2%–5% of all family practice consultations are accounted for by dyspepsia.²⁴ The factors that determine whether a patient consults a physician are poorly defined, but

Differential diagnosis of dyspepsia

In patients with dyspepsia who are investigated, four major causes can be identified for their complaints: chronic peptic ulcer disease, gastroesophageal reflux (with or without esophagitis), malignancy, and functional (or non-ulcer) dyspepsia (Table 1, Table 2).17, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65

Diagnostic tests

The yield from upper endoscopy in patients being investigated for dyspepsia increases with advancing age.49, 96, 97 Once a single adequate endoscopy has been performed, the value of most additional tests is at best marginal based on the data available.51, 58, 84, 106, 107, 108 Gastric emptying testing may detect delayed solid or liquid emptying in 25%–50% of patients with functional dyspepsia, but this usually does not alter management.89, 92 Ultrasonography of the gallbladder in dyspepsia has

Endoscopy versus barium meal to exclude ulcer and cancer

In family practice, upper gastrointestinal radiographs are still commonly used to exclude peptic ulcer and other diseases in patients with dyspepsia. However, endoscopy has consistently been shown to provide superior diagnostic accuracy in detecting structural causes of dyspepsia than radiography (Table 3).38, 112, 113, 114

. Sensitivity and specificity of endoscopy vs. double-contrast radiography

Empty Cell	Empty Cell	Barium meal		Upper endoscopy
Study, yr (no. of patients)	Diagnosis	Sensitivity	Specificity	Sensitivity	Empty Cell

Stratifying for patients at high and low risk of structural disease

Because resources are always limited in relation to needs, directing diagnostic tests only to those with a high probability of benefiting from having their diagnosis definitely established (e.g., those with peptic ulcer, gastric cancer) is valuable. One predictive factor is age49, 106, 123; Williams et al.⁴⁹ noted that abnormal findings were made much more often in older people compared with younger people. The frequency of abnormal findings in older people was 69% by endoscopy and 58% by

Natural history of dyspepsia

Patients with functional dyspepsia typically have a relapsing condition.8, 11, 21, 22, 136, 137, 138, 139 In one report,¹³⁹ 65% of those with dyspepsia at study entry reported the same symptom 3 years later. A U.S. study⁸ found that 86% still reported dyspepsia after 12–20 months, and a British study²² found dyspepsia was present in 74% of the cases after 2 years. Chronic peptic ulcer is also a relapsing disease unless H. pylori is eradicated or maintenance therapy is given; symptomatic relapse

Decision analyses on management of dyspepsia

Many investigators have used decision analysis to evaluate alternate strategies for the diagnosis or management of patients with dyspepsia. A systematic review of all published decision analysis was undertaken.109, 144, 145, 146, 147, 148, 149, 150, 151, 152, 153, 154, 155 These decision analyses differ in the clinical problem addressed (peptic ulcer disease or dyspepsia), the perspective of the analysis, the time frame considered, the underlying causes considered in the analysis, the patients

Trials of management strategies

There is some, albeit limited, empiric evidence that the frequently recommended conservative strategy of an initial trial of empiric therapy in younger patients before investigation is nearly as costly as a strategy of initial investigation and may be less satisfying to the patient.60, 156 In a randomized study in a family physician setting, Goulston et al.¹⁵⁷ compared an “Australian strategy,” which required a positive diagnosis of an ulcer or ulcerative esophagitis at endoscopy or radiography

Treat or investigate: A close call

Based on the literature review and review of the available decision analyses and trials, noninvasive testing and empiric H. pylori treatment seems to represent an acceptable strategy and may be the least expensive approach. How much will be saved in the long term over a strategy of endoscoping all cases on presentation largely depends on the costs of endoscopy, the cost of physician visits, and the symptom recurrence rate.

Recommendations to manage patients with dyspepsia by empiric H. pylori

Conclusions

While management must be individualized, based on the available evidence the following is concluded regarding strategies for management of new adult patients with chronic or recurrent dyspepsia in Western nations. Endoscopy remains the gold standard approach because it is still the optimal means of establishing a firm diagnosis, targeting therapy, and providing adequate reassurance. Prompt endoscopy is always indicated in older patients or in those with alarm features such as weight loss. This

Acknowledgements

The Clinical Practice and Practice Economics Committee acknowledges the following individuals whose critiques of this review paper provided valuable guidance to the authors: Naoki Chiba, M.D., F.R.C.P.C., Andrew H. Soll, M.D., Vincent A. DeLuca, M.D., and Mark Feldman, M.D.

