Evaluation of dyspepsia

Summary

Dyspepsia is a symptom or a combination of symptoms that alerts a clinician to the presence of an upper gastrointestinal (UGI) problem. Typical symptoms include epigastric pain or burning, early satiety and postprandial fullness, belching, bloating, nausea, or discomfort in the upper abdomen. Symptoms are the central focus of this assessment; it is therefore essential that they are described in a manner that is relevant to patients.[1]

Clinicians using symptom-based assessment of UGI symptoms need to be aware of the diagnostic uncertainty inherent in this approach. These assessments can provide functional working diagnoses, but there is always a danger of misclassification. An important consequence of the inability to make a definitive diagnosis based on symptoms alone is an over-diagnosis of GERD and the under-recognition of Helicobacter pylori-related disease. Periodic reassessment can add a layer of safety, but the timing and frequency of reassessment needs to be individualized.[2]

The nomenclature for dyspepsia is confusing. Some medical organizations include all UGI symptoms in the term dyspepsia, then separate patients with symptoms suggesting GERD for appropriate management. Others recognize the overlap in symptoms between the various causes of UGI symptoms but choose to separate the symptoms suggesting GERD before applying the term dyspepsia. Both approaches recommend identifying patients whose symptoms suggest GERD and managing them as having reflux disease.

The American College of Gastroenterology and the Canadian Association of Gastroenterology have published joint guidelines for the management of dyspepsia.[3] The operational definition for dyspepsia used in the guideline is predominant epigastric pain. The authors recognize that patients may present with nausea, vomiting, or fullness but, providing that the patient's primary concern is epigastric pain, they should be managed as patients with dyspepsia.

A technical review from the American Gastroenterological Association for the evaluation of dyspepsia excludes patients with symptoms that suggest GERD, and includes only those with the typical symptoms.[4] The American College of Gastroenterology have published separate guidance on the diagnosis and management of GERD, which excludes the management of functional heartburn and other functional upper gastrointestinal symptoms.[5] The UK National Institute for Health and Care Excellence guideline on GERD and dyspepsia in adults suggests a discrete algorithm for patients with symptoms typical of GERD.[6]

Classification of dyspepsia

Patients with dyspepsia can be classified based on the type or outcomes of the investigations they have received. Research papers often refer to different categories of patients with dyspepsia; it is important to understand the descriptions of the most common subgroups that have been described.

Uninvestigated dyspepsia is classified as a condition with characteristic symptoms clinically assessed to be originating in the upper gastrointestinal (UGI) tract, but which has not been recently investigated by UGI endoscopy.[3] [4] [6] Symptoms include epigastric pain or burning, early satiety and postprandial fullness, belching, bloating, nausea, or discomfort in the upper abdomen.

Functional dyspepsia (FD) (sometimes called nonulcer dyspepsia) refers to a situation where investigations have not revealed a potential cause for the dyspepsia.[7] The term is generally reserved for patients with a normal endoscopy whose symptoms do not suggest GERD. The ROME IV criteria require one or more of the following symptoms, without evidence of structural disease (including at upper GI endoscopy) that is likely to explain the symptoms, for a diagnosis of FD to be made:Rome Foundation: Rome IV criteria

Bothersome postprandial fullness
Bothersome early satiation
Bothersome epigastric pain
Bothersome epigastric burning

The Rome IV classification subdivides FD into 3 categories:[8]

Postprandial distress syndrome (PDS), which is characterized by meal-induced dyspeptic symptoms, such as discomfort, pain, nausea, and fullness
Epigastric pain syndrome (EPS), which refers to epigastric pain, or epigastric burning, that does not occur exclusively postprandially, can occur during fasting, and can even be improved by meal ingestion
Overlapping PDS and EPS, which is characterized by meal-induced dyspeptic symptoms and epigastric pain or burning.

