Dyspepsia
Dyspepsia is a symptom complex of recurrent epigastric pain or discomfort, often accompanied by bloating, early satiety, or nausea, originating from the gastroduodenal region.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding | Probability |
|---|---|---|---|---|
| Probability Diagnosis | Functional dyspepsia (FD) (~60%) [2][4] | Young (<40), no alarms, chronic, normal OGD; meets Rome criteria (postprandial fullness / early satiety / epigastric pain ≥6 months) | 「食完嘢之後成日覺得好脹、好快飽？已經持續咗幾耐？」 | ~45% |
| GERD | Heartburn/acid regurgitation worse postprandially and supine | 「瞓低嗰陣有冇酸水湧上嚟？」 | ~25% | |
| H. pylori-related PUD | Epigastric gnawing pain, relation to meals, +ve HP test | 「食嘢之後痛定空肚嗰陣痛？有冇驗過幽門螺旋菌？」 | ~10% | |
| Serious Not To Miss | Acute coronary syndrome | Epigastric pain + risk factors, exertional, diaphoresis | 「行路或者做運動嗰陣會唔會痛？有冇出冷汗？」 | ~2% |
| Gastric / oesophageal carcinoma | Age ≥55, alarm features (weight loss, dysphagia, anaemia, mass) | 「體重輕咗幾多？吞嘢有冇困難？」 | ~1% | |
| Pancreatic carcinoma | Epigastric pain radiating to back, jaundice, weight loss, new-onset DM | 「痛有冇去到背脊？有冇變黃？」 | <1% | |
| Pitfalls | Drug-induced dyspepsia | Temporal relationship to NSAID/aspirin/alendronate use | 「開始食呢隻藥之後先至唔舒服？」 | ~15% |
| Biliary colic / cholecystitis | RUQ/epigastric pain after fatty meals, episodic, radiates to scapula | 「食完油膩嘢有冇右邊肋骨下面痛？」 | ~8% | |
| Chronic pancreatitis | Epigastric pain boring to back, alcohol history, steatorrhoea | 「有冇長期飲酒？大便有冇好油、浮喺水面？」 | <1% | |
| Masquerades | Drugs (as above) | Medication history | 「你依家食緊咩藥？」 | ~15% |
| Depression | Low mood, insomnia, anhedonia causing somatic GI symptoms | 「最近心情點？瞓得好唔好？有冇無精神做嘢？」 | ~8% | |
| Diabetes / DKA | Polyuria, polydipsia, nausea, abdominal pain in DKA | 「有冇成日口渴、去好多次廁所？」 | <1% | |
| Trying to Tell Me Something? | Work/family stress | Functional symptoms worsened by stress | 「工作或者家庭有冇嘢令你好大壓力？」 | ~15% |
| Cancer phobia / anxiety | Recent bereavement, friend with cancer, health anxiety | 「你最擔心嘅係咩？有冇朋友或者親人最近有呢個病？」 | ~10% |
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, set agenda | 「你好！我姓X，係今日嘅醫生。請問點稱呼你？今日想了解吓你嘅情況，可以㗎嘛？」 | Builds rapport; scores interpersonal marks for greeting, introduction, and asking permission |
| 0:30–2:00 | HPI: explore dyspepsia – SOCRATES for pain/discomfort; timing with food; associated symptoms | 「可唔可以講吓你個胃邊度唔舒服？幾時開始？食完嘢之後有冇覺得脹或者痛？有冇火燒心或者反酸？」 | Defines the chief complaint precisely; identifies symptom subtype (ulcer-like vs dysmotility-like vs reflux-like) |
| 2:00–3:00 | Red flags screen – weight loss, dysphagia, vomiting, GI bleeding, anaemia symptoms, jaundice | 「體重有冇輕咗？吞嘢有冇困難？有冇嘔血或者屙黑色大便？」 | Directly determines urgency and whether OGD is indicated; examiners look for this |
| 3:00–3:45 | PMH, Drug Hx, Allergy – NSAIDs/aspirin, PPI use, H. pylori Tx history; FHx upper GI cancer | 「你有冇食止痛藥好似Brufen或者阿士匹靈？有冇藥物敏感？屋企人有冇胃癌或者腸癌？」 | Drug-induced dyspepsia is a key DDx; FHx is an alarm feature [1][2] |
| 3:45–4:30 | Social Hx & functional impact – smoking, alcohol, stress/work, diet, sleep | 「你有冇食煙飲酒？最近工作壓力大唔大？瞓得好唔好？」 | Uncovers psychosocial problems; functional dyspepsia is strongly linked to stress [3] |
| 4:30–5:15 | ICE – uncover hidden agenda | 「你自己覺得係咩原因？你最擔心啲乜嘢？嚟睇醫生你最想我幫你做啲咩？」(Idea / Concern / Expectation) | Marks are given for eliciting ICE; the hidden agenda is often fear of cancer or wanting a scope |
| 5:15–5:45 | Summarise & check understanding | 「等我總結吓：你話胃痛咗幾個星期，食完嘢之後仲差，冇嘔血冇黑便，最擔心會唔會係癌症。我有冇遺漏㗎？」 | Demonstrates active listening; scores summarising marks |
| 5:45–6:00 | Close & safety net | 「多謝你！如果之後有嘔血、屙黑便、突然好痛，記得即刻去急症室。」 | Safe closure; shows you addressed red flags for safety netting |
Hidden agenda tip: The simulated patient often worries about stomach cancer (especially if FHx+ve or recent bereavement/friend diagnosed). Ask "你最擔心啲乜嘢？" early in ICE — the answer drives the RFC.