References (160)

GR Locke et al.
Prevalence and clinical spectrum of gastroesophageal reflux in the community
Gastroenterology
(1997)
NJ Talley et al.
Dyspepsia and dyspepsia subgroups: a population-based study
Gastroenterology
(1992)
L Agréus et al.
Irritable bowel syndrome and dyspepsia in the general population: overlap and lack of stability over time
Gastroenterology
(1995)
AG Klauser et al.
Symptoms in gastro-oesophageal reflux disease
Lancet
(1990)
NJ Talley et al.
Lack of discriminant value of dyspepsia subgroups in patients referred for upper endoscopy
Gastroenterology
(1993)
P. Bytzer
Diagnosing dyspepsia: any controversies left?
Gastroenterology
(1996)
SS Fedail et al.
Upper gastrointestinal fibreoptic endoscopy experience in the Sudan: analysis of 2500 endoscopies
Lancet
(1983)
B Williams et al.
Do young patients with dyspepsia need investigation?
Lancet
(1988)
P Bytzer et al.
Empirical H2-blocker therapy or prompt endoscopy in management of dyspepsia
Lancet
(1994)
V Stanghellini et al.
Risk indicators of delayed gastric emptying of solids in patients with functional dyspepsia
Gastroenterology
(1996)

GM Sobala et al.

Screening dyspepsia by serology to Helicobacter pylori

Lancet

(1991)

P Patel et al.

Prospective screening of dyspeptic patients by Helicobacter pylori serology

Lancet

(1995)

F Mearin et al.

The origin of symptoms on the brain-gut axis in functional dyspepsia

Gastroenterology

(1991)

B Coffin et al.

Selective gastric hypersensitivity and reflex hyporeactivity in functional dyspepsia

Gastroenterology

(1994)

NJ Talley et al.

Association of anxiety, neuroticism, and depression with dyspepsia of unknown cause: a case-control study

Gastroenterology

(1986)

P Langeluddecke et al.

Psychological factors in dyspepsia of unknown cause: a comparison with peptic ulcer disease

J Psychosom Res

(1990)

NJ Talley et al.

Gastrointestinal tract symptoms and self-reported abuse: a population-based study

Gastroenterology

(1994)

L Agréus et al.

Challenges in managing dyspepsia in general practice

BMJ

(1997)

MJ Shirlow et al.

A study of caffeine consumption and symptoms: indigestion, palpitations, tremor, headache and insomnia

Int J Epidemiol

(1985)

M Gaburri et al.

Functional gut disorders and health care seeking behaviour in an Italian non-patient population

Recenti Prog Med

(1989)

R Johnsen et al.

Peptic ulcer and non-ulcer dyspepsia: a disease and a disorder

Scand J Prim Health Care

(1988)

R Jones et al.

Dyspepsia in England and Scotland

Gut

(1990)

NJ Talley et al.

Onset and disappearance of gastrointestinal symptoms and functional gastrointestinal disorders

Am J Epidemiol

(1992)

DA Drossman et al.

U.S. householder survey of functional gastrointestinal disorders: prevalence, sociodemography, and health impact

Dig Dis Sci

(1993)

G Holtmann et al.

Dyspepsia in consulters and non-consulters: prevalence, health-care seeking behaviour and risk factors

Eur J Gastroenterol Hepatol

(1994)

PK Small et al.

Importance of reflux symptoms in functional dyspepsia

Gut

(1995)

NJ Talley et al.

Functional dyspepsia: a classification with guidelines for diagnoses and management

Gastroenterol Int

(1991)

KR DeVault et al.

Guidelines for the diagnosis and treatment of gastroesophageal reflux disease. Practice Parameters Committee of the American College of Gastroenterology

Arch Intern Med

(1995)

NJ Talley et al.

Discriminant value of dyspeptic symptoms: a study of the clinical presentation of 221 patients with dyspepsia of unknown cause, peptic ulceration, and cholelithiasis

Gut

(1987)

RP Adang et al.

