Gastroenterology
Volume 114, Issue 3 , Pages 579-581, March 1998

American Gastroenterological Association medical position statement: Evaluation of dyspepsia☆

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Abstract 

This document presents the official recommendations of the American Gastroenterological Association (AGA) on the evaluation of dyspepsia. It was approved by the Clinical Practice and Practice Economics Committee on September 6, 1997, and by the AGA Governing Board on November 8, 1997.

GASTROENTEROLOGY 1998;114:579-581

 

The following guidelines were developed to assist the primary care physician, internist, and gastroenterologist with the diagnosis and treatment of new-onset dyspepsia. Dyspepsia refers to chronic or recurrent pain or discomfort centered in the upper abdomen. These guidelines are based on a comprehensive review of the medical literature and a systematic review of the decision analyses conducted.1

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Differential diagnosis of dyspepsia 

The major organic diseases causing dyspepsia are gastroduodenal ulcer, atypical gastroesophageal reflux, and gastric cancer.1, 2 Gastroesophageal reflux can cause burning epigastric pain that typically radiates up toward the neck, but this disease may be confused with functional dyspepsia. More than 50% of patients with pathological gastroesophageal reflux will not have macroscopic evidence of reflux esophagitis at upper endoscopy, but a good medical history frequently can accurately identify this group of patients. Gastroduodenal ulcer disease is found in approximately 15%–25% of patients with dyspepsia but cannot be accurately distinguished from functional dyspepsia based on the symptom pattern. Up to 60% of patients with dyspepsia have no definite explanation and are classified as having functional dyspepsia. Between 30% and 60% of these patients have Helicobacter pylori–induced gastritis if appropriate testing is undertaken, but it is unclear whether this infection causes the symptoms.

Endoscopy is the test of choice to exclude gastroduodenal ulceration, reflux esophagitis, and upper gastrointestinal tract malignancy. Upper gastrointestinal radiographs have inferior diagnostic accuracy to upper endoscopy.

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Management options for new-onset dyspepsia 

For the patient who presents with dyspepsia, the major options are (1) empiric medical therapy (e.g., an antisecretory or prokinetic drug) with any subsequent investigation reserved for failures; (2) immediate diagnostic evaluation in all cases, applying endoscopy preferably; (3) testing for H. pylori infection by serology or urea breath test and reserving endoscopy for positive cases to look for ulcer disease or cancer; and (4) testing for H. pylori and treating all positive cases with antibacterial therapy to cure ulcer disease.

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Management recommendations 

Referral for early upper endoscopy is always indicated in older patients presenting with new-onset dyspepsia. This is because the incidence of gastric cancer in the United States and other Western countries increases with advancing age; a threshold of 45 years is recommended. However, in populations where the age-specific incidence of gastric cancer is greater in younger age groups, a lower age threshold should be applied. Patients with alarm symptoms (e.g., weight loss, recurrent vomiting, dysphagia, evidence of bleeding, or anemia) should be referred for prompt endoscopy. Patients whose symptoms have failed to respond to empiric therapeutic approaches described below also should undergo endoscopy.

If endoscopy has been competently performed once, there is no indication to repeat it unless new alarm symptoms have developed that require investigation. After endoscopy, treatment should be targeted at the underlying diagnosis, but the majority of patients will be labeled as having functional (or nonulcer) dyspepsia; these patients may respond to reassurance and explanation followed, if necessary, by a course of antisecretory or prokinetic therapy. Although the role of H. pylori in functional dyspepsia remains uncertain, in those who have documented infection, eradication therapy is reasonable after fully explaining the risks and limitations. In patients with persistent symptoms, other treatments that may be considered include behavioral therapy, psychotherapy, or antidepressant therapy, but these approaches are not of established value.

In younger patients with no alarm features who have not been investigated previously, it is recommended that a locally validated noninvasive H. pylori test (e.g., serology or urea breath test) is undertaken to determine if the patient is infected (Figure 1).

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  • Fig. 1. 

    Management algorithm for patients presenting with dyspepsia who have not been previously investigated. GERD, gastroesophageal reflux disease; IBS, irritable bowel syndrome; Hp, H. pylori. The words fails and failure refer to symptomatic failure. Alarm features include unexplained weight loss, recurrent vomiting, dysphagia, evidence of anemia or gastrointestinal bleeding, or an abdominal mass or lymphadenopathy.

A breath test is more costly but has greater accuracy for documenting current H. pylori infection.2 If there is documented H. pylori infection, then an empiric trial of anti–H. pylori therapy is recommended.1, 3 The rationale is that ulcer disease will heal and the ulcer diathesis will be abolished. A follow-up visit is recommended within 4–8 weeks. If symptoms fail to respond or rapidly recur or alarm features develop, then prompt upper endoscopy is indicated. It is unlikely that an early (and hence curable) gastric cancer would progress to advanced cancer within 1–2 months of presentation; hence, follow-up within this time period is recommended.

A trial of noninvasive testing followed by empiric therapy for H. pylori assumes that background prevalence of infection is not universally high and gastric cancer is not common. In regions where there is a high background incidence of gastric cancer, a strategy of H. pylori testing and endoscopy of those who test positive for the infection (to definitely exclude malignancy) may be preferable to a test and treat strategy, although data are unavailable.

In younger patients with no alarm features who are H. pylori negative, it is recommended that a trial of antisecretory therapy (e.g., H2-blocker or proton pump inhibitor) or a prokinetic (e.g., cisapride) be prescribed for 1 month.4, 5 If this fails to relieve symptoms, therapy may be switched between the antisecretory and prokinetic classes. If after 8 weeks of therapy symptoms persist or rapidly recur on stopping treatment, then endoscopy is recommended.

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References 

  1. Talley NJ, Silverstein MD, Agréus L, Nyrén O, Sonnenberg A, Holtmann G. Evaluation of dyspepsia. Gastroenterology. 1998;114:582–595
  2. Agréus L, Talley N. Challenges in managing dyspepsia. BMJ. 1997;315:1284–1288
  3. The European Helicobacter pylori Study Group . Current European concepts in the management of Helicobacter pylori infection: the Maastricht consensus report. Gut. 1997;41:8–13
  4. Jones RH, Baxter G. Lansoprazole 30mg daily versus ranitidine 150mg bd in the treatment in acid-related dyspepsia in general practice. Aliment Pharmacol Ther. 1997;11:541–546
  5. Velduhyzen van Zanten SJO, Cleary C, Talley NJ, Peterson TC, Nyren O, Bradley LA, et al. Drug treatment of functional dyspepsia: a systematic analysis of trial methodology with recommendations for the design of future trials. Report of an International Working Party. Am J Gastroenterol. 1996;91:660–673

☆ 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.

PII: S0016-5085(98)70541-4

Gastroenterology
Volume 114, Issue 3 , Pages 579-581, March 1998

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