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think of |
|---|---|---|---|---|
| Symptom site | Where exactly is the discomfort? | 「邊度唔舒服？上腹定係心口？」 | Localise to epigastrium vs retrosternal | GERD if retrosternal; PUD/FD if epigastric |
| Character | Burning, gnawing, or fullness? | 「係痛、脹、定係好似火燒咁？」 | Ulcer-like vs dysmotility-like vs reflux-like | PUD = gnawing; GERD = burning; FD = fullness |
| Onset & duration | When did it start? How long? | 「幾時開始？持續咗幾耐？」 | Acute vs chronic; Rome criteria need ≥6 months for FD | Acute → r/o pancreatitis, MI; Chronic → FD, PUD |
| Relation to food | Better or worse after eating? | 「食完嘢好啲定差啲？」 | GU worsened by food; DU relieved by food [4] | GU vs DU discrimination |
| Night pain | Does pain wake you at night? | 「半夜會唔會痛醒？」 | Nocturnal pain suggests DU | Duodenal ulcer |
| Heartburn/reflux | Any burning behind chest or acid taste? | 「有冇火燒心或者酸水湧上嚟？」 | GERD is overdiagnosed in dyspepsia — do NOT conclude GERD unless typical symptoms [3] | GERD |
| Early satiety | Do you feel full very quickly? | 「食少少就飽？」 | Rome criteria for FD; also alarm if new | FD (postprandial distress); gastric CA |
| Dysphagia | Any difficulty swallowing? | 「吞嘢有冇卡住或者吞唔到？」 | Alarm feature → OGD [1][2] | Oesophageal CA, stricture |
| Weight loss | Unintentional weight loss? | 「體重有冇輕咗？輕咗幾多？」 | Alarm: >10% BW in 12 months → malignancy [2] | Gastric/oesophageal CA, pancreatic CA |
| GI bleeding | Black stools or vomiting blood? | 「有冇屙黑便或者嘔血、嘔啡色嘢？」 | Alarm feature → urgent OGD | PUD with bleeding, CA |
| Vomiting | Any vomiting? How often? | 「有冇嘔？嘔幾多次？」 | Persistent vomiting = alarm; vomiting old food = GOO | GOO, pancreatitis |
| Jaundice | Any yellow skin or eyes? | 「皮膚或者眼白有冇變黃？」 | Alarm → hepato-pancreatic-biliary cause [2] | Pancreatic CA, gallstone, hepatitis |
| Drug Hx | Taking NSAIDs, aspirin, bisphosphonates? | 「有冇食止痛藥、薄血藥、或者骨質疏鬆藥？」 | NSAIDs, aspirin, alendronate commonly cause dyspepsia [2][4] | Drug-induced dyspepsia |
| H. pylori Hx | Ever tested/treated for H. pylori? | 「有冇驗過或者醫過幽門螺旋菌？」 | Guides test-and-treat strategy [1] | H. pylori-related PUD |
| FHx | Family history of stomach cancer? | 「屋企人有冇胃癌？」 | Alarm feature [2] | Gastric CA screening |
| Smoking/alcohol | Smoking and alcohol habits? | 「食煙飲酒情況點？」 | RFs for PUD and GERD | PUD, GERD, pancreatitis |
| Stress/mood | Work stress? Feeling low? | 「最近壓力大唔大？有冇唔開心？」 | Psychological factors strongly associated with FD [3] | Functional dyspepsia; depression as masquerade |
| Dietary triggers | Spicy food, coffee, fatty food? | 「食辣嘢、咖啡、油膩嘢會唔會差啲？」 | Dietary triggers for GERD and FD | GERD, FD |
| Functional impact | Does it affect work/sleep/eating? | 「影唔影響返工、瞓覺、食飯？」 | Captures social/functional problem for biopsychosocial | Biopsychosocial problem |
Case Report Form Answer Builder
High-yield points to capture:
- CC: Epigastric discomfort/pain × [duration]
- HPI: Site (epigastric), character (burning/fullness/gnawing), onset, duration, relation to food, aggravating/relieving factors, associated symptoms (nausea, bloating, heartburn, regurgitation)
- Red flags screened: weight loss (−), dysphagia (−), GI bleeding (−), vomiting (−), jaundice (−) — document even if negative
- Drug history: NSAID/aspirin use, PPI use, H. pylori treatment history
- Social: smoking, alcohol, stress, functional impact
Likely RFC examples:
- "Worried about stomach cancer because a relative was recently diagnosed"
- "Persistent epigastric discomfort affecting eating and work"
- "Wants investigation (endoscopy) to find out the cause"
