Skip to main content
NCBI home page
CMAJ : Canadian Medical Association Journal logoLink to CMAJ : Canadian Medical Association Journal
. 1995 Aug 1;153(3):293–299.

Dyspepsia: is a trial of therapy appropriate?

W G Thompson 1
PMCID: PMC1487203  PMID: 7614445

Abstract

Dyspepsia is a common, benign condition that may be distinguished from gastroesophageal reflux, irritable bowel syndrome and pancreatobiliary, coronary or musculoskeletal disease by a careful history and physical examination. However, the presence or absence of a peptic ulcer in dyspepsia can be determined only by an endoscopic examination or a barium-contrast radiograph. Although the American College of Physicians has recommended trying drug therapy for patients with dyspepsia before diagnostic tests are done, new data support early diagnosis. Although therapy is initially cheaper than endoscopic examination, over a year the costs even out because most patients with dyspepsia eventually need an endoscopic examination, and many patients with nonulcer dyspepsia are given medication unnecessarily. Endoscopic examination, if available to general practitioners, is the most cost-effective approach to dyspepsia. An approach that does not include endoscopy lacks the opportunity to offer patients convincing reassurance that their illness is not serious, which is arguably the most important treatment in cases of nonulcer dyspepsia. Studies supporting the use of endoscopic examination predate the treatment of peptic ulcers with antibiotics, which makes an initial endoscopic examination to determine whether the patient has an ulcer even more important.

