Version July 2025
INTRODUCTION —
Dyspepsia is a common symptom with an extensive differential diagnosis and a heterogeneous pathophysiology. It occurs in up to 20 percent of the population, although prevalence rates vary depending on which diagnostic criteria are used to establish the diagnosis [1,2]. Although most people with dyspepsia do not seek medical evaluation for their symptoms [1,2], dyspepsia is still a common reason for outpatient medical visits. In an analysis of ambulatory visits for chronic upper gastrointestinal symptoms in the United States, dyspepsia was the second most common reason for a visit, with more than 1.2 million visits annually [3]. Although dyspepsia does not affect survival, it significantly reduces quality of life and results in substantial health care costs [4-7].
This topic reviews the definition, etiology, and general approach to the evaluation and management of the patient with dyspepsia. The epidemiology, clinical presentation, and management of functional dyspepsia are discussed separately. (See "Functional dyspepsia in adults".)
ETIOLOGY
Definition — Dyspepsia refers to bothersome upper abdominal symptoms that are often meal related. The predominant symptoms are fullness (or bloating) after meals, early satiety (inability to finish a normal-sized meal because of postprandial discomfort), or epigastric pain (or burning) that may or may not be related to meals. If dyspepsia is chronic, epigastric pain is a less common feature than postprandial fullness or satiety. Pain is not required to make a diagnosis of dyspepsia.
Functional dyspepsia — Seventy-five to 80 percent of patients have functional dyspepsia, which is also referred to as idiopathic or nonulcer dyspepsia [8]. Functional dyspepsia is defined by the presence of one or more of the following: postprandial fullness, early satiation, epigastric pain, or burning without evidence of structural disease that explains the symptoms [9].
The diagnosis of functional dyspepsia requires the exclusion of other organic causes of dyspepsia [10] (see 'Dyspepsia secondary to organic disease' below). Its epidemiology, clinical presentation, diagnostic criteria, and management are discussed separately. (See "Functional dyspepsia in adults".)
Dyspepsia secondary to organic disease — Approximately 20 to 25 percent of patients with dyspepsia have an underlying organic cause (table 1). A range of gastrointestinal, hepatobiliary, and systemic diseases can cause dyspepsia; the most common of these include peptic ulcer disease, Helicobacter pylori infection, lactose intolerance, and medications, most frequently nonsteroidal anti-inflammatory agents (table 1). Gastric cancer is a potentially life-threatening, but relatively uncommon, cause of dyspepsia, especially in North America [11]. (See "Epidemiology of gastric cancer", section on 'Incidence'.)
●Peptic ulcer disease – Individuals with peptic ulcer disease typically experience upper abdominal pain or discomfort. Although discomfort from ulcers is usually centered in the epigastrium, it may occasionally localize to the right or left upper quadrants [12]. Peptic ulcers can also cause postprandial belching, epigastric fullness, early satiation, fatty food intolerance, nausea, and occasional vomiting. The timing of symptoms does not accurately predict an ulcer's presence or location. Although the timing of abdominal pain related to eating was historically believed to differentiate duodenal from gastric ulcer disease, this concept is outdated. (See "Peptic ulcer disease: Clinical manifestations and diagnosis".)
●Gastroesophageal malignancy – Gastroesophageal malignancy is an uncommon cause of chronic dyspepsia in the Western Hemisphere. However, the incidence increases with older age and is higher in Asian Americans, Hispanic Americans, and African Caribbean Americans. Early in the disease, patients can be asymptomatic or experience mild, vague, epigastric pain. As the disease progresses, pain becomes constant and more severe. Additional symptoms and signs (eg, fatigue, weight loss, anemia) typically evolve with disease progression. (See "Epidemiology and risk factors for esophageal cancer", section on 'Epidemiology' and "Epidemiology of gastric cancer" and "Clinical presentation, diagnosis, and staging of gastric cancer", section on 'Clinical presentation'.)
