What is the most optimal management of someone with functional dyspepsia?

Optimal Management of Functional Dyspepsia

For patients with confirmed functional dyspepsia, test for H. pylori and eradicate if positive, then use empirical proton pump inhibitor therapy for epigastric pain or prokinetic agents for postprandial fullness/early satiety, with dose titration to the lowest effective level and consideration of withdrawal once symptoms are controlled. 1, 2

Initial Diagnostic Approach and Risk Stratification

Before treating functional dyspepsia, exclude organic disease through appropriate investigation:

• Urgent endoscopy is mandatory for patients ≥55 years with dyspepsia and weight loss, or those >40 years from high gastric cancer risk areas or with family history of gastro-esophageal cancer 1, 3
• Non-urgent endoscopy should be performed in patients ≥55 years with treatment-resistant dyspepsia or those with raised platelet count, nausea, or vomiting 1
• Perform full blood count in all patients ≥55 years and celiac serology in those with overlapping IBS symptoms 1
• For patients ≥60 years with abdominal pain and weight loss, urgent abdominal CT is needed to exclude pancreatic cancer 1, 3

Establishing the Therapeutic Relationship

Build an empathic doctor-patient relationship as the foundation of management, as this reduces healthcare utilization and improves quality of life 1

• Explain that FD is a disorder of gut-brain interaction, not a psychological problem or "all in their head" 1, 2
• Describe how the gut-brain axis is impacted by diet, stress, cognitive and emotional responses, and postinfectious changes 1
• Clarify the natural history and common symptom triggers to set realistic expectations 1

First-Line Pharmacological Management

H. pylori Testing and Eradication

All patients without alarm features should receive non-invasive H. pylori testing (stool antigen or urea breath test, not serology) 1, 2

• Eradicate H. pylori if positive, as this cures underlying peptic ulcer disease and prevents future gastroduodenal disease 1
• Acknowledge that many H. pylori-positive patients with functional dyspepsia will not gain symptomatic benefit, but eradication is still recommended 1
• Confirmation of eradication is only necessary in high-risk patients for gastric cancer, not routinely 2

Symptom-Based Empirical Therapy

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

• Epigastric pain or burning (ulcer-like dyspepsia): Use full-dose PPI as first-line therapy (e.g., omeprazole 20 mg once daily) 1, 2
• Postprandial fullness, early satiety, or bloating (dysmotility-like dyspepsia): Use a prokinetic agent such as domperidone or itopride 1, 2, 4
• There is no dose-response relationship with PPIs, so use the lowest dose that controls symptoms 2

Treatment Duration and Withdrawal Strategy

If symptoms are controlled, attempt withdrawal of therapy or dose reduction to avoid long-term unnecessary medication use 1, 2

• Consider "on-demand" therapy with the successful agent for symptom recurrence 1
• If first-line therapy fails after 4-8 weeks, switch to an alternative class (e.g., from PPI to prokinetic or vice versa) 1

Non-Pharmacological Interventions

Implement lifestyle and dietary modifications as adjunctive therapy:

• Recommend regular aerobic exercise for all patients with functional dyspepsia 2
• Advise avoiding foods that trigger symptoms, but involve a dietitian early in severe cases to prevent excessively restrictive diets 2
• Avoid large meals, fatty foods, spicy foods, citrus, and very hot or cold foods 5
• Elevate the head of the bed for patients with nocturnal symptoms 5

Management of Refractory Functional Dyspepsia

For patients who fail initial empirical therapy:

• Trial high-dose PPI therapy if not already attempted 1
• Perform endoscopy if not previously done to confirm the diagnosis 1
• Re-evaluate the diagnosis and provide further reassurance 1, 6
• Consider low-dose tricyclic antidepressants (e.g., amitriptyline 10-25 mg at bedtime) or selective serotonin reuptake inhibitors 1, 4, 6
• Offer behavioral therapy or psychotherapy 1, 6
• Establish a multidisciplinary support team for severe or refractory cases 2

Critical Pitfalls to Avoid

Do not order routine gastric emptying studies or 24-hour pH monitoring in typical FD, as they have low diagnostic yield and delay appropriate treatment 3

Avoid opioids and surgery in patients with severe or refractory FD to minimize iatrogenic harm 5, 2

Do not perform repeated endoscopies if the diagnosis is established and no new alarm symptoms develop 5

Screen for eating disorders in patients with severe dietary restriction and weight loss 2

Recognize that approximately 20% of dyspepsia patients will have organic disease (peptic ulcer or erosive esophagitis), so maintain clinical vigilance 1, 3