What are the management options for functional dyspepsia?

Management of Functional Dyspepsia

Begin with H. pylori testing and eradication in all patients with functional dyspepsia, followed by proton pump inhibitors for epigastric pain syndrome or prokinetics for postprandial distress syndrome, with tricyclic antidepressants reserved as second-line therapy for refractory cases. 1, 2

Initial Diagnosis and Assessment

Diagnose functional dyspepsia clinically in patients with bothersome epigastric pain or burning, early satiation, and/or postprandial fullness lasting >8 weeks, without alarm symptoms. 1

Required Laboratory Testing:

• Perform full blood count in patients ≥55 years 1, 2
• Order coeliac serology in all patients with overlapping IBS-type symptoms 1, 2
• Test all patients for H. pylori using non-invasive methods (breath test or stool antigen) 2, 3

Endoscopy Indications:

• Urgent endoscopy: Patients ≥55 years with weight loss, or >40 years from high-risk gastric cancer areas or with family history of gastro-oesophageal cancer 2
• Non-urgent endoscopy: Patients ≥55 years with treatment-resistant dyspepsia, raised platelet count, nausea, or vomiting 2
• Consider urgent abdominal CT in patients ≥60 years with abdominal pain and weight loss to exclude pancreatic cancer 2

First-Line Treatment Algorithm

Step 1: H. pylori Eradication

All H. pylori-positive patients must receive eradication therapy as the initial intervention, regardless of symptom subtype. 1, 2, 3 This provides modest but meaningful symptom improvement in functional dyspepsia. 4

Step 2: Symptom-Based Pharmacotherapy

For Epigastric Pain Syndrome (EPS) - predominant epigastric pain or burning:

• Start proton pump inhibitors (PPIs) at standard doses 2, 5
• Alternative: H2 receptor antagonists 2
• Use the lowest effective dose of PPIs 2

For Postprandial Distress Syndrome (PDS) - predominant fullness, bloating, early satiety:

• Start prokinetic agents as first-line 2, 5
• Metoclopramide is the only currently available effective prokinetic in many regions, but use short-term with discussion of side effects 6
• Avoid combining prokinetics with medications that prolong QT interval 2, 3

Step 3: Lifestyle Modifications

• Recommend regular aerobic exercise for all patients 2
• Advise avoiding specific trigger foods while preventing overly restrictive diets 2, 3
• Encourage frequent small meals and low-fat diet 6
• Recommend cessation of smoking and minimizing alcohol and coffee intake 6

Critical Pitfall: Do not prescribe overly restrictive diets that may lead to malnutrition or abnormal eating habits. 2, 3 There is insufficient evidence to recommend specialized diets, including low FODMAP diets, for functional dyspepsia. 2

Second-Line Treatment

Tricyclic antidepressants (TCAs) at low doses are the recommended second-line therapy, particularly for EPS. 2, 5 Start with low doses (e.g., amitriptilina 10 mg once daily at bedtime) 3 to treat visceral hypersensitivity. 6

If initial therapy fails, consider switching from PPI to prokinetic or vice versa before escalating to TCAs. 6

Management of Severe or Refractory Cases

When to Refer to Gastroenterology:

• Diagnostic uncertainty 2
• Symptoms severe or refractory to first-line treatments 2
• Treatment-resistant dyspepsia in patients ≥55 years 2

Multidisciplinary Team Approach:

Patients with severe refractory symptoms require management by a team including primary care physicians, dietitians, gastroenterologists, and psychologists. 1, 3 This is particularly important for patients presenting with weight loss and food restriction. 1

Assessment for Eating Disorders:

Screen patients with severe FD presenting with weight loss and food restriction for eating disorders and disordered eating, including avoidant restrictive food intake disorder (ARFID). 1

Early Dietitian Involvement:

Refer to dietitian early in refractory cases to prevent overly restrictive diets. 1

Combination Therapies:

Consider dual therapy approaches in refractory cases, such as:

• Histamine-1 and histamine-2 receptor antagonists together 1, 3
• TCA in combination with SSRI 1, 3

Critical Safety Warnings

Avoid opioids and surgery in patients with severe or refractory functional dyspepsia to minimize iatrogenic harm. 1

Do not routinely perform gastric emptying testing or 24-hour pH monitoring in patients with typical functional dyspepsia symptoms. 2

Doctor-Patient Communication

Establish an empathic relationship and explain that functional dyspepsia is a disorder of gut-brain interaction, not a psychological condition or "all in their head." 1 Discuss the underlying pathophysiology, natural history, and common symptom triggers to improve quality of life and reduce healthcare utilization. 1