Diagnosis of Functional Dyspepsia: a Systematic Review

Hye-kyung Jung; Bo Ra Keum; Yoon Ju Jo; Sam Ryong Jee; Poong-Lyul Rhee; Young Woo Kang

doi:10.4166/kjg.2010.55.5.296

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Jung, Keum, Jo, Jee, Rhee, Kang, and The Korean Society of Neurogastroenterology and Motility: Diagnosis of Functional Dyspepsia: a Systematic Review

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Korean J Gastroenterol 2010;55(5):296-307.

Published online: 21 February 2010

DOI: https://doi.org/10.4166/kjg.2010.55.5.296

Diagnosis of Functional Dyspepsia: a Systematic Review

Hye-kyung Jung, M.D., Bo Ra Keum, M.D.^∗, Yoon Ju Jo, M.D.^†, Sam Ryong Jee, M.D.^‡, Poong-Lyul Rhee, M.D.^§, Young Woo Kang, M.D.^∥,; The Korean Society of Neurogastroenterology and Motility

Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea

^∗Department of Internal Medicine, College of Medicine, Korea University, Korea

^†Eulji University College of Medicine, Seoul, Korea

^‡Inje University College of Medicine, Busan, Korea

^§ Sungkyunkwan University School of Medicine, Seoul, Korea

^∥Konyang University College of Medicine, Daejeon, Korea

Correspondence to: Young Woo Kang, M.D. Department of Internal Medicine, Konyang University, Gasoo-won-dong, Seo-gu, Daejeon 302-718, Korea Tel: +82-42-600-9127, Fax: +82-42-600-9096 E-mail: kang45@kyuh.co.kr

Abstract

This review tried to set up an initial diagnostic strategy in patients with functional dyspepsia. Dyspepsia was defined as chronic or recurrent pain, or discomfort centered in the upper abdomen (i.e., epigastrium), excluding heartburn and acute abdominal conditions. We reviewed the available data in order to produce currently applicable recommendations for the diagnosis of dyspepsia in Korea. Two investigators independently conducted an independent literature search of published reports on dyspepsia and diagnosis, including alarm symptoms, Helicobacter pylori (H. pylori) test, empirical pharmacological therapy, and early upper gastrointestinal (GI) endoscopy. The evidence concerning alarm features does not allow clear guideline whether early endoscopy should be performed or not. In Asia, including Korea, the prevalence of H. pylori and gastric cancer are high. Therefore, ‘H. pylori test and treatment'strategy is not suitable for the initial diagnostic approach for uninvestigated dyspepsia. Longterm empirical pharmacological therapy is not recommended in Korea because of the possibility of missing or delaying the diagnosis of gastric cancer. There have been a lot of evidences showing that early upper GI endoscopy might be more effective than empirical medication, which is different from Western countries. However, cutoff age for early endoscopy is not clear, especially in case of young age. Further research is necessary to define highrisk age for gastric cancer and for a health economic study in the management of patients with dyspepsia in Korea.

Keywords: Dyspepsia, Diagnosis, Functional gastrointestinal disorders

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Fig. 1.

Proportion of endoscopically diagnosed organic gastrointestinal disease in Korea. GU, gastric ulcer; DU, duodenal ulcer; EGC, early gastric cancer; AGC, advanced gastric cancer; RE, reflux esophagitis; H. pylori, Helicobacter pylori.

Fig. 2.

Flow chart for searching strategy.

Table 1.

Definition of Dyspepsia

1. Rome II definition 1999⁷

- At least 12 weeks, which need not be consecutive, within the preceding 12 months of:

(1) Persistent or recurrent dyspepsia (pain or discomfort centered in the upper abdomen); and

(2) No evidence of organic disease (including at upper endoscopy) that is likely to explain the symptoms; and

(3) No evidence that dyspepsia is exclusively relieved by defecation or associated with the onset of a change in stool frequency or stool form (i.e., not irritable bowel).

- Subtype: ulcer-like, dysmotility-like, unspecified

2. Rome III definition 2006⁸

- Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis

- Required one or more of the following symptoms: (1) bothersome postprandial fullness, (2) early satiation, (3) epigastric pain, and (4) epigastric burning.

- No evidence of any structural diseases (including at on upper endoscopy) that is likely to explain the symptom was required.

- Subtype: epigastric pain syndrome, postprandial distress syndrome

3. Asia Pacific Working Party 1998²

- Unexplained pain or discomfort centered in the upper abdomen. Discomfor may be described by the patient as bloating, distension, fullness or nausea.

- Rome I definition

4. National Institute for Clinical Excellence, England 2004⁹

- Any symptom referable to the upper gastrointestinal tract, present for at least four weeks and including upper abdominal pain or discomfort, heartburn, acid reflux, nausea and vomiting.

