What is the initial treatment approach for a patient with functional dyspepsia, without alarm symptoms or significant medical history?

Treatment for Functional Dyspepsia

For patients with functional dyspepsia without alarm symptoms, test for H. pylori and eradicate if positive, followed by empirical proton pump inhibitor therapy if symptoms persist or if H. pylori negative. 1, 2

Initial Management Algorithm

Step 1: H. pylori Testing and Eradication

• All patients with functional dyspepsia should receive non-invasive H. pylori testing (stool antigen or urea breath test) as this is the only therapy that can potentially alter the natural history of the disease 1, 3, 2
• If positive, provide eradication therapy with appropriate antibiotic combination 1, 2
• This approach has superseded empirical therapy as the initial management strategy in uninvestigated dyspepsia 1
• Confirmation of eradication is only needed in patients at increased risk for gastric cancer 1

Step 2: Empirical Acid Suppression for Persistent Symptoms

• Proton pump inhibitors (PPIs) are first-line therapy for patients who are H. pylori negative or whose symptoms persist after eradication 1, 2
• PPIs are superior to H2-receptor antagonists, antacids, and placebo for symptom relief 1
• Use the lowest effective dose that controls symptoms, as there is no clear dose-response relationship 1
• H2-receptor antagonists are an alternative but less effective option 1

Step 3: Consider Prokinetic Agents

• Prokinetics may be effective, particularly for patients with postprandial fullness, early satiation, or bloating (dysmotility-like symptoms) 1, 2
• Efficacy varies by drug class: tegaserod has moderate evidence (strong recommendation), while acotiamide, itopride, and mosapride have lower quality evidence (weak recommendation) 1
• Important caveat: Many prokinetics are unavailable outside Asia and the USA 1
• Metoclopramide should be used cautiously with short-term treatment only due to side effect profile 4

Second-Line Treatment for Refractory Symptoms

Tricyclic Antidepressants as Neuromodulators

• Low-dose tricyclic antidepressants (TCAs) are the evidence-based second-line option when first-line therapies fail 1, 2
• Start with amitriptyline 10 mg once daily at bedtime and titrate slowly to 30-50 mg once daily 1, 2
• Careful patient counseling is essential: explain these are used as gut-brain neuromodulators to reduce nerve hypersensitivity, not as antidepressants 1
• TCAs have moderate quality evidence supporting their efficacy 1

Lifestyle and Non-Pharmacological Interventions

Exercise Recommendation

• All patients should be advised to take regular aerobic exercise (strong recommendation, though evidence quality is very low) 1, 2

Dietary Modifications

• There is insufficient evidence to recommend specific dietary therapies, including low-FODMAP diets 1
• Avoid overly restrictive diets that could lead to malnutrition or disordered eating 3
• Early dietitian involvement is recommended if food restriction develops 3
• General advice includes frequent small meals and avoiding specific trigger foods, though evidence is limited 4, 5

When to Consider Endoscopy

Endoscopy is NOT routinely needed for typical functional dyspepsia but is indicated in specific circumstances:

• Age ≥55 years with treatment-resistant dyspepsia 1
• Age ≥55 years with raised platelet count, nausea, or vomiting 1
• Age >40 years with family history of gastroesophageal cancer or from high-risk geographic areas 3
• Presence of alarm symptoms (weight loss, dysphagia, persistent vomiting, evidence of GI bleeding) 1
• Age ≥60 years with abdominal pain and weight loss warrants urgent CT scanning to exclude pancreatic cancer 1

Critical Pitfalls to Avoid

• Never use opioids or surgery for refractory functional dyspepsia to minimize iatrogenic harm 3
• Do not routinely perform gastric emptying studies or 24-hour pH monitoring in typical functional dyspepsia 1
• Avoid empirical H. pylori eradication without testing, as this leads to considerable overtreatment 1
• Do not overlook GERD as a cause of upper abdominal symptoms—heartburn as the predominant symptom suggests GERD rather than functional dyspepsia 1

Patient Education and Expectations

• Establish an empathic relationship and explain that functional dyspepsia is a chronic, fluctuating disorder of gut-brain interaction 3
• Set realistic expectations: treatment focuses on symptom management rather than cure 3
• The condition has no effect on mortality but can significantly impact quality of life 3
• Symptoms persist chronically in approximately two-thirds of patients, with a fluctuating rather than progressive pattