What are the recommended management strategies for functional dyspepsia?

Management of Functional Dyspepsia

The management of functional dyspepsia should follow a stepwise approach, starting with H. pylori testing and treatment, followed by acid suppression therapy, and then tricyclic antidepressants for refractory cases, with lifestyle modifications implemented throughout the treatment process. 1

Diagnosis and Initial Approach

• Functional dyspepsia (FD) should be diagnosed in patients with bothersome epigastric pain/burning, early satiation, and/or postprandial fullness lasting >8 weeks without alarm features 1
• Establish an effective doctor-patient relationship by explaining FD as a disorder of gut-brain interaction 1
• Initial testing should include:
  • H. pylori testing in all patients without alarm features
  • Full blood count in patients ≥55 years
  • Coeliac serology in patients with overlapping IBS symptoms 1

Endoscopy Indications

• Urgent endoscopy only for:
  • Patients ≥55 years with weight loss
  • Patients >40 years from high gastric cancer risk areas or with family history 1
• Non-urgent endoscopy for:
  • Patients ≥55 years with treatment-resistant symptoms
  • Patients with raised platelet count, nausea, or vomiting 1

First-Line Treatment Algorithm

1. H. pylori testing and eradication

   • Offer non-invasive H. pylori testing to all patients without alarm features
   • If positive, provide eradication therapy
   • Confirm successful eradication only in patients at increased risk of gastric cancer 1

2. Acid suppression therapy

   • For H. pylori-negative patients or those with persistent symptoms after eradication
   • Proton pump inhibitors (PPIs) at lowest effective dose
   • Histamine-2 receptor antagonists are alternative options 1

3. Prokinetic agents

   • Consider for patients with predominant postprandial fullness or early satiation
   • Options include acotiamide, itopride, mosapride, or tegaserod where available 1

Lifestyle and Dietary Modifications

• Regular aerobic exercise for all patients 1
• Dietary recommendations:
  • Small, frequent meals (4-6 per day) of easily digestible foods
  • Include rice, bread, bananas, apples, yogurt, and lean proteins
  • Avoid fatty, spicy, acidic, and processed foods
  • Eat slowly and chew thoroughly
  • Separate liquids from solids during meals
  • Avoid carbonated beverages 2

Second-Line Treatment

• Tricyclic antidepressants (TCAs)

  • Start with amitriptyline 10 mg once daily
  • Titrate slowly to 30-50 mg once daily as needed
  • Explain rationale as gut-brain neuromodulators, not as antidepressants
  • Counsel about side effects (dry mouth, constipation, drowsiness) 1, 2

• Antipsychotics

  • Consider sulpiride 100 mg four times daily or levosulpiride 25 mg three times daily
  • Provide careful explanation and counsel about side effects 1

Management of Severe or Refractory FD

• Involve a multidisciplinary team including gastroenterologists, psychologists, and dietitians 1, 2
• Early dietitian involvement to avoid overly restrictive diets 1
• Screen for eating disorders in patients with weight loss and food restriction 1
• Avoid opioids and surgery as these can worsen outcomes and cause iatrogenic harm 1

Treatment Based on FD Subtype

• Epigastric Pain Syndrome (EPS)

  • PPIs or H2 receptor antagonists as initial therapy
  • TCAs particularly effective for this subtype 3, 4

• Postprandial Distress Syndrome (PDS)

  • Prokinetics as initial therapy
  • Focus on meal pattern modifications and eating behaviors 3, 5

Common Pitfalls to Avoid

1. Failure to test for H. pylori before initiating other treatments
2. Prolonged PPI use without reassessment
3. Using TCAs at antidepressant doses rather than lower neuromodulatory doses
4. Prescribing opioids for pain management
5. Recommending overly restrictive diets without dietitian involvement
6. Pursuing unnecessary testing (gastric emptying studies, 24-hour pH monitoring) 1
7. Misdiagnosing GERD or IBS as functional dyspepsia 6

By following this evidence-based approach, most patients with functional dyspepsia can achieve significant symptom improvement and better quality of life.