What are the guidelines for managing dyspepsia?

Management of Functional Dyspepsia: Guidelines and Treatment 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, and managed with a stepwise approach beginning with H. pylori testing and eradication, followed by acid suppression therapy, and then tricyclic antidepressants for refractory cases. 1

Definition and Diagnosis

Dyspepsia refers to symptoms such as epigastric pain or burning, early satiation (feeling full during a meal), and postprandial fullness (heaviness after eating) that originate from the stomach or duodenum. Functional dyspepsia is diagnosed when these symptoms persist for more than 8 weeks without evidence of structural abnormalities on investigation. 2

Diagnostic Criteria:

• Bothersome epigastric pain or burning
• Early satiation and/or postprandial fullness
• Symptoms present for >8 weeks
• No structural abnormality to explain symptoms

Initial Assessment:

• Full blood count in patients ≥55 years
• Coeliac serology in patients with overlapping IBS symptoms
• H. pylori testing in all patients without alarm features 2, 1

Alarm Features Requiring Urgent Investigation:

• Age ≥55 years with weight loss
• Age >40 years from high gastric cancer risk areas or with family history
• Raised platelet count
• Persistent nausea or vomiting
• Treatment-resistant symptoms in patients ≥55 years 2

Management Algorithm

First-Line Treatment:

1. H. pylori test and treat strategy:

   • Offer non-invasive testing (breath or stool test) for H. pylori
   • If positive, provide eradication therapy
   • Only confirm successful eradication in patients at increased risk of gastric cancer 2

2. Acid suppression therapy (for H. pylori negative patients or those with persistent symptoms):

   • Proton pump inhibitors (PPIs) at lowest effective dose
   • Histamine-2 receptor antagonists as an alternative 2, 1

3. Lifestyle modifications:

   • Regular aerobic exercise for all patients
   • Small, frequent meals of easily digestible foods
   • Avoid fatty, spicy, acidic, and processed foods 1

Second-Line Treatment:

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

   • Start with amitriptyline 10 mg once daily
   • Titrate slowly to 30-50 mg once daily as needed
   • Provide clear explanation of their use as neuromodulators, not antidepressants 2, 1

2. Prokinetics (especially for postprandial fullness or early satiation):

   • Options include acotiamide, itopride, mosapride, or tegaserod
   • Availability varies by region 2, 1

Refractory Cases:

1. Antipsychotics:

   • Sulpiride 100 mg four times daily or levosulpiride 25 mg three times daily
   • Careful explanation and counseling about side effects 2

2. Multidisciplinary approach:

   • Involve gastroenterologists, psychologists, and dietitians
   • Early dietitian involvement to avoid overly restrictive diets
   • Screen for eating disorders in patients with weight loss 2, 1

Important Cautions

Avoid:

• Opioids and surgery, which can worsen outcomes and cause iatrogenic harm 2
• Prolonged PPI use without reassessment
• Using TCAs at full antidepressant doses
• Unnecessary testing (gastric emptying studies, 24-hour pH monitoring) 2, 1

Doctor-Patient Communication

Establishing an effective doctor-patient relationship is crucial for successful management:

• Explain FD as a disorder of gut-brain interaction
• Provide a simple explanation of the gut-brain axis and how it's affected by diet, stress, and emotional responses
• Reassure patients that FD is a common condition affecting approximately 7% of the population 2, 3
• Explain that symptoms typically fluctuate over time but can be managed effectively

Special Considerations

Severe or Refractory FD:

• Assess for eating disorders, including avoidant restrictive food intake disorder (ARFID)
• Early dietitian involvement to prevent nutritional deficiencies
• Consider referral to specialized centers with multidisciplinary teams 2

Subtyping FD:

• Epigastric pain syndrome (EPS): PPIs are first-line therapy
• Postprandial distress syndrome (PDS): Prokinetics may be more effective 4

By following this evidence-based approach to managing functional dyspepsia, clinicians can provide effective symptom relief while minimizing unnecessary investigations and treatments, ultimately improving patients' quality of life.