What is the initial management for patients presenting with indigestion and dyspepsia?

Initial Management of Indigestion and Dyspepsia

Test all patients for Helicobacter pylori and eradicate if positive, then offer empirical acid suppression with a proton pump inhibitor (PPI) at the lowest effective dose if H. pylori is negative. 1, 2

Immediate Risk Stratification and Red Flags

Before initiating empirical treatment, identify patients requiring urgent investigation:

• Age ≥55 years with weight loss: Urgent endoscopy within 2 weeks 1, 2
• Age >40 years from high-risk gastric cancer areas OR family history of gastroesophageal malignancy: Urgent endoscopy 1, 2
• Age ≥60 years with abdominal pain AND weight loss: Urgent CT scan to exclude pancreatic cancer 1, 2
• Age ≥55 years with treatment-resistant dyspepsia, elevated platelet count, nausea, or vomiting: Non-urgent endoscopy 1, 2

Baseline Investigations

Perform these tests before starting treatment:

• Complete blood count in all patients aged ≥55 years 1, 2
• Celiac serology if patient has overlapping IBS-type symptoms (diarrhea, constipation, bloating) 1, 2
• H. pylori testing via breath or stool test (non-invasive) in all patients 1, 2

Avoid routine gastric emptying studies or 24-hour pH monitoring in patients with typical dyspepsia symptoms—these do not change management 2, 3

First-Line Treatment Algorithm

Step 1: H. pylori Management

• If H. pylori positive: Eradicate with triple therapy (omeprazole 20 mg + amoxicillin 1000 mg + clarithromycin 500 mg, all twice daily for 10 days) 1, 4
• This provides modest but meaningful symptom improvement even in functional dyspepsia 1, 2

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

• PPI therapy: Omeprazole 20 mg once daily (or equivalent) for 4-8 weeks 1, 4
• Use the lowest effective dose that controls symptoms 1, 2
• PPIs are particularly effective for epigastric pain syndrome subtype 1, 3
• Take before meals; antacids may be used concomitantly 4

Step 3: Symptom-Based Approach if PPI Fails

• For ulcer-like symptoms (epigastric pain/burning): Continue or increase PPI, or switch to H2-receptor antagonist 1
• For dysmotility-like symptoms (fullness, bloating, early satiety): Consider prokinetic agent, though options are limited due to cardiac toxicity concerns with older agents like cisapride 1

Lifestyle Modifications (Concurrent with Pharmacotherapy)

• Regular aerobic exercise for all patients 2, 3
• Avoid trigger foods but do not adopt overly restrictive diets that risk malnutrition 2, 3
• Small, frequent meals and low-fat diet may help 5
• Minimize coffee, alcohol, and smoking cessation 5

Patient Education and Engagement

Establish an empathic relationship and explain functional dyspepsia as a disorder of gut-brain interaction, not a psychological condition 2, 3. This explanation alone reduces healthcare utilization and improves quality of life 2. Discuss that 80% of patients with dyspepsia have functional dyspepsia after investigation, emphasizing the benign nature of the condition 1, 6.

Second-Line Treatment (If First-Line Fails After 4-8 Weeks)

• Low-dose tricyclic antidepressants (e.g., amitriptyline 10 mg once daily at bedtime, titrate slowly to 30-50 mg) are the most effective second-line option with moderate-quality evidence 1, 2
• Carefully explain the rationale (gut-brain neuromodulation, not depression treatment) and counsel about side effects 1, 2
• Antipsychotics (sulpiride 100 mg four times daily or levosulpiride 25 mg three times daily) may be considered as alternatives 1, 2

Trial of Therapy Withdrawal

If symptoms are controlled after initial 4-8 week course, attempt withdrawal of therapy 1. If symptoms recur, restart the same successful treatment 1, 7. On-demand therapy is an option for maintenance 1.

When to Refer to Gastroenterology

• Diagnostic uncertainty after initial workup 2, 3
• Severe or refractory symptoms despite first- and second-line treatments 2, 3
• Patient request for specialist evaluation 2

Critical Pitfalls to Avoid

• Do not prescribe overly restrictive diets—these lead to malnutrition and may trigger eating disorders including avoidant/restrictive food intake disorder (ARFID) 1, 2
• Avoid opioids and surgery in severe/refractory functional dyspepsia to minimize iatrogenic harm 1, 2
• Do not use cisapride due to cardiac toxicity 1
• Do not perform routine endoscopy in young patients (<55 years) without alarm features—yield is extremely low (<0.5% malignancy rate) 1

Management of Severe or Refractory Cases

For patients not responding to standard treatments:

• Multidisciplinary team involvement (primary care, dietitian, gastroenterologist, psychologist) 1, 2
• Screen for eating disorders in patients with weight loss and food restriction 1, 2
• Early dietitian referral to prevent nutritional deficiencies 1, 2
• Consider combination therapies or newer agents under specialist guidance 1