The discriminative value of patient characteristics and dyspeptic symptoms for upper gastrointestinal endoscopic findings: a study on the clinical presentation of 1,147 patients

Digestion

(1996)

D Colin-Jones et al.

Management of dyspepsia: report of a working party

Lancet

(1988)

RC. Heading

Definitions of dyspepsia

Scand J Gastroenterol

(1991)

T Johannessen et al.

The intensity and variability of symptoms in dyspepsia

Scand J Prim Health Care

(1993)

R Jones et al.

Dyspepsia in the community: a follow-up study

Br J Clin Pract

(1992)

L. Agréus

Socio-economic factors, health care consumption and rating of abdominal symptom severity: a report from The Abdominal Symptom Study

Fam Pract

(1993)

RP. Knill-Jones

Geographical differences in the prevalence of dyspepsia

Scand J Gastroenterol

(1991)

S Lydeard et al.

Factors affecting the decision to consult with dyspepsia: comparison of consulters and non-consulters

J R Coll Gen Pract

(1989)

Health and Public Policy Committee

Endoscopy in the evaluation of dyspepsia

Ann Intern Med

(1985)

O. Nyrén

Therapeutic trial in dyspepsia: its role in the primary care setting

Scand J Gastroenterol

(1991)

JR. Malagelada

When and how to investigate the dyspeptic patient

Scand J Gastroenterol

(1991)

MJ Whitaker et al.

Controversy and consensus in the management of upper gastrointestinal disease in primary care. The International Gastro Primary Care Group

Int J Clin Pract

(1997)

RJ Barnes et al.

Study of dyspepsia in a general practice as assessed by endoscopy and radiology

BMJ

(1974)

KM Møllmann et al.

A diagnostic study of patients with upper abdominal pain

Scand J Gastroenterol

(1975)

JA Fisher et al.

Upper gastrointestinal endoscopy: a GP service

BMJ

(1977)

AK Beavis et al.

Evaluation of one-visit endoscopic clinic for patients with dyspepsia

BMJ

(1979)

G Holdstock et al.

Open-access endoscopy service for general practitioners

BMJ

(1979)

MW Gear et al.

Endoscopic studies of dyspepsia in a general practice

BMJ

(1980)

MW Gear et al.

Endoscopic studies of dyspepsia in the community: an “open-access” service

BMJ

(1980)

R Greenlaw et al.

Gastroduodenitis: a broader concept of peptic ulcer disease

Dig Dis Sci

(1980)

HO Adami et al.

Klinisk misstanke eller endoskopi som underlag för cimetidinterapi vid ulcus

Läkartidningen

(1981)

Cited by (396)

