Dyspepsia

Symptom complex of upper abdominal pain/discomfort, often meal related, functional (~70%, no organic cause found) or organic (PUD, GERD, gastric malignancy, biliary disease).

Epigastric pain/burning, early satiety, postprandial fullness, bloating, nausea.

Alarm features (urgent endoscopy): dysphagia, weight loss, persistent vomiting, GI bleeding, iron-deficiency anemia, palpable mass, age ≥55 with new onset, family history of upper GI cancer.

• Age <55, no alarm features: H. pylori "test and treat" (urea breath test/stool antigen), empirical PPI trial if negative
• Age ≥55 or alarm features: upper GI endoscopy
• FBC; LFTs/amylase if biliary/pancreatic cause suspected
• Abdominal ultrasound if gallstone disease suspected

Differentials: functional dyspepsia, GERD, PUD, gastritis, gastric/esophageal malignancy, biliary colic, pancreatitis, cardiac ischemia, medication-induced (NSAIDs, bisphosphonates).

• H. pylori eradication if positive
• Empirical PPI: omeprazole 20mg od × 4-8 weeks if H. pylori negative/eradicated and symptoms persist
• Functional dyspepsia: PPI/H2RA trial; prokinetic (domperidone/metoclopramide, short courses) if bloating/early satiety predominant; low-dose amitriptyline 10-25mg nocte for refractory cases
• Lifestyle: smaller frequent meals, avoid triggers, weight loss, smoking cessation, avoid late meals
• Review/stop causative medications where possible
• Psychological approaches (CBT, gut-directed hypnotherapy) for refractory functional dyspepsia

Referral: gastroenterology for alarm features, refractory functional dyspepsia, diagnostic uncertainty.