Definitions of Dyspepsia

R . C. HEADING
Dept. of Medicine, Royal Infirmary, Edinburgh, Scotland

Heading RC. Definitions of dyspepsia. Scand J Gastroenterol 1991, 26(suppl 182),

1-6
The definition of the term dyspepsia and of derived terms such as organic dyspepsia,
functional dyspepsia, reflux-like dyspepsia, and non-ulcer dyspepsia continues to
provoke controversy. In recent literature, however, it is apparent that a measure of
agreement is now emerging with regard to 'dyspepsia', which is considered simply to
denote episodic or persistent symptoms that include abdominal pain or discomfort and
which are referable to the upper gastrointestinal tract. Particular symptom patterns
may justify the use of descriptions such as reflux-like dyspepsia, ulcer-like dyspepsia,
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or dysmotility-like dyspepsia, but these terms should not carry any implication that the
symptom patterns can be attributed to particular pathogenetic processes. In many
patients with dyspepsia. clinical assessment and investigation fail to identify any
abnormality to which the symptoms can reasonably be attributed. The label of
'functional dyspepsia' is well-established medical parlance in these circumstances and
is generally accepted as the converse of 'organic dyspepsia', which denotes dyspepsia
for which a responsible disease process has been identified.
Key words: Abdominal pain; dyspepsia; gastrointestinal symptoms
R . C. Heading. Dept. of Medicine, Royal Infirmary, Edinburgh EH3 9YW, Scotland
For personal use only.

Although dyspepsia is a term widely used in
clinical practice, it is apparent from the published
literature that its definition causes much frustra-
tion to clinical investigators. In consequence,
some published papers have labelled the term
with signals of scientific disapproval-it has been
said to be ill-defined (l), poorly defined ( 2 ) ,
defying definition (3), and vague and misunder-
stood (4). Other authors, perhaps wishing to
avoid controversy, use the word dyspepsia with-
out any definition or explanation at all. It seems
accepted, howcver, that the word is in widespread
u5e among physicians, and it must therefore
be thought to afford useful communication of
information. Why, then, is there so much dif-
ficulty with definition?
Physicians may describe patients as having
dyspepsia when the patients themselves say they
have indigestion. The former is derived from
Greek and the latter from Latin, but the two
words otherwise have the same construction and
the same meaning. This incorporates a clear
inference of relationship t o the gastrointestinal
tract and, more specifically, to that part of the
gastrointestinal tract thought to relate to food
intake and digestion rather than the process of
defaecation. Of course, belief that a patient's
symptoms have a gastrointestinal origin may be
in error, but use of the words indigestion or
dyspepsia indicates that this interpretation has
been applied. Both words are unquestionably
imprecise and nonspecific, and so any definition
that attempts to render them otherwise will have
difficulty gaining general acceptance. Likewise,
any definition that fails to incorporate the gastro-
intestinal interpretation of symptoms implied by
the words is attempting to change their meaning,
rather than describing present usage.
Thus the terms indigestion and dyspepsia are
not only imprecise; they describe a combination
of facts (the symptoms) with an interpretation
put upon them. Given that the symptoms are
variable and their interpretation is a matter of
judgement, investigators understandably feel un-
comfortable about beginning studies from this
foundation.
 2 R. C. Heading
There can b e no doubt that a generally accept-
able definition of dyspepsia would assist studies of
the problem. Although many varied definitions
have been offered during the past 20 years, a
measure of agreement now seems to be emerging,
at least for ‘dyspepsia’. In recent years, however,
there has been increasing use of derived terms
such as non-ulcer dyspepsia, functional dyspepsia,
flatulent dyspepsia, and reflux-like dyspepsia to
describe particular clinical patterns within the
totality of dyspepsia. Significant confusion in the
use of these terms is apparent, and there are also
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some doubts about their clinical and biological
validity.
In a strictly logical world, agreement about
terminology would be a preliminary to systematic
investigation, which would then lead to better
understanding of the nature of dyspepsia. In
reality. however, agreement on terminology
evolves in parallel with the emergence and
acceptance of new concepts. It may therefore be
helpful to attempt to distinguish purely semantic
For personal use only.
differences from more fundamental conceptual
disagreements when considering the terminology.
TERMINOLOGY IN C U R R E N T USE
Dyspepsia
There is no doubt that physicians are very
uncertain about what they mean by dyspepsia.
Published definitions include: ‘Has ever had
‘indigestion’ for more than a few days, whether
the symptoms were in the upper abdomen or
whether they had the characteristics of heartburn’
( 5 ) ; ‘Episodic, recurrent o r persistent abdominal
pain o r discomfort, or any other symptom refer-
able to the alimentary tract excluding jaundice or
bleeding’ (6); ‘Any pain, discomfort or nausea
rcferable to the upper alimentary tract which may
be inieimittent or continuous, has been present
for one month or more, and is not precipitated by
exertion and not relieved within five minutes by
rest’ (7); ‘Abdominal (usually upper abdominal)
or retrosternal pain, accompanied by other symp-
toms rcferable to the upper gastrointestinal tract,
such as nausea, vomiting, loss of appetite or
jaundice’ (8). Thus one group of investigators
believes that dyspepsia includes jaundice, while
another excludes it. In several recent papers,
however, it is apparent that broadly similar
definitions for the word dyspepsia have emerged:
episodic or persistent symptoms thought by the
physician to be referable to the proximal gastro-
intestinal tract (2,9-11). Relevant symptoms are
specified in Table I , and any combination of these
symptoms which includes abdominal pain or dis-
comfort may fall within the definition. Some
relationship between symptoms and food intake is
often apparent, but it is not an essential element
for the definition. Some authors suggest that
symptoms should be present for several weeks or
months before the term dyspepsia is applied (4). It
may be sensible to require chronicity of symptoms
for formal studies of dyspepsia, but chronicity is
not essential to definition of the word itself.
Organic dyspepsia
It has been suggested that organic dyspepsia
is an appropriate term to indicate dyspepsia
for which the cause is clearly identified. One
definition, however, restricts this to specific
lesions such as peptic ulcer, oesophagitis, gastric
carcinoma, and cholelithiasis. which are readily
identified on routine investigation (10). Another
proposed definition of organic dyspepsia includes
dyspepsia due to psychiatric illness, alcoholism,
and, presumably, metabolic disease ( 2 ) . The term
does have attractions, however, if it is taken to
indicate that a disease process that is thought to be
responsible for a patient’s dyspepsia has been
identified. Nevertheless, it must be recognized
that it may be difficult to establish cause-effect
relationships with certainty. In patients found to
have gastritis or gallstones, there may be con-
siderable doubt about whether the symptoms
Table I . Dyspeptic symptoms
Abdominal pain or discomfort
Postprandial fullness
Abdominal bloating
Belching
Early satiety
Anorexia
Nausea
Vomiting
Heartburn
Regurgitation
 Definitions of Dyspepsia 3

