Korean J Gastroenterol.  2010 May;55(5):296-307. 10.4166/kjg.2010.55.5.296.

Diagnosis of Functional Dyspepsia: a Systematic Review

• Jung HK
• Keum BR
• Jo YJ
• Jee SR
• Rhee PL
• Kang YW
• The Korean Society of Neurogastroenterology and Motility

• KMID: 1718335
• DOI: http://doi.org/10.4166/kjg.2010.55.5.296

Abstract

This review tried to set up an initial diagnostic strategy in patients with functional dyspepsia. Dyspepsia was defined as chronic or recurrent pain, or discomfort centered in the upper abdomen (i.e., epigastrium), excluding heartburn and acute abdominal conditions. We reviewed the available data in order to produce currently applicable recommendations for the diagnosis of dyspepsia in Korea. Two investigators independently conducted an independent literature search of published reports on dyspepsia and diagnosis, including alarm symptoms, Helicobacter pylori (H. pylori) test, empirical pharmacological therapy, and early upper gastrointestinal (GI) endoscopy. The evidence concerning alarm features does not allow clear guideline whether early endoscopy should be performed or not. In Asia, including Korea, the prevalence of H. pylori and gastric cancer are high. Therefore, 'H. pylori test and treatment' strategy is not suitable for the initial diagnostic approach for uninvestigated dyspepsia. Long-term empirical pharmacological therapy is not recommended in Korea because of the possibility of missing or delaying the diagnosis of gastric cancer. There have been a lot of evidences showing that early upper GI endoscopy might be more effective than empirical medication, which is different from Western countries. However, cut-off age for early endoscopy is not clear, especially in case of young age. Further research is necessary to define highrisk age for gastric cancer and for a health economic study in the management of patients with dyspepsia in Korea.

Keyword

Dyspepsia; Diagnosis; Functional gastrointestinal disorders

MeSH Terms

Dyspepsia/*diagnosis
Endoscopy, Digestive System
Helicobacter Infections/diagnosis
Helicobacter pylori
Humans

Figure

• 

  Fig. 1. Proportion of endoscopically diagnosed organic gastrointestinal disease in Korea. GU, gastric ulcer; DU, duodenal ulcer; EGC, early gastric cancer; AGC, advanced gastric cancer; RE, reflux esophagitis; H. pylori, Helicobacter pylori.

• 

  Fig. 2. Flow chart for searching strategy.

Reference

1. Yang SY, Lee OY, Bak YT, et al. Prevalence of gastroesophageal reflux disease symptoms and uninvestigated dyspepsia in Korea: a population-based study. Dig Dis Sci. 2008; 53:188–193.

2. Talley NJ, Lam SK, Goh KL, Fock KM. Management guidelines for uninvestigated and functional dyspepsia in the Asia-Pacific region: First Asian Pacific Working Party on Functional Dyspepsia. J Gastroenterol Hepatol. 1998; 13:335–353.

3. Kim JS, Lee KJ, Kim JH, Hahm KB, Cho SW. Functional gastrointestinal disorders in patients referred to specialist gastroenterologists in a tertiary hospital. Korean J Gastrointest Motil. 2004; 10:111–117.

4. Han CH, Lee JS, Ahn JO, et al. The meaning of warning symptoms in the patients with dyspepsia. Korean J Med. 2007; 73:25–33.

5. Kim JI, Kim SG, Kim N, et al. Changing prevalence of upper gastrointestinal disease in 28,893 Koreans from 1995 to 2005. Eur J Gastroenterol Hepatol. 2009; 21:787–793.

6. Shin MH, Oh HK, Ahn YO. Ten year trend of cancer incidence in Seoul, Korea: 1993–2002. J Prev Med Public Health. 2008; 41:92–99.

7. Talley NJ, Stanghellini V, Heading RC, Koch KL, Malagela-da JR, Tytgat GN. Functional gastroduodenal disorders. Gut. 1999; 45(suppl 2):II37–II42.

8. Tack J, Talley NJ, Camilleri M, et al. Functional gastroduodenal disorders. Gastroenterology. 2006; 130:1466–1479.

9. National Institute for Clinical Excellence. Dyspepsia: Managing dyspepsia in adults in primary care. www.nice.org.uk/pdf/CG-017fullguideline.pdf2004.

