What is the recommended treatment approach for managing dyspepsia?

Management of Dyspepsia: Evidence-Based Treatment Approach

The recommended first-line approach for managing dyspepsia is to test for Helicobacter pylori infection and treat if positive, followed by proton pump inhibitor therapy for those who are H. pylori negative or remain symptomatic after eradication therapy. 1

Initial Diagnostic Approach

• Patients aged ≥55 years with dyspepsia or those with alarm symptoms (weight loss, vomiting, bleeding, dysphagia) should undergo prompt endoscopy to exclude organic disease 1
• Urgent abdominal CT scanning should be considered in patients aged ≥60 years with abdominal pain and weight loss to exclude pancreatic cancer 1
• All other patients with dyspepsia should be offered non-invasive testing for H. pylori ("test and treat" strategy) using breath test or fecal antigen test 1
• H. pylori serology is not recommended due to lower specificity compared to other non-invasive tests 1

First-Line Treatment Algorithm

For H. pylori-positive patients:

1. Provide eradication therapy as first-line treatment 1
2. Confirmation of successful eradication is only necessary in patients with increased risk of gastric cancer 1
3. If symptoms persist after successful eradication, proceed to acid suppression therapy 1

For H. pylori-negative patients:

1. Offer empirical acid suppression therapy with proton pump inhibitors (PPIs) 1
2. Use the lowest effective dose of PPI that controls symptoms 1
3. Consider histamine-2 receptor antagonists as an alternative, though they may be less effective than PPIs 1, 2

Treatment Based on Predominant Symptoms

• For epigastric pain syndrome (EPS) or ulcer-like symptoms: PPI therapy is most effective 1
• For postprandial distress syndrome (PDS) or dysmotility-like symptoms: Consider prokinetic agents where available (acotiamide, itopride, mosapride, or tegaserod) 1
• Advise all patients with functional dyspepsia to take regular aerobic exercise 1

Second-Line Treatment Options

• Tricyclic antidepressants (TCAs) are effective second-line treatments for functional dyspepsia 1
• Start with low-dose amitriptyline (10 mg once daily) and titrate slowly to 30-50 mg once daily 1
• Provide careful explanation about the neuromodulatory rationale for TCA use and counsel patients about potential side effects 1
• Antipsychotics such as sulpiride (100 mg four times daily) or levosulpiride (25 mg three times daily) may be considered in refractory cases 1

Management of Severe or Refractory Dyspepsia

• Refer patients with severe or refractory symptoms to specialized care 1
• Involve a multidisciplinary team including gastroenterologists, dietitians, and psychologists 1
• Avoid opioids and surgery as they can cause iatrogenic harm 1
• Screen for eating disorders in patients with weight loss and food restriction 1
• Involve dietitians early to prevent overly restrictive diets 1

Common Pitfalls and Caveats

• Do not routinely perform gastric emptying testing or 24-hour pH monitoring in patients with typical functional dyspepsia symptoms 1
• Recognize the overlap between functional dyspepsia and gastroesophageal reflux disease (GERD), which can complicate diagnosis and treatment 1
• Avoid prolonged empirical therapy without a diagnosis in patients with alarm symptoms 1
• Be aware that approximately 80% of individuals with dyspepsia have no structural explanation (functional dyspepsia) 3
• Dietary restrictions should be minimal; there is insufficient evidence to recommend specialized diets including low FODMAP diets 1

By following this evidence-based approach, clinicians can effectively manage most patients with dyspepsia, improving symptoms and quality of life while minimizing unnecessary investigations and treatments.