What's the next step in managing a patient with suspected functional dyspepsia or peptic ulcer disease?

Management of Suspected Functional Dyspepsia or Peptic Ulcer Disease

For patients with suspected functional dyspepsia or peptic ulcer disease, the next step should be testing for H. pylori infection and treating if positive, followed by empiric proton pump inhibitor therapy if symptoms persist or the test is negative. 1

Initial Assessment and Testing

Age and Alarm Feature Evaluation

• Patients ≥55 years or with alarm features (dysphagia, weight loss, persistent vomiting, evidence of bleeding, family history of gastro-oesophageal cancer) should undergo prompt endoscopy 2, 1
• Patients <55 years without alarm features should follow the "test and treat" approach 2, 1
• Laboratory testing: Full blood count to identify anemia, particularly in those aged ≥55 years 1

H. pylori Testing

• Use non-invasive testing methods:
  • Urea breath test (preferred)
  • Stool antigen test
  • Avoid serology due to lower specificity 2

Management Algorithm

Step 1: Test for H. pylori

• If H. pylori positive: Provide eradication therapy 2, 1
  • Triple therapy: Omeprazole 20 mg + Amoxicillin 1000 mg + Clarithromycin 500 mg (all twice daily for 10 days) 3
  • Continue omeprazole 20 mg daily for an additional 18 days if ulcer is present 3

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

• For ulcer-like dyspepsia (predominant epigastric pain/burning):

  • Full dose PPI therapy (e.g., omeprazole 20 mg once daily for 4-8 weeks) 2, 3, 4

• For dysmotility-like dyspepsia (predominant fullness, bloating, early satiety):

  • Prokinetic agent 2, 5
  • Note: Cisapride is no longer recommended due to cardiac toxicity 2

Step 3: If initial therapy fails

• Switch therapy (from PPI to prokinetic or vice versa) 2, 4
• Consider high-dose PPI trial 2
• If symptoms still persist, refer for endoscopy if not already performed 2

Treatment Considerations

Duration of Therapy

• Initial empiric therapy: 4-8 weeks 2, 3
• If symptoms are controlled:
  • Consider trial withdrawal of therapy
  • Restart if symptoms recur
  • Consider on-demand therapy with the successful agent 2

Endoscopy Indications

• Age ≥55 years with dyspepsia
• Presence of alarm symptoms
• Treatment-resistant dyspepsia
• Regular NSAID use (except COX-2 specific NSAIDs) 2
• Patients aged >40 years from areas with increased risk of gastric cancer 1

Management Pitfalls to Avoid

1. Failure to test for H. pylori before starting empiric acid suppression - this is a critical first step 1
2. Overreliance on individual alarm symptoms in patients <60 years - these are poor predictors of malignancy 1
3. Not distinguishing between functional dyspepsia and GORD - management approaches differ 1
4. Repeated endoscopies in patients with typical functional dyspepsia symptoms without new alarm features 1
5. Overlooking overlapping conditions such as irritable bowel syndrome 1

Resistant Functional Dyspepsia

For patients with resistant symptoms after the above approaches:

• Re-evaluate diagnosis 2
• Consider psychological factors 2
• Consider low-dose tricyclic antidepressants, particularly effective for epigastric pain syndrome 4, 5
• Consider behavioral therapy or psychotherapy 2

The British Society of Gastroenterology guidelines (2022) support this approach, emphasizing that testing for H. pylori and treating if positive, followed by empiric acid suppression therapy, is the most cost-effective initial strategy for managing dyspepsia 2, 1.