10. Scottish Intercollegiate Guidelines Network. Dyspepsia: A national clinical guideline. www.sign.ac.uk/pdf/sign68.pdf. 2003.

11. Talley NJ, Vakil NB, Moayyedi P. American gastroenterological association technical review on the evaluation of dyspepsia. Gastroenterology. 2005; 129:1756–1780.

12. Rubin G, Meineche-Schmidt V, Roberts A, de Wit N. The use of consensus to develop guidelines for the management of Helicobacter pylori infection in primary care. European Society for Primary Care Gastroenterology. Fam Pract. 2000; 17(Suppl 2):S21–S26.

13. Veldhuyzen van Zanten SJ, Bradette M, Chiba N, et al. Evidence-based recommendations for short- and longterm management of uninvestigated dyspepsia in primary care: an update of the Canadian Dyspepsia Working Group (CanDys) clinical management tool. Can J Gastroenterol. 2005; 19:285–303.

14. Jeong JJ, Choi MG, Cho YS, et al. Chronic gastrointestinal symptoms and quality of life in the Korean population. World J Gastroenterol. 2008; 14:6388–6394.

15. Ji SW, Park H, Lee PR, Lee OY, Kim DK. Effects of mo-sapride on upper gastrointestinal symptoms and gastric emptying in patients with functional dyspepsia. Korean J Gastrointest Motil. 2004; 10:27–34.

16. Cho KR, Lee OY, Yoon DH, et al. The influence of depression on gastrointestinal symptoms in women. Korean J Gastrointest Motil. 2007; 13:146–151.

17. Rhie SY, Choi CH, Lee HW, et al. The frequency of functional dyspepsia subtypes and its related factors for health check up subjects. Korean J Gastrointest Motil. 2007; 13:31–37.

18. Kim ES, Lee BJ, Kim YS, Lee SI, Park H. Validation of rome III criteria in the diagnosis of functional gastrointestinal disorders in Korean patients. Korean J Gastrointest Motil. 2008; 14:39–44.

19. Yang SY, Lee OY, Kim HE, et al. Dietary related risk factors and quality of life in patients with gastroesophageal reflux disease. Korean J Med. 2006; 70:627–635.

20. Noh YW, Jung HK, Kim SE, Jung SA. Overlap of erosive and non-erosive reflux diseases with functional gastrointestinal disorders according to rome III criteria. Korean J Neurogastroenterol Motil. 2010; 16:148–156.

21. Bak YT. Evidence based guideline for diagnosis and treatment: Therapeutic guideline for GERD. Kor J Neurogastroenterol Motil. 2005; 11:13–17.

22. Zagari RM, Law GR, Fuccio L, Pozzato P, Forman D, Bazzoli F. Dyspeptic symptoms and endoscopic findings in the community: the loiano-monghidoro study. Am J Gastroenterol. 2010; 105:565–571.

23. Moayyedi P, Talley NJ, Fennerty MB, Vakil N. Can the clinical history distinguish between organic and functional dyspepsia? JAMA. 2006; 295:1566–1576.

24. Bowrey DJ, Griffin SM, Wayman J, Karat D, Hayes N, Raimes SA. Use of alarm symptoms to select dyspeptics for endoscopy causes patients with curable esophagogastric cancer to be overlooked. Surg Endosc. 2006; 20:1725–1728.

25. Kapoor N, Bassi A, Sturgess R, Bodger K. Predictive value of alarm features in a rapid access upper gastrointestinal cancer service. Gut. 2005; 54:40–45.

26. Blaser MJ. Hypothesis: the changing relationships of Helicobacter pylori and humans: implications for health and disease. J Infect Dis. 1999; 179:1523–1530.

27. Thomson AB, Barkun AN, Armstrong D, et al. The prevalence of clinically significant endoscopic findings in primary care patients with uninvestigated dyspepsia: the Canadian Adult Dyspepsia Empiric Treatment - Prompt Endoscopy (CADET-PE) study. Aliment Pharmacol Ther. 2003; 17:1481–1491.

28. McColl KE, el-Nujumi A, Murray L, et al. The Helicobacter pylori breath test: a surrogate marker for peptic ulcer disease in dyspeptic patients. Gut. 1997; 40:302–306.

29. Hansen JM, Wildner-Christensen M, Hallas J, Schaffalitzky de Muckadell OB. Effect of a community screening for Helicobacter pylori: a 5-Yr follow-up study. Am J Gastroenterol. 2008; 103:1106–1113.