●Biliary pain – Classic biliary pain consists of episodic, intense, dull pain located in the right upper quadrant or epigastrium. Less commonly, patients present with substernal pain or pain that radiates to the right shoulder blade or back. The pain is constant, not colicky, and often associated with diaphoresis, nausea, and vomiting [13]. It is not exacerbated or reproduced by movement or relieved by squatting, belching, bowel movements, or passage of flatus. The pain typically lasts at least 30 minutes, plateaus within an hour, and then subsides. An entire attack usually lasts less than six hours. (See "Approach to the management of gallstones" and "Clinical manifestations and evaluation of gallstone disease in adults".)
●Drug-induced dyspepsia – Nonsteroidal anti-inflammatory drugs and cyclooxygenase 2 selective inhibitors can cause dyspepsia even in the absence of peptic ulcer disease. Other drugs that have been implicated in drug-induced dyspepsia appear in a table (table 1) [14,15]. (See "Nonselective NSAIDs: Overview of adverse effects", section on 'Gastrointestinal effects'.)
●Other causes – Rarely, celiac disease and chronic pancreatitis present with dyspeptic symptoms alone. Other rare causes of dyspepsia include infiltrative diseases of the stomach (eg, eosinophilic gastroenteritis [16], Crohn disease, sarcoidosis [17], lymphoma [18], and amyloidosis [19,20]), diabetic radiculopathy [21], metabolic disturbances (eg, hypercalcemia, heavy metal toxicity), hepatoma, steatohepatitis, celiac artery compression syndrome, superior mesenteric artery syndrome, abdominal wall pain [22], and intestinal angina (table 1). (See "Granulomatous gastritis", section on 'Crohn disease' and "Median arcuate ligament syndrome" and "Superior mesenteric artery syndrome" and "Chronic mesenteric ischemia", section on 'Clinical presentations' and "Epidemiology, pathogenesis, and clinical manifestations of celiac disease in adults", section on 'Gastrointestinal manifestations' and "Overview of extrapulmonary manifestations of sarcoidosis", section on 'Gastrointestinal and hepatic'.)
An extensive body of literature suggests that gastritis identified on upper endoscopy does not correlate with the presence of dyspepsia symptoms. As an example, in a population-based, endoscopic study from Sweden, 40 percent of participants had gastritis on biopsy, but the prevalence of gastritis was similar in those with and without symptoms of dyspepsia [23]. Gastric erythema or erosions or histologic gastritis is typically asymptomatic.
INITIAL EVALUATION —
The initial evaluation of individuals with new onset of dyspepsia includes a comprehensive history, focused physical examination, and laboratory testing.
Goals of initial evaluation — The goals of the initial evaluation are as follows:
●Identify patients who require urgent evaluation, including those with alarm features for gastroesophageal malignancy
●Identify patients whose initial evaluation should include upper endoscopy
●Identify organic causes of dyspepsia
●Generate and narrow the differential diagnosis
The presence or absence of alarm features is a key component of the evaluation. Alarm features include overt gastrointestinal bleeding, dysphagia, odynophagia, persistent vomiting, family history of upper gastrointestinal cancer, unintentional weight loss, palpable mass or lymphadenopathy, and unexplained iron deficiency anemia (table 2). The presence or absence of alarm features and other results of the initial evaluation determine the urgency of additional workup and guide the diagnostic approach. (See 'Diagnostic approach' below.)
History — A comprehensive history includes a description of the timing, location, and characteristics of the patient's symptoms; medications; and aspects of the past medical, family, and social history that suggest an organic cause of dyspepsia. Common features that can narrow the differential diagnosis and guide the diagnostic workup of dyspepsia include the following:
●Location – Clinicians should localize the patient's symptoms, especially to differentiate between epigastric and substernal pain. Substernal pain (ie, "heartburn") or regurgitation suggests gastroesophageal reflux disease (GERD). Differentiating between GERD and dyspepsia is important because both conditions are common and they can coexist [24,25]. (See "Clinical manifestations and diagnosis of gastroesophageal reflux in adults", section on 'Clinical manifestations' and "Functional dyspepsia in adults", section on 'Selected comorbidities'.)