Full text

PDF
293

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Bainton D., Davies G. T., Evans K. T., Gravelle I. H. Gallbladder disease. Prevalence in a South Wales industrial town. N Engl J Med. 1976 May 20;294(21):1147–1149. doi: 10.1056/NEJM197605202942103. [DOI] [PubMed] [Google Scholar]
  2. Barbara L., Camilleri M., Corinaldesi R., Crean G. P., Heading R. C., Johnson A. G., Malagelada J. R., Stanghellini V., Wienbeck M. Definition and investigation of dyspepsia. Consensus of an international ad hoc working party. Dig Dis Sci. 1989 Aug;34(8):1272–1276. doi: 10.1007/BF01537277. [DOI] [PubMed] [Google Scholar]
  3. Bateman D. N. NSAIDs: time to re-evaluate gut toxicity. Lancet. 1994 Apr 30;343(8905):1051–1052. doi: 10.1016/s0140-6736(94)90175-9. [DOI] [PubMed] [Google Scholar]
  4. Bornman P. C., Krige J. E., Terblanche J. Management of oesophageal varices. Lancet. 1994 Apr 30;343(8905):1079–1084. doi: 10.1016/s0140-6736(94)90186-4. [DOI] [PubMed] [Google Scholar]
  5. Bytzer P., Hansen J. M., Schaffalitzky de Muckadell O. B. Empirical H2-blocker therapy or prompt endoscopy in management of dyspepsia. Lancet. 1994 Apr 2;343(8901):811–816. doi: 10.1016/s0140-6736(94)92023-0. [DOI] [PubMed] [Google Scholar]
  6. Bytzer P., Schaffalitzky de Muckadell O. B. Prediction of major pathologic conditions in dyspeptic patients referred for endoscopy. A prospective validation study of a scoring system. Scand J Gastroenterol. 1992 Nov;27(11):987–992. doi: 10.3109/00365529209000176. [DOI] [PubMed] [Google Scholar]
  7. COGHILL N. F., EDWARDS F., LEWIS T. H., WILLIAMS A. W. Investigation of nonulcer dyspepsia by gastric biopsy. Br Med J. 1957 Feb 16;1(5015):372–377. [PMC free article] [PubMed] [Google Scholar]
  8. Chiba N., Rao B. V., Rademaker J. W., Hunt R. H. Meta-analysis of the efficacy of antibiotic therapy in eradicating Helicobacter pylori. Am J Gastroenterol. 1992 Dec;87(12):1716–1727. [PubMed] [Google Scholar]
  9. Collen M. J., Loebenberg M. J. Basal gastric acid secretion in nonulcer dyspepsia with or without duodenitis. Dig Dis Sci. 1989 Feb;34(2):246–250. doi: 10.1007/BF01536059. [DOI] [PubMed] [Google Scholar]
  10. Crean G. P., Card W. I., Beattie A. D., Holden R. J., James W. B., Knill-Jones R. P., Lucas R. W., Spiegelhalter D. "Ulcer--like dyspepsia". Scand J Gastroenterol Suppl. 1982;79:9–15. [PubMed] [Google Scholar]
  11. Daneshmend T. K., Bell G. D., Logan R. F. Sedation for upper gastrointestinal endoscopy: results of a nationwide survey. Gut. 1991 Jan;32(1):12–15. doi: 10.1136/gut.32.1.12. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Davis R. E., Graham D. Y. Endoscopic complications: the Texas experience. Gastrointest Endosc. 1979 Nov;25(4):146–149. doi: 10.1016/s0016-5107(79)73405-5. [DOI] [PubMed] [Google Scholar]
  13. Dooley C. P., Larson A. W., Stace N. H., Renner I. G., Valenzuela J. E., Eliasoph J., Colletti P. M., Halls J. M., Weiner J. M. Double-contrast barium meal and upper gastrointestinal endoscopy. A comparative study. Ann Intern Med. 1984 Oct;101(4):538–545. doi: 10.7326/0003-4819-101-4-538. [DOI] [PubMed] [Google Scholar]
  14. Drossman D. A., Li Z., Andruzzi E., Temple R. D., Talley N. J., Thompson W. G., Whitehead W. E., Janssens J., Funch-Jensen P., Corazziari E. U.S. householder survey of functional gastrointestinal disorders. Prevalence, sociodemography, and health impact. Dig Dis Sci. 1993 Sep;38(9):1569–1580. doi: 10.1007/BF01303162. [DOI] [PubMed] [Google Scholar]
  15. Endoscopy in the evaluation of dyspepsia. Health and Public Policy Committee, American College of Physicians. Ann Intern Med. 1985 Feb;102(2):266–269. [PubMed] [Google Scholar]
  16. FRY J. PEPTIC ULCER: A PROFILE. Br Med J. 1964 Sep 26;2(5412):809–812. doi: 10.1136/bmj.2.5412.809. [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Gotthard R., Bodemar G., Jönsson K. A. Diagnostic outcome in patients with dyspepsia. A preliminary report. Scand J Gastroenterol Suppl. 1987;128:86–89. doi: 10.3109/00365528709090973. [DOI] [PubMed] [Google Scholar]
  18. Goulston K. J., Dent O. F., Mant A., Logan J., Ngu M. Use of H2-receptor antagonists in patients with dyspepsia and heartburn: a cost comparison. Med J Aust. 1991 Jul 1;155(1):20–26. doi: 10.5694/j.1326-5377.1991.tb116372.x. [DOI] [PubMed] [Google Scholar]