The Natural History of Chronic Unexplained Gastrointestinal Disorders and Gastroesophageal Reflux During 20 Years: A US Population-Based Study
2021, Mayo Clinic Proceedings
To explore the natural history of chronic unexplained gastrointestinal (GI) symptoms and to determine the longitudinal trends of prevalence during a 20-year period in a single US community.
Between January 1, 1990, and December 31, 2009, valid self-report questionnaires of GI symptoms were mailed to randomly selected cohorts of a community. The study used respondents who answered questions on 1 or more of 3 surveys (initial, 1990-1992; second, 2003-2004; and third, 2008-2009). The trends of prevalence of GI symptoms over time were analyzed in responders who completed 3 surveys, and the natural history or transition was evaluated.
The overall prevalence of major symptom groupings including gastroesophageal reflux disease was consistent among residents in a community on 3 survey time points (1990-1992, 2003-2004, and 2008-2009). The transitions of GI symptoms were common in 228 patients who responded to all 3 surveys; only 29% had the same symptom category in 3 surveys; otherwise, symptoms changed over time, resolving, recurring, or transitioning to another disorder. Observed proportions of symptom transitions were significantly different from expected during 20 years (P<.001). Higher non-GI somatic symptom scores were significantly associated with both symptom transitions (odds ratio, 3.9; 95% CI, 1.38 to 10.77) and having sustained symptoms (odds ratio, 12.7; 95% CI, 4.62 to 34.90).
The overall population prevalence of chronic unexplained GI symptoms is stable, but in individuals, transitions seem to be the rule. As these various GI syndromes appear to be so intimately interconnected, the common underlying pathogenesis may account for a major subgroup of chronic unexplained GI disorders.
Effects of Amitriptyline and Escitalopram on Sleep and Mood in Patients With Functional Dyspepsia
2018, Clinical Gastroenterology and Hepatology
Tricyclic antidepressants are effective in reducing symptoms of functional dyspepsia (FD). We performed a post hoc analysis of data from a previous randomized clinical trial to determine whether the benefits of an antidepressant on gastrointestinal symptoms in patients with FD were mediated by improving sleep or reducing anxiety. We explored the relationships between psychological measures, quality of sleep, and relief of symptoms.
We analyzed data from a multicenter, double-blind trial that evaluated the efficacy of antidepressants on symptoms of FD, from October 2006 through October 2012. Patients (n = 292) were randomly assigned to groups given 50 mg amitriptyline, 10 mg escitalopram, or placebo for 12 weeks. During the study, participants completed the following validated psychological questionnaires: Symptom Check List 90, Symptom Somatic Checklist, Hospital Anxiety Depression Scale, Profile of Mood States, State Trait Anxiety Inventory, and Pittsburgh Sleep Quality Index at baseline and 12 weeks following treatment.
Baseline scores for the psychological and sleep measures were similar among groups; after 12 weeks there were no significant differences in scores among groups. Baseline mean global Pittsburgh Sleep Quality Index scores indicated poor sleep quality in all groups at baseline and after 12 weeks. Overall, antidepressants affected sleep duration scores: patients given amitriptyline had lower (better) scores than patients given placebo or escitalopram (P = .019). In all groups, responders had decreased anxiety and improvements in some sleep components.
In a post hoc analysis of data from a clinical trial that evaluated the effects of antidepressants in patients with FD, amitriptyline was found to reduce symptoms of FD, but its mechanism is unlikely to involve reductions in psychological distress. The drug may modestly improve sleep. Clinicaltrials.gov no: NCT00248651.
Development and validation of a high throughput UPLC–MS/MS method for simultaneous quantification of esomeprazole, rabeprazole and levosulpiride in human plasma
2016, Journal of Pharmaceutical Analysis
A high throughput ultra pressure liquid chromatography–mass spectrometry (UPLC–MS/MS) method with good sensitivity and selectivity has been developed and validated for simultaneous quantification of esomeprazole, rabeprazole and levosulpiride in human plasma using lansoprazole as internal standard (IS). The extraction method based on liquid–liquid extraction technique was used to extract the analytes and IS from of 50 µL of human plasma using methyl tert-butyl ether:ethyl acetate (80:20, v/v), which offers a high recovery. Chromatographic separation of analytes and IS was achieved on a Hypersil gold C₁₈ column using gradient mobile phase consisting of 2 mM ammonium formate/acetonitrile. The flow rate was set at 0.5 mL/min to elute all the analytes and IS within 1.00 min runtime. Detection of target compounds was performed on a triple quadruple mass spectrometer by multiple reaction monitoring (MRM) mode via positive electrospray ionization (ESI). Method validation results demonstrated that the developed method has good precision and accuracy over the concentration ranges of 0.1–2000 ng/mL for each analyte. Stability of compounds was established in a battery of stability studies, i.e., bench top, autosampler, dry extract and long-term storage stability as well as freeze-thaw cycles. The validated method has been successfully applied to analyze human plasma samples for application in pharmacokinetic studies.
The use of Benincasa hispida for the treatment of uninvestigated dyspepsia: Preliminary results of a non-randomised open label pilot clinical trial
2015, Advances in Integrative Medicine
Dyspepsia is becoming a common health problem for which an individual seeks medical help. The approach to the management of dyspepsia is complex with high treatment costs and possible adverse effects.
A prospective pilot study was designed to assess the effectiveness of the fruit juice of Ash Gourd (Benincasa hispida) on twenty dyspeptic subjects, who were followed up for 45 days. Measures of retrosternal pain, post-prandial fullness, bloating, sour belching, nausea, vomiting and changes in bowel habits were taken at three times periods (baseline, 30 days and 45 days).
Statistically significant improvements were seen in several parameters, including pain (p < 0.001), retrosternal burning (p < 0.001), nausea (p < 0.001), belching (p < 0.001) and bowel habits (p < 0.05), which are considered as the classical symptoms of dyspepsia. Bloating, though not a common symptom also improved (p < 0.001) over time.
The trial drug is an effective remedy for uninvestigated dyspepsia. Randomised controlled trials are further needed to confirm the pharmaco-dynamics of the trial drug for anti-ulcer, acid suppression, H₂ receptor antagonistic, anti-cholinergic properties.
Epidemiology of functional dyspepsia and gastroparesis as diagnosed in Flemish-Belgian primary care: A registry-based study from the Intego database
2024, Neurogastroenterology and Motility
Intestinal Metaplasia Associated with Symptoms of Dyspepsia
2023, Research Square