●Timing – The timing of dyspeptic symptoms, particularly in relation to food, can point to gallbladder disease. Symptomatic cholelithiasis commonly presents with severe, episodic epigastric or right upper quadrant abdominal pain that occurs after ingestion of fatty food, lasts at least 30 minutes, and is often accompanied by nausea and/or vomiting [26]. (See "Acute calculous cholecystitis: Clinical features and diagnosis", section on 'Clinical manifestations'.)
●Radiation – Epigastric pain or discomfort that radiates to the back may indicate pancreatitis, pancreatic cancer, or a perforating duodenal ulcer. Biliary colic can cause pain that radiates to the right shoulder blade.
●Associated gastrointestinal symptoms
•Dysphagia or odynophagia – Dysphagia or odynophagia should prompt consideration of functional or anatomic esophageal pathology, including esophageal web or stricture, achalasia, esophageal ulceration, or esophageal cancer.
•Nausea or vomiting – Nausea and vomiting that occur with recurrent or persistent upper abdominal pain raise the possibility of gastroparesis or gastric outlet obstruction, especially in patients with risk factors. (See "Gastroparesis: Etiology, clinical manifestations, and diagnosis", section on 'Clinical manifestations'.)
•Diarrhea – Epigastric discomfort and/or bloating that occur with lower gastrointestinal symptoms, such as diarrhea, cramping, or malabsorption, raise the possibility of irritable bowel syndrome, celiac disease, inflammatory bowel disease, or eosinophilic gastroenteritis [27]. (See "Approach to the adult with chronic diarrhea in resource-abundant settings" and "Eosinophilic gastrointestinal diseases", section on 'Clinical manifestations'.)
•Bleeding – Melena suggests occult gastrointestinal blood loss, such as that caused by peptic ulcer disease or gastric cancer.
●Constitutional symptoms – Significant weight loss or anorexia raises the suspicion of underlying severe illness, including gastrointestinal or pancreatic malignancy. (See "Clinical presentation, diagnosis, and staging of gastric cancer", section on 'Clinical presentation'.)
●Cardiovascular symptoms – In patients with cardiovascular risk factors and dyspepsia, it is important to ask about exertional symptoms and other manifestations of angina, such as dyspnea, diaphoresis, chest pressure, and nausea.
●Past medical history and medications – We ask about systemic diseases with gastrointestinal manifestation that can cause dyspepsia. These are myriad and include atherosclerotic diseases (eg, atypical angina, chronic mesenteric ischemia), rheumatologic diseases (eg, systemic sclerosis), infiltrative diseases (eg, sarcoidosis, eosinophilic gastroenteritis), and endocrine conditions (eg, diabetes mellitus). The use of aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) raises the possibility of NSAID-induced dyspepsia or peptic ulcer disease. (See 'Dyspepsia secondary to organic disease' above and "Nonselective NSAIDs: Overview of adverse effects", section on 'Gastrointestinal effects'.)
●Family history – Assessment of family history includes asking about a family history of gastrointestinal cancers.
Physical examination — We perform a thorough abdominal examination and tailor the remainder of the physical examination to investigate specific concerns in the history and assess for potentially serious causes of dyspepsia.
The physical examination in individuals with dyspepsia is usually normal. Although some individuals will endorse epigastric tenderness, its presence or absence does not accurately differentiate between functional and organic causes of dyspepsia.
●Abdominal examination – The abdominal examination should include inspection, auscultation, percussion, and palpation. Inspection may reveal signs of chronic liver disease, such as bulging flanks from ascites or caput medusae from portal hypertension. Alternatively, ascites can indicate peritoneal carcinomatosis. Auscultation may detect an epigastric bruit (celiac artery compression syndrome) or succussion splash (gastric outlet obstruction). To elicit a succession splash, the patient is rocked back and forth at the hips while the examiner listens for a "splash" of retained gastric material. (See "Gastric outlet obstruction in adults", section on 'Physical examination'.)
