CCFP priority topic 32 of 105
Dyspepsia on the CCFP exam
3 key features, the mistakes that cost marks, and a practice question.
Checked by a Canadian family physician, MD, CCFP. Updated October 20, 2026.
What the exam tests
Key features
The CFPC’s 3 key features for Dyspepsia. Each one below has how the exam asks it, the common mistakes and the approach.
Practice question
Try one before you read
A real case from the bank, in the new short-menu format. Answer it first. Then read the key features.
Key feature 1 of 3
Think of the heart
Keep heart disease on your list whenever the complaint sounds like indigestion.
CFPC skill Clinical reasoningPhase Hypothesis generationSources Choosing Wisely Canada
On the exam
A teen hockey player with heartburn at practice, or a sweaty infant called a refluxer. Expect a short menu (pick several from a list) of causes.
Pick the causes to rule out first.
Common mistakes
Calling it reflux because a parent already treats it as reflux. Burning that starts with effort and stops with rest, or sweating with feeds, points to the heart. In an adult with heart risks, calling effort-linked upper belly discomfort indigestion misses angina.
Approach
- Ask what brings it on. Discomfort that starts with effort and eases within minutes of rest is the heart until shown otherwise, at any age.
- Ask what the stomach cannot explain: sweating, shortness of breath, palpitations, fainting, or pain in the jaw, arm or back.
- In an adult with heart risks, indigestion that comes with effort may be angina (heart pain from a narrowed artery).
- In an infant, sweating with feeds, stopping to rest, fast breathing and poor weight gain point to the heart. Small, effortless spit-ups do not explain them.
- An infant with poor growth needs a work-up before anyone calls it reflux.
- Listen to the heart standing as well as lying. Lying down can soften the murmur of a thick heart muscle (hypertrophic cardiomyopathy) until it is missed.
| Clue | Points to the stomach | Points to the heart |
|---|---|---|
| Brought on by | Meals, lying flat, bending | Effort, such as sport or stairs |
| Eased by | Antacids or acid blockers | Rest, within minutes |
| Comes with | Sour taste, belching, bloating | Sweating, shortness of breath, palpitations, fainting |
| In an infant | Small, effortless spit-ups; growing well | Sweating with feeds, rest pauses, fast breathing, poor weight gain |
Key feature 2 of 3
Sort the cause
Tell reflux, ulcer, stomach inflammation and cancer apart from the story and the exam.
CFPC skill Clinical reasoningPhase History, physicalSources Canadian Association of Gastroenterology, Choosing Wisely Canada
On the exam
Two months of burning upper belly pain at 45, on naproxen. Expect a short menu (pick several from a list) of questions, then one best answer for the first step.
Pick the questions that sort it, then the first step.
Common mistakes
Scoping everyone, or ordering a barium X-ray. Under 60 without alarm features, test for Helicobacter pylori first. Missing an anti-inflammatory painkiller costs marks too.
Approach
- Dyspepsia means mainly upper middle belly pain for at least a month. If heartburn and sour regurgitation are the main complaint, think of reflux instead.
- Ask about NSAIDs (non-steroidal anti-inflammatory drugs) such as naproxen and ibuprofen. Dyspepsia is more common in people who take them, and in smokers.
- Pain that bores through to the back points to the pancreas or gallbladder. It needs imaging such as ultrasound or computed tomography (CT).
- Under 60 with no alarm features: a non-invasive test for Helicobacter pylori, and treatment if positive. Wait at least 4 weeks after treatment to judge the response.
- Negative, or still unwell after treatment: a trial of a proton pump inhibitor (PPI). If that fails, a tricyclic antidepressant or a drug that speeds stomach emptying can be tried.
- At 60 or older, endoscopy (a camera test of the stomach) is suggested to rule out cancer. A family history or a childhood in a high-risk country can lower that age.
- Do not order a barium X-ray of the upper gut (upper GI series). It gives more false results than a scope.
| Cause | Clues in the story | Clues on exam |
|---|---|---|
| Reflux | Heartburn and sour fluid rising, worse lying flat or bending | Usually normal |
| Gastritis or ulcer | Burning upper pain; NSAIDs, smoking or Helicobacter pylori | Upper middle tenderness; pale if bleeding |
| Stomach or esophageal cancer | Older age, weight loss, worsening trouble swallowing, vomiting | Pallor, a mass, a hard lump above the left collarbone |
| Pancreas or gallbladder | Pain through to the back, attacks after meals, yellow skin | Upper right tenderness, jaundice |
| Functional dyspepsia | Long history, no alarm features, normal scope | Normal |
Key feature 3 of 3
Alarm features
Look for warning signs such as bleeding, losing weight and trouble swallowing in anyone with indigestion.