30. Li XB, Liu WZ, Ge ZZ, Chen XY, Shi Y, Xiao SD. Helicobacter pylori "test-and-treat" strategy is not suitable for the management of patients with uninvestigated dyspepsia in Shanghai. Scand J Gastroenterol. 2005; 40:1028–1031.

31. Suh SO, Lee DH, Park YS, et al. Difference in Helicobacter pylori eradication rates in patients with peptic ulcer and non-ulcer dyspepsia. Korean J Med. 2006; 70:505–510.

32. Jung HK, Na YJ, Moon IH. Changes of Helicobacter pylori- positive peptic ulcer disease: based on data from a general hospital. Korean J Gastrointest Endosc. 2006; 32:1–8.

33. Kim KC, Park HJ, Lee HW, et al. Relation of serum gastrin and pepsinogen levels to serologic recognition of CagA and VacA in Helicobacter pylori infection. Korean J Gastroenterol. 1997; 29:25–34.

34. Park IS, Lee YC, Park HJ, et al. Helicobacter pylori infection in Korea. Yonsei Med J. 2001; 42:457–470.

35. Hwang IR, Kim JH, Lee KJ, Cho SW. Can Helicobacter pylori serology predict non-ulcer dyspepsia in young dyspeptic patients? Korean J Gastrointest Endosc. 2000; 21:696–703.

36. Nyré n O, Adami HO, Bates S, et al. Absence of therapeutic benefit from antacids or cimetidine in non-ulcer dyspepsia. N Engl J Med. 1986; 314:339–343.

37. Delaney B, Ford AC, Forman D, Moayyedi P, Qume M. Initial management strategies for dyspepsia. Cochrane Database Syst Rev. 2005. CD001961.

38. Liou JM, Lin JT, Wang HP, et al. The optimal age threshold for screening upper endoscopy for uninvestigated dyspepsia in Taiwan, an area with a higher prevalence of gastric cancer in young adults. Gastrointest Endosc. 2005; 61:819–825.

39. Kim SJ, Kim HY, Lee JY, et al. The evaluation and treatment of patients with dyspepsia and Helicobacter pylori infection in Korean primary care physician. Korean J Int Med. 2003; 65:645–651.

40. Dooley CP, Larson AW, Stace NH, et al. Double-contrast barium meal and upper gastrointestinal endoscopy. A comparative study. Ann Intern Med. 1984; 101:538–545.

41. Bustamante M, Devesa F, Borghol A, Ortuñ o J, Ferrando MJ. Accuracy of the initial endoscopic diagnosis in the discrim-ination of gastric ulcers: is endoscopic follow-up study al-ways needed? J Clin Gastroenterol. 2002; 35:25–28.

42. Maniatis AG, Eisen GM, Brazer SR. Endoscopic discrim-ination of gastric ulcers. J Clin Gastroenterol. 1997; 24:203–206.

43. Thomopoulos KC, Melachrinou MP, Mimidis KP, et al. Gastric ulcers and risk for cancer. Is follow-up necessary for all gastric ulcers? Int J Clin Pract. 2004; 58:675–677.

44. Choi KS, Kwak MS, Lee HY, Jun JK, Hahm MI, Park EC. Screening for gastric cancer in Korea: population-based pref-erences for endoscopy versus upper gastrointestinal series. Cancer Epidemiol Biomarkers Prev. 2009; 18:1390–1398.

45. Shaw PC, van Romunde LK, Griffioen G, Janssens AR, Kreuning J, Lamers CB. Detection of gastric erosions: comparison of biphasic radiography with fiberoptic endoscopy. Radiology. 1991; 178:63–66.

46. Stevenson GW, Norman G, Frost R, Somers S. Barium meal or endoscopy? A prospective randomized study of patient preference and physician decision making. Clin Radiol. 1991; 44:317–321.

47. Gillen D, McColl KE. Does concern about missing malignancy justify endoscopy in uncomplicated dyspepsia in patients aged less than 55? Am J Gastroenterol. 1999; 94:75–79.

48. Phull PS, Salmon CA, Park KG, Rapson T, Thompson AM, Gilbert FJ. Age threshold for endoscopy and risk of missing upper gastrointestinal malignancy–data from the Scottish au-dit of gastric and oesophageal cancer. Aliment Pharmacol Ther. 2006; 23:229–233.

