Dyspepsia: Evaluation & Management
Indications for endoscopy, functional dyspepsia, and step-up management — ACG/CAG Clinical Guideline
- Define dyspepsia and distinguish it from GERD
- Apply the ACG test-and-treat algorithm for initial evaluation
- Identify alarm features that mandate prompt upper endoscopy
- Know the ACG age threshold (≥60 years) for endoscopy in new-onset dyspepsia
- Diagnose functional dyspepsia using Rome IV criteria and classify by subtype
- Apply step-up pharmacologic management based on symptom subtype
Sections
What is dyspepsia?
Dyspepsia refers to chronic or recurrent discomfort centered in the upper abdomen. It is one of the most common GI conditions encountered in primary care and gastroenterology, affecting up to 20% of the US population. The ACG/CAG Clinical Guideline (2017) provides the framework for evaluation and management.
Cardinal Symptoms of Dyspepsia
Epigastric pain
Discomfort or pain localized to the upper abdomen
Epigastric burning
Burning quality distinct from heartburn
Postprandial fullness
Unpleasant lingering sensation after normal meal
Early satiation
Inability to finish a normal-sized meal
~20%
Prevalence in US population
>70%
Cases are functional dyspepsia (no structural cause)
<5%
Cases harbor serious pathology (cancer, ulcer)
Organic / Structural
• Peptic ulcer disease (5–10%)
• Gastric or esophageal cancer (<1–2%)
• Gastroesophageal reflux disease (GERD)
• H. pylori gastritis
• Medication-induced (NSAIDs, aspirin, iron, antibiotics)
• Gastroparesis
Functional (no structural cause found)
• Postprandial distress syndrome (PDS)
• Epigastric pain syndrome (EPS)
• Often overlap with IBS, anxiety, depression
• Gut-brain axis dysregulation
Important Distinction
GERD symptoms (heartburn, regurgitation) are NOT part of the dyspepsia definition, though GERD may coexist. Dyspepsia symptoms must be centered in the upper abdomen, not the chest.