CFPC skill Clinical reasoningPhase History, physicalSources Canadian Association of Gastroenterology, Choosing Wisely Canada
On the exam
Indigestion at 52, a few kilograms lost and food that sticks. Expect a short menu (pick several from a list) of questions and findings to check.
Pick the warning signs to ask and look for.
Common mistakes
Skipping the questions on bleeding, weight and swallowing. Or scoping everyone under 60 for one mild alarm feature: the cancer risk stays under 1%.
Approach
- Ask every patient about black or bloody stools, vomiting blood, weight loss, trouble swallowing that is getting worse, and vomiting that keeps going.
- Look for anemia, a mass, a hard lump above the left collarbone and jaundice. Anemia counts as an alarm feature.
- Under 60, one alarm feature does not by itself mean a scope. It raises the risk of upper GI cancer 2 to 3 times, but the risk stays under 1%.
- Under 60, scope when the feature is marked: weight loss over about 9 kg (20 lb), or trouble swallowing that worsens fast. Several features together count too.
- Lower the bar with age, a family history of upper GI cancer, or a childhood in a country with high stomach cancer rates.
- New dyspepsia at 60 or older: endoscopy, and think of the pancreas too. An abdominal ultrasound can be added to look at it.
- In an infant, poor growth, repeated chest problems or bleeding need a work-up. Acid blockers do not ease crying or spitting up.
Flashcards
Answer it first, then check.
KF 1A teen gets burning chest pressure mid-practice that stops with rest. Stomach or heart?
Heart until shown otherwise. Effort brings it on and rest ends it; meals do not.
KF 1An infant sweats during feeds and stops to rest. Why not call it reflux?
Spit-ups do not cause sweating or rest pauses with feeds. Think of the heart, and work up poor growth. Source: Choosing Wisely Canada
KF 1Why listen for a thick-muscle murmur with the patient standing, not only lying?
Lying down fills the heart and can soften the murmur until it is missed. Standing makes it louder.
KF 2Dyspepsia at 45 with no alarm features. What is the first step?
A non-invasive Helicobacter pylori test, and treatment if positive. A PPI trial follows if needed. Source: Canadian Association of Gastroenterology
KF 2The main complaint is heartburn and sour regurgitation. Is that dyspepsia?
No, that pattern points to reflux. Dyspepsia is mainly upper middle belly pain for a month or more. Source: Canadian Association of Gastroenterology
KF 2Why avoid a barium X-ray of the upper gut for dyspepsia?
It gives more false results than endoscopy, and it is not cost-effective. Use the steps instead. Source: Choosing Wisely Canada
KF 3Dyspepsia at 35 with mild anemia. Is a scope automatic?
No. Under 60, one alarm feature is weighed case by case. Still find the cause of the anemia. Source: Canadian Association of Gastroenterology
KF 3New dyspepsia at 66. What do you offer?
An endoscopy to rule out cancer. Think of the pancreas too; an ultrasound can look at it. Source: Canadian Association of Gastroenterology
FAQ
Which dyspepsia guideline should I know?
The joint 2017 guideline from the Canadian and American gastroenterology associations. Its age line for endoscopy is 60. Older guidelines used 55, so check the year of what you read.
How long should a PPI keep going?
Use the lowest dose that works, and try stopping at least once a year. The exceptions are Barrett's esophagus (changed lining low in the gullet), severe esophagitis (a badly inflamed gullet) and a past gut bleed.
Why does a child's heart case sit under dyspepsia?
Children and parents call chest pressure heartburn, and an infant in heart failure can look like reflux. Marks go to asking what triggers it before you treat the stomach.
Do infants with reflux need an acid blocker?
Usually not. Acid blockers do not ease crying or spitting up, and they raise the risk of chest and gut infections. Poor growth or bleeding needs a work-up instead.
Sources
Written from the CFPC Assessment Objectives and Canadian guidelines first. Checked by a Canadian family physician, MD, CCFP.
Last reviewed October 20, 2026For exam study. Not advice for a patient in front of you.
- Assessment Objectives for Certification in Family Medicine, 2nd editionCollege of Family Physicians of Canada · 2020
- Choosing Wisely recommendationsChoosing Wisely Canada
- Gastroenterology guideline libraryCanadian Association of Gastroenterology