Patients with GERD with normal endoscopy are said to have nonerosive reflux disease.[3] [4] [5] [9] The American College of Gastroenterology recommends that a diagnosis of nonerosive reflux disease should only be made if endoscopy is performed with the patient off proton pump inhibitors.[5]

GERD and dyspepsia are related and may overlap. There is no gold standard for the diagnosis of GERD. The diagnosis is based on a combination of symptom presentation, endoscopic evaluation of esophageal mucosa, reflux monitoring, and response to therapeutic intervention.[5] It is known that many patients with GERD will have atypical presentations such as epigastric burning or pain, and therefore their symptoms will cause them to be placed into the group of uninvestigated patients with dyspepsia. Among those undergoing endoscopy for typical GERD symptoms, normal mucosa is the most common finding.[5]

The extent or severity of the patient's dyspepsia is measured by the patient's report of the impact of symptoms on quality of life and function. The patient's assessment of the severity of dyspepsia usually relates to the degree to which it affects work, sleep, diet, or leisure.[4] [6]

Epidemiology

One meta-analysis that included 256,915 patients from 40 countries found that the overall global pooled prevalence of FD was 8.4% (95% CI 7.4 to 9.5), with the highest prevalence when the Rome 1 criteria was used for diagnosis (11.9%; 95% CI 5.1 to 25.4) and lowest with Rome IV criteria (6.8%; 95% CI 5.8 to 7.9).[10] The same meta-analysis found that developing countries had higher prevalence rates when compared to developed countries (9.1% vs. 8.0%), and prevalence was higher in women (9.0% vs. 7.0%).[10]

The prevalence of FD varies by country, suggesting that economic status, geographical region, ethnicity, dietary and/or genetic influences may play a role.[10] [11] The global prevalence has been gradually declining.[10]

An internet-based cross-sectional health survey found that Rome IV FD is significantly more prevalent in the US (232 [12%] of 1949 responses) than in Canada (167 [8%] of 1988 responses) and the UK (152 [8%] of 1994 responses; p<0·0001).[12] The subtype distribution was 61% postprandial distress syndrome, 18% epigastric pain syndrome, and 21% overlapping variant with both syndromes; this pattern was similar across countries.

There is evidence of particular concerns relating to FD in women.[13] Dyspepsia has been shown to have a significant negative impact on quality of life. The impact relates to changes in sleep, diet, and interference with work and leisure activities. Women who have experienced emotional or physical abuse appear to be particularly vulnerable to developing FD and irritable bowel syndrome (IBS).

There is much overlap between FD and IBS. Patients who have both disorders have a substantially greater symptom burden and are more likely to consult a physician.[14]

Citations

Key Articles

Moayyedi PM, Lacy BE, Andrews CN, et al. ACG and CAG clinical guideline: management of dyspepsia. Am J Gastroenterol. 2017 Jul;112(7):988-1013. [Abstract][Full Text]
Talley NJ, Vakil NB, Moayyedi P. AGA technical review: evaluation of dyspepsia. Gastroenterology. 2005 Nov;129(5):1756-80.[Abstract][Full Text]
Katz PO, Dunbar KB, Schnoll-Sussman FH, et al. ACG clinical guideline for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2022 Jan 1;117(1):27-56.[Abstract][Full Text]
National Institute for Health and Care Excellence. Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management. Oct 2019 [internet publication].[Full Text]
American College of Radiology. ACR Appropriateness Criteria®: epigastric pain. Nov 2021 [internet publication].[Full Text]