49. Bytzer P, Hansen JM, Schaffalitzky de Muckadell OB. Empirical H2-blocker therapy or prompt endoscopy in management of dyspepsia. Lancet. 1994; 343:811–816.

50. Duggan AE, Elliott CA, Miller P, Hawkey CJ, Logan RF. Clinical trial: a randomized trial of early endoscopy, H. pylori testing and empirical therapy for the management of dyspepsia in primary care. Aliment Pharmacol Ther. 2008; 29:55–68.

51. Delaney BC, Wilson S, Roalfe A, et al. Randomised controlled trial of Helicobacter pylori testing and endoscopy for dyspepsia in primary care. BMJ. 2001; 322:898–901.

52. Laheij RJ, Severens JL, Van de Lisdonk EH, Verbeek AL, Jansen JB. Randomized controlled trial of omeprazole or endoscopy in patients with persistent dyspepsia: a cost-effective-ness analysis. Aliment Pharmacol Ther. 1998; 12:1249–1256.

53. Ford AC, Qume M, Moayyedi P, et al. Helicobacter pylori “test and treat” or endoscopy for managing dyspepsia: an individual patient data metaanalysis. Gastroenterology. 2005; 128:1838–1844.

54. Heaney A, Collins JS, Watson RG, McFarland RJ, Bamford KB, Tham TC. A prospective randomised trial of a “test and treat” policy versus endoscopy based management in young Helicobacter pylori positive patients with ulcer-like dyspepsia, referred to a hospital clinic. Gut. 1999; 45:186–190.

55. Hu WH, Lam SK, Lam CL, et al. Comparison between empirical prokinetics, Helicobacter test-and-treat and empirical endoscopy in primary-care patients presenting with dyspepsia: a one-year study. World J Gastroenterol. 2006; 12:5010–5016.

56. Cardin F, Zorzi M, Terranova O. Implementation of a guideline versus use of individual prognostic factors to prioritize waiting lists for upper gastrointestinal endoscopy. Eur J Gastroenterol Hepatol. 2007; 19:549–553.

57. Sumathi B, Navaneethan U, Jayanthi V. Appropriateness of indications for diagnostic upper gastrointestinal endoscopy in India. Singapore Med J. 2008; 49:970–976.

58. Schmidt N, Peitz U, Lippert H, Malfertheiner P. Missing gastric cancer in dyspepsia. Aliment Pharmacol Ther. 2005; 21:813–820.

59. Sundar N, Muraleedharan V, Pandit J, Green JT, Crimmins R, Swift GL. Does endoscopy diagnose early gastrointestinal cancer in patients with uncomplicated dyspepsia? Postgrad Med J. 2006; 82:52–54.

60. Kim JH, Kim HY, Kim NY, et al. Seroepidemiological study of Helicobacter pylori infection in asymptomatic people in South Korea. J Gastroenterol Hepatol. 2001; 16:969–975.

61. Tytgat GN. Role of endoscopy and biopsy in the work up of dyspepsia. Gut. 2002; 50(suppl 4):iv13–iv16.

62. Salkic NN, Zildzic M, Zerem ES, et al. Simple uninvestigated dyspepsia: age threshold for early endoscopy in Bosnia and Herzegovina. Eur J Gastroenterol Hepatol. 2009; 21:39–44.

63. Shiota S, Murakami K, Takayama A, et al. Evaluation of Helicobacter pylori status and endoscopic findings among new outpatients with dyspepsia in Japan. J Gastroenterol. 2009; 44:930–934.

64. Lee JH, Kim HY, Rho SH, et al. Dyspepsia in Korean population: who needs endoscopy? Korean J Gastrointest Endosc. 2001; 22:1–7.

65. Delaney BC, Wilson S, Roalfe A, et al. Cost effectiveness of initial endoscopy for dyspepsia in patients over age 50 years: a randomised controlled trial in primary care. Lancet. 2000; 356:1965–1969.

66. Hungin AP, Thomas PR, Bramble MG, et al. What happens to patients following open access gastroscopy? An outcome study from general practice. Br J Gen Pract. 1994; 44:519–521.

67. van Kerkhoven LA, van Rossum LG, van Oijen MG, Tan AC, Laheij RJ, Jansen JB. Upper gastrointestinal endoscopy does not reassure patients with functional dyspepsia. Endoscopy. 2006; 38:879–885.