Dyspepsia: Symptoms & Alarm Features

Contributor: Dr. D Armstrong

Introduction

Dyspepsia symptoms are generally the only indication that there is a problem with the upper digestive tract and they are, therefore, a very important factor in helping your physician to decide on the best treatment. This article will discuss symptoms that are sometimes called 'Alarm Features', 'Warning Signs' or 'Red Flags'. To do this, it will also review the importance of symptoms in deciding how to treat dyspepsia.

Background

Although dyspepsia is often discussed as a distinct entity, it is important to realize that, unlike pneumonia, for example, dyspepsia is not a specific condition. Someone with dyspepsia has one or more symptoms, which suggest that she, or he has a problem affecting the upper part of the digestive tract - that is, the esophagus, stomach or duodenum. However, dyspepsia may be caused by a number of different conditions and dyspeptic symptoms do not necessarily mean that the sufferer has a particular condition such as ulcer, esophagitis, gastritis or cancer.
As an example, chest pain, a cough, a fever or shortness of breath can all be symptoms of pneumonia (lung infection); however, it is important to recognize that:
(a) these symptoms can occur in someone who does not have pneumonia (e.g. influenza or the "flu"),
(b) these symptoms can occur in another condition such as a pulmonary embolus (blood clot in the lungs), and
(c) pneumonia can occur in someone who does not have any of these symptoms.

If one was not sure, at first, what had caused the symptoms, one could, for argument's sake, coin a new term such as "dysrespia" to indicate that the patient has symptoms, which suggest that she or he has a problem affecting the respiratory tract (i.e. the throat, bronchi and lungs). This approach would help guide treatment but it would require further information determine the best possible treatment.

In a recent paper from the Canadian Dyspepsia (CanDys) Working Group, dyspepsia was defined as a:

"symptom complex of epigastric pain or discomfort thought to originate in the upper gastrointestinal tract that may include any of the following symptoms: heartburn, acid regurgitation, excessive burping/belching, increased abdominal bloating, nausea, a feeling of abnormal or slow digestion, or early satiety."

Based on this definition, the CanDys Working Group published a dyspepsia treatment strategy that was based primarily on the patient's symptoms. To help with this, the working group identified a number of symptoms, listed above, which should guide treatment; however, they also identified symptoms, which would suggest that the patient's symptoms are not related to the upper digestive tract or that they are related to a serious disease, which may need earlier investigation.

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Symptoms That Help Determine the Best Treatment

The dyspepsia symptoms identified by the CanDys Working Group are highly suggestive of problems affecting the upper digestive tract; however, it can still be very difficult to decide whether an individual symptom is associated with a particular type of disease (e.g. inflammation, ulcer, erosions) or site of disease (i.e. esophagus, stomach or duodenum). However, if someone is taking an 'NSAID' or 'ASA' medication (i.e. aspirin or certain types of pain killers or arthritis medications), it is quite likely that the symptoms may be due to this medication. If the person is not taking an NSAID or ASA and if his or her main symptom is 'heartburn' or 'acid regurgitation', then it is likely that the dyspeptic symptoms are due to reflux disease (gastroesophageal reflux disease or GERD). If, on the other hand, the person's main symptom is 'heartburn' or 'acid regurgitation', one must consider the possibility that the dyspepsia is related to a stomach infection caused by Helicobacter pylori leading to peptic ulcer disease or non-dyspepsia. If a blood test or breath test shows an infection with H. pylori, a course of 2 antibiotics plus a drug to reduce stomach acidity will often relieve the dyspepsia symptoms. If the test does not show an H. pylori infection, treatment with a drug to reduce stomach acidity or a 'prokinetic' drug (to help motility- movement) may be helpful. In most cases, this approach allows treatment to be started safely without the need for any other specialized tests.

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Symptoms That Do Not Suggest Dyspepsia

Some dyspepsia symptoms are similar to those that arise from other organs including the heart, the lungs, the chest wall, the liver and gallbladder and the pancreas. Symptoms which suggest that the upper digestive tract is not the major problem include:

Heart problems
- 'crushing' chest pain,
- shortness of breath,
- pain in the jaw, arm or back
- sweating and faintness

Liver or gallbladder
- jaundice (yellow eyes or skin)
- severe colicky pain in the upper abdomen
- pain in area of right shoulder blade
- triggering of pain by fatty / large meals

Chest wall
- pain made worse by (deep) breathing
- shortness of breath
- history of recent injury

Lungs
- shortness of breath
- cough, with or without phlegm / sputum
- coughing up blood
- pain made worse by breathing or coughing
- fevers / chills

It is still possible that some of these symptoms can occur with dyspepsia but, in general, they would lead most physicians to consider something other than dyspepsia.