  19. Grainger S. L., Klass H. J., Rake M. O., Williams J. G. Prevalence of dyspepsia: the epidemiology of overlapping symptoms. Postgrad Med J. 1994 Mar;70(821):154–161. doi: 10.1136/pgmj.70.821.154. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Greibe J., Bugge P., Gjorup T., Lauritzen T., Bonnevie O., Wulff H. R. Long-term prognosis of duodenal ulcer: follow-up study and survey of doctors' estimates. Br Med J. 1977 Dec 17;2(6102):1572–1574. doi: 10.1136/bmj.2.6102.1572. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Gudmand-Høyer E., Jensen K. B., Krag E., Rask-Madsen J., Rahbek I., Rune S. J., Wulff H. R. Prophylactic effect of cimetidine in duodenal ulcer disease. Br Med J. 1978 Apr 29;1(6120):1095–1097. doi: 10.1136/bmj.1.6120.1095. [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Hallissey M. T., Allum W. H., Jewkes A. J., Ellis D. J., Fielding J. W. Early detection of gastric cancer. BMJ. 1990 Sep 15;301(6751):513–515. doi: 10.1136/bmj.301.6751.513. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Hart R., Classen M. Complications of diagnostic gastrointestinal endoscopy. Endoscopy. 1990 Sep;22(5):229–233. doi: 10.1055/s-2007-1010734. [DOI] [PubMed] [Google Scholar]
  24. Heading R. C. Definitions of dyspepsia. Scand J Gastroenterol Suppl. 1991;182:1–6. doi: 10.3109/00365529109109529. [DOI] [PubMed] [Google Scholar]
  25. Hungin A. P., Thomas P. R., Bramble M. G., Corbett W. A., Idle N., Contractor B. R., Berridge D. C., Cann G. What happens to patients following open access gastroscopy? An outcome study from general practice. Br J Gen Pract. 1994 Nov;44(388):519–521. [PMC free article] [PubMed] [Google Scholar]
  26. Hungin A. P., Thomas P. R., Bramble M. G., Corbett W. A., Idle N., Contractor B. R., Berridge D. C., Cann G. What happens to patients following open access gastroscopy? An outcome study from general practice. Br J Gen Pract. 1994 Nov;44(388):519–521. [PMC free article] [PubMed] [Google Scholar]
  27. Jones R., Lydeard S. Dyspepsia in the community: a follow-up study. Br J Clin Pract. 1992 Summer;46(2):95–97. [PubMed] [Google Scholar]
  28. Jones R., Lydeard S. Prevalence of symptoms of dyspepsia in the community. BMJ. 1989 Jan 7;298(6665):30–32. doi: 10.1136/bmj.298.6665.30. [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Jones R. What happens to patients with non-ulcer dyspepsia after endoscopy? Practitioner. 1988 Jan;232(1441):75-6, 78. [PubMed] [Google Scholar]
  30. KOCH J. P., DONALDSON R. M., Jr A SURVEY OF FOOD INTOLERANCES IN HOSPITALIZED PATIENTS. N Engl J Med. 1964 Sep 24;271:657–660. doi: 10.1056/NEJM196409242711304. [DOI] [PubMed] [Google Scholar]
  31. Kagevi I., Löfstedt S., Persson L. G. Endoscopic findings and diagnoses in unselected dyspeptic patients at a primary health care center. Scand J Gastroenterol. 1989 Mar;24(2):145–150. doi: 10.3109/00365528909093029. [DOI] [PubMed] [Google Scholar]
  32. Kang J. Y., Tay H. H., Wee A., Guan R., Math M. V., Yap I. Effect of colloidal bismuth subcitrate on symptoms and gastric histology in non-ulcer dyspepsia. A double blind placebo controlled study. Gut. 1990 Apr;31(4):476–480. doi: 10.1136/gut.31.4.476. [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Kennedy H., Dehay C. The importance of developmental timing in cortical specification. Perspect Dev Neurobiol. 1993;1(2):93–99. [PubMed] [Google Scholar]
  34. Klauser A. G., Voderholzer W. A., Knesewitsch P. A., Schindlbeck N. E., Müller-Lissner S. A. What is behind dyspepsia? Dig Dis Sci. 1993 Jan;38(1):147–154. doi: 10.1007/BF01296788. [DOI] [PubMed] [Google Scholar]
  35. Lagarde S. P., Spiro H. M. Non-ulcer dyspepsia. Clin Gastroenterol. 1984 May;13(2):437–446. [PubMed] [Google Scholar]
  36. Langman M. J., Weil J., Wainwright P., Lawson D. H., Rawlins M. D., Logan R. F., Murphy M., Vessey M. P., Colin-Jones D. G. Risks of bleeding peptic ulcer associated with individual non-steroidal anti-inflammatory drugs. Lancet. 1994 Apr 30;343(8905):1075–1078. doi: 10.1016/s0140-6736(94)90185-6. [DOI] [PubMed] [Google Scholar]
