What are the symptoms and treatment options for dyspepsia?

Symptoms of Dyspepsia

Dyspepsia presents with one or more of the following core symptoms: bothersome epigastric pain, bothersome epigastric burning, bothersome postprandial fullness, and bothersome early satiation, with symptoms present for at least 6 months and active within the past 3 months. 1

Core Symptom Criteria

According to the Rome IV diagnostic criteria, functional dyspepsia requires at least one of these cardinal symptoms 1:

• Epigastric pain - severe enough to impact usual activities
• Epigastric burning - severe enough to impact usual activities
• Postprandial fullness - severe enough to impact usual activities
• Early satiation - severe enough to prevent finishing a regular-sized meal

The symptoms must have begun at least 6 months before diagnosis and be active within the past 3 months, with no structural disease found on upper endoscopy that explains the symptoms. 1

Functional Dyspepsia Subtypes

Dyspepsia is classified into two distinct subtypes based on predominant symptoms 1:

Epigastric Pain Syndrome (EPS)

• Requires bothersome epigastric pain or burning at least 1 day per week 1
• Pain may be induced by meals, relieved by meals, or occur while fasting 1
• Postprandial bloating, belching, and nausea can coexist 1

Postprandial Distress Syndrome (PDS)

• Requires bothersome postprandial fullness or early satiation at least 3 days per week 1
• Postprandial epigastric pain, burning, bloating, excessive belching, and nausea may accompany these symptoms 1

Additional Associated Symptoms

Beyond the core criteria, patients commonly report 2, 3:

• Bloating - sensation of abdominal distension
• Belching - excessive eructation
• Nausea - with or without vomiting
• Anorexia - reduced appetite

Critical Distinctions

Heartburn and acid regurgitation occurring more than once weekly should be classified as gastroesophageal reflux disease (GERD), not dyspepsia. 1 However, recognize that substantial symptom overlap exists between these conditions in clinical practice. 1

Symptoms relieved by bowel movements or passage of gas should not be considered dyspeptic symptoms and suggest irritable bowel syndrome instead. 1

Persistent vomiting warrants consideration of disorders other than functional dyspepsia. 1

Treatment Approach Based on Symptoms

First-Line Management for All Patients

All patients with dyspepsia must undergo H. pylori testing and receive eradication therapy if positive, regardless of symptom subtype. 4 This provides modest but meaningful symptom improvement and prevents future gastroduodenal disease. 1, 4

Symptom-Directed Therapy After H. pylori Management

For patients with predominant epigastric pain or burning (EPS) 1, 4:

• Initiate full-dose PPI therapy (e.g., omeprazole 20 mg once daily) as first-line treatment
• H2-receptor antagonists are an alternative but less effective option
• Low-dose tricyclic antidepressants as second-line therapy if PPIs fail

For patients with predominant fullness, bloating, or early satiation (PDS) 1, 4:

• Consider prokinetic agents as first-line therapy
• Note: Cisapride is contraindicated due to cardiac toxicity 1
• Metoclopramide is the primary available prokinetic, but use short-term with discussion of side effects 5

Management of Treatment Failure

If initial symptom-directed therapy fails 1:

1. Switch treatment class (e.g., from prokinetic to PPI or vice versa)
2. Trial high-dose PPI therapy to identify misclassified GERD
3. Consider endoscopy if not previously performed
4. Re-evaluate diagnosis for other functional bowel disorders

For refractory cases after standard treatments fail 1, 4:

• Low-dose tricyclic antidepressants at bedtime for visceral hypersensitivity 5
• Behavioral therapy, psychotherapy, or antidepressants 1
• Multidisciplinary team management including dietitian, gastroenterologist, and psychologist 4

Red Flag Symptoms Requiring Urgent Investigation

Patients aged ≥55 years with dyspepsia and weight loss require urgent 2-week wait endoscopy. 1

Additional alarm features warranting urgent or non-urgent endoscopy include 1:

• Dysphagia at any age (urgent endoscopy)
• Age ≥55 with treatment-resistant dyspepsia (non-urgent endoscopy)
• Age ≥55 with nausea, vomiting, or raised platelet count (non-urgent endoscopy)
• Age >40 from high-risk areas for gastric cancer or family history of gastro-oesophageal cancer (urgent endoscopy)

Common Pitfalls

Avoid overly restrictive diets that may lead to malnutrition or disordered eating patterns, including avoidant restrictive food intake disorder (ARFID). 4 Early dietitian referral is recommended for refractory cases. 4

Do not routinely perform gastric emptying studies or 24-hour pH monitoring in patients with typical functional dyspepsia symptoms. 4

Never prescribe opioids or recommend surgery for functional dyspepsia, as these cause iatrogenic harm. 4