1. Approach to dyspepsia
   • Definition, symptom complex, causes
   • History, examination, alarm features
   • Initial investigations and endoscopy indications
2. GERD
   • Typical and atypical features
   • Differentiation from cardiac pain, peptic ulcer, and malignancy
   • Investigations, lifestyle measures, PPI treatment, complications
3. Gastritis
   • Acute versus chronic gastritis
   • H. pylori, NSAID, autoimmune, bile-reflux causes
   • Diagnosis, biopsy, eradication and prevention
4. Peptic ulcer disease
   • Gastric versus duodenal ulcer differentiation
   • Perforation, bleeding, penetration, gastric outlet obstruction
   • H. pylori eradication, PPI, endoscopic and surgical management
5. Esophageal cancer
   • Progressive dysphagia and other red flags
   • Diagnosis, staging, treatment principles
6. Gastric cancer
   • Clinical features, risk factors, diagnosis by endoscopic biopsy
   • Staging and treatment principles
7. Functional dyspepsia
   • Rome IV-based clinical diagnosis after exclusion of structural disease
   • Treatment: reassurance, diet, H. pylori testing, PPI, prokinetic or neuromodulator when appropriate

1. Approach to dyspepsia
   • Definition, symptom complex, causes
   • History, examination, alarm features
   • Initial investigations and endoscopy indications
2. GERD
   • Typical and atypical features
   • Differentiation from cardiac pain, peptic ulcer, and malignancy
   • Investigations, lifestyle measures, PPI treatment, complications
3. Gastritis
   • Acute versus chronic gastritis
   • H. pylori, NSAID, autoimmune, bile-reflux causes
   • Diagnosis, biopsy, eradication and prevention
4. Peptic ulcer disease
   • Gastric versus duodenal ulcer differentiation
   • Perforation, bleeding, penetration, gastric outlet obstruction
   • H. pylori eradication, PPI, endoscopic and surgical management
5. Esophageal cancer
   • Progressive dysphagia and other red flags
   • Diagnosis, staging, treatment principles
6. Gastric cancer
   • Clinical features, risk factors, diagnosis by endoscopic biopsy
   • Staging and treatment principles
7. Functional dyspepsia
   • Rome IV-based clinical diagnosis after exclusion of structural disease
   • Treatment: reassurance, diet, H. pylori testing, PPI, prokinetic or neuromodulator when appropriate

Dyspeptic Syndrome: Differential Diagnosis and Treatment

1. Definition

• Epigastric pain or burning
• Postprandial fullness
• Early satiety
• Bloating, belching
• Nausea

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2. Viva Approach to a Patient With Dyspepsia

A. Key history

1. Site and nature of pain
   • Burning retrosternal: GERD
   • Epigastric gnawing/burning: peptic ulcer disease
   • Persistent vague epigastric discomfort: functional dyspepsia or gastric cancer
2. Relation to food
   • Worse after meals: gastric ulcer, gastritis, gastric cancer, postprandial distress syndrome
   • Relieved by food but recurs 2-3 hours later or at night: duodenal ulcer
   • Worse on lying down, bending, after large/fatty meals: GERD
3. Associated symptoms
   • Heartburn/regurgitation: GERD
   • Nausea/vomiting: gastritis, gastric outlet obstruction, gastroparesis
   • Dysphagia: esophageal cancer or complicated GERD
   • Hematemesis/melena: bleeding peptic ulcer or malignancy
   • Weight loss/anorexia: malignancy until proven otherwise
   • Early satiety: gastric cancer, functional dyspepsia, gastroparesis
4. Risk factors
   • NSAIDs, aspirin, steroids, anticoagulants: gastritis/peptic ulcer and bleeding
   • H. pylori exposure or previous infection: gastritis, ulcer, gastric cancer
   • Smoking/alcohol: GERD, ulcer, esophageal cancer
   • Obesity and hiatal hernia: GERD
   • Barrett esophagus: esophageal adenocarcinoma
   • Family history of gastric cancer or hereditary cancer syndrome
5. Drug history
   • NSAIDs, aspirin, potassium, bisphosphonates, iron
   • Drugs causing dyspeptic symptoms: metformin, GLP-1 agonists, antibiotics, opioids