How to phrase: State the patient's primary motivation in one sentence. Often it is a concern (fear of cancer) rather than the symptom itself.
| Likely Content | Exact Wording to Write | |
|---|---|---|
| Idea | "I think I might have a stomach ulcer" or "Maybe it's from stress" | "Patient thinks the pain may be due to a stomach ulcer / stress" |
| Concern | "I'm worried it could be stomach cancer" | "Patient is worried about the possibility of stomach cancer, especially given FHx / friend's diagnosis" |
| Expectation | "I want to have a gastroscopy" or "I want medication to relieve the pain" | "Patient expects referral for endoscopy / medication to relieve symptoms" |
Functional dyspepsia is the most likely diagnosis (~60% of dyspepsia cases) if: age < 40–45, no alarm features, chronic symptoms (≥6 months), normal examination [2][4].
If alarm features are present → peptic ulcer disease or malignancy should be considered.
Minimum supporting evidence: Young patient with chronic postprandial fullness/early satiety/epigastric discomfort, no red flags, no weight loss, no GI bleeding, normal abdominal examination.
| DDx | Key Discriminator |
|---|---|
| 1. GERD | Heartburn and acid regurgitation, worse supine/postprandial; relieved by PPI |
| 2. Peptic ulcer disease (H. pylori / NSAID) | Gnawing epigastric pain related to meals; +ve H. pylori test or NSAID use |
| 3. Gastric carcinoma | Age ≥55, alarm features (weight loss, dysphagia, anaemia, mass) — must exclude |
| Domain | Problem |
|---|---|
| Biological | Chronic epigastric discomfort causing reduced oral intake / nutritional impact |
| Psychological | Anxiety about possible malignancy (cancer phobia); or underlying depression/stress |
| Social | Impaired work performance / social eating avoidance / sleep disturbance due to symptoms |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Diagnosis |
|---|---|---|---|
| Functional dyspepsia (most likely Dx) | No reliable specific physical sign in brief FM station — examination is characteristically normal; mild epigastric tenderness is non-specific and NOT diagnostically valuable [3] | Perform abdominal exam: inspect, auscultate, palpate epigastrium | A normal abdominal examination in a young patient with chronic dyspepsia and no alarms supports FD (diagnosis of exclusion) |
| GERD | No specific sign; may have dental erosions or epigastric tenderness — generally a clinical diagnosis | Inspect teeth for erosions; palpate epigastrium | Dental erosion suggests chronic acid reflux |
| Peptic ulcer disease | Epigastric tenderness on palpation (localised) | Deep palpation of epigastrium | Localised tenderness suggests mucosal lesion, but is non-specific |
| Gastric carcinoma | Palpable epigastric mass, left supraclavicular lymphadenopathy (Virchow's node), or signs of anaemia (pallor) | Palpate epigastrium for mass; palpate left supraclavicular fossa; check conjunctival pallor | Mass/LN = alarm finding; pallor suggests occult GI blood loss |
| Biliary disease | RUQ tenderness, positive Murphy's sign | Palpate RUQ during inspiration | Arrest of inspiration during RUQ palpation = cholecystitis |
Exam Tip: Physical Sign for FD
If your most likely diagnosis is functional dyspepsia, write: "Normal abdominal examination with no palpable mass, no lymphadenopathy, and no organomegaly — supporting the absence of organic pathology." Examiners accept that FD has no specific sign; the key is demonstrating you looked for alarming signs and found none.
