1. In a patient presenting with dyspepsia, include cardiovascular disease in the differential diagnosis.

  2. Attempt to differentiate, by history and physical examination, between conditions presenting with dyspepsia (e.g., gastroesophageal reflux disease, gastritis, ulcer, cancer), as plans for investigation and management may be very different.

  3. In a patient presenting with dyspepsia, ask about and examine the patient for worrisome signs/symptoms (e.g., gastrointestinal bleeding, weight loss, dysphagia).

General Overview

  • Definition: One of the following symptoms - Postprandial fullness, early satiation, epigastric pain

    • Precipitating factors: NSAID/ASA, smoking, alcohol, high fat meals

  • H pylori associated with dyspepsia (but treatment does not necessarily improve symptoms)

    • Incidence 20-40% in Canada, higher in First Nations (>50%), lower in children born in Canada.

    • Risk of ulcer (10-20% vs. 1-2%) and gastric cancer (33% relative reduction)

  • Ddx

    • Functional/IBS (no organic cause) - 60%

    • PUD - 25%

      • Upper abdominal pain prominent, back pain atypical

      • Gastric worse with food, Duodenal better with food

      • Postprandial belching, epigastric fullness, early satiation, N/V

    • GERD

      • Retrosternal pain/regurgitation

    • GI Malignancy

      • Age

      • Dysphagia, odynophagia

      • Systemic signs (anemia, fatigue, weight loss)

    • Drug-induced dyspepsia (NSAIDs and COX-2 inhibitors)

    • Other: Celiac, chronic pancreatitis, gastritis, Crohn's, cardiac

Red Flags (VWBAAAD)

  • Vomiting

  • Weight Loss (Involuntary)

  • Blood loss (melena, hematemesis, anemia)

  • Age >50

  • Anemia

  • Abdominal mass or lymphadenopathy

  • Dysphagia, odynophagia, early satiety

  • Family history of upper GI cancer

Note for chest pain, r/o CAD

Physical Exam

  • Carnett's sign: Abdominal tenderness on muscle tensing (positive test), suggests abdominal wall pain rather than viscera

  • Lymphadenopathy (left supraclavicular, periumbilical)

  • Palpable abdominal mass (hepatoma), jaundice (liver mets), pallor (anemia)


  • Consider CBC r/o anemia if hx of GI bleed

  • H Pylori

    • Urea breath test (stop PPI 2w prior to test, antacids PRN)

      • Consider in <50yo with dyspepsia but no red flags (especially if family history of peptic ulcer or cancer)

        • Note: Not necessary to screen nonulcer dyspepsia with GERD prominent symptoms (heartburn/regurgitation)

    • Stool antigen test can be considered if UBT not available

    • IgG antibody testing helpful if negative (but does not distinguish cleared infection if positive)

      • Could be acceptable in documented PUD given high pretest probability

  • Endoscopy if

    • >50yo with new-onset dyspepsia

    • Atypical features or red flags

    • No response (or limited) after 4-8w of adequate PPI

    • Consider in chronic GERD with 3 risk factors for Barrett's esophagus (male > 50 years old, Caucasian, central obesity, smokers and family history of BE)


  • Lifestyle

    • Weight loss if overweight

    • Stop smoking, excessive alcohol

    • Stop NSAID/ASA

    • Avoid food/drinks that trigger (Alcohol, fried foods, spicy foods, garlic/onion, orange/citrus, chocolate/peppermint, coffee/caffeine, tomatoes)

    • Eat smaller meals

    • Elevate head of bed, avoid meal 2-3h before bedtime if nocturnal GERD

  • Mild (<3 episodes/week, low intensity, short duration)

    • Alginates, antacids, low-dose H2 receptors-antagonist

    • Reassess after 1 month

  • Moderate/Severe

    • Rabeprazole (Pariet) 20mg PO daily x 4-8w

    • Reasssess in 4-8w

      • If good response, trial of D/C (20% remain asymptomatic, consider antacid or H2 Blocker PRN)