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B. Alarm features or red flags

• Dysphagia or odynophagia
• GI bleeding: hematemesis, melena, occult blood loss
• Iron-deficiency anemia
• Persistent/recurrent vomiting
• Unintentional weight loss
• Anorexia or early satiety that is progressive
• Palpable abdominal mass or supraclavicular lymph node
• Jaundice
• New-onset dyspepsia in an older patient, especially in a high-incidence gastric-cancer setting
• Strong family history of upper-GI malignancy

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C. Initial investigations

• CBC: anemia, bleeding
• Stool occult blood if appropriate
• Liver function tests, renal function, glucose
• Lipase if pancreatic pain is suspected
• ECG/troponin when cardiac ischemia is possible
• Noninvasive H. pylori test:
  • Urea breath test, or
  • Stool antigen test
• Upper GI endoscopy:
  • Alarm features
  • Older/high-risk patients
  • Persistent symptoms despite adequate treatment
  • Suspected ulcer or cancer
  • Dysphagia

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3. Differential Diagnosis: High-Yield Comparison

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4. GERD

Definition

Clinical features

Typical symptoms

• Heartburn
• Acid regurgitation
• Sour taste in mouth
• Retrosternal burning, often after meals or on lying down

Extra-esophageal features

• Chronic cough
• Hoarseness
• Laryngitis
• Asthma-like symptoms
• Dental erosions

Differential diagnosis of GERD

• Peptic ulcer disease
• Functional heartburn
• Esophageal motility disorder, for example achalasia
• Esophageal cancer
• Angina/acute coronary syndrome
• Biliary colic
• Pill esophagitis

Investigations

• Typical uncomplicated GERD: empirical PPI trial is reasonable.
• Endoscopy if alarm symptoms, bleeding, dysphagia, recurrent vomiting, weight loss, or failure of treatment.
• Ambulatory pH monitoring: when diagnosis remains uncertain or before antireflux surgery.
• Manometry: before surgery or if a motility disorder is suspected.

Treatment

Lifestyle measures

• Weight loss if overweight
• Avoid meals within 2-3 hours before sleep
• Elevate head of bed for nocturnal symptoms
• Stop smoking; reduce alcohol
• Avoid individual trigger foods if they provoke symptoms
• Review drugs that worsen reflux

Drugs

1. PPI first-line
   • Examples: omeprazole, pantoprazole, esomeprazole.
   • Take 30-60 minutes before breakfast.
   • Use once daily initially, then optimize dose/adherence if symptoms persist.
2. H2-receptor blocker
   • May help mild or intermittent symptoms, or nocturnal breakthrough symptoms.
3. Antacid/alginate
   • Useful for rapid, short-term relief.

Surgery/endoscopic therapy

Complications

• Erosive esophagitis
• Peptic stricture
• Barrett esophagus
• Esophageal adenocarcinoma

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5. Gastritis

Definition

Causes

• H. pylori infection
• NSAIDs/aspirin
• Alcohol
• Severe physiological stress: burns, sepsis, trauma, ventilation
• Bile reflux
• Autoimmune gastritis
• Radiation, caustics
• Crohn disease and other infiltrative conditions

Clinical features

• Epigastric discomfort/burning
• Nausea, vomiting
• Early satiety
• Sometimes asymptomatic
• Hematemesis or melena if erosive/hemorrhagic gastritis

Types and distinguishing features

Diagnosis

• H. pylori testing: urea breath test or stool antigen test
• Endoscopy with biopsy when alarm symptoms, bleeding, suspected malignancy, or persistent symptoms
• CBC and vitamin B12/iron studies when autoimmune atrophic gastritis is suspected

Treatment

1. Remove the cause
   • Stop NSAID if possible.
   • Avoid alcohol and smoking.
   • If NSAID must continue, prescribe a PPI; consider a COX-2 selective NSAID where appropriate.
2. H. pylori positive
   • Eradicate infection and confirm eradication.
3. Acid suppression
   • PPI for symptom relief and mucosal healing.
4. Autoimmune gastritis
   • Long-term vitamin B12 replacement if deficient/pernicious anemia.
   • Endoscopic surveillance may be needed because of neoplasia risk.