Other Online Resources

Rome Foundation: Rome IV criteria

Referenced Articles

1. Vakil NB, Halling K, Becher A, et al. Systematic review of patient-reported outcome instruments for gastroesophageal reflux disease symptoms. Eur J Gastroenterol Hepatol. 2013 Jan;25(1):2-14. [Abstract]
2. World Gastroenterology Organisation. World Gastroenterology Organisation global guidelines: coping with common GI symptoms in the community. May 2013 [internet publication].[Full Text]
3. Moayyedi PM, Lacy BE, Andrews CN, et al. ACG and CAG clinical guideline: management of dyspepsia. Am J Gastroenterol. 2017 Jul;112(7):988-1013. [Abstract][Full Text]
4. Talley NJ, Vakil NB, Moayyedi P. AGA technical review: evaluation of dyspepsia. Gastroenterology. 2005 Nov;129(5):1756-80.[Abstract][Full Text]
5. Katz PO, Dunbar KB, Schnoll-Sussman FH, et al. ACG clinical guideline for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2022 Jan 1;117(1):27-56.[Abstract][Full Text]
6. National Institute for Health and Care Excellence. Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management. Oct 2019 [internet publication].[Full Text]
7. Black CJ, Paine PA, Agrawal A, et al. British Society of Gastroenterology guidelines on the management of functional dyspepsia. Gut. 2022 Sep;71(9):1697-723.[Abstract][Full Text]
8. Stanghellini V, Chan FK, Hasler WL, et al. Gastroduodenal disorders. Gastroenterology. 2016 May;150(6):1380-92.[Abstract]
9. Vakil N, van Zanten SV, Kahrilas P, et al. The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus. Am J Gastroenterol. 2006 Aug;101(8):1900-20.[Abstract]
10. Lee K, Kwon CI, Yeniova AÖ, et al. Global prevalence of functional dyspepsia according to Rome criteria, 1990-2020: a systematic review and meta-analysis. Sci Rep. 2024 Feb 20;14(1):4172.[Abstract][Full Text]
11. Barberio B, Mahadeva S, Black CJ, et al. Systematic review with meta-analysis: global prevalence of uninvestigated dyspepsia according to the Rome criteria. Aliment Pharmacol Ther. 2020 Sep;52(5):762-73.[Abstract][Full Text]
12. Aziz I, Palsson OS, Törnblom H, et al. Epidemiology, clinical characteristics, and associations for symptom-based Rome IV functional dyspepsia in adults in the USA, Canada, and the UK: a cross-sectional population-based study. Lancet Gastroenterol Hepatol. 2018 Apr;3(4):252-62.[Abstract]
13. Flier SN, Rose S. Is functional dyspepsia of particular concern in women? A review of gender differences in epidemiology, pathophysiologic mechanisms, clinical presentation, and management. Am J Gastroenterol. 2006 Dec;101(12 Suppl):S644-53.[Abstract]
14. Vakil N, Stelwagon M, Shea EP, et al. Symptom burden and consulting behavior in patients with overlapping functional disorders in the US population. United European Gastroenterol J. 2016 Jun;4(3):413-22. [Abstract][Full Text]
15. Ford AC, Marwaha A, Lim A, et al. What is the prevalence of clinically significant endoscopic findings in subjects with dyspepsia? Systematic review and meta-analysis. Clin Gastroenterol Hepatol. 2010 Oct;8(10):830-7, 837.e1-2.[Abstract][Full Text]
16. Wauters L, Dickman R, Drug V, et al. United European Gastroenterology (UEG) and European Society for Neurogastroenterology and Motility (ESNM) consensus on functional dyspepsia. United European Gastroenterol J. 2021 Apr;9(3):307-31.[Abstract][Full Text]
17. Mittal R, Vaezi MF. Esophageal motility disorders and gastroesophageal reflux disease. N Engl J Med. 2020 Nov 12;383(20):1961-72.
18. National Institute for Health and Care Excellence. Suspected cancer: recognition and referral. May 2025 [internet publication].[Full Text]
19. Yap PR, Goh KL. Non-steroidal anti-inflammatory drugs (NSAIDs) induced dyspepsia. Curr Pharm Des. 2015;21(35):5073-81.[Abstract]
20. Bytzer P. Dyspepsia as an adverse effect of drugs. Best Pract Res Clin Gastroenterol. 2010 Apr;24(2):109-20.[Abstract]
21. Egboh SM, Duncanson K, Potter M, et al. Functional dyspepsia and gastroparesis: are they distinct disorders, a spectrum of diseases or one disease? eGastroenterology. 2025;3(1):e100119.[Abstract][Full Text]
22. Tack J, Carbone F. Functional dyspepsia and gastroparesis. Curr Opin Gastroenterol. 2017 Nov;33(6):446-54.[Abstract]