        • If symptoms relapse

          • Return to previous PPI dose, can prescribe on-demand (take during periods needed)

      • Inadequate can try to double dose, BID, or switch PPI

        • Reassess in 4w

      • Endoscopy if no response after adequate trial

  • Longterm

    • Attempt to stop/reduce PPI yearly (except in Barrett's, esophagitis, or GI bleed), consider H2 blocker maintenance

      • Risks of PPI

        • Hip fracture (0.4% vs. 0.18%)

        • C Diff (OR 1.96)

        • Pneumonia (OR 1.73, NNH 226)

        • Low: Vit B12, iron, magnesium, calcium, parathyroid

    • Consider endoscopy if requires >10y of treatment r/o Barrett's esophagus

H pylori


  • Low SES

  • Number of siblings

  • Infected parents (mother)

  • Born outside North America (immigrants)

Indications for Testing

  • Dyspepsia (consider endoscopy if >50yo or alarm features)

    • GERD-prominent symptoms do not require testing

  • Active/previous peptic ulcer disease

  • Low-grade gastric mucosa-associated lymphoid tissue lymphoma (MALT) or history of gastric cancer resection, or family history of gastric cancer

  • Longterm NSAIDs

H pylori Management

  • If clarithromycin resistance rates known to be <15% (and in patients without previous macrolide exposure) or proven high local eradication rates >85%

    • Note: From a study in 2000 by Fallone, primary resistance to H pylori in Canada is estimated to be approximately 20% for metronidazole and 1-4% for clarithromycin

    • Standard Triple Therapy (PAC) x 14d

      • PPI, eg. Lansoprazole 30mg PO BID

      • Amoxicillin 1g PO BID

      • Clarithromycin 500mg PO BID

  • In areas of clarithromycin resistance:

    • Non-Bismuth Quadruple (PAMC) x 14d

      • PPI, eg. Lansoprazole 30mg PO BID

      • Amoxicillin 1g PO BID

      • Metronidazole 500mg PO BID

      • Clarithromycin 500mg PO BID

  • If allergy to penicillin, or failure of standard therapy:

    • Bismuth quadruple therapy (PBMT) x 14d

      • PPI BID

      • Bismuth subsalicylate 524mg (or 30mL) QID

      • Metronidazole 250mg QID

      • Tetracycline 500mg QID

  • Confirm eradication if

    • ACG 2017 recommends testing all patients ≥ 4 weeks after antibiotic completed and 1-2 weeks after proton pump inhibitor (PPI) withheld

    • Symptomatic after treatment (UBT after 28d of antibiotic, 3d PPI)

    • H. pylori positive gastric/duodenal ulcer or gastric cancer (endoscopy)

Peptic Ulcer Disease

  • Diagnosis

    • Suspect in dyspepsia with chronic NSAID use

    • Definitive diagnosis by upper endoscopy

  • Rule out complications

    • Bleeding

    • Gastric outlet obstruction

    • Perforation

  • Eradication of H pylori

    • Confirm eradication >4w after completion of therapy

  • Stop/avoid

    • Smoking, alcohol

    • NSAIDs

    • Foods that cause symptoms (although no evidence that foods increase the risk of ulcers)

  • PPI

    • If H pylori-positive ulcer, consider short 14-day course along with H pylori treatment, as most (>90%) heal without PPI and as effective as 4w PPI

    • In complicated ulcer consider 8 week course (or after confirming ulcer healing by endoscopy)

    • NSAID-induced ulcer consider 8 week course (or longer if continued NSAID use)

    • Consider maintenance PPI in the following cases

      • Refractory peptic ulcer

      • H pylori-negative and NSAID-negative ulcer

      • >2cm ulcer and comorbidities

      • Frequent peptic ulcers (>2 per year)

      • Continued NSAID use