can properly be attributed to the observed ab-
normality, and thus there is doubt about whether
the patient’s dyspepsia is organic.
Nonorganic dyspepsia
Nonorganic dyspepsia is obviously the converse
of the above, and the term has been used to
indicate dyspepsia of unknown cause. In practice,
the terms non-ulcer dyspepsia and functional
dyspepsia are often used with the same meaning,
but there is inconsistency in the published litera-
ture, and no consensus seems to be emerging for
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Recent evidence has shown that when heart-
burn and acid regurgitation are the dominant
symptoms reported, gastro-oesophageal reflux
can be confirmed objectively in the large majority
of patients (13). Thus when these are the domi-
nant complaints, they may be regarded as highly
specific indicators of reflux, but, in contrast, when
they are merely present together with other symp-
toms, the diagnosis of reflux cannot be made
reliably. Other evidence also indicates that the
classic symptoms of gastro-oesophageal reflux
are specific but not sensitive indicators of the

these latter terms. Use of the term functional diagnosis (14).

dyspepsia seems particularly appropriate if some
disorder of function such as a tachygastria has
been clearly demonstrated and is thought res-
ponsible for the symptoms. Nevertheless, some
would argue that dyspepsia clearly due to an
abnormality of this sort is no less ‘organic’ than
dyspepsia clearly attributable to peptic ulcer or
cholelithiasis. With most disorders of function,
however, it is exceptional to establish cause/effect
For personal use only.
It is difficult to see much advantage in the
term ‘gastro-oesophageal reflux-like dyspepsia’
for individuals with classic heartburn and acid
regurgitation. These symptoms do not merely
resemble the symptoms of reflux, they are the
symptoms of reflux and are only rarely en-
countered in patients without evidence of reflux at
endoscopy or on pH monitoring. When heartburn
and acid regurgitation are present together with

