What is the initial management for patients presenting with dyspepsia symptoms?

Initial Management of Dyspepsia

All patients presenting with dyspepsia should first be risk-stratified by age and alarm features, with those ≥55 years with weight loss requiring urgent endoscopy, while younger patients without alarm symptoms should receive H. pylori testing followed by eradication therapy if positive, or empirical acid suppression if negative. 1

Risk Stratification and Alarm Features

The initial approach must identify patients requiring urgent investigation versus those suitable for empirical management:

Patients Requiring Urgent Endoscopy (2-week wait):

• Age ≥55 years with dyspepsia and weight loss 1
• Age >40 years from areas with increased gastric cancer risk or family history of gastro-oesophageal cancer 1
• Any age with alarm symptoms: hematemesis, dysphagia, recurrent vomiting, anemia, jaundice, or palpable mass 1

Patients Requiring Non-Urgent Endoscopy:

• Age ≥55 years with treatment-resistant dyspepsia 1
• Age ≥55 years with dyspepsia plus nausea/vomiting or raised platelet count 1

Additional Investigations:

• Urgent CT scan for age ≥60 years with abdominal pain and weight loss (to exclude pancreatic cancer) 1
• Full blood count in all patients aged ≥55 years 1
• Coeliac serology in patients with overlapping IBS-type symptoms 1

Management Algorithm for Patients Without Alarm Features

Step 1: H. pylori Testing (Test and Treat Strategy)

All patients without alarm features should be offered non-invasive H. pylori testing using either stool antigen or breath test 1. This is the cornerstone of initial management in populations with H. pylori prevalence ≥10% 2.

• If H. pylori positive: Provide eradication therapy with antibiotics 1
  • This has high-quality evidence for efficacy in functional dyspepsia 1
  • Adverse events are more common than control therapy but treatment is justified 1
  • Confirmation of eradication is only needed in patients at increased risk of gastric cancer 1

Step 2: Empirical Acid Suppression

If H. pylori negative, or if symptoms persist after successful eradication, offer empirical acid suppression therapy 1, 2:

• Proton pump inhibitors (PPIs) are first-line with strong evidence for efficacy 1

  • Use the lowest dose that controls symptoms (no dose-response relationship demonstrated) 1
  • Trial for 4-8 weeks 2
  • PPIs are well-tolerated 1

• Histamine-2 receptor antagonists are an alternative with weaker evidence 1

  • May be efficacious and well-tolerated 1
  • Reasonable for intermittent "on-demand" therapy 3

Step 3: Lifestyle Modifications (Concurrent with Medical Therapy)

Advise all patients to take regular aerobic exercise 1. This has strong recommendation despite very low-quality evidence, reflecting the safety and potential benefit.

Avoid overly restrictive diets as there is insufficient evidence for specialized diets including low-FODMAP diets in functional dyspepsia 1. However, patients may benefit from avoiding specific trigger foods identified through their own experience 1.

Management of Treatment-Resistant Dyspepsia

If initial therapy fails after 4-8 weeks:

Consider Second-Line Options:

• Prokinetic agents (if available): acotiamide, itopride, mosapride, or tegaserod 1

  • Efficacy varies by drug class and geographic availability 1
  • Most are well-tolerated 1

• Tricyclic antidepressants (TCAs) as neuromodulators for second-line treatment 1

  • Work on the gut-brain axis to reduce nerve hypersensitivity 1
  • Low-dose therapy at bedtime may help visceral hypersensitivity 3

Referral to Gastroenterology:

Refer to secondary care when there is diagnostic doubt, severe symptoms, refractoriness to first-line treatments, or patient request 1. Ideally, patients should be managed in specialist clinics with access to dietetic support, efficacious drugs, and gut-brain behavioral therapies 1.

Critical Pitfalls to Avoid

• Do not perform routine gastric emptying testing or 24-hour pH monitoring in patients with typical dyspepsia symptoms 1
• Do not use empirical H. pylori eradication without testing except in very high prevalence areas where testing is unavailable 1
• Do not endoscope all patients empirically - the yield for malignancy is <0.5% in unselected populations and cost per cancer diagnosis exceeds $80,000 1
• Age thresholds for endoscopy should be adjusted locally based on regional gastric cancer incidence 1
• Endoscopy should be performed when symptoms are present and after minimum one month off antisecretory therapy 1

Patient Education

Establish an empathic doctor-patient relationship and explain that functional dyspepsia is a disorder of gut-brain interaction, not a psychological condition 1. Most patients (80%) with dyspepsia will have functional dyspepsia after investigation 1. Reassurance that normal tests do not mean "nothing is wrong" but rather reflect altered gut-brain communication is essential 1.