23. Ye Y, Yin Y, Huh SY, et al. Epidemiology, etiology, and treatment of gastroparesis: real-world evidence from a large US National Claims Database. Gastroenterology. 2022 Jan;162(1):109-21.e5.[Abstract][Full Text]
24. Goetze O, Nikodem AB, Wiezcorek J, et al. Predictors of gastric emptying in Parkinson's disease. Neurogastroenterol Motil. 2006 May;18(5):369-75.[Abstract]
25. Hasler WL. Gastroparesis: symptoms, evaluation, and treatment. Gastroenterol Clin North Am. 2007 Sep;36(3):619-47, ix.[Abstract]
26. Camilleri M, Chedid V, Ford AC, et al. Gastroparesis. Nat Rev Dis Primers. 2018 Nov 1;4(1):41.[Abstract]
27. Soykan I, Sivri B, Sarosiek I, et al. Demography, clinical characteristics, psychological and abuse profiles, treatment, and long-term follow-up of patients with gastroparesis. Dig Dis Sci. 1998 Nov;43(11):2398-404.[Abstract]
28. Flook N, Unge P, Agreus L, et al. Approach to managing undiagnosed chest pain: could gastroesophageal reflux disease be the cause? Can Fam Physician. 2007 Feb;53(2):261-6.[Abstract][Full Text]
29. Chang AM, Fischman DL, Hollander JE, et al. Evaluation of chest pain and acute coronary syndromes. Cardiol Clin. 2018 Feb;36(1):1-12.[Abstract]
30. Moshiree B, Drossman D, Shaukat A. AGA clinical practice update on evaluation and management of belching, abdominal bloating, and distention: expert review. Gastroenterology. 2023 Sep;165(3):791-800.e3.[Abstract][Full Text]
31. Dilley J, Gentry-Maharaj A, Ryan A, et al. Ovarian cancer symptoms in pre-clinical invasive epithelial ovarian cancer - an exploratory analysis nested within the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS). Gynecol Oncol. 2023 Dec;179:123-30.[Abstract][Full Text]
32. 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 Jun 15;17(12):1481-91.[Abstract][Full Text]
33. Kapoor N, Bassi A, Sturgess R, et al. Predictive value of alarm features in a rapid access upper gastrointestinal cancer service. Gut. 2005 Jan;54(1):40-5.[Abstract][Full Text]
34. Shaukat A, Wang A, et al. ASGE Standards of Practice Committee. The role of endoscopy in dyspepsia. Gastrointest Endosc. 2015 Aug;82(2):227-32.[Abstract][Full Text]
35. Vakil N, Moayyedi P, Fennerty MB, et al. Limited value of alarm features in the diagnosis of upper gastrointestinal malignancy: systematic review and meta-analysis. Gastroenterology. 2006 Aug;131(2):390-401.[Abstract]
36. Talley NJ. What the physician needs to know for correct management of gastro-oesophageal reflux disease and dyspepsia. Aliment Pharmacol Ther. 2004;20(suppl 2):S23-30.[Abstract]
37. American College of Radiology. ACR Appropriateness Criteria®: epigastric pain. Nov 2021 [internet publication].[Full Text]
38. American College of Radiology. ACR practice parameter for the performance of esophagrams and upper gastrointestinal examinations in adults. 2024 [internet publication]. [Full Text]
39. Talley NJ. How to manage the difficult-to-treat dyspeptic patient. Nat Clin Pract Gastroenterol Hepatol. 2007 Jan;4(1):35-42.[Abstract]
40. Sundar N, Muraleedharan V, Pandit J, et al. Does endoscopy diagnose early gastrointestinal cancer in patients with uncomplicated dyspepsia? Postgrad Med J. 2006 Jan;82(963):52-4.[Abstract][Full Text]
41. Best LM, Takwoingi Y, Siddique S, et al. Non-invasive diagnostic tests for Helicobacter pylori infection. Cochrane Database Syst Rev. 2018 Mar 15;(3):CD012080.[Abstract][Full Text]
42. Gwee KA, Lee YY, Suzuki H, et al. Asia-Pacific guidelines for managing functional dyspepsia overlapping with other gastrointestinal symptoms. J Gastroenterol Hepatol. 2023 Feb;38(2):197-209.[Abstract][Full Text]
43. Carmona-Sánchez RI, Vázquez-Elizondo G, Rodríguez-Leal MC, et al. Good clinical practice recommendations for the diagnosis and treatment of functional dyspepsia: An expert review from the Asociación Mexicana de Gastroenterología. Rev Gastroenterol Mex (Engl Ed). 2025 Apr-Jun;90(2):227-51.[Abstract][Full Text]
44. Sarnelli G, Pesce M, Barbara G, et al. Italian guidelines for the diagnosis and treatment of functional dyspepsia - joint consensus from the Italian societies of gastroenterology and endoscopy (SIGE), neurogastroenterology and motility (SINGEM), hospital gastroenterologists and endoscopists (AIGO), digestive endoscopy (SIED) and general medicine (SIMG). Dig Liver Dis. 2025 Sep;57(9):1730-47.[Abstract][Full Text]
