What are the recommended management strategies for dyspepsia?

Management of Dyspepsia

Test all patients for Helicobacter pylori and eradicate if positive, then use proton pump inhibitors as first-line empirical therapy for persistent symptoms, reserving endoscopy for patients over 55 years or those with alarm features. 1, 2

Initial Assessment and Risk Stratification

Immediate Endoscopy Indications

Refer for urgent upper gastrointestinal endoscopy in patients with: 1

• Age ≥55 years with new-onset dyspepsia 1
• Alarm symptoms: unintentional weight loss, progressive dysphagia, persistent vomiting, evidence of gastrointestinal bleeding, iron deficiency anemia, or palpable abdominal mass 1
• Regular NSAID use (standard non-steroidal anti-inflammatory drugs) 1
• Dyspepsia with weight loss if age ≥55 years 1
• Age >40 years from areas at increased risk of gastric cancer or with family history of gastro-oesophageal malignancy 1

Baseline Investigations

Obtain the following before initiating treatment: 1

• Full blood count in all patients ≥55 years 1, 2
• Coeliac serology in patients with overlapping IBS-type symptoms 1, 2
• H. pylori testing via breath or stool test (not serology) 1, 2

Distinguishing GORD from Dyspepsia

Identify the predominant symptom to differentiate gastro-oesophageal reflux disease from functional dyspepsia. 1

• If heartburn or acid regurgitation occurs more than once weekly as the predominant symptom, treat as GORD, not dyspepsia 3
• Dyspepsia is defined as chronic or recurrent pain or discomfort centered in the epigastrium (upper abdomen) 1, 2
• There is considerable symptom overlap in practice, but the predominant symptom should guide initial classification 1

Primary Management Strategy

Step 1: H. pylori Test and Treat

This is the preferred initial approach in populations with ≥10% H. pylori prevalence: 1, 2, 3

• Test all dyspeptic patients for H. pylori using validated non-invasive testing (breath or stool test) 1, 2
• Eradicate if positive using appropriate antibiotic therapy 1, 2
• This strategy cures most underlying peptic ulcer disease and prevents future gastroduodenal disease 1
• Confirmation of eradication is only necessary in patients at high risk of gastric cancer 2
• Many H. pylori-positive patients with functional dyspepsia will not gain symptomatic benefit, but eradication serves as preventative medicine 1

Step 2: Empirical Acid Suppression

For H. pylori-negative patients or those with persistent symptoms after eradication: 1, 2

For Ulcer-Like Dyspepsia (Predominant Epigastric Pain):

• Proton pump inhibitors at full dose are first-line therapy 1, 2, 3
• Omeprazole 20 mg once daily is effective and confirms the acid-related nature of symptoms 1, 2
• PPIs are superior to H2-receptor antagonists for symptom relief 1, 3
• Trial for 4-8 weeks initially 3

For Dysmotility-Like Dyspepsia (Predominant Fullness, Bloating, Early Satiety):

• Consider a prokinetic agent 1, 2, 4
• Metoclopramide is currently the only available effective prokinetic, but use short-term and discuss potential side effects 4
• Cisapride is no longer recommended due to cardiac toxicity 1

Step 3: Treatment Adjustment

If initial therapy fails after 2-4 weeks: 1, 3

• Switch drug class (e.g., from PPI to prokinetic or vice versa) 1
• Consider high-dose PPI therapy if symptoms persist 1
• Use the lowest PPI dose that controls symptoms, as there is no clear dose-response relationship 2

Step 4: Maintenance Strategy

Once symptoms are controlled: 1

• Trial withdrawal of therapy after 4-8 weeks 1, 3
• If symptoms recur, repeat the same successful treatment 1, 3
• On-demand therapy with the successful agent is an alternative approach 1

Non-Pharmacological Management

Patient Education and Relationship Building

Establishing an effective, empathic doctor-patient relationship is fundamental and may reduce healthcare utilization: 1, 2

• Explain functional dyspepsia as a disorder of gut-brain interaction 1, 2
• Describe how the gut-brain axis is affected by diet, stress, cognitive, behavioral, and emotional responses 1, 2
• Discuss the natural history and common symptom triggers 1, 2
• Provide reassurance that normal investigations do not mean there is no cause—the problem lies in nerve sensitivity and gut-brain communication 1

Lifestyle Modifications

• Regular aerobic exercise is recommended for all patients 2
• Avoid foods that trigger symptoms (fatty foods, spicy foods, soft drinks commonly worsen symptoms) 1, 2, 5
• Consider frequent small meals and low-fat diet 4
• Minimize coffee intake, avoid excess alcohol, and cease smoking 4
• Address irregular eating habits (meal skipping, late-night snacking) 5

Dietary Interventions

• Early dietitian involvement is recommended to avoid overly restrictive diets 1, 2
• There is no evidence for specialized diets, but individual food triggers should be identified 1
• Higher adherence to Mediterranean diet patterns may be beneficial compared to Western diets 5

Management of Refractory Functional Dyspepsia

When initial antisecretory therapy and H. pylori eradication fail: 1, 3

Re-evaluation and Reassurance

• Re-evaluate the diagnosis to ensure functional dyspepsia is correct 1
• Consider 24-hour oesophageal pH monitoring or high-dose diagnostic PPI course for atypical GORD 1
• Provide further reassurance 1

Advanced Therapies

• Low-dose tricyclic antidepressants at bedtime for visceral hypersensitivity 3, 4
• Consider behavioral therapy, psychotherapy, or antidepressants 1, 2
• Psychological or behavioral therapies may be beneficial, though availability is limited 1

Severe or Refractory Cases

A multidisciplinary team approach is essential: 1, 2

• Include gastroenterologists, dietitians, GPs, and psychologists 1
• Assess for eating disorders, including avoidant restrictive food intake disorder (ARFID), in patients with weight loss and food restriction 1, 2
• Avoid opioids and surgery to minimize iatrogenic harm 1, 2

Critical Pitfalls to Avoid

• Do not perform routine endoscopy in young patients without alarm features—the yield for malignancy is <0.5%, and the cost per cancer diagnosis exceeds $80,000 1
• Do not use empirical PPI therapy alone in populations with high H. pylori prevalence (≥10%)—this inadequately treats underlying peptic ulcer disease 1, 3
• Do not restrict diet excessively—this can lead to malnutrition and abnormal eating patterns 1
• Do not continue ineffective therapy indefinitely—switch drug classes or refer for endoscopy if not already performed 1
• Do not use prokinetics as first-line therapy for uninvestigated dyspepsia 3