What are the management options for functional dyspepsia?

Management of Functional Dyspepsia

All patients with functional dyspepsia should undergo non-invasive H. pylori testing and receive eradication therapy if positive, followed by empirical proton pump inhibitor therapy if symptoms persist, with tricyclic antidepressants reserved as second-line treatment. 1

Diagnostic Approach and Initial 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
• Perform full blood count in patients ≥55 years with dyspepsia 1
• Check coeliac serology in patients with overlapping IBS-type symptoms 1
• Urgent endoscopy is warranted in patients ≥55 years with weight loss, or those >40 years from high-risk areas for gastric cancer or with family history of gastro-oesophageal cancer 1
• Consider urgent abdominal CT scanning in patients ≥60 years with abdominal pain and weight loss to exclude pancreatic cancer 1
• Avoid routine gastric emptying testing or 24-hour pH monitoring in patients with typical FD symptoms 1

First-Line Treatment Algorithm

Step 1: H. pylori Testing and Eradication

• All patients with functional dyspepsia must receive non-invasive H. pylori testing (breath test or stool antigen) and eradication therapy if positive, regardless of symptom subtype 1, 2
• This provides modest but meaningful symptom improvement and should be the initial intervention 1

Step 2: Empirical Acid Suppression (if H. pylori negative or symptoms persist after eradication)

• Proton pump inhibitors are effective for functional dyspepsia, especially for epigastric pain syndrome (EPS) subtype 1
• Use the lowest effective dose of PPI 1
• H2 receptor antagonists are an alternative for EPS 1

Step 3: Symptom Subtype-Directed Therapy

• For EPS (predominant epigastric pain): PPI or H2 receptor antagonist as first-line 1
• For PDS (predominant fullness, bloating, early satiety): Prokinetic agent as first-line 1

Lifestyle Modifications (concurrent with pharmacotherapy)

• Regular aerobic exercise is recommended for all patients 1
• Avoid foods that trigger symptoms while being cautious not to adopt overly restrictive diets that could lead to malnutrition 1, 2
• There is insufficient evidence to recommend specialized diets, including low FODMAP diets 1

Second-Line Treatment

• Tricyclic antidepressants at low doses (e.g., amitriptilina 10 mg once daily) are recommended as second-line therapy, particularly for EPS 1, 2
• Switch therapy from PPI to prokinetic or vice versa if initial treatment fails 3
• Combination therapies may be considered, such as dual therapy with different medication classes 1, 2

Management of Refractory Cases

• Patients with severe refractory symptoms require management by a multidisciplinary team including primary care physicians, dietitians, gastroenterologists, and psychologists 1, 2
• 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
• Refer to dietitian early in refractory cases to prevent overly restrictive diets 1, 2
• Referral to gastroenterology is appropriate when there is diagnostic doubt or symptoms are severe or refractory to first-line treatments 1
• Psychotherapy is effective for those who have severe symptoms and refractoriness 4

Critical Safety Warnings and Pitfalls

• Avoid opioids and surgery in patients with severe or refractory functional dyspepsia to minimize iatrogenic harm 1
• Avoid prescribing overly restrictive diets that may lead to malnutrition or abnormal eating habits 1, 2
• Do not use cinitaprida with other medications that may prolong the QT interval 1, 2
• If metoclopramide is used as a prokinetic, limit to short-term treatment and discuss possible side effects with the patient 3

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