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6. Peptic Ulcer Disease

Definition

Major causes

1. H. pylori
2. NSAIDs/aspirin

Gastric Versus Duodenal Ulcer

Complications

1. Hemorrhage

• Hematemesis, coffee-ground vomiting, melena, shock
• Management: resuscitation, IV PPI, urgent endoscopy and endoscopic hemostasis; interventional radiology or surgery if uncontrolled.

2. Perforation

• Sudden severe pain, rigid “board-like” abdomen, free air under diaphragm
• Management: resuscitation, IV antibiotics, IV PPI, urgent surgical assessment.

3. Gastric outlet obstruction

• Persistent vomiting, early satiety, succussion splash
• Management: fluid/electrolyte correction, nasogastric decompression when needed, endoscopy; dilation or surgery depending on cause.

4. Penetration

• Pain radiating to back, may involve pancreas
• Requires imaging and specialist management.

Diagnosis

• H. pylori testing
• Upper GI endoscopy: most sensitive test and permits biopsy/hemostasis.
• Test for anemia/occult bleeding.

Treatment of uncomplicated ulcer

A. H. pylori-associated ulcer

• Eradicate H. pylori.
• Continue PPI to ensure ulcer healing.
• Confirm eradication at least 4 weeks after antibiotics. Hold PPI for about 2 weeks before urea breath or stool antigen testing to reduce false-negative results.

B. NSAID-associated ulcer

• Stop NSAID if possible.
• PPI therapy.
• Test for and eradicate H. pylori if present.
• If NSAID is essential: lowest effective dose, PPI gastroprotection, and assess cardiovascular/GI risk.

C. Gastric ulcer

• Biopsy at initial endoscopy.
• Repeat endoscopy after treatment to confirm healing and exclude malignancy.

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7. Esophageal Cancer

Main types

1. Squamous cell carcinoma
   • Common in upper/mid esophagus
   • Risks: smoking, alcohol, achalasia, caustic injury, poor nutrition
2. Adenocarcinoma
   • Usually distal esophagus
   • Risks: GERD, Barrett esophagus, obesity, smoking

Clinical features

• Progressive dysphagia: solids first, then liquids
• Odynophagia
• Weight loss
• Retrosternal/epigastric pain
• Regurgitation
• Hoarseness due to recurrent laryngeal nerve involvement
• Chronic cough or aspiration
• Iron-deficiency anemia

Diagnosis and staging

1. Upper GI endoscopy with biopsy: establishes diagnosis.
2. CT chest/abdomen/pelvis: metastatic and regional staging.
3. Endoscopic ultrasound: local T and nodal staging.
4. PET-CT: selected patients to detect occult metastases.

Treatment principles

• Very early superficial disease: endoscopic mucosal resection/submucosal dissection in selected cases, often with ablation for residual Barrett mucosa.
• Resectable locally advanced disease: neoadjuvant chemoradiotherapy or perioperative systemic therapy followed by esophagectomy in suitable patients.
• Definitive chemoradiotherapy: often for unresectable disease or patients unsuitable for surgery.
• Metastatic/advanced disease: systemic therapy, selected immunotherapy/targeted therapy according to tumor biomarkers, and palliation.
• Dysphagia palliation: esophageal stent, radiotherapy, endoscopic dilation in selected cases, nutritional support.