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Symptoms That Suggest Serious Disease ('Alarm Features')

In the majority of cases, dyspepsia symptoms can be managed effectively and there is no need for urgent or extensive investigation. However, in a small proportion of cases, there are indications that the dyspepsia symptoms should be investigated promptly. These indications are commonly termed 'alarm features' or 'red flags'. Not all people with 'alarm features' have serious disease but 'alarm features' do indicate a higher probability that someone has a condition, which requires more rapid attention.

Alarm features include symptoms that someone may describe as well as abnormalities that may be discovered when a physician examines a patient or performs tests. To help with this, the CanDys Working Group identified a number of features which they listed using the acronym 'VBAD'.

- V - Vomiting This refers only to people who have recurrent or persistent vomiting over a period of days or more. Vomiting is a common symptom related, for example, to food poisoning, viral gastroenteritis, alcohol and some medications and, if there is a clear reason for the vomiting or if it is an isolated episode of vomiting, this is not an 'alarm feature'.

- B - Bleeding This refers to the possibility that there may be bleeding from the digestive tract. In some people, this is seen only because they have anemia (i.e. a low hemoglobin on a blood test) or, specifically, iron-deficiency anemia caused by chronic blood loss. In other cases, there may be direct evidence of blood loss from the digestive tract: hematemesis refers to vomiting up blood (bright red or darker 'coffee grounds') and melena refers to the loss of partially digested blood in stools (black or very, very dark, tarry-looking stools). In addition, further testing should be considered if someone has rectal bleeding although it would be very unusual for this to be related to dyspepsia symptoms.

- A - Abdominal Mass or Weight Loss If a physician finds an unusual mass or area of tenderness on examining the abdomen, it suggests that further tests are needed to ensure that any symptoms rally are due to simple dyspepsia. Similarly, it is unusual for someone to lose a significant amount of weight (other than by choice) as a result of most of the conditions associated with dyspepsia symptoms.

- D - Dysphagia This term refers to difficulty in swallowing. Many people with GERD may have an occasional sensation that food does not go down normally; however, this is almost always temporary and it will usually settle completely with standard GERD treatment. However, if someone is having persistent or increasing difficulty swallowing - for example, food seems to stick for a long period of time so that they have to vomit or drink lots of fluids to clear the blockage - further tests may be necessary. In addition, some people experience pain when they swallow: this is known as odynophagia and, again, if this persists, further tests may be necessary.

In addition to the 'alarm features' described above, physicians will consider a number of other factors when deciding on further tests. In particular, severe symptoms or symptoms that have not improved with standard treatment may lead to further tests. Tests will also be considered in someone whose symptoms have started for the first time after age of 50 years. In general, severe disease is less common in younger people so, unless alarm features are present, tests are not usually necessary in people under the age of 50 years. In addition, dyspepsia symptoms may wax and wane over many years, so tests are not usually necessary in someone over the age of 50 years, provided that their symptoms have been present for several years and have not changed during that time.

This approach to symptoms was designed for someone with dyspepsia symptoms who has not had previous digestive tract problems. However, physicians will often assess symptoms differently if there is any history of other digestive tract problems, including surgery, previous abnormal tests and previous conditions such as peptic ulcer or digestive tract blood loss.

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Summary

The treatment of dyspepsia is determined mainly by the type and severity of symptoms. Safe and effective treatment can be given to the majority of patients without the need for extensive testing even though it can be difficult to make a precise diagnosis on the basis of symptoms alone. However, in addition to standard, accepted dyspepsia symptoms there are some symptoms, which suggest that other tests may be necessary. Some are symptoms, which suggest that the main problem is not in the upper digestive tract whilst others are 'alarm features' or 'red flags', which suggest that further tests are needed. It is helpful for patients with dyspepsia symptoms to be aware of these differences so that they can help themselves and help their physicians to select the best treatment.

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Past reports

Endoscopy-Negative Reflux Disease (GERD)

Gastric Adenocarcinoma and Helicobactor pylori

Press Release: NEXIUM®- Now Available in Canada

Non-ulcer Dyspepsia and Helicobacter Pylori Infection: To Treat or Not to Treat

Gastroesophageal Reflux Disease in Pregnancy

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