What is the management approach for functional abdominal pain and dyspepsia disorders?

Management of Functional Dyspepsia and Functional Abdominal Pain Disorders

Functional dyspepsia should be diagnosed clinically when patients present with bothersome epigastric pain or burning, early satiation, and/or postprandial fullness lasting more than 8 weeks without alarm features, and managed with a stepwise approach starting with H. pylori testing and eradication, followed by proton pump inhibitors, and then tricyclic antidepressants if first-line therapies fail. 1

Understanding the Condition

Functional dyspepsia is a disorder of gut-brain interaction (DGBI), not a diagnosis of exclusion or psychological condition. 1 The condition follows a chronic, fluctuating course in approximately two-thirds of patients, with no increased mortality risk but substantial impact on quality of life and work productivity. 2

Key Pathophysiologic Mechanisms to Explain to Patients:

• Altered gut-brain axis communication affecting gastric sensitivity 1
• Postinfectious changes (threefold increased odds after gastroenteritis) 2
• Impact of diet, stress, and emotional responses on symptoms 1
• Disordered gastrointestinal motility and visceral hypersensitivity 3, 4

Diagnostic Approach

Initial Clinical Diagnosis

Diagnose functional dyspepsia clinically without extensive testing when symptoms of epigastric pain/burning, early satiation, or postprandial fullness persist >8 weeks without alarm features. 1

Age-Stratified Investigation Strategy:

For patients <55 years without alarm features:

• Perform non-invasive H. pylori testing ("test and treat") 1
• Check coeliac serology only if overlapping IBS-type symptoms present 1
• Avoid routine endoscopy, gastric emptying studies, or 24-hour pH monitoring 1

For patients ≥55 years:

• Full blood count is mandatory 1
• Urgent endoscopy only if: weight loss present, OR age >40 years with family history of gastro-oesophageal cancer, OR from high-risk gastric cancer area 1, 2
• Non-urgent endoscopy if: treatment-resistant dyspepsia, raised platelet count, or persistent nausea/vomiting 1

For patients ≥60 years with abdominal pain AND weight loss:

• Urgent abdominal CT scan to exclude pancreatic cancer 1

Treatment Algorithm

Step 1: Establish Therapeutic Relationship and Lifestyle Modifications

Create an empathic doctor-patient relationship with shared understanding of the chronic nature—this reduces healthcare utilization and improves quality of life. 1, 2

• Prescribe regular aerobic exercise for all patients (strong recommendation) 1
• Advise frequent small meals and low-fat diet 5
• Recommend cessation of smoking, limiting alcohol and coffee intake 5
• Do not routinely recommend low FODMAP diet (insufficient evidence) 1

Step 2: First-Line Pharmacotherapy

H. pylori-positive patients:

• Eradicate H. pylori—this is the only therapy that may change the natural history of functional dyspepsia (strong recommendation, high-quality evidence) 1, 2, 6
• Counsel patients that adverse events are more common than control therapy 1
• Confirm eradication only in patients at increased gastric cancer risk 1

H. pylori-negative patients or persistent symptoms after eradication:

• Initiate proton pump inhibitors (PPIs) at the lowest effective dose (strong recommendation, high-quality evidence) 1, 2, 6
• No dose-response relationship exists, so avoid dose escalation 1
• Alternative: Histamine-2 receptor antagonists (weaker evidence, but well-tolerated) 1, 5

For postprandial distress syndrome (PDS) symptoms:

• Consider prokinetics after H. pylori and PPI trials 6
• Acotiamide 100 mg three times daily (weak recommendation, low-quality evidence) 6
• Alternatives: itopride (weak evidence), tegaserod (stronger evidence but limited availability) 1, 6

Step 3: Second-Line Therapy (After 4-8 Weeks of Failed First-Line Treatment)

Initiate tricyclic antidepressants (TCAs) as gut-brain neuromodulators (strong recommendation, moderate-quality evidence) 1, 2, 6

Specific dosing protocol:

• Start amitriptyline 10 mg once daily at bedtime 1, 5
• Titrate slowly to maximum 30-50 mg once daily 1
• Provide careful explanation of rationale (neuromodulation, not depression treatment) and counsel about side effects 1

Alternative second-line options:

• Sulpiride 100 mg four times daily or levosulpiride 25 mg three times daily (with careful counseling about antipsychotic side effects) 1

Step 4: Refractory or Severe Disease Management

Refer to gastroenterology when:

• Diagnostic doubt exists 1
• Symptoms are severe or refractory to first-line treatments 1
• Patient requests specialist opinion 1

For severe/refractory functional dyspepsia:

• Involve multidisciplinary support team (strong recommendation) 1
• Screen for eating disorders including avoidant restrictive food intake disorder (ARFID) if weight loss and food restriction present 1, 2
• Arrange early dietitian involvement to prevent overly restrictive diets 1, 2
• Consider cognitive behavioral therapy or other gut-brain behavioral therapies 1, 3

Critical Pitfalls to Avoid

Never prescribe opioids for functional dyspepsia—this causes iatrogenic harm (strong recommendation) 1, 2

Avoid surgery for refractory symptoms (strong recommendation) 1, 2

Do not perform repetitive or extensive investigations without alarm features—this reinforces illness behavior and provides no diagnostic yield. 1, 4

Do not dismiss symptoms as "psychological"—functional dyspepsia has demonstrable pathophysiologic mechanisms involving gut-brain interaction. 1, 3

Functional Abdominal Pain Syndrome

Functional abdominal pain syndrome represents a distinct entity from functional dyspepsia, characterized by chronic abdominal pain without specific localization to the epigastrium and without the meal-related symptoms of dyspepsia. 3

Management approach:

• Establish effective patient-physician relationship 3
• Avoid opioids entirely 3
• Consider low-dose tricyclic antidepressants for visceral hypersensitivity 3, 5
• Implement behavioral and psychological approaches, particularly cognitive behavioral therapy 3
• Utilize multidisciplinary pain management programs for chronic cases 3

Prognosis Counseling

Inform patients that functional dyspepsia follows a chronic, fluctuating course rather than progressive deterioration, with no mortality risk. 2 Even when symptoms improve, they often fluctuate to other disorders of gut-brain interaction rather than completely resolving. 2 This realistic expectation-setting, combined with empathic communication, reduces healthcare utilization and improves quality of life outcomes. 1, 2