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8. Gastric Cancer

Risk factors

• Chronic H. pylori infection
• Chronic atrophic gastritis and intestinal metaplasia
• Pernicious anemia
• Smoking
• High-salt, smoked/preserved foods
• Previous partial gastrectomy
• Family history, especially hereditary diffuse gastric cancer
• Epstein-Barr virus in a subset

Clinical features

• Persistent dyspepsia not responding to standard treatment
• Early satiety
• Loss of appetite
• Weight loss
• Epigastric mass or pain
• Nausea/vomiting, especially with outlet obstruction
• Iron-deficiency anemia
• Occult or overt GI bleeding

Classical signs of advanced disease

• Virchow node: left supraclavicular lymphadenopathy
• Sister Mary Joseph nodule: umbilical metastatic deposit
• Krukenberg tumor: ovarian metastasis
• Blumer shelf: rectal shelf from pelvic peritoneal metastasis

Diagnosis

• Upper GI endoscopy with multiple biopsies: diagnostic test of choice.
• CT chest/abdomen/pelvis for staging.
• Endoscopic ultrasound for local staging where useful.
• Diagnostic laparoscopy, particularly for potentially resectable advanced disease, to detect peritoneal metastasis.
• Tumor biomarker assessment in advanced disease guides systemic treatment.

Treatment

Early gastric cancer

• Endoscopic resection in carefully selected superficial lesions with negligible lymph-node risk.

Resectable cancer

• Curative surgery: subtotal or total gastrectomy with adequate lymph-node dissection.
• Perioperative systemic therapy is commonly used for locally advanced resectable disease, depending on stage, fitness, and regional protocol.

Unresectable/metastatic cancer

• Palliative systemic therapy chosen according to performance status and biomarkers.
• Palliative radiotherapy, stent, gastrojejunostomy, or endoscopic interventions for bleeding/obstruction.
• Nutritional, anemia, symptom, and palliative-care support.

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9. Functional Dyspepsia

Definition

Rome IV-based symptom pattern

• Bothersome postprandial fullness
• Early satiation
• Epigastric pain
• Epigastric burning

Subtypes

1. Postprandial distress syndrome

• Postprandial fullness
• Early satiety

2. Epigastric pain syndrome

• Epigastric pain/burning
• May occur independent of meals

Diagnosis

• Peptic ulcer disease
• H. pylori infection
• GERD
• Gastric cancer
• Drug-induced dyspepsia
• Biliary, pancreatic, cardiac, and metabolic disease

Treatment

1. Explain and reassure
   • Symptoms are real but no dangerous structural disease is found.
   • Establish a therapeutic relationship.
2. Lifestyle
   • Regular small meals.
   • Identify personal food triggers.
   • Avoid smoking and excess alcohol.
   • Address anxiety, poor sleep, and stress.
3. H. pylori test and treat
   • Eradicate if positive.
4. PPI trial
   • More useful in epigastric pain/burning phenotype.
5. Prokinetic
   • Consider especially if postprandial fullness/early satiety predominates, subject to local availability and safety.
6. Neuromodulator
   • Low-dose tricyclic antidepressant may help refractory epigastric pain or visceral hypersensitivity.
   • SSRIs are not generally first choice solely for dyspepsia.
7. Psychological therapy
   • CBT, gut-directed psychotherapy, and stress-management approaches may help selected refractory patients. A recent systematic review supports a potential role for psychotherapeutic approaches, although treatment should be individualized (PMID 39210762).

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10. Short Viva Algorithm

1. Assess stability and rule out cardiac/acute abdomen.
2. Look for alarm features.
   • Present: urgent endoscopy, biopsy if lesion.
   • Absent: test for H. pylori or empirical PPI depending on local protocol and patient risk.
3. If H. pylori positive: eradicate and confirm cure.
4. If symptoms persist: ensure adherence, review NSAIDs/drugs, perform endoscopy if not done.
5. If endoscopy is normal and other diseases excluded: functional dyspepsia management.