Epigastric tenderness may suggest peptic ulcer, pancreatic, or gallstone disease or functional dyspepsia. Right upper quadrant tenderness may indicate hepatitis or gallstone disease. Percussion or palpation may also reveal hepatosplenomegaly or, rarely, an abdominal mass from hepatoma or gastric outlet obstruction.
In patients with palpable abdominal tenderness, clinicians should differentiate whether the pain arises from the abdominal wall or underlying viscera. The presence of increased local tenderness during muscle tensing (positive Carnett's sign) suggests abdominal wall pathology. In contrast, decreased pain with muscle tensing (negative Carnett's sign) suggests that the pain more likely originates from an intra-abdominal source because tensing the abdominal wall muscles protects the viscera. (See "Anterior cutaneous nerve entrapment syndrome", section on 'Diagnostic approach'.)
●Other pertinent findings – In addition to the abdominal examination, the clinician should look for systemic signs that suggest an organic cause of dyspepsia. Some of these include the following:
•Vital signs and general appearance – The presence of an abnormal heart rate or blood pressure or signs of orthostasis suggest volume depletion from blood loss or poor oral intake. Cachexia or weight loss raises the possibility of esophageal, gastric, or pancreatic malignancy, gastric outlet obstruction, or severe gastroparesis.
•Skin – Clinicians should assess for signs of anemia, jaundice, and spider angiomata. Spider angiomata may be a manifestation of cirrhosis, and jaundice suggests underlying liver or hepatobiliary disease or hepatobiliary or pancreatic malignancy. Signs of anemia, such as palmar or conjunctival rim pallor, may indicate gastrointestinal blood loss. Less commonly, skin findings may suggest metabolic or hormonal abnormalities that occasionally present with dyspepsia, such as dryness and hyperkeratosis in hypothyroidism or hyperpigmentation in adrenal insufficiency.
•Lymph nodes – Periumbilical or left supraclavicular adenopathy raises the possibility of gastric cancer.
•Cardiopulmonary – Peripheral edema can indicate weight loss or impairment of hepatic synthetic function.
•Musculoskeletal – Patients with an underlying malignancy may exhibit muscle wasting and loss of subcutaneous fat.
Laboratory tests — Laboratory testing can potentially identify alarm features (eg, iron deficiency anemia) or metabolic diseases that can cause dyspepsia (eg, diabetes, hypercalcemia, uremia) (table 2). Testing typically includes a blood count and blood chemistries, including liver function tests and serum electrolytes, glucose, creatinine, calcium, lipase, and amylase. (See "Clinical manifestations of hypercalcemia", section on 'Gastrointestinal' and "Diabetic autonomic neuropathy of the gastrointestinal tract".)
DIFFERENTIAL DIAGNOSIS —
The differential diagnosis of dyspepsia includes other conditions that cause epigastric or abdominal pain (table 1). Several of these can coexist with functional dyspepsia. (See "Functional dyspepsia in adults", section on 'Selected comorbidities'.)
Gastroesophageal reflux disease — The most common symptoms of gastroesophageal reflux disease are regurgitation and heartburn (ie, retrosternal burning pain). By contrast, in functional dyspepsia, symptoms of epigastric discomfort and fullness typically predominate [24]. Patients and clinicians can confuse the epigastric pain of functional dyspepsia with heartburn, highlighting the challenge of differentiating between these two disorders. (See 'History' above.)
Gastroparesis — The symptoms of gastroparesis can overlap with those of dyspepsia; abnormal gastric emptying and symptoms of nausea and postprandial bloating, fullness, and discomfort can occur in both disorders [28,29]. However, in patients with gastroparesis, vomiting typically predominates, rather than abdominal pain or epigastric fullness.