5. Scottish Intercollegiate Guideline Network, 2003¹⁰

- Dyspepsia refers to pain or discomfort centered in the upper abdomen. Heartburn is included as a symptom, not equal to gastroesophageal reflux.

6. American gastroenterological association 2005¹¹

- Dyspepsia is defined as chronic or recurrent pain or discomfort centered in the upper abdomen. Discomfort is defined as a subjective negative feeling that is nonpainful, and can incorporate a variety of symptoms including early satiety or upper abdominal fullness. Patients presenting with predominant or frequent (more than once a week) heartburn or acid regurgitation should be considered to have gastroesophageal reflux disease until proven otherwise.

- Rome II definition

7. European Society of Primary Care Gastroenterology 2000¹²

- All GI symptoms, unspecified

8. Canadian Dyspepsia Working Group, 2005¹³

- Dyspepsia includes all upper GI symptoms. Heartburn and acid regurgitation symptoms are considered as a part of the dyspepsia symptom complex.

Table 2.

Prevalence of Dyspepsia in Korea

Study	Subjects	Date	Case ascertainment	Sample size (response rate)	Case definition	Prevalence (per 100)	Subtype (%)
Jeong et al.¹⁴	Community	2000-2001	Face-face interview	1,417 (78.4%)	Rome II	11.7 (F 12.8, M 10.8)	UL 28.3; D 69.9; U 1.8
Ji et al.¹⁵	Tertiary hospital	2001	Self reported questionnaire with endoscopy	274	Rome II	40.5	UL 10.2; D 63.2; U 26.5
Kim et al.³	Tertiary hospital	2004	Self reported questionnaire with endoscopy and imaging study	476	Rome II	37	UL 41.0; D 60.0
Cho et al.¹⁶	Health screening	2004-2007	Self reported questionnaire with endoscopy	8,169	13 GI symptom	Early satiety 22.3 s	Depression OR 2.6 for any GI symptoms
Rhie et al.¹⁷	Health screening	2006	Self reported questionnaire with endoscopy	708 (85.3%)	Rome II	13.4 (F 16.1, M 9.0, p＜0.05)	UL 24.2; D 69.5; U 6.3
Kim et al.¹⁸	Tertiary hospital	2007	Self reported questionnaire with endoscopy	166	Rome III	35	PDS 70.6; EPS 5.9; U 26.5
Yang et al.¹⁹	Community	2008	Telephone interview	1,044 (29%)	Rome II	12.2	UL 33.9; D 55.9; U 10.2
Noh et al.²⁰	Health screening	2008-2009	Self reported questionnaire with endoscopy	2,675	Rome III	8.1	EPS 4.6; PDS 6.0

UL, ulcer-like; D, dysmotility-like; U, Unspecified; GI, gastrointestinal; EPS, epigastric pain syndrome; PDS, postprandial distress syndrome.

Table 3.

Diagnostic Yield of Endoscopy in Patients with Dyspepsia in Asia

Author	Date	Setting	Country	Endoscopy no.	Proportion of organic GI disease	Outcome	Comments
Liou et al.³⁸	2005	Tertiary hospital	Taiwan	17,894	225 cancer (12.6 per 1000 endoscopy)	1.8 per 1000 endoscopy below 45 years old; 1.02 below 40 years old; 0.59 below 35 years old	Optimal age cutoff for endoscopy: 40 years
Sumathi et al.⁵⁷	2008	Tertiary hospital	India	3,432	284 (8.3%) GI cancer	18.3% of cancer in young ages (25-45 years of age)	Optimal age cutoff for endoscopy: 38 years for female, 43.5 years for males
Salkic et al.⁶²	2009	Tertiary hospital	Bosnia	4,403	82 (1.9%) GI cancer	No cancer below 40 years old; 1.45 cases of missed upper GI cancer per 1000 for ＜45 years old in women; 0.98 for ＜50 years old in men	38.8% endoscopy can be avoided by age cutoff of 45 years old for women and 50 years old for men
Shiota et al.⁶³	2009	Tertiary hospital	Japan	258	Gastric cancer 3 (2.2%), H. pylori positive 47.8% in dyspeptics	All gastric cancer 3/92(3.6%) in H. pylori (＋), no cancer in H. pylori (−)	Recommend endoscopy in H. pylori positive dyspeptics
Lee et al.⁶⁴	2001	Tertiary hospital	Korea	141	Gastric cancer 4 (2.8%), H. pylori positive 49.6% in dyspeptics	No cancer below 35 years old	Low diagnostic yield of alarm symptoms or H. pylori test

GI, gastrointestinal; H. pylori, Helicobacter pylori.

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