What is the best treatment approach for a patient presenting with dyspepsia?

Treatment Approach for Dyspepsia

For patients presenting with dyspepsia, implement a "test and treat" strategy for H. pylori as first-line management in primary care, reserving prompt endoscopy for those ≥55 years old or with alarm features (weight loss, bleeding, dysphagia, anemia, recurrent vomiting), followed by empirical proton pump inhibitor therapy for H. pylori-negative patients or those with persistent symptoms after eradication. 1, 2, 3

Initial Risk Stratification and Diagnostic Approach

Immediate Endoscopy Required For:

• Patients ≥55 years with new-onset dyspepsia 1, 2, 3
• Alarm symptoms present: weight loss, recurrent vomiting, bleeding, anemia, dysphagia, jaundice, or palpable mass 1, 2
• Patients >40 years from high gastric cancer risk regions or with family history of gastroesophageal cancer 3
• Patients ≥60 years with abdominal pain and weight loss require urgent abdominal CT to exclude pancreatic cancer 3

Laboratory Testing:

• Complete blood count in all patients ≥55 years 2, 3
• Celiac serology in patients with overlapping irritable bowel syndrome symptoms 2, 3

First-Line Management Strategy (Patients Without Alarm Features)

Test and Treat for H. pylori:

Non-invasive H. pylori testing should be performed first, as this strategy ranks highest for symptom reduction at 12 months and significantly reduces need for endoscopy compared to all other approaches. 1, 2, 3 Network meta-analysis demonstrates "test and treat" has a relative risk of 0.89 for remaining symptomatic at 12 months. 1

• If H. pylori positive: Administer eradication therapy 2, 3
• Eradication cures underlying peptic ulcer disease and prevents future gastroduodenal complications 3
• Confirmation of successful eradication is only necessary in patients at high risk of gastric cancer 2
• Do not use serology for H. pylori testing due to lower specificity than other non-invasive tests 1

For H. pylori-Negative Patients or Persistent Symptoms After Eradication:

Symptom-directed therapy based on predominant complaint:

Epigastric Pain or Burning (Ulcer-like/Epigastric Pain Syndrome):

• Full-dose PPI as first-line therapy 2, 3
• Omeprazole 20 mg once daily is effective and confirms acid-related nature of symptoms 2, 4
• No dose-response relationship exists for PPIs, so use lowest effective dose 2

Postprandial Fullness, Early Satiety, or Bloating (Postprandial Distress Syndrome):

• Prokinetic agent (domperidone or itopride) should be considered 2, 3

Essential Doctor-Patient Communication

Establishing an empathic therapeutic relationship is fundamental and reduces healthcare utilization while improving quality of life. 1, 2, 3

• Explain that functional dyspepsia is a disorder of gut-brain interaction, NOT a psychological problem 1, 3
• Discuss the natural history, common symptom triggers, and how diet, stress, and emotional responses impact the gut-brain axis 1, 2
• Reassure that most patients (approximately 80%) will have functional dyspepsia rather than serious organic disease 1, 5

Non-Pharmacological Interventions

• Regular aerobic exercise is recommended for all patients 2, 3
• Avoid foods that trigger symptoms 2, 6
• Early dietitian involvement in severe or refractory cases prevents excessively restrictive diets 2
• Screen for eating disorders in patients with severe symptoms, weight loss, and dietary restriction 2

Management of Refractory Functional Dyspepsia

If Initial Empirical Therapy Fails:

• Trial high-dose PPI therapy if not already attempted 3
• Perform endoscopy if not previously done to confirm diagnosis 3
• Consider low-dose tricyclic antidepressants or selective serotonin reuptake inhibitors 2, 3
• Multidisciplinary support team involvement for severe cases 2

Critical Pitfalls to Avoid:

• Do NOT routinely order gastric emptying studies or 24-hour pH monitoring in typical functional dyspepsia—these have low diagnostic yield and delay appropriate treatment 3
• AVOID opioids and surgery in severe or refractory functional dyspepsia to minimize iatrogenic harm 2, 3
• Do NOT use PPIs longer than medically indicated due to risks of hypomagnesemia, vitamin B12 deficiency, fundic gland polyps, and drug-induced lupus 4
• AVOID concomitant use of omeprazole with clopidogrel due to CYP2C19 inhibition reducing clopidogrel's antiplatelet activity 4

Important Clinical Context

Approximately 20% of patients with dyspepsia will have organic disease (peptic ulcer or erosive esophagitis), making empirical acid suppression a reasonable strategy even before testing. 1, 3 However, the "test and treat" approach remains superior because it addresses both H. pylori-related disease and provides a framework for subsequent management. 1

The age threshold for endoscopy should be defined locally based on gastric cancer incidence—traditionally 45 years in Western countries, but potentially 50 years in very low-risk populations or lower in high-risk regions. 1