relationships beyond doubt. A rigorous approach other dyspeptic symptoms, use of the term reflux-
to classification would recognize that in the vast like dyspepsia can be justified.
majority of patients with non-organic dyspepsia
the source of the symptoms is unknown. Idio- Ulcer dyspepsia
pathic dyspepsia would therefore be an appro- This term is conventionally used to denote a
priate term, but, unfortunately, it has been used in pattern of dyspeptic symptoms thought to be
the literature with a much narrower meaning (4, typical of peptic ulceration. Features such as well-
lo), compounding the terminological confusion. localized epigastric pain, night pain causing the
patient to awaken, relief by food and antacids,
Symptoms suggesting gastro-oesophageal reflux and a pattern of remission and relapse have all
The classic symptoms of gastro-oesophageal been shown to be more frequently encountered in
reflux (heartburn and acid regurgitation) were patients with a peptic ulcer than in those without
considered by the Health and Public Policy Com- an ulcer (7, 15, 16). Nevertheless, many patients
mittee of the American College of Physicians to with a peptic ulcer do not have these so-called
be distinguishable from dyspepsia and were there- typical features, and now that endoscopy is so
fore not included in it (12). Talley & Phillips noted generally available, few gastroenterologists place
that patients with dyspepsia often have heartburn much reliance on symptom patterns to confirm or
and acid regurgitation but did not consider these refute a diagnosis of peptic ulcer. In addition,
symptoms alone represented dyspepsia (4). In computer-aided diagnostic systems have shown
contrast, the reports of two consensus working that other information that may be gained from
parties included symptoms of gastro-oesophageal the clinical history, such as the patient’s age, sex,
reflux within their concepts of dyspepsia (10, 11). and smoking habits, contributes more to the
One of these groups advocated the term gastro- correct discrimination of ulcer from non-ulcer
oesophageal reflux-like dyspepsia to describe the patients than some aspects of the dyspepsia itself
occurrence of such symptoms in individuals with- (15, 16).
out endoscopic abnormality (10). Ulcer-like dyspepsia has been favoured by
 4 R. c' Headrrrg
some authors to denote a pattern of symptoms
considered typical of peptic ulceration occurring
in a patient who does not have an ulcer (2, 10).
Non-ulcer dyspepsia
It is clear from the literature that this ungainly
term is often used to indicate dyspepsia occurring
in a patient in whom no abnormality is identified
by conventional gastroenterological investigation.
It would thus seem to be synonymous with the
terms nonorganic dyspepsia and functional dys-
pepsia. Xowever, this is an oversimplification,
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because non-ulcer dyspepsia seems to carry an
implication that the symptoms are ulcer-like.
Barbara et al. (11) took this view unequivocally,
although their definition of non-ulcer dyspepsia-
ulcer-like symptoms when no ulcer is found-has
also been used by others. As a working definition.
Talky & Phillips (4) proposed 'patients with
non-ulcer dyspepsia have symptoms that prompt a
physician to believe an ulcer may be present, but
no ulcer is found on evaluation'. This corresponds
For personal use only.
t o ulcer-like dyspepsia. as defined by Colin-Jones
et al. (10) and by Dobrilla (2). The discrepancy
thus centres on patients with dyspeptic symptoms
that are thought atypical for ulcer disease: are
they or are they not to be included in non-ulcer
dyspepsia?
Recognizing the limitations of the term non-
ulcer dyspepsia, Nyren et al. (17) proposed 'epi-
gastric distress syndrome' as a term to embrace
upper abdominal discomfwt with or without
ulcer-like features. It is difficult to contest the
view that the term non-ulcer dyspepsia is used
inconsistently and that confusion about its mean-
ing is inherent in the fact that it may with equal
!yitimacv be seen primarily to suggest either
dyspepsia in the absence of a peptic ulcer or
the absence of an ulcer plus the presence of
specifically ulcer-like symptoms.
Dysrnotdity-like dyspepsia
Dyspepsia in which features such ;as flatulence.
bloating. distension, and early satiety are promi-
nent has been termed dysmotility-like dyspepsia
(10). The term flatulent dyspepsia has been used
with much the same meaning (2). This pattern of
dyspepsia is thought to overlap with symptoms of
the irritable bowel syndrome, as defined by
Manning et al. (18).
T o suggest that this pattern of dyspepsia is
particularly associated with dysmotility is specula-
tion. Although several studies have shown ah-
normalities of gastric or small-intestinal motility
in patients with functional dyspepsia, no specific
association with one particular pattern of dys-
peptic symptoms has been established. Delayed
gastric emptying is an established finding in a
significant proportion of patients with gastro-
oesophageal reflux disease, and in consequence
an association of delayed gastric emptying and
reflux symptoms can be predicted. It appears,
however, that a similar frequency of delayed
gastric emptying is also found in other dyspeptic
patients (19. 20).
Biliary ciyspepsia
Traditional teaching associates 'flatulent dys-
pepsia' with biliary tract disease, but in fact
systematic studies have shown no convincing link
between cholelithiasis and symptoms of belching.
postprandial fullness, and discomfort (21-23).
The term dyspepsia is not usually used in con-
nection with the severe pain of biliary tract disease.
probably because the pain usually dominates
other symptoms to such an extent that 'dyspepsia'
seems inadequate to convey its severity.
A erophagia
Aerophagia has been proposed as one type
(cause?) of dyspepsia (10). The evidence is
meagre, and indeed it is claimed that aerophagia
occurs with equal frequency in all varieties of
dyspepsia (24).
CONCLUSIONS
Three conclusions may be suggested from the
foregoing observations on the terminology in
current use. First, it is apparent from recent
publications that the extent of agreement about
the definition of dyspepsia and the nature of
symptom patterns that indicate different types of
dyspepsia is greater than might be anticipated
from the oft-repeated declarations that the term
dyspepsia is vague and ill-defined.