Gastroparesis is uncommon; however, it is frequently misdiagnosed. Making the diagnosis requires an assessment of gastric motility, most commonly by a validated scintigraphy test of gastric emptying [30]. (See "Gastroparesis: Etiology, clinical manifestations, and diagnosis", section on 'Assess gastric motility'.)
Irritable bowel syndrome — Irritable bowel syndrome (IBS) is characterized by abdominal pain or discomfort associated with a change in stool form or frequency. Although patients may have difficulty differentiating epigastric from abdominal pain, changes in stool form or frequency suggest a lower gastrointestinal disorder, such as IBS, rather than dyspepsia. (See "Clinical manifestations and diagnosis of irritable bowel syndrome in adults".)
Cardiac ischemia — Angina or acute myocardial infarction uncommonly presents with epigastric discomfort. Features that suggest cardiac ischemia as the etiology of dyspepsia include an exertional component and associated symptoms, such as dyspnea or diaphoresis, especially in a patient with cardiac risk factors (eg, hypertension, elevated cholesterol, and tobacco use). (See "Approach to the patient with suspected angina pectoris".)
DIAGNOSTIC APPROACH —
The diagnostic approach to a patient with dyspepsia is based on the clinical presentation, patient's age, and presence of alarm features (table 2 and algorithm 1) [31]. We further individualize our approach based on the patient's family history, race/ethnicity, and the regional incidence of gastric cancer (see "Clinical presentation, diagnosis, and staging of gastric cancer"). Our approach is largely consistent with guidelines from the American College of Gastroenterology, the American Gastroenterological Association, and the Canadian Association of Gastroenterology [11,32].
Test for Helicobacter pylori in all patients — All individuals with dyspepsia should be tested for H. pylori and receive treatment if infection is detected. (See "Functional dyspepsia in adults", section on 'Patients with H. pylori' and "Indications and diagnostic tests for Helicobacter pylori infection in adults".)
Patients with alarm features — We perform upper gastrointestinal endoscopy in selected patients with dyspepsia to rule out gastroesophageal malignancy and evaluate for organic causes of dyspepsia, such as peptic ulcer disease, gastritis, peptic stricture, or gastric outlet obstruction. This includes individuals with the following features (table 2):
●Clinically significant, unintentional weight loss (>5 percent usual body weight over 6 to 12 months)
●Overt gastrointestinal bleeding (eg, hematemesis, hematochezia, melena)
●Dysphagia
●Odynophagia
●Unexplained iron deficiency anemia
●Persistent vomiting
●Palpable mass or lymphadenopathy
●Family history of upper gastrointestinal cancer
In such patients, we perform prompt upper endoscopy, preferably within two to four weeks. Endoscopic evaluation should include gastric biopsies to test for H. pylori. (See 'Test for Helicobacter pylori in all patients' above.)
Multiple studies have evaluated the yield of upper endoscopy in patients with dyspepsia [33-36]. Data suggest that individual alarm features have limited predictive value for detecting gastric cancer or other organic pathology, especially in younger individuals (age <60 years) [11]. As an example, in a 2006 meta-analysis of seven studies that evaluated 46,161 patients with dyspepsia who underwent upper endoscopy, the presence of one or more alarm features demonstrated a pooled sensitivity and specificity of 66 and 67 percent, respectively, and a pooled positive likelihood ratio of 2.7 [37]. Conversely, the pooled negative likelihood ratio of 0.51 indicated that the risk of missing serious disease remains even in those without alarm features. In a subsequent meta-analysis of 5389 patients with dyspepsia, the most prevalent findings were erosive esophagitis and peptic ulcer disease (pooled prevalence 6 and 8 percent, respectively) [38].
International guidelines differ on the indications and timing of upper endoscopy for individuals with dyspepsia [11,39-42]. (See 'Age ≥60 years' below.)
Patients without alarm features — In the absence of alarm features, our approach to individuals with dyspepsia depends on the patient's age.
Age ≥60 years — We perform an upper endoscopy to evaluate dyspepsia in patients aged ≥60 years and obtain gastric biopsies to test for H. pylori [11]. (See 'Test for Helicobacter pylori in all patients' above.)
