What is the initial management for a patient presenting with dyspepsia?

Initial Management of Dyspepsia

The initial management for a patient presenting with dyspepsia should follow a "test and treat" strategy for Helicobacter pylori, followed by a proton pump inhibitor (PPI) trial if symptoms persist. 1

Diagnostic Approach

Initial Assessment

• Rule out alarm features requiring immediate endoscopy:

  • Age ≥55 years (Western countries) or locally defined threshold
  • Weight loss
  • Recurrent vomiting
  • Dysphagia
  • Bleeding/anemia
  • Jaundice
  • Palpable mass 1, 2

• Differentiate from GERD:

  • Patients with predominant heartburn or acid regurgitation occurring more than once weekly should be managed as GERD 3

Management Algorithm

1. Patients with alarm features or age ≥55:

   • Immediate endoscopy 1, 2

2. Patients without alarm features:

   • Test for H. pylori using a validated non-invasive test 1, 2, 3
   • This "test and treat" strategy is most cost-effective in populations with moderate to high H. pylori prevalence (≥10%) 3

3. H. pylori positive patients:

   • Provide eradication therapy 1, 2
   • Strong recommendation, high-quality evidence 1
   • Eradication therapy is effective even though many patients may not experience symptom improvement 1

4. H. pylori negative patients or persistent symptoms after eradication:

   • Trial of PPI for 4-8 weeks 1, 2, 3
   • Strong recommendation, high-quality evidence 1
   • Use lowest effective dose that controls symptoms 1

5. Persistent symptoms despite PPI:

   • Consider switching medication class or dosing 3
   • For ulcer-like symptoms (epigastric pain): continue PPI therapy 1
   • For dysmotility-like symptoms (fullness, bloating, early satiety): consider prokinetic agent 1

6. Refractory symptoms:

   • Refer for endoscopy if not previously performed 1, 3
   • Consider tricyclic antidepressants (TCAs) as second-line therapy 1, 3
   • Start at low dose (e.g., amitriptyline 10mg daily) and titrate slowly to 30-50mg 1

Additional Therapeutic Considerations

Non-Pharmacological Approaches

• Regular aerobic exercise is strongly recommended for all patients 1, 2
• Dietary interventions have insufficient evidence, but common-sense dietary counseling may help with meal-related symptoms 4
• Avoid overly restrictive diets 1

Pharmacological Options

• PPIs are more effective than H2-receptor antagonists and antacids 1, 5
• H2-receptor antagonists may be considered as an alternative (weak recommendation) 1
• For controlled symptoms, consider trial of withdrawal or on-demand therapy 1

Management Pitfalls to Avoid

1. Overuse of endoscopy in young patients without alarm features, which increases costs without improving outcomes 1, 5

2. Failure to recognize functional dyspepsia subtypes:

   • Epigastric Pain Syndrome (EPS): epigastric pain/burning
   • Postprandial Distress Syndrome (PDS): early satiation, postprandial fullness 2

3. Inadequate patient education about H. pylori eradication, which may not resolve symptoms in functional dyspepsia 1

4. Inappropriate use of opioids in patients with severe or refractory symptoms 1

5. Neglecting psychological factors in patients with persistent symptoms 1, 6

For patients with severe or refractory symptoms, a multidisciplinary approach involving gastroenterologists, dietitians, and psychologists is strongly recommended 1, 2.