View all citing articles on Scopus

^☆: Address requests for reprints to: Chair, Clinical Practice and Practice Economics Committee, AGA National Office, 7910 Woodmont Avenue, 7th Floor, Bethesda, Maryland 20814. Fax: (301) 654-5920.

^☆☆: Supported by the American Gastroenterological Association.

View full text

American Gastroenterological AssociationAGA technical review: Evaluation of dyspepsia☆,☆☆

Abstract

Section snippets

Definitions and epidemiology

The problem: What is the optimal management of dyspepsia?

Differential diagnosis of dyspepsia

Diagnostic tests

Endoscopy versus barium meal to exclude ulcer and cancer

Stratifying for patients at high and low risk of structural disease

Natural history of dyspepsia

Decision analyses on management of dyspepsia

Trials of management strategies

Treat or investigate: A close call

Conclusions

Acknowledgements

Gastroenterology

Gastroenterology

Gastroenterology

Lancet

Gastroenterology

Gastroenterology

Lancet

Lancet

Lancet

Gastroenterology

Lancet

Lancet

Gastroenterology

Gastroenterology

Gastroenterology

J Psychosom Res

Gastroenterology

Challenges in managing dyspepsia in general practice

BMJ

A study of caffeine consumption and symptoms: indigestion, palpitations, tremor, headache and insomnia

Int J Epidemiol

Functional gut disorders and health care seeking behaviour in an Italian non-patient population

Recenti Prog Med

Peptic ulcer and non-ulcer dyspepsia: a disease and a disorder

Scand J Prim Health Care

Dyspepsia in England and Scotland

Gut

Onset and disappearance of gastrointestinal symptoms and functional gastrointestinal disorders

Am J Epidemiol

U.S. householder survey of functional gastrointestinal disorders: prevalence, sociodemography, and health impact

Dig Dis Sci

Dyspepsia in consulters and non-consulters: prevalence, health-care seeking behaviour and risk factors

Eur J Gastroenterol Hepatol

Importance of reflux symptoms in functional dyspepsia

Gut

Functional dyspepsia: a classification with guidelines for diagnoses and management

Gastroenterol Int

Guidelines for the diagnosis and treatment of gastroesophageal reflux disease. Practice Parameters Committee of the American College of Gastroenterology

Arch Intern Med

Discriminant value of dyspeptic symptoms: a study of the clinical presentation of 221 patients with dyspepsia of unknown cause, peptic ulceration, and cholelithiasis

Gut

The discriminative value of patient characteristics and dyspeptic symptoms for upper gastrointestinal endoscopic findings: a study on the clinical presentation of 1,147 patients

Digestion

Management of dyspepsia: report of a working party

Lancet

Definitions of dyspepsia

Scand J Gastroenterol

The intensity and variability of symptoms in dyspepsia

Scand J Prim Health Care

Dyspepsia in the community: a follow-up study

Br J Clin Pract

Socio-economic factors, health care consumption and rating of abdominal symptom severity: a report from The Abdominal Symptom Study

Fam Pract

Geographical differences in the prevalence of dyspepsia

Scand J Gastroenterol

Factors affecting the decision to consult with dyspepsia: comparison of consulters and non-consulters

J R Coll Gen Pract

Endoscopy in the evaluation of dyspepsia

Ann Intern Med

Therapeutic trial in dyspepsia: its role in the primary care setting

Scand J Gastroenterol

When and how to investigate the dyspeptic patient

Scand J Gastroenterol

Controversy and consensus in the management of upper gastrointestinal disease in primary care. The International Gastro Primary Care Group

Int J Clin Pract

American Gastroenterological Association
AGA technical review: Evaluation of dyspepsia☆,☆☆