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11. Rapid-Fire Viva Questions

Dyspeptic Syndrome: Differential Diagnosis and Treatment

1. Definition

• Epigastric pain or burning
• Postprandial fullness
• Early satiety
• Bloating, nausea, belching

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2. First Approach in a Viva

Key history

1. Nature and site of pain
   • Burning retrosternal pain: GERD
   • Epigastric gnawing pain: peptic ulcer disease
   • Persistent vague discomfort with early satiety: gastric cancer or functional dyspepsia
2. Relation to meals
   • Pain worse after meals: gastric ulcer, gastritis, gastric cancer
   • Pain relieved by food but recurring 2-5 hours later or at night: duodenal ulcer
   • Symptoms after fatty meals, bending, lying down: GERD
3. Associated symptoms
   • Heartburn/regurgitation: GERD
   • Vomiting, early satiety: gastric outlet obstruction, gastric cancer, gastroparesis
   • Dysphagia: esophageal cancer or stricture until proved otherwise
   • GI bleeding: ulcer or malignancy
   • Weight loss, anorexia: malignancy
   • NSAID use: gastritis or peptic ulcer
   • Alcohol, smoking, family history of gastric cancer
4. Drug history
   • NSAIDs, aspirin, steroids, anticoagulants
   • Bisphosphonates, potassium chloride, iron
   • Drugs causing dyspepsia or reflux: calcium-channel blockers, nitrates, anticholinergics, theophylline

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Alarm features: indications for urgent endoscopy

• GI bleeding: hematemesis, melena, occult blood loss
• Iron-deficiency anemia
• Unintentional weight loss
• Progressive dysphagia or odynophagia
• Persistent vomiting
• Palpable epigastric mass or lymphadenopathy
• Jaundice
• New-onset dyspepsia in an older patient or a person at high risk of gastric cancer
• Family history of upper GI cancer

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3. Differential Diagnosis of Dyspeptic Syndrome

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4. GERD

Definition

Clinical features

Typical

• Heartburn
• Acid regurgitation
• Sour taste in mouth
• Retrosternal burning after meals
• Symptoms worse on lying down or bending forward

Extra-esophageal symptoms

• Chronic cough
• Hoarseness
• Sore throat
• Asthma-like symptoms
• Dental enamel erosion

Complications

• Reflux esophagitis
• Peptic stricture
• Barrett esophagus
• Esophageal adenocarcinoma

Diagnosis

• Typical symptoms without alarm signs: empirical PPI trial is reasonable.
• Upper GI endoscopy if alarm symptoms, refractory symptoms, suspected complications, or Barrett screening is indicated.
• Ambulatory pH or impedance-pH monitoring if diagnosis remains uncertain.
• Manometry is mainly used before antireflux surgery or to assess motility disorders.

Treatment

Lifestyle measures

• Weight reduction if overweight
• Stop smoking
• Avoid meals within 2-3 hours of sleep
• Elevate head end of bed for nocturnal symptoms
• Avoid individual triggers such as alcohol, fatty meals, chocolate, mint, coffee, or spicy food if these clearly provoke symptoms
• Avoid tight clothing

Drugs

1. PPI first-line
   • Omeprazole 20-40 mg once daily, or equivalent
   • Take 30-60 minutes before breakfast
   • Usually trial for 8 weeks
   • If partial response, verify adherence and timing; selected patients may need twice-daily therapy temporarily.
2. H2-receptor antagonist
   • May help occasional or nocturnal symptoms.
   • Less effective than PPIs for erosive disease.
3. Antacid/alginate
   • Rapid short-term relief for intermittent symptoms.

Surgery/endoscopic treatment

• Persistent troublesome regurgitation despite optimized medical therapy
• Large hiatal hernia
• Patient preference to avoid long-term medication
• PPI intolerance

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5. Gastritis

Definition

Causes

Acute gastritis/gastropathy

• NSAIDs and aspirin
• Alcohol
• Severe physiological stress: burns, sepsis, shock, ICU illness
• Bile reflux
• Corrosive ingestion

Chronic gastritis

• Helicobacter pylori infection
• Autoimmune gastritis
• Chemical/reactive gastritis from NSAIDs or bile reflux
• Less commonly Crohn disease, infections, radiation

Clinical features

• May be asymptomatic
• Epigastric discomfort, nausea, vomiting
• Anorexia, bloating
• Bleeding if erosive: hematemesis or melena
• Autoimmune gastritis: vitamin B12 deficiency, pernicious anemia

Diagnosis

• Upper GI endoscopy if alarm features, bleeding, persistent symptoms, or high cancer risk
• Biopsy for histology and H. pylori
• Noninvasive H. pylori testing:
  • Urea breath test
  • Stool antigen test
• Check CBC, iron studies, and vitamin B12 if atrophic/autoimmune gastritis suspected.