Although the optimal age cutoff for endoscopic evaluation in patients with dyspepsia is controversial, the diagnostic yield of upper endoscopy increases with age [33,35]. Age cutoffs vary between countries and depend in part on the prevalence of gastric cancer. Limited evidence suggests that the risk of malignancy is low in most United States populations below the age of 60 years.
Guidelines from the American Gastroenterological Association suggest that it may be reasonable in some resource-abundant countries to consider the age of 60 or 65 years as the threshold age at which to offer endoscopy to those with new-onset dyspepsia. An age cutoff of 45 or 50 years may be more appropriate for populations with a high incidence of gastric cancer in young individuals and those with an increased risk of gastric cancer, such as Asian Americans, Hispanic Americans, and African Caribbean Americans [13]. Guidelines from the British Society of Gastroenterology recommend upper endoscopy in individuals aged 55 years or older with either weight loss, nausea or vomiting, or refractory symptoms or aged 40 years or older with a family history of gastroesophageal malignancy or from an area with an increased prevalence of gastric cancer [39]. A European consensus statement recommends endoscopy in adults older than 50 years old who present with persistent dyspepsia [42].
Age <60 years — In individuals who are younger than age 60 years without alarm features or other findings on initial evaluation that suggest an organic cause of dyspepsia, we perform testing for H. pylori as the next step in the diagnostic evaluation. (See 'Test for Helicobacter pylori in all patients' above.)
In the absence of alarm features, upper endoscopy in younger patients is unlikely to find a worrisome cause. Data from large cohort studies suggest that individual alarm features have low positive predictive value for an upper gastrointestinal tract malignancy [11,37,39]. (See 'Patients with alarm features' above.)
INITIAL MANAGEMENT —
The initial management of individuals with dyspepsia depends on whether an underlying cause is identified and infection with H. pylori is present (algorithm 1).
Patients with organic disease — Individuals with abnormal findings on upper endoscopy and/or laboratory testing should be treated for the identified medical condition. Patients with persistent symptoms may require additional evaluation and management as detailed below. (See 'Subsequent evaluation and management' below.)
Patients with H. pylori infection — Patients with H. pylori infection should receive an appropriate antibiotic regimen in addition to treatment for the underlying diagnosis (eg, peptic ulcer disease) and undergo testing to confirm H. pylori eradication. The rationale for treating H. pylori infection in individuals with dyspepsia, selection of an antibiotic regimen, duration of treatment, and eradication testing are discussed separately. (See "Functional dyspepsia in adults", section on 'Patients with H. pylori' and "Treatment of Helicobacter pylori infection in adults".)
Patients with normal initial evaluation — Most patients with a normal upper endoscopy and routine laboratory tests have functional dyspepsia. In individuals with a normal initial evaluation who are H. pylori negative or who continue to have symptoms after successful eradication of H. pylori, we initiate treatment for functional dyspepsia. (See "Functional dyspepsia in adults", section on 'Management'.)
SUBSEQUENT EVALUATION AND MANAGEMENT
Evaluation of persistent symptoms — Some individuals have symptoms of dyspepsia that are refractory to initial management. These patients include those with persistent H. pylori infection, functional dyspepsia, or an alternate diagnosis. (See "Functional dyspepsia in adults".)
Patients with continued symptoms of dyspepsia should be carefully reassessed, paying specific attention to the type of ongoing symptoms, the degree to which symptoms have improved or worsened, and their adherence to medications.
●Upper endoscopy – We perform an upper endoscopy in patients with persistent dyspepsia who have not undergone previous endoscopy. Biopsies of the duodenum should be performed to rule out celiac disease or inflammatory conditions [27,43]. Biopsies for H. pylori should be performed in patients who have not previously been tested for H. pylori. (See "Indications and diagnostic tests for Helicobacter pylori infection in adults".)
