How to manage dyspepsia?

Management of Dyspepsia

All patients with dyspepsia should undergo non-invasive testing for Helicobacter pylori and receive eradication therapy if positive, followed by empirical acid suppression with a proton pump inhibitor (PPI) if H. pylori is negative or symptoms persist after eradication. 1, 2, 3

Initial Assessment and Risk Stratification

Identify Patients Requiring Urgent Endoscopy

• Age ≥55 years with weight loss requires urgent endoscopy 2, 3
• Age >40 years from high-risk geographic areas for gastric cancer or with family history of gastroesophageal cancer requires urgent endoscopy 2, 3
• Age ≥60 years with abdominal pain and weight loss requires urgent abdominal CT scanning to exclude pancreatic cancer 2
• Patients with alarm symptoms (dysphagia, persistent vomiting, gastrointestinal bleeding) should undergo prompt upper endoscopy 1
• Regular NSAID users should be referred for early endoscopy 1

Non-Urgent Endoscopy Indications

• Age ≥55 years with treatment-resistant dyspepsia, elevated platelet count, nausea, or vomiting warrants non-urgent endoscopy 2, 3

Laboratory Testing

• Perform complete blood count in all patients ≥55 years 2, 3
• Perform celiac serology in patients with overlapping IBS-type symptoms 2, 3

Tests to Avoid

• Do not routinely perform gastric emptying studies or 24-hour pH monitoring in patients with typical functional dyspepsia symptoms 2, 3

First-Line Treatment Algorithm

Step 1: H. pylori Testing and Eradication

• Test all patients for H. pylori using validated non-invasive testing (stool antigen or urea breath test) 1, 2, 3, 4
• If positive, provide eradication therapy with appropriate antibiotic regimen 1, 2, 3, 4
• This strategy cures most underlying peptic ulcer disease and prevents future gastroduodenal disease, though many patients with functional dyspepsia will not gain symptomatic benefit 1

Step 2: Empirical Acid Suppression

• For H. pylori-negative patients or those with persistent symptoms after eradication, prescribe a PPI at the lowest effective dose for 4-8 weeks 2, 3, 4, 5
• PPIs are particularly effective for epigastric pain syndrome (EPS) subtype 2, 4
• If symptoms are controlled, attempt withdrawal of therapy after 4-8 weeks; if symptoms recur, repeat the same treatment 1, 5
• Alternative: H2-receptor antagonists can be used for EPS subtype 1, 2

Step 3: Lifestyle Modifications (Concurrent with Pharmacotherapy)

• Recommend regular aerobic exercise for all patients 1, 2, 3, 4
• Advise patients to avoid specific trigger foods while cautioning against overly restrictive diets that may lead to malnutrition or eating disorders 1, 2, 3
• There is insufficient evidence to recommend specialized diets, including low FODMAP diets 2

Second-Line Treatment for Non-Responders

Switching or Adding Therapy

• If initial PPI therapy fails after 2-4 weeks, consider changing drug class or dosing 5
• For postprandial distress syndrome (PDS) with predominant fullness, bloating, or early satiety, consider a prokinetic agent 2
• Metoclopramide is available but carries significant risks: can cause tardive dyskinesia (TD), an irreversible movement disorder, with risk increasing with duration of treatment beyond 12 weeks 6
• If metoclopramide is used, limit to short-term treatment, discuss side effects including TD risk, and monitor for involuntary facial movements 6, 7

Tricyclic Antidepressants (TCAs)

• Low-dose TCAs are the most effective second-line treatment, particularly for EPS 1, 2, 3
• Start with amitriptyline 10 mg daily at bedtime, slowly titrate up to 30-50 mg as tolerated 4
• TCAs are effective for visceral hypersensitivity and pain modulation 7

Alternative Second-Line Options

• Antipsychotics such as sulpiride 100 mg four times daily or levosulpiride 25 mg three times daily may be effective with appropriate counseling on side effects 3
• Consider combination therapies such as dual therapy with H1 and H2 receptor antagonists, or TCA with SSRI 1

Management of Severe or Refractory Cases

Multidisciplinary Approach

• Refer patients with severe or refractory symptoms to a multidisciplinary team including primary care physicians, dietitians, gastroenterologists, and psychologists 1, 2, 3
• Referral to gastroenterology is appropriate when there is diagnostic doubt, severe symptoms, or failure of first-line treatments 2, 3

Screen for Eating Disorders

• Assess patients with severe FD presenting with weight loss and food restriction for eating disorders, including avoidant restrictive food intake disorder (ARFID) 1, 2, 3
• Involve a dietitian early to prevent overly restrictive diets 1, 2, 3

Additional Therapeutic Considerations

• Consider behavioral therapy, cognitive behavioral therapy (CBT), or psychotherapy for refractory cases 1
• SNRIs, mirtazapine, or 5-HT1A agonists may be considered for pain and psychological response modulation 1
• High-dose PPI therapy can be trialed if standard doses fail 1

Critical Safety Warnings

Medications to Avoid

• Avoid opioids and surgery in patients with severe or refractory functional dyspepsia to minimize iatrogenic harm 1, 2, 3

PPI Safety Considerations

• Long-term PPI use (>3 years) may lead to vitamin B12 deficiency, hypomagnesemia, increased risk of Clostridium difficile-associated diarrhea, and osteoporosis-related fractures 8
• PPIs may cause or exacerbate cutaneous and systemic lupus erythematosus; discontinue if signs develop 8
• Use the lowest effective dose for the shortest duration appropriate to the condition 8

Metoclopramide Safety Considerations

• Metoclopramide should not be used for more than 12 weeks due to TD risk 6
• Risk of TD is higher in elderly patients, women, and diabetics 6
• Acute dystonic reactions occur in approximately 1 in 500 patients, more frequently in those <30 years of age 6
• Contraindicated in patients with pheochromocytoma, seizure disorders, or those taking medications causing movement disorders 6

Patient Communication Strategy

Establish Therapeutic Alliance

• Explain that functional dyspepsia is a disorder of gut-brain interaction, not a psychological condition or "all in their head" 2
• Discuss underlying pathophysiology, natural history, and common symptom triggers to improve quality of life and reduce healthcare utilization 2
• Address patient concerns about serious underlying disease, as this is a significant factor influencing consultation 1

Set Realistic Expectations

• Acknowledge that functional dyspepsia is chronic with fluctuating symptoms in most patients 9
• Normal test results do not mean there is no cause; symptoms arise from disordered gut-brain communication 1