Treatment

General

• Stop NSAIDs, aspirin, alcohol, and smoking where feasible.
• Treat the underlying cause.
• Use PPI for symptomatic erosive gastritis or NSAID-related mucosal injury.

H. pylori gastritis

• PPI twice daily
• Bismuth subsalicylate or subcitrate four times daily
• Tetracycline 500 mg four times daily
• Metronidazole 500 mg three or four times daily

Autoimmune gastritis

• Long-term vitamin B12 replacement, often parenteral
• Correct iron deficiency if present
• Endoscopic surveillance may be indicated because of increased gastric neoplasia risk.

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6. Peptic Ulcer Disease

Definition

Major causes

1. H. pylori infection
2. NSAIDs/aspirin

• Severe illness and stress ulceration
• Smoking
• Zollinger-Ellison syndrome
• Corticosteroids, especially with NSAIDs
• Malignancy, particularly when an ulcer is gastric

Gastric versus duodenal ulcer

Complications

• Upper GI bleeding
• Perforation
• Penetration into pancreas or adjacent structures
• Gastric outlet obstruction
• Recurrent/refractory ulcer

Diagnosis

• Upper GI endoscopy is the best test.
• Biopsy all suspicious gastric ulcers, including ulcer edge/base as appropriate, to exclude malignancy.
• Test for H. pylori.
• CBC and stool testing if bleeding suspected.

Treatment

Uncomplicated ulcer

1. PPI
   • Standard-dose PPI for about 4 weeks for many duodenal ulcers.
   • Gastric ulcers often require 8 weeks and repeat endoscopy to confirm healing.
2. H. pylori eradication
   • Use an effective local regimen, commonly 14-day bismuth quadruple therapy.
   • Confirm cure after treatment.
3. NSAID-associated ulcer
   • Stop NSAID if possible.
   • Give PPI.
   • If an NSAID is essential, use the lowest effective dose, consider a COX-2 selective agent when appropriate, and co-prescribe a PPI.
   • Assess need for aspirin carefully. In secondary cardiovascular prevention, aspirin is often restarted early after hemostasis in consultation with the treating team.

Bleeding ulcer

• ABC resuscitation, large-bore IV access, blood grouping/crossmatch.
• IV PPI.
• Urgent endoscopy for diagnosis and endoscopic hemostasis when indicated.
• Endoscopic options: injection, thermal therapy, mechanical clipping, or combination treatment.
• Interventional radiology embolization or surgery if endoscopic treatment fails.

Perforated ulcer

• Surgical emergency.
• Resuscitation, IV fluids, antibiotics, IV PPI, nasogastric decompression as appropriate.
• Urgent surgical review. Many patients need operative repair.

Gastric outlet obstruction

• Fluid and electrolyte correction, NG decompression, PPI, endoscopic evaluation.
• Endoscopic balloon dilatation or surgery depending on cause and response.

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7. Esophageal Cancer

Main histological types

• Squamous cell carcinoma: often upper/mid esophagus; associated with tobacco, alcohol, achalasia, caustic injury, nutritional factors.
• Adenocarcinoma: often distal esophagus; associated with chronic GERD, Barrett esophagus, obesity.

Clinical features

• Progressive dysphagia: solids first, then liquids
• Odynophagia
• Weight loss
• Regurgitation
• Persistent vomiting
• Retrosternal pain
• Hoarseness from recurrent laryngeal nerve involvement
• Iron-deficiency anemia
• Aspiration or recurrent pneumonia

Diagnosis and staging

1. Upper GI endoscopy with biopsy confirms diagnosis.
2. CT chest/abdomen assesses spread.
3. Endoscopic ultrasound assesses local depth and nodes.
4. PET-CT is useful for distant metastasis in potentially curable disease.
5. Bronchoscopy may be needed for upper/mid-esophageal tumors where airway invasion is suspected.

