What is the initial management for a patient presenting with dyspepsia?

Initial Management of Dyspepsia

Age-Based Stratification and Alarm Features

Patients ≥55 years old or those with alarm symptoms (weight loss, recurrent vomiting, bleeding, anemia, dysphagia, jaundice, palpable mass) require prompt endoscopy before initiating empirical therapy. 1, 2, 3

• In Western countries, the age cutoff of 55 years is appropriate, though this should be adjusted lower in regions with higher gastric cancer incidence at younger ages 1, 4
• Urgent abdominal CT scanning should be considered in patients ≥60 years with abdominal pain and weight loss to exclude pancreatic cancer 2, 4
• Patients on regular traditional NSAIDs presenting with dyspepsia warrant endoscopy due to risk of life-threatening ulcer complications, though this does not apply to COX-2 specific NSAIDs 1

First-Line Management for Patients Without Alarm Features

All patients with dyspepsia should undergo non-invasive H. pylori testing, and if positive, receive eradication therapy as the initial intervention. 2, 4, 5

• H. pylori "test and treat" is the preferred initial strategy in populations with moderate to high prevalence (≥10%) of infection 5
• Eradication of H. pylori cures underlying peptic ulcer disease and serves as preventative medicine against future gastroduodenal disease, even in patients without ulcers 1
• This approach has largely superseded empirical antisecretory therapy alone because empirical therapy without H. pylori testing results in inadequate treatment of peptic ulcer disease if present 1

Empirical Acid Suppression Therapy

For H. pylori-negative patients or after successful eradication with persistent symptoms, initiate a proton pump inhibitor (PPI) at full dose—specifically omeprazole 20 mg once daily taken 30-60 minutes before breakfast—for 4-8 weeks. 2, 5

• PPIs are superior to H2 receptor antagonists, placebo, and antacid-alginate in relieving symptoms in uninvestigated dyspepsia 1
• In low H. pylori prevalence situations (<10%), empirical PPI therapy is an acceptable initial option even before H. pylori testing 5
• If symptoms persist after 4 weeks on once-daily PPI, escalate to twice-daily dosing (omeprazole 20 mg before breakfast and dinner) 2

Symptom-Based Treatment Selection

Documentation of the patient's most bothersome symptom guides treatment selection, particularly after initial therapy fails. 1, 2

• For ulcer-like dyspepsia (predominant epigastric pain): Full-dose PPI is the first therapeutic option 2, 6
• For dysmotility-like dyspepsia (fullness, bloating, early satiety): Consider a prokinetic agent such as metoclopramide, though availability is limited and short-term use is advised due to side effects 2, 6
• Symptom subgrouping has limited value in predicting underlying structural disease but helps predict response to specific therapies 1

Response Assessment and Ongoing Management

Assess treatment response at 4-8 weeks; if symptoms resolve, attempt therapy withdrawal and use on-demand therapy for recurrences. 2, 5

• Use the lowest effective dose that controls symptoms rather than continuing full-dose therapy indefinitely 2
• If symptoms recur after stopping treatment, repeat the same successful treatment 2, 5
• If symptoms persist despite initial therapy, switch medication class (e.g., from PPI to prokinetic or vice versa) before considering endoscopy 2, 6

Second-Line Treatment for Refractory Symptoms

Tricyclic antidepressants at low doses (e.g., amitriptyline 10 mg once daily, gradually increased to maximum 30-50 mg once daily) are effective second-line therapy for functional dyspepsia, particularly for epigastric pain syndrome. 2, 4, 5

• Regular aerobic exercise is recommended for all patients with functional dyspepsia 2, 4
• Consider referral to gastroenterology when diagnostic doubt exists or symptoms are severe and refractory to first-line treatments 4

Critical Pitfalls to Avoid

Do not continue H2 receptor antagonists like famotidine indefinitely hoping for delayed response—9 weeks is well beyond the timeframe where additional benefit would be expected, and escalation to PPI is indicated. 2

• Avoid pursuing additional endoscopy at this stage unless the patient fails twice-daily PPI therapy; the next appropriate step is therapeutic escalation, not further diagnostic workup 2
• Do not prescribe overly restrictive diets that may lead to malnutrition or abnormal eating habits 4
• Avoid opioids and surgery in patients with functional dyspepsia to minimize iatrogenic harm 4
• Emphasize the safety of PPIs for dyspepsia treatment; concerns about PPI-associated adverse events should not drive treatment decisions when there is a clear indication for use 2