Dyspepsia classification

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Fahad Hasan, M.D.[2] Ajay Gade MD[3]]

Overview

Dyspepsia is a symptom complex referring to chronic or recurrent pain or discomfort centered in the upper abdomen, including epigastric pain or burning, postprandial fullness, and early satiety. Contemporary classification has moved away from the older dichotomy of "ulcer" versus "non-ulcer" dyspepsia. Patients are now categorized along a three-tier framework: uninvestigated dyspepsia (symptoms present but no diagnostic workup yet performed), organic (secondary) dyspepsia (an identifiable structural, H. pylori-related, metabolic, or drug-induced cause is found), and functional dyspepsia (FD) (no explanatory organic disease is found on evaluation, including a normal upper endoscopy). Functional dyspepsia, as redefined by the Rome IV criteria, is further split into postprandial distress syndrome (PDS) and epigastric pain syndrome (EPS), which frequently overlap. More than 70% of patients with uninvestigated dyspepsia ultimately meet criteria for functional dyspepsia rather than organic disease.

Classification

Dyspepsia is classified according to whether a diagnostic evaluation has been performed and, if so, whether it reveals structural or biochemical disease.

Uninvestigated Dyspepsia

• Refers to patients with dyspeptic symptoms who have not yet undergone endoscopy or other diagnostic testing.
• Initial management is guided by patient age and the presence of alarm features (see algorithm below), per the 2017 American College of Gastroenterology (ACG) and Canadian Association of Gastroenterology (CAG) joint guideline.

Organic (Secondary) Dyspepsia

• Organic dyspepsia accounts for approximately 20-30% of all dyspepsia cases and is present when investigation reveals a structural, infectious, or biochemical explanation for symptoms.
• Recognized causes include peptic ulcer disease, gastroesophageal reflux disease (GERD), gastric or esophageal cancer, pancreatic or biliary disease, medication-induced dyspepsia (e.g., NSAIDs), and H. pylori-associated disease.
• Endoscopy is abnormal or another investigation identifies the causative lesion.
• The 2015 Kyoto Global Consensus Report designated H. pylori'-associated dyspepsia as a distinct clinicopathological entity, separate from functional dyspepsia, defined by dyspeptic symptoms attributable to H. pylori gastritis that resolve or improve following successful eradication; this entity should be excluded before a diagnosis of FD is assigned.

Functional Dyspepsia (Rome IV Criteria)

• Functional dyspepsia (FD) is now defined by the Rome IV criteria (superseding Rome III), which require the presence of one or more of the following symptoms, bothersome enough to interfere with usual activities, with onset at least 6 months before diagnosis and symptoms active for the last 3 months: postprandial fullness, early satiation, epigastric pain, or epigastric burning — with no evidence of structural disease (including a normal upper endoscopy) to explain the symptoms.
• Patients with predominant heartburn or reflux symptoms should be evaluated for GERD, and a coexisting reflux diagnosis does not exclude FD given the high rate of overlap between the two conditions.
• FD is subdivided into two, frequently overlapping, subtypes:

Subtype	Defining symptoms (Rome IV)	Frequency threshold
Postprandial Distress Syndrome (PDS)	Bothersome postprandial fullness or early satiation that prevents finishing a regular-sized meal	≥3 days/week
Epigastric Pain Syndrome (EPS)	Bothersome epigastric pain or epigastric burning, not exclusively postprandial and often unrelated to meals	≥1 day/week

• Compared with Rome III, the Rome IV criteria significantly reduce diagnostic overlap between PDS and EPS; when patients with any postprandial symptom are classified as PDS, overlap falls to less than 20%.
• There is no evidence that symptom subtype (PDS versus EPS) predicts differential response to proton pump inhibitor (PPI) therapy, and subtype should not by itself be used to select treatment.
• Proposed pathophysiological mechanisms contributing to FD include:
  • Impaired gastric accommodation and delayed gastric emptying (motor dysfunction)
  • Visceral hypersensitivity
  • Low-grade duodenal eosinophilic inflammation and impaired mucosal integrity
  • Helicobacter pylori infection (when symptoms persist despite eradication, this is classified as FD rather than H. pylori-associated dyspepsia)
  • Psychosocial factors, anxiety, and depression, consistent with FD's status as a disorder of gut-brain interaction

Overlap with Other Disorders

• FD commonly overlaps with gastroesophageal reflux disease and irritable bowel syndrome (IBS). In patients clinically fulfilling Rome IV criteria for FD, GERD-FD overlap is more common than either disorder alone, PDS overlaps with GERD more than EPS does, and organic dyspepsia is uncommon in this population.