45. Sandberg MA, Pawlyk BS, Berson EL. Full-field electroretinograms in miniature poodles with progressive rod-cone degeneration. Invest Ophthalmol Vis Sci. 1986 Jul;27(7):1179-84.[Abstract][Full Text]
46. Talley NJ, Vakil N, Lauritsen K, et al. Randomized-controlled trial of esomeprazole in functional dyspepsia patients with epigastric pain or burning: does a 1-week trial of acid suppression predict symptom response? Aliment Pharmacol Ther. 2007 Sep 1;26(5):673-82.[Abstract][Full Text]
47. van Zanten SV, Flook N, Talley NJ, et al. One-week acid suppression trial in uninvestigated dyspepsia patients with epigastric pain or burning to predict response to 8 weeks' treatment with esomeprazole: a randomized, placebo-controlled study. Aliment Pharmacol Ther. 2007 Sep 1;26(5):665-72.[Abstract][Full Text]
48. van Zanten SV, Armstrong D, Chiba N, et al. Esomeprazole 40 mg once a day in patients with functional dyspepsia: the randomized, placebo-controlled "ENTER" trial. Am J Gastroenterol. 2006 Sep;101(9):2096-106.[Abstract]
49. Pinto-Sanchez MI, Yuan Y, Hassan A, et al. Proton pump inhibitors for functional dyspepsia. Cochrane Database Syst Rev. 2017 Nov 21;11(11):CD011194.[Abstract][Full Text]
50. Heyman MB, Committee on Nutrition. Lactose intolerance in infants, children, and adolescents. Pediatrics. 2006 Sep;118(3):1279-86.[Abstract][Full Text]
51. Thygesen K, Alpert JS, Jaffe AS, et al. Fourth universal definition of myocardial infarction (2018). Glob Heart. 2018 Dec;13(4):305-38.
52. National Institute for Health and Care Excellence. Recent-onset chest pain of suspected cardiac origin: assessment and diagnosis. Nov 2016 [internet publication].[Full Text]
53. Gardner TB, Adler DG, Forsmark CE, et al. ACG clinical guideline: chronic pancreatitis. Am J Gastroenterol. 2020 Mar;115(3):322-39.[Abstract][Full Text]
54. Tenner S, Vegge SS, Sheth SG, et al. American College of Gastroenterology guideline: management of acute pancreatitis. Am J Gastroenterol. 2024 Mar;119(3):419-37.[Full Text]
55. Rompianesi G, Hann A, Komolafe O, et al. Serum amylase and lipase and urinary trypsinogen and amylase for diagnosis of acute pancreatitis. Cochrane Database Syst Rev. 2017 Apr 21;4(4):CD012010.[Abstract][Full Text]
56. Leppäniemi A, Tolonen M, Tarasconi A, et al. 2019 WSES guidelines for the management of severe acute pancreatitis. World J Emerg Surg. 2019 Jun 13:14:27.[Abstract][Full Text]
57. IAP/APA/EPC/IPC/JPS Working Group. Electronic address: info@internationalpancreatology.org, IAP/APA/EPC/IPC/JPS Working Group. International Association of Pancreatology Revised Guidelines on Acute Pancreatitis 2025: supported and endorsed by the American Pancreatic Association, European Pancreatic Club, Indian Pancreas Club, and Japan Pancreas Society. Pancreatology. 2025 Sep;25(6):770-814.[Abstract][Full Text]
58. American College of Radiology. ACR appropriateness criteria: acute pancreatitis. 2019 [internet publication].[Full Text]
59. National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: pancreatic adenocarcinoma [internet publication].[Full Text]
60. Conroy T, Pfeiffer P, Vilgrain V, et al. Pancreatic cancer: ESMO clinical practice guideline for diagnosis, treatment and follow-up. Ann Oncol. 2023 Nov;34(11):987-1002.[Full Text]
61. Tuxen MK, Sölétormos G, Dombernowsky P. Tumor markers in the management of patients with ovarian cancer. Cancer Treat Rev. 1995 May;21(3):215-45.
62. Cannistra SA. Cancer of the ovary. N Engl J Med. 2004 Dec 9;351(24):2519-29.
63. Charkhchi P, Cybulski C, Gronwald J, et al. CA125 and ovarian cancer: a comprehensive review. Cancers (Basel). 2020 Dec 11;12(12):3730.[Abstract][Full Text]
64. Expert Panel on GYN and OB Imaging, Patel-Lippmann KK, Wasnik AP, et al. ACR appropriateness criteria® clinically suspected adnexal mass, no acute symptoms: 2023 update. J Am Coll Radiol. 2024 Jun;21(6s):S79-99.[Abstract]
65. Ford AC, Ching E, Moayyedi P. Meta-analysis: yield of diagnostic tests for coeliac disease in dyspepsia. Aliment Pharmacol Ther. 2009 Jul;30(1):28-36.[Abstract]

Diseases