What are the treatment options for stress-induced dyspepsia?

Treatment of Stress-Induced Dyspepsia

For stress-induced dyspepsia, begin with H. pylori testing and eradication if positive, followed by empirical proton pump inhibitor therapy, and if symptoms persist after these first-line treatments, initiate low-dose tricyclic antidepressants (amitriptyline 10 mg once daily) as second-line therapy. 1, 2

Understanding the Condition

Stress-induced dyspepsia represents a disorder of gut-brain interaction where psychological stress triggers alterations in gastrointestinal motility, increases visceral hypersensitivity, changes intestinal permeability, and affects the gut microbiota. 3 The condition manifests as epigastric pain or burning, early satiation, and postprandial fullness lasting more than 8 weeks. 1, 2

Critical point: Explain to patients that this is a real physiological condition involving disrupted gut-brain communication, not a psychological problem or "all in their head." 2 This empathic communication reduces healthcare utilization and improves quality of life. 1

First-Line Treatment Algorithm

Step 1: Test for H. pylori

• Perform non-invasive testing (stool test or breath test) for all patients with dyspepsia. 1, 2
• If positive, provide eradication therapy immediately regardless of symptom subtype. 2
• This provides modest but meaningful symptom improvement even in functional dyspepsia. 2

Step 2: Empirical Acid Suppression

• For patients without H. pylori infection (or those who remain symptomatic after eradication), prescribe proton pump inhibitors. 1, 2
• Specific dosing: Omeprazole 20 mg once daily taken before meals for 4-8 weeks. 4
• PPIs are particularly effective for epigastric pain syndrome subtype. 2
• If initial therapy fails after 2-4 weeks, consider changing drug class or dosing before proceeding to next step. 5

Step 3: Lifestyle Modifications

• Recommend regular aerobic exercise for all patients. 2
• Advise avoiding specific foods that trigger symptoms, but avoid overly restrictive diets that could lead to malnutrition or disordered eating. 1, 2
• There is insufficient evidence for specialized diets including low FODMAP diets. 2

Second-Line Treatment for Persistent Symptoms

When first-line therapies fail, initiate tricyclic antidepressants as neuromodulators, not antidepressants. 1, 6

TCA Protocol:

• Start amitriptyline 10 mg once daily at bedtime. 6
• TCAs have strong evidence with a number needed to treat of 3.2 and response rate of approximately 75%. 6
• Mechanism explanation for patients: These work through neuromodulation of visceral hypersensitivity in the gut-brain axis, not as psychiatric treatment. 6
• Counsel patients about potential side effects (dry mouth, drowsiness, constipation) before initiating. 6

Management of Refractory Cases

For patients not responding to both PPI therapy and TCAs:

• Refer to gastroenterology when symptoms are severe, refractory to first-line treatments, or when diagnostic doubt exists. 1, 2
• Engage a multidisciplinary team including primary care physicians, dietitians, gastroenterologists, and psychologists. 2, 6
• Consider psychological interventions: Cognitive behavioral therapy shows effectiveness in reducing gastrointestinal symptoms and decreasing anxiety and depression levels. 7
• Screen for eating disorders including avoidant restrictive food intake disorder (ARFID) in patients with weight loss and food restriction. 2

Combination Therapies (Experimental):

• Dual therapy with H1 and H2 receptor antagonists may be considered. 1
• TCA plus SSRI combination remains investigational and requires further research. 1, 6

Critical Safety Warnings

• Avoid opioids and surgery in patients with severe or refractory functional dyspepsia to minimize iatrogenic harm. 2
• Do not routinely perform gastric emptying testing or 24-hour pH monitoring in patients with typical symptoms. 1, 2
• Avoid cinitaprida with medications that prolong QT interval. 2, 8

When to Investigate Further

Urgent endoscopy is warranted for:

• Patients ≥55 years with weight loss. 1, 2
• Patients >40 years from high-risk areas for gastric cancer or with family history of gastro-oesophageal cancer. 1, 2

Non-urgent endoscopy for:

• Patients ≥55 years with treatment-resistant dyspepsia, raised platelet count, nausea, or vomiting. 1, 2

Urgent abdominal CT scanning for:

• Patients ≥60 years with abdominal pain and weight loss to exclude pancreatic cancer. 1, 2

Common Pitfalls to Avoid

• Do not prescribe overly restrictive diets that may lead to malnutrition or abnormal eating habits—refer to dietitian early in refractory cases. 1, 2
• Do not dismiss the role of stress in symptom generation; address psychological comorbidity including anxiety and depression. 9, 7
• Do not continue ineffective treatments indefinitely; if symptoms persist after 8 weeks of PPI therapy, move to second-line options rather than increasing PPI dose. 1, 2
• Do not assume normal endoscopy means "nothing is wrong"—functional dyspepsia has real pathophysiological mechanisms involving gut-brain axis dysfunction. 1, 9