  37. Lindberg G., Seensalu R., Nilsson L. H., Forsell P., Kagar L., Knill-Jones R. P. Transferability of a computer system for medical history taking and decision support in dyspepsia. A comparison of indicants for peptic ulcer disease. Scand J Gastroenterol Suppl. 1987;128:190–196. doi: 10.3109/00365528709090990. [DOI] [PubMed] [Google Scholar]
  38. Loffeld R. J., Potters H. V., Stobberingh E., Flendrig J. A., van Spreeuwel J. P., Arends J. W. Campylobacter associated gastritis in patients with non-ulcer dyspepsia: a double blind placebo controlled trial with colloidal bismuth subcitrate. Gut. 1989 Sep;30(9):1206–1212. doi: 10.1136/gut.30.9.1206. [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Longstreth G. F. Long-term costs after gastroenterology consultation with endoscopy versus radiography in dyspepsia. Gastrointest Endosc. 1992 Jan-Feb;38(1):23–26. doi: 10.1016/s0016-5107(92)70325-3. [DOI] [PubMed] [Google Scholar]
  40. Lydeard S., Jones R. Factors affecting the decision to consult with dyspepsia: comparison of consulters and non-consulters. J R Coll Gen Pract. 1989 Dec;39(329):495–498. [PMC free article] [PubMed] [Google Scholar]
  41. Management of dyspepsia: report of a working party. Lancet. 1988 Mar 12;1(8585):576–579. [PubMed] [Google Scholar]
  42. Mansi C., Mela G. S., Pasini D., Grosso M., Corti L., Moretti M., Celle G. Patterns of dyspepsia in patients with no clinical evidence of organic diseases. Dig Dis Sci. 1990 Dec;35(12):1452–1458. doi: 10.1007/BF01540561. [DOI] [PubMed] [Google Scholar]
  43. Martin T. R., Vennes J. A., Silvis S. E., Ansel H. J. A comparison of upper gastrointestinal endoscopy and radiography. J Clin Gastroenterol. 1980 Mar;2(1):21–25. doi: 10.1097/00004836-198003000-00004. [DOI] [PubMed] [Google Scholar]
  44. McCarthy C., Patchett S., Collins R. M., Beattie S., Keane C., O'Morain C. Long-term prospective study of Helicobacter pylori in nonulcer dyspepsia. Dig Dis Sci. 1995 Jan;40(1):114–119. doi: 10.1007/BF02063953. [DOI] [PubMed] [Google Scholar]
  45. McColl K. E., Fullarton G. M. Duodenal ulcer pain--the role of acid and inflammation. Gut. 1993 Oct;34(10):1300–1302. doi: 10.1136/gut.34.10.1300. [DOI] [PMC free article] [PubMed] [Google Scholar]
  46. McNulty C. A., Gearty J. C., Crump B., Davis M., Donovan I. A., Melikian V., Lister D. M., Wise R. Campylobacter pyloridis and associated gastritis: investigator blind, placebo controlled trial of bismuth salicylate and erythromycin ethylsuccinate. Br Med J (Clin Res Ed) 1986 Sep 13;293(6548):645–649. doi: 10.1136/bmj.293.6548.645. [DOI] [PMC free article] [PubMed] [Google Scholar]
  47. Nebel O. T., Fornes M. F., Castell D. O. Symptomatic gastroesophageal reflux: incidence and precipitating factors. Am J Dig Dis. 1976 Nov;21(11):953–956. doi: 10.1007/BF01071906. [DOI] [PubMed] [Google Scholar]
  48. Nyrén O., Adami H. O., Gustavsson S., Lindgren P. G., Löf L., Nyberg A. The "epigastric distress syndrome". A possible disease entity identified by history and endoscopy in patients with nonulcer dyspepsia. J Clin Gastroenterol. 1987 Jun;9(3):303–309. [PubMed] [Google Scholar]
  49. Nyrén O., Lindberg G., Lindström E., Marké LA, Seensalu R. Economic costs of functional dyspepsia. Pharmacoeconomics. 1992 May;1(5):312–324. doi: 10.2165/00019053-199201050-00003. [DOI] [PubMed] [Google Scholar]
  50. PRICE W. H. Gall-bladder dyspepsia. Br Med J. 1963 Jul 20;2(5350):138–141. doi: 10.1136/bmj.2.5350.138. [DOI] [PMC free article] [PubMed] [Google Scholar]
  51. Priebe W. M., DaCosta L. R., Beck I. T. Is epigastric tenderness a sign of peptic ulcer disease? Gastroenterology. 1982 Jan;82(1):16–19. [PubMed] [Google Scholar]
  52. Quill Timothy E., Suchman Anthony L. Uncertainty and control: learning to live with medicine's limitations. Humane Med. 1993 Apr;9(2):109–120. [PubMed] [Google Scholar]
  53. Quine M. A., Bell G. D., McCloy R. F., Devlin H. B., Hopkins A. Appropriate use of upper gastrointestinal endoscopy--a prospective audit. Steering Group of the Upper Gastrointestinal Endoscopy Audit Committee. Gut. 1994 Sep;35(9):1209–1214. doi: 10.1136/gut.35.9.1209. [DOI] [PMC free article] [PubMed] [Google Scholar]
  54. Rhind J. A., Watson L. Gall stone dyspepsia. Br Med J. 1968 Jan 6;1(5583):32–32. doi: 10.1136/bmj.1.5583.32. [DOI] [PMC free article] [PubMed] [Google Scholar]
