What are the management instructions for a patient with dyspepsia?

Management of Dyspepsia

The management of dyspepsia should follow a stepwise approach beginning with H. pylori testing and treatment if positive, followed by acid suppression therapy with proton pump inhibitors (PPIs), and tricyclic antidepressants as second-line therapy for persistent symptoms. 1

Initial Evaluation and Testing

Age-Based Assessment

• For patients ≥55 years:

  • Full blood count recommended 2
  • Consider non-urgent endoscopy if treatment-resistant dyspepsia 2
  • Consider non-urgent endoscopy if dyspepsia with raised platelet count, nausea, or vomiting 2

• For patients ≥60 years with abdominal pain and weight loss:

  • Urgent abdominal CT scan to exclude pancreatic cancer 2

• For patients ≥55 years with dyspepsia and weight loss OR >40 years from high-risk area for gastric cancer:

  • Urgent endoscopy warranted 2

Testing for All Patients

• Coeliac serology in patients with overlapping IBS-type symptoms 2
• Non-invasive H. pylori testing (breath or stool test) for patients without alarm features 2, 1

First-Line Treatment

H. pylori "Test and Treat" Strategy

1. Test all patients without alarm features for H. pylori infection 2
2. Provide eradication therapy if positive 2
3. Confirm eradication only in patients with increased risk of gastric cancer 2

Acid Suppression Therapy

• For H. pylori-negative patients or those with persistent symptoms after eradication:
  • PPIs are strongly recommended (high quality evidence) 2
  • Use lowest effective dose that controls symptoms 2
  • H2-receptor antagonists are an alternative option (weak recommendation) 2

Lifestyle and Diet Recommendations

• Regular aerobic exercise is strongly recommended for all patients 2
• Dietary modifications:
  • Eat small, frequent meals (4-6 times daily) 1
  • Eat slowly and chew thoroughly 1
  • Avoid trigger foods and carbonated beverages 1
  • Low-fat diet may help (though evidence is limited) 3

Second-Line Treatment

For Persistent Symptoms

• Tricyclic antidepressants (TCAs) are effective second-line therapy 2, 1
  • Start with low dose and titrate slowly as needed
  • Provide careful explanation about mechanism of action and side effects

Prokinetic Agents

• Consider for patients with predominant fullness, bloating, early satiety (dysmotility-like symptoms) 2, 3
• Options include acotiamide, itopride, mosapride (weak recommendation) and tegaserod (stronger evidence) where available 2
• Metoclopramide is available but should be used short-term with discussion of side effects 3

Referral to Gastroenterology

Referral is appropriate when:

• Diagnostic uncertainty exists
• Symptoms are severe or refractory to first-line treatments
• Patient requests specialist opinion 2

Management Algorithm

1. Initial assessment:

   • Check for alarm features and age-specific risk factors
   • Perform appropriate testing based on age and risk factors

2. First-line treatment:

   • H. pylori test and treat if positive
   • For H. pylori negative or persistent symptoms: PPI therapy
   • Implement lifestyle modifications and dietary changes

3. If symptoms persist:

   • For epigastric pain predominance: Increase PPI dose
   • For fullness/bloating predominance: Add prokinetic agent
   • Consider switching therapy class (from PPI to prokinetic or vice versa) 2, 3

4. Second-line treatment:

   • Add low-dose TCA for persistent symptoms
   • Consider specialist referral

Common Pitfalls to Avoid

• Overuse of endoscopy in patients without alarm features, especially under 55 years 2, 1
• Failure to establish effective doctor-patient relationship and explain diagnosis properly 2
• Avoidance of opioids and surgery as they can worsen outcomes and cause iatrogenic harm 1
• Overly restrictive diets that may compromise nutrition 4
• Routine use of gastric emptying testing or 24-hour pH monitoring in typical functional dyspepsia patients 2

By following this structured approach to dyspepsia management, clinicians can provide effective symptom relief while minimizing unnecessary testing and interventions, ultimately improving patients' quality of life and reducing healthcare costs.