What is the initial management approach for functional dyspepsia?

Initial Management of Functional Dyspepsia

The initial management approach for functional dyspepsia (FD) should be testing for Helicobacter pylori with a breath or stool test and, if positive, providing eradication therapy as first-line treatment. 1

Diagnostic Approach

Before initiating treatment, establish a positive diagnosis of FD:

• Diagnose FD in patients with bothersome epigastric pain/burning, early satiation, and/or postprandial fullness lasting >8 weeks without alarm symptoms 1
• Perform limited investigations based on patient characteristics:
  • For patients ≥55 years: Full blood count 1
  • For patients with IBS-type overlap symptoms: Coeliac serology 1
  • For all patients: H. pylori breath or stool testing 1

When to consider further investigation:

• Urgent abdominal CT for patients ≥60 years with abdominal pain and weight loss (to exclude pancreatic cancer) 1
• Non-urgent endoscopy for patients ≥55 years with treatment-resistant dyspepsia or dyspepsia with raised platelet count, nausea, or vomiting 1

Treatment Algorithm

First-Line Treatments:

1. H. pylori test and treat approach:

   • Test all patients for H. pylori using breath or stool testing
   • If positive, provide eradication therapy
   • Confirm successful eradication only in patients with increased risk of gastric cancer 1

2. If H. pylori negative or symptoms persist after eradication:

   • Offer empirical acid suppression therapy 1
     • Proton pump inhibitors (PPIs) at lowest effective dose 1
     • OR Histamine-2 receptor antagonists 1

3. Lifestyle modifications:

   • Regular aerobic exercise for all FD patients 1, 2
   • Dietary adjustments:
     • Consume small, frequent meals (4-6 per day)
     • Choose easily digestible foods (rice, bread, bananas, apples, yogurt, lean proteins)
     • Avoid fatty, spicy, acidic, and processed foods 2
     • Eat slowly and chew thoroughly 2

Second-Line Treatments:

If first-line treatments fail:

1. Tricyclic antidepressants (TCAs) as gut-brain neuromodulators:

   • Start with low-dose amitriptyline 10 mg once daily
   • Titrate slowly to maximum of 30-50 mg once daily based on response
   • Provide careful explanation about rationale for use and counsel about side effects (dry mouth, constipation, drowsiness) 1, 2

2. Prokinetics (if available):

   • Options include acotiamide, itopride, mosapride, or tegaserod
   • Efficacy varies by drug class and many are unavailable outside Asia and USA 1

3. Antipsychotics (if TCAs ineffective):

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

Patient Education and Communication

Establishing an effective doctor-patient relationship is crucial:

• Explain FD as a disorder of gut-brain interaction 1
• Provide a simple explanation of the gut-brain axis and how it's affected by diet, stress, and emotional responses 1, 2
• Discuss common symptom triggers and natural history of the condition 1
• Set realistic expectations about symptom management

When to Refer to Secondary Care

Referral to gastroenterology is appropriate when:

• Diagnostic uncertainty exists
• Symptoms are severe or refractory to first-line treatments
• Patient requests specialist opinion 1

Important Caveats

• Avoid routine gastric emptying testing or 24-hour pH monitoring 1
• There is insufficient evidence to recommend specialized diets like low FODMAP 1
• Avoid opioids and surgery as these can worsen outcomes 2
• For severe, refractory cases, consider a multidisciplinary approach including gastroenterologists, psychologists, and dietitians 2

By following this structured approach to the initial management of functional dyspepsia, clinicians can provide evidence-based care that addresses both the physiological and psychological aspects of this common disorder.