Treatment principles

Palliation

• Esophageal stent for dysphagia
• Radiotherapy or brachytherapy in selected cases
• Feeding tube or nutritional support
• Analgesia and symptom control

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8. Gastric Cancer

Risk factors

• Chronic H. pylori gastritis
• Atrophic gastritis and intestinal metaplasia
• Family history/genetic syndromes such as hereditary diffuse gastric cancer
• Smoking
• High-salt or processed-food diet
• Previous partial gastrectomy
• Pernicious anemia
• Gastric adenomatous polyps

Clinical features

• Persistent epigastric pain/discomfort
• Early satiety
• Anorexia
• Weight loss
• Nausea/vomiting
• GI bleeding or iron-deficiency anemia
• Palpable epigastric mass
• Left supraclavicular node: Virchow node
• Periumbilical nodule: Sister Mary Joseph nodule
• Ascites or hepatomegaly in advanced disease

Diagnosis

• Upper GI endoscopy with multiple biopsies is diagnostic.
• CT chest/abdomen/pelvis for staging.
• Endoscopic ultrasound may assess local stage.
• Diagnostic laparoscopy with peritoneal cytology is often used in potentially resectable advanced disease.

Treatment principles

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9. Functional Dyspepsia

Definition

• One or more of:
  • Bothersome postprandial fullness
  • Early satiation
  • Epigastric pain
  • Epigastric burning
• Symptoms must be chronic and evaluation should not reveal another explanatory disease.

Subtypes

1. Postprandial distress syndrome
   • Postprandial fullness
   • Early satiation
2. Epigastric pain syndrome
   • Epigastric pain and/or burning
   • Not necessarily meal-related

Diagnosis

• No alarm features in low-risk patient: noninvasive H. pylori test-and-treat strategy is appropriate.
• Persistent symptoms or alarm features: upper GI endoscopy.
• Consider CBC, liver tests, coeliac testing, imaging, and gastric emptying studies only when history suggests alternative pathology.

Treatment

1. Explain and reassure

• Symptoms are real but no ulcer, cancer, or dangerous structural disease is found.
• Discuss chronic/relapsing nature and treatment expectations.

2. Lifestyle and dietary measures

• Regular smaller meals
• Avoid foods that reliably trigger symptoms
• Limit excess alcohol and smoking
• Address sleep, anxiety, and stress
• Avoid unnecessary NSAIDs

3. Test and treat H. pylori

• Eradicate if positive.
• Confirm eradication after treatment.

4. Acid suppression

• PPI trial, especially with epigastric pain/burning or overlap reflux symptoms.
• H2 blockers are less effective.

5. Prokinetic therapy

6. Neuromodulators

• Low-dose tricyclic antidepressant, for example amitriptyline 10-25 mg at night, may help pain-predominant symptoms.
• SSRIs have less consistent evidence for dyspeptic symptom relief.

7. Psychological therapy

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10. Viva Algorithm for Uninvestigated Dyspepsia

1. Check for emergency conditions
   • Acute coronary syndrome, perforation, major bleeding, acute pancreatitis.
2. Look for alarm features
   • If present: urgent endoscopy and targeted tests.
3. No alarm features and low cancer risk
   • Test for H. pylori using urea breath test or stool antigen test.
   • Treat if positive.
   • If negative or still symptomatic: trial PPI.
4. Persistent symptoms despite treatment
   • Confirm compliance, drug timing, NSAID exposure, and H. pylori cure.
   • Endoscopy if not already done.
   • Consider GERD, functional dyspepsia, biliary disease, pancreatic disease, cardiac disease, and medication-induced symptoms.
5. Endoscopy normal with persistent symptoms
   • Consider functional dyspepsia and treat stepwise.

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11. Short Viva Questions and Answers