Top Traps That Lose Marks
- Jumping to GERD without typical reflux symptoms — GERD is overdiagnosed in dyspepsia [3]. Only diagnose GERD if heartburn/regurgitation dominate.
- Forgetting red flag screening — Examiners specifically check: weight loss, dysphagia, GI bleeding, persistent vomiting, age ≥55 (some guidelines say ≥45 or ≥60 — use the GC slide cut-off of age ≥60 for OGD indication [1]).
- Missing drug-induced dyspepsia — Always ask about NSAIDs, aspirin, alendronate [2][4].
- Not asking about H. pylori — The test-and-treat strategy is the core management pathway for uninvestigated dyspepsia in patients < 60 without alarms [1].
- Not eliciting ICE — The hidden concern (usually cancer fear) is often the RFC; missing it costs marks in both interpersonal skills and the Case Report Form.
- Forgetting non-GI causes — MI/ACS can present as epigastric pain [2][4]. Ask about exertional symptoms and cardiac risk factors.
- Not asking functional impact — You need a social/functional problem for the biopsychosocial section.
Three-step approach to uninvestigated dyspepsia (GC slide high yield): [1]
- OGD first if age ≥60 OR red flag symptoms (weight loss, anaemia, dysphagia, persistent vomiting)
- If < 60 and no red flags → test for H. pylori and treat if positive
- If H. pylori negative or no response → empirical antisecretory therapy (PPI) → TCA/prokinetic → psychotherapy
Must-not-miss red flags (mnemonic: "VBAD FLAWS"):
- Vomiting (persistent)
- Bleeding (haematemesis, melena, iron-deficiency anaemia)
- Anorexia / early satiety (new)
- Dysphagia / odynophagia
- Family Hx upper GI cancer
- Lymphadenopathy / mass
- Age ≥55–60 new onset
- Weight loss (unintentional)
- Surgery (previous gastric surgery or malignancy)
Shortest safe management/safety-net line: 「如果有嘔血、屙黑便、吞嘢困難、或者體重突然輕好多，記得即刻返嚟或者去急症室。」
High Yield Summary
What to ASK: Symptom character (burning/fullness/gnawing), relation to food, red flags (weight loss, dysphagia, GI bleeding, vomiting, jaundice), drug history (NSAIDs/aspirin), H. pylori history, FHx upper GI cancer, stress/mood, functional impact, ICE.
What to WRITE: CC with duration → HPI with negatives documented → RFC (often cancer fear) → ICE → Most likely Dx: Functional dyspepsia (if no alarms, young) → DDx: GERD, PUD, gastric CA → Biopsychosocial: reduced intake / cancer anxiety / work impairment → Physical sign: normal exam (or epigastric tenderness if PUD more likely; Virchow's node/mass if CA).
What NOT to MISS: Red flags → OGD referral; ACS mimicking dyspepsia; drug-induced cause; hidden cancer fear as RFC; always screen H. pylori status.
Active Recall - Family Medicine Clinical Test
[1] Lecture slides: GC 068. Indigestion and 'heartburn'.pdf (three-step approach to uninvestigated dyspepsia; OGD indications; GERD overlap) [2] Senior notes: Block A - Upper abdominal pain_ peptic ulcer; pancreatitis and gallstone.pdf (alarming features, DDx for epigastric pain, drug causes, non-GI causes) [3] Senior notes: Ryan Ho GI.pdf (approach to dyspepsia, functional dyspepsia pathophysiology, GERD overdiagnosis, Carnett sign, management guidelines) [4] Senior notes: Maksim Medicine Notes.pdf (PUD aetiology, GU vs DU features, NSAID-related ulcers, test-and-treat approach, alarm features) [5] Senior notes: Block A - Indigestion and 'heartburn'_ nausea and vomiting; gastric motility problems; benign esophageal lesions.pdf (GERD clinical features, overlap between GERD/NCCP/dyspepsia, three-step workup) [6] Senior notes: MBBS Final MB (Medicine) (Felix PY Lai).pdf (Rome III criteria, alarming features, epidemiology of FD vs organic causes) [7] Lecture slides: #1. GCBC_FM Introductory Seminar_2025-2026_AN23012026.pdf (clinical test format, marking scheme)
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