Second, when confusion exists in the literature,
it is more often semantic than conceptual. For
example, a patient with ulcer-like symptoms but
without apparent disease on investigation is cate-
gorized as having the ulcer-like dyspepsia variant
of non-ulcer dyspepsia according to one scheme
(lo), the non-ulcer dyspepsia variant of functional
dyspepsia by another (11). and the ulcer-like
dyspepsia variant of functional dyspepsia by a
third (2). Nevertheless, all three schemes recog-
nize the existence of patients with classical ulcer-
like symptoms among those with dyspepsia for
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which no cause is found on investigation. Thus
they share the same concepts; it is simply the
terminology that differs.
Third, there is considerable agreement in the
recent literature not only that dyspepsia is a term
embracing various patterns of (upper) gastro-
intestinal symptoms but also that to attempt
identification of broad patterns of symptoms that
characterize constituent variants of dyspepsia
and other functional gastrointestinal disorders
For personal use only.
represents a worthwhile route towards better
understanding of the problems (25). There is no
certainty, however, that better analysis of the
symptoms will permit the identification of specific
disorders responsible for functional dyspepsia.
Recent experience with peptic ulcer disease and
with gastro-oesophageal reflux disease suggests
the contrary, in that symptom patterns are fre-
quently so nonspecific that diagnosis from the
clinical history is not possible. There is no well-
founded reason to believe that relationships be-
tween symptoms and their cause are any closer in
functional dyspepsia.
RECOMMENDATIONS
The following proposals on terminology are made
with the unanimous endorsement of the con-
tributors to this supplement.
1. Dyspepsia. Episodic or persistent symptoms
that include abdominal pain or discomfort: the
commonly encountered symptoms are those given
in Table I. The term dyspepsia is not applied to
patients whose symptoms are thought to be arising
from outside the proximal gastrointestinal tract.
2 . The terms reflux-like dyspepsia, ulcer-like
Definitions of Dyspepsia 5
dyspepsia, and dysmotility-like dyspepsia denote
certain patterns of symptoms, viz:
Reflux-like dyspepsia. Dyspepsia with heart-
burn and regurgitation prominent among the
symptoms.
Ulcer-like dyspepsia. Dyspepsia considered
‘classical’ of peptic ulcer, usually including well-
localized epigastric pain, relief of pain by food and
antacids. and a pattern of remission and relapse.
Dysrnotility-like dyspepsia. Dyspepsia with
bloating, early satiety, nausea, and poorly local-
ized abdominal discomfort prominent among the
symptoms.
Nonspecific dyspepsia. Denotes dyspepsia that
does not fall into one of the above three categories.
(Please note that these terms describe symp-
toms and are therefore applicable to the uninvesti-
gated patient. Their validity as descriptions does
not imply that assumptions may be made about
diagnosis in individual patients, nor that patho-
genic mechanisms responsible for the dyspepsia
have been established.)
3. Relationships with underlying disease.
Organic dyspepsia. Dyspepsia for which an
underlying disease process, thought to be respon-
sible for the symptoms, has been identified. (If the
disease improves, heals, or is eliminated, im-
provement in symptoms may be expected.)
Functional dyspepsia. Dyspepsia for which no
underlying disease process has been identified to
explain the symptoms. (Use of the term functional
dyspepsia implies that a patient has been investi-
gated to identify organic disease.)
4. Non-ulcer dyspepsia. This term is potentially
confusing and its use is not recommended.
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