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

Initial Management of Dyspepsia

Immediate Risk Stratification and Age-Based Approach

For patients presenting with dyspepsia, the initial management depends critically on age and alarm symptoms: patients ≥55 years or those with alarm features (weight loss, recurrent vomiting, bleeding, anemia, dysphagia, jaundice, palpable mass) require prompt endoscopy, while younger patients without alarm symptoms should receive H. pylori test-and-treat as the first-line strategy. 1, 2, 3

Age and Alarm Feature Assessment

• Urgent endoscopy is mandatory for patients ≥55 years with weight loss, or those >40 years from high-risk areas for gastric cancer or with family history of gastro-esophageal cancer 3
• Consider urgent abdominal CT scan in patients ≥60 years with abdominal pain and weight loss to exclude pancreatic cancer 2, 3
• Non-urgent endoscopy should be considered in patients ≥55 years with treatment-resistant dyspepsia or dyspepsia with raised platelet count, nausea, or vomiting 2, 3
• The age threshold of 55 years is based on the rising incidence of gastric cancer in Western populations; lower thresholds may be appropriate in regions with higher gastric cancer rates 1

First-Line Strategy for Younger Patients Without Alarm Features

H. pylori Test-and-Treat Approach

All patients with uninvestigated dyspepsia who do not require immediate endoscopy should undergo non-invasive H. pylori testing, and if positive, receive eradication therapy as the initial intervention. 1, 2, 3

• This strategy is preferable in populations with H. pylori prevalence ≥10% 4
• H. pylori eradication cures underlying peptic ulcer disease in a significant proportion of infected dyspeptic patients 1
• Even in H. pylori-positive patients without peptic ulcer disease, eradication serves as preventative medicine by reducing future gastroduodenal disease risk 1
• Confirm successful eradication only in patients at higher risk of gastric cancer 2

Important Caveat About Functional Dyspepsia

• Be aware that H. pylori eradication does not reliably relieve symptoms of functional dyspepsia within one year of follow-up, though it remains indicated for long-term disease prevention 1
• Patients should be counseled that symptomatic benefit may not occur immediately after eradication 1

Empirical Acid Suppression for H. pylori-Negative Patients

PPI Therapy as First-Line

For patients who test negative for H. pylori or whose symptoms persist after successful eradication, initiate full-dose proton pump inhibitor therapy with omeprazole 20 mg once daily taken 30-60 minutes before breakfast for 4-8 weeks. 2, 4

• PPIs are significantly more effective than H2-receptor antagonists (RR 0.63,95% CI 0.47 to 0.85) and antacids (RR 0.72,95% CI 0.64 to 0.80) for dyspepsia 5
• PPIs are particularly effective for patients with ulcer-like dyspepsia where epigastric pain is the predominant symptom 2, 6
• Assess response at 4 weeks; if inadequate, escalate to twice-daily dosing (omeprazole 20 mg before breakfast and dinner) 2

Alternative: H2-Receptor Antagonists

• H2-receptor antagonists may be used as initial therapy in low H. pylori prevalence populations (<10%) 4
• However, if symptoms persist after an appropriate trial (e.g., 9 weeks of famotidine), switch to PPI rather than continuing H2RA indefinitely 2

Symptom-Based Treatment Selection

For Ulcer-Like Dyspepsia (Predominant Epigastric Pain)

• First-line: Full-dose PPI 2, 6
• This subgroup shows the best response to acid suppression 2

For Dysmotility-Like Dyspepsia (Fullness, Bloating, Early Satiety)

• Consider prokinetic agents as first-line therapy 2, 6
• Metoclopramide is the only available effective prokinetic in many regions, but use short-term with discussion of potential side effects 6
• Alternative prokinetics include levosulpiride (where available), though this is not first-line per guidelines 3

Management of Initial Treatment Response

If Symptoms Resolve

• Taper to the lowest effective dose that controls symptoms after 4-8 weeks 2, 4
• Consider on-demand therapy rather than continuous daily use 2
• If symptoms recur after stopping treatment, repeat the same successful treatment 2, 4

If Symptoms Persist Despite Initial Therapy

• For PPI non-responders: Consider switching from once-daily to twice-daily dosing 2
• If still inadequate after 4-8 weeks of optimized PPI: Consider switching medication class (e.g., from PPI to prokinetic or vice versa) 2, 6
• Second-line options include low-dose tricyclic antidepressants (e.g., amitriptyline 10 mg once daily, gradually increasing to 30-50 mg) 2, 3

Special Considerations

NSAID Users

• Endoscopy is recommended in patients taking traditional NSAIDs regularly who present with dyspepsia due to risk of life-threatening ulcer complications 1
• This does not apply to COX-2 specific NSAIDs 1
• If NSAID therapy must continue and endoscopy shows erosions or ulcers, prophylactic therapy should be considered 1

Lifestyle and General Measures

• Regular aerobic exercise is recommended for all patients with dyspepsia 2, 3
• Dietary modifications: frequent small meals, low-fat diet, avoidance of trigger foods 6
• Cessation of smoking, minimizing alcohol and coffee intake 6

Critical Pitfalls to Avoid

• Do not perform routine endoscopy in young patients (<55 years) without alarm features—this is not cost-effective and delays appropriate empirical management 1, 4
• Do not continue H2-receptor antagonists indefinitely hoping for delayed response—escalate to PPI after an adequate trial period 2
• Do not pursue additional diagnostic testing (gastric emptying studies, pH monitoring) before completing therapeutic trials of H. pylori eradication and acid suppression 2, 3
• Avoid opioids and surgery in patients with functional dyspepsia to minimize iatrogenic harm 3
• Do not dismiss patient concerns—establish an empathic relationship and explain that functional dyspepsia is a disorder of gut-brain interaction, not a psychological condition 3

When to Refer to Gastroenterology

• Symptoms severe or refractory to first-line treatments (H. pylori eradication and PPI therapy) 3
• Diagnostic doubt after initial evaluation 3
• Patients requiring multidisciplinary management including dietitians and psychologists 3
• Screen for eating disorders (including ARFID) in patients with severe symptoms, weight loss, and food restriction 3