●Role of additional diagnostic testing – Most individuals with a normal upper endoscopy have functional dyspepsia and do not need additional diagnostic workup. However, we selectively perform additional testing in patients whose symptoms raise concern for an alternative diagnosis. Patients with concurrent jaundice or pain suggestive of a biliary/pancreatic source should undergo an abdominal ultrasound or computed tomography scan. In patients with persistent nausea and vomiting and symptoms concerning for motility disorders, we perform a four-hour solid-phase scintigraphic gastric emptying scan.
Subsequent management — Individuals in whom additional workup does not identify a cause of dyspepsia most likely have functional dyspepsia. The management of these patients is discussed separately. (See "Functional dyspepsia in adults", section on 'Subsequent approach'.)
SOCIETY GUIDELINE LINKS —
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Dyspepsia".)
INFORMATION FOR PATIENTS —
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topic (see "Patient education: Stomach ache and stomach upset (The Basics)")
●Beyond the Basics topic (see "Patient education: Upset stomach (functional dyspepsia) in adults (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●Etiology – Dyspepsia is defined as one or more of the following symptoms: postprandial fullness, early satiation, epigastric pain, or burning. Approximately 25 percent of patients with dyspepsia are found to have an underlying organic disease on diagnostic evaluation (table 1). Approximately 75 percent of patients have functional (idiopathic or nonulcer) dyspepsia. (See 'Etiology' above.)
●Initial evaluation – We perform a detailed history, physical examination, and laboratory studies to narrow the differential diagnosis and identify features that may warrant additional evaluation (table 2). (See 'Initial evaluation' above and 'Differential diagnosis' above.)
●Diagnostic evaluation – The diagnostic approach to patients with dyspepsia depends on the patient's age and the presence or absence of alarm features (table 2 and algorithm 1). (See 'Diagnostic approach' above.)
•Helicobacter pylori testing for all patients – All adults with dyspepsia should undergo testing for active H. pylori infection either at the time of upper endoscopy or with stool antigen or urea breath test. (See 'Test for Helicobacter pylori in all patients' above.)
•Patients with alarm features – Individuals with any of the following symptoms or signs should undergo prompt endoscopy (table 2) (see 'Patients with alarm features' above):
-Clinically significant, unintentional weight loss (>5 percent usual body weight over 6 to 12 months)
-Overt gastrointestinal bleeding
-Dysphagia
-Odynophagia
-Unexplained iron deficiency anemia
-Persistent vomiting
-Palpable mass or lymphadenopathy
-Family history of upper gastrointestinal cancer
•Patients without alarm features – Patients ≥60 years of age with dyspepsia should also undergo upper endoscopy. In patients without alarm features who are <60 years of age, we initiate workup with testing for H. pylori. (See 'Patients without alarm features' above and 'Test for Helicobacter pylori in all patients' above.)
We perform additional evaluation in select patients whose symptoms suggest an alternative diagnosis (eg, abdominal imaging with an ultrasound or computed tomography scan in patients with concurrent jaundice or pain suggestive of a biliary/pancreatic source).
●Initial management
•Most patients with a normal initial workup have functional dyspepsia and should be managed accordingly. (See "Functional dyspepsia in adults", section on 'Management'.)
•Patients who test positive for H. pylori infection should undergo treatment with eradication therapy. (See "Functional dyspepsia in adults", section on 'Patients with H. pylori' and "Treatment of Helicobacter pylori infection in adults".)
●Additional evaluation in patients with refractory symptoms – Patients with persistent dyspepsia despite trials of treatment for functional dyspepsia should undergo endoscopic evaluation with an upper endoscopy and biopsies, if not previously performed (algorithm 2). Further evaluation should be performed selectively based on the patient's symptoms. Patients with continued symptoms of dyspepsia for three months with symptom onset at least six months before diagnosis and no evidence of structural disease to explain the symptoms should be diagnosed and treated as functional dyspepsia. (See 'Evaluation of persistent symptoms' above and "Functional dyspepsia in adults".)
