Children often experience epigastric discomfort or dyspepsia either as a presenting symptom or during hospitalization. The challenge to the hospitalist is to identify the cause or causes based on typically vague complaints, a wide differential, generally indirect examination of the affected area, and laboratory and radiographic evaluations that are nonspecific and rarely diagnostic.

Nausea, vomiting, heartburn, regurgitation, early satiety, postprandial abdominal bloating or distention, excess gas with or without belching or flatulence, queasiness, fullness, and retching are all common presentations of gastric dysfunction. These symptoms overlap with the discussions of other disorders such as abdominal pain, gastrointestinal (GI) bleeding, failure to thrive, and feeding issues.

Dyspepsia is defined as chronic or recurrent pain or discomfort in the upper abdomen (above the umbilicus), with discomfort being a subjective sensation that may include fullness and early satiety.^1-3 These symptoms are typically to the exclusion of “heartburn” or a burning sensation in the retrosternal region, which is generally presumed to be gastroesophageal reflux disease (GERD).³ In one study of children at a tertiary center evaluated for unexplained recurrent abdominal pain, 15.9% met criteria for functional dyspepsia, a term applied to dyspeptic symptoms absent other identifiable disease.⁴

The timing of symptoms is often helpful in determining the presence of underlying disease. Pain attributable to gastric ulceration often peaks when the stomach is empty, whereas pain associated with functional dyspepsia usually develops immediately after eating and may linger for hours.

Many disorders can cause dyspepsia, including functional, mucosal, and anatomic abnormalities of the stomach or extragastric GI system. In addition, extra-GI disorders, such as genitourinary or psychiatric dysfunction, can have prominent dyspeptic symptoms (Table 77-1).

The broad differential diagnosis and the subjective nature of these symptoms can present a challenge, and a standard approach or algorithm for evaluation is difficult to establish. Certainly a timeline as well as any type of symptom journal that the patient or family can provide is helpful. Initial questions should include duration of symptoms, antecedent infection or antibiotic use, degree of disability associated with symptoms, medication history, and measures—effective and ineffective—taken thus far to address the symptoms. If symptom severity has dictated hospitalization it is generally incumbent on the hospitalist to begin some investigation, but it should be measured. A reasonable initial laboratory workup might include a complete blood count, inflammatory markers (erythrocyte sedimentation rate or C-reactive protein), chemistry profile (including liver and renal function tests), pancreatic enzymes, (amylase, lipase) stool testing for ova and parasites, urinalysis, and screening for Helicobacter pylori. While screening for H. pylori is the most likely to yield a positive result in this setting, the practitioner should be aware that a positive H. pylori screen does not necessarily mean the source for the symptoms has been identified. As guidelines for diagnosis and treatment of H. pylori in children evolve, further consultation with a gastroenterologist or infectious disease specialist may be indicated to determine the most effective means of diagnosis and therapy.⁵ Noninvasive tests for H. pylori including a ¹³C urea breath test and a stool antigen test are currently recommended to be obtained after therapy to confirm eradication.⁵ The combination of the history, physical findings, and laboratory results may indicate the need for further evaluation into conditions including inflammatory bowel disease (IBD), H. pylori gastroenteritis, eosinophilic gastroenteritis, chronic hepatitis, chronic renal disease, or parasitic infection. Further evaluation should proceed in a stepwise fashion and may include radiographic imaging or endoscopy. Ultrasonography, upper GI series, or computed tomography should be considered where there is particular suspicion for pancreatitis, obstruction, or renal disease. Hydrogen breath tests may be a useful diagnostic tool for the evaluation of clinically suspected bacterial overgrowth and lactose or carbohydrate malabsorption, but these are rarely indicated in the inpatient setting.