  55. Richter J. E. Dyspepsia: organic causes and differential characteristics from functional dyspepsia. Scand J Gastroenterol Suppl. 1991;182:11–16. doi: 10.3109/00365529109109531. [DOI] [PubMed] [Google Scholar]
  56. SHINER M., DONIACH I. A study of x-ray negative dyspepsia with reference to histologic changes in the gastric mucosa. Gastroenterology. 1957 Feb;32(2):313–324. [PubMed] [Google Scholar]
  57. Schlemper R. J., van der Werf S. D., Vandenbroucke J. P., Biemond I., Lamers C. B. Nonulcer dyspepsia in a Dutch working population and Helicobacter pylori. Ulcer history as an explanation of an apparent association. Arch Intern Med. 1995 Jan 9;155(1):82–87. [PubMed] [Google Scholar]
  58. Sloth H., Jørgensen L. S. Chronic non-organic upper abdominal pain: diagnostic safety and prognosis of gastrointestinal and non-intestinal symptoms. A 5- to 7-year follow-up study. Scand J Gastroenterol. 1988 Dec;23(10):1275–1280. doi: 10.3109/00365528809090204. [DOI] [PubMed] [Google Scholar]
  59. Spiro H. M. Visceral viewpoints. Moynihan's disease? The diagnosis of duodenal ulcer. N Engl J Med. 1974 Sep 12;291(11):567–569. doi: 10.1056/NEJM197409122911107. [DOI] [PubMed] [Google Scholar]
  60. Stevenson G. W., Norman G., Frost R., Somers S. Barium meal or endoscopy? A prospective randomized study of patient preference and physician decision making. Clin Radiol. 1991 Nov;44(5):317–321. doi: 10.1016/s0009-9260(05)81266-8. [DOI] [PubMed] [Google Scholar]
  61. Susi D., Neri M., Ballone E., Mezzetti A., Cuccurullo F. Five-year maintenance treatment with ranitidine: effects on the natural history of duodenal ulcer disease. Am J Gastroenterol. 1994 Jan;89(1):26–32. [PubMed] [Google Scholar]
  62. Sutton G. C. How accurate is computer-aided diagnosis? Lancet. 1989 Oct 14;2(8668):905–908. doi: 10.1016/s0140-6736(89)91560-2. [DOI] [PubMed] [Google Scholar]
  63. Talley N. J., McNeil D., Hayden A., Colreavy C., Piper D. W. Prognosis of chronic unexplained dyspepsia. A prospective study of potential predictor variables in patients with endoscopically diagnosed nonulcer dyspepsia. Gastroenterology. 1987 Apr;92(4):1060–1066. [PubMed] [Google Scholar]
  64. Talley N. J., Phillips S. F. Non-ulcer dyspepsia: potential causes and pathophysiology. Ann Intern Med. 1988 Jun;108(6):865–879. doi: 10.7326/0003-4819-108-6-865. [DOI] [PubMed] [Google Scholar]
  65. Talley N. J., Piper D. W. The association between non-ulcer dyspepsia and other gastrointestinal disorders. Scand J Gastroenterol. 1985 Sep;20(7):896–900. doi: 10.3109/00365528509088842. [DOI] [PubMed] [Google Scholar]
  66. Talley N. J., Weaver A. L., Tesmer D. L., Zinsmeister A. R. Lack of discriminant value of dyspepsia subgroups in patients referred for upper endoscopy. Gastroenterology. 1993 Nov;105(5):1378–1386. doi: 10.1016/0016-5085(93)90142-y. [DOI] [PubMed] [Google Scholar]
  67. Thompson W. G., Heaton K. W. Functional bowel disorders in apparently healthy people. Gastroenterology. 1980 Aug;79(2):283–288. [PubMed] [Google Scholar]
  68. Thompson W. G., Heaton K. W. Heartburn and globus in apparently healthy people. Can Med Assoc J. 1982 Jan 1;126(1):46–48. [PMC free article] [PubMed] [Google Scholar]
  69. Thompson W. G. Irritable bowel syndrome: pathogenesis and management. Lancet. 1993 Jun 19;341(8860):1569–1572. doi: 10.1016/0140-6736(93)90705-l. [DOI] [PubMed] [Google Scholar]
  70. Thompson W. G. Nonulcer dyspepsia. Can Med Assoc J. 1984 Mar 1;130(5):565–569. [PMC free article] [PubMed] [Google Scholar]
  71. Veldhuyzen van Zanten S. J., Tytgat K. M., Pollak P. T., Goldie J., Goodacre R. L., Riddell R. H., Hunt R. H. Can severity of symptoms be used as an outcome measure in trials of non-ulcer dyspepsia and Helicobacter pylori associated gastritis? J Clin Epidemiol. 1993 Mar;46(3):273–279. doi: 10.1016/0895-4356(93)90075-c. [DOI] [PubMed] [Google Scholar]
  72. Williams B., Luckas M., Ellingham J. H., Dain A., Wicks A. C. Do young patients with dyspepsia need investigation? Lancet. 1988 Dec 10;2(8624):1349–1351. doi: 10.1016/s0140-6736(88)90879-3. [DOI] [PubMed] [Google Scholar]

Articles from CMAJ: Canadian Medical Association Journal are provided here courtesy of Canadian Medical Association

RESOURCES