Management of Dyspepsia: A Systematic Approach
The best approach to managing dyspepsia is to first test for Helicobacter pylori in patients without alarm symptoms and treat if positive, followed by acid suppression therapy with proton pump inhibitors for those with persistent symptoms or those who test negative. 1, 2
Initial Assessment and Diagnosis
- Diagnose functional dyspepsia (FD) in patients with bothersome epigastric pain/burning, early satiation, and/or postprandial fullness of >8 weeks duration without alarm symptoms 1
- Perform full blood count in patients ≥55 years with dyspepsia and consider coeliac serology in those with overlapping IBS symptoms 1
- Consider urgent endoscopy only in patients ≥55 years with weight loss, or those >40 years from areas with increased risk of gastric cancer or with family history of gastro-oesophageal cancer 1
- Consider non-urgent endoscopy in patients ≥55 years with treatment-resistant dyspepsia or dyspepsia with raised platelet count, nausea, or vomiting 1
- Consider urgent abdominal CT scanning in patients ≥60 years with abdominal pain and weight loss to exclude pancreatic cancer 1, 2
First-Line Management Strategy
- Offer non-invasive testing for H. pylori (urea breath test or stool antigen test) to all patients with dyspepsia without alarm symptoms 1, 2, 3
- If H. pylori positive, provide eradication therapy as first-line treatment 1, 2, 4
- Confirm successful eradication only in patients with increased risk of gastric cancer 1, 2
- For patients who are H. pylori negative or remain symptomatic after eradication, offer empirical acid suppression therapy 1, 2
Symptom-Based Treatment Approach
- For epigastric pain (ulcer-like dyspepsia): Full-dose PPI therapy (e.g., omeprazole 20 mg once daily) is recommended as first-line treatment 1, 2
- For fullness, bloating, or early satiety (dysmotility-like dyspepsia): Consider a prokinetic agent 1, 2
- If symptoms are controlled by initial therapy, consider a trial of withdrawal after 4-8 weeks with repeat therapy if symptoms recur 1, 2
- On-demand therapy with the successful agent is a valid option for long-term management 1, 2
Second-Line Management
- If first-line treatment fails, consider switching treatment approaches (e.g., from prokinetic to PPI or vice versa) 1, 2
- Tricyclic antidepressants (TCAs) are an effective second-line treatment for functional dyspepsia 1, 2, 4
- Consider antipsychotics such as sulpiride 100 mg four times daily or levosulpiride 25 mg three times daily as alternative second-line treatments 1, 2
Management of Refractory Dyspepsia
- Involve a multidisciplinary support team for patients with severe or refractory FD 1
- Avoid opioids and surgery in patients with severe or refractory FD to minimize iatrogenic harm 1
- Assess for eating disorders and disordered eating in patients presenting with weight loss and food restriction 1
- Consider early dietitian involvement to avoid overly restrictive diets 1
- Regular aerobic exercise is recommended for all patients with functional dyspepsia 2
Important Considerations and Cautions
- PPI therapy may be associated with increased risk of Clostridium difficile-associated diarrhea, bone fractures with long-term use, and vitamin B12 deficiency 5
- Prokinetic agents like metoclopramide carry risks of extrapyramidal symptoms and tardive dyskinesia, especially with prolonged use (>12 weeks) 6
- TCAs require careful explanation of their use and counseling about side effects 1
- Symptoms may fluctuate over time, and functional dyspepsia is often a chronic condition requiring long-term management strategies 7
- Establishing an effective doctor-patient relationship and providing clear explanation of the condition is key to successful management 1
By following this systematic approach to dyspepsia management, clinicians can provide evidence-based care while minimizing unnecessary investigations and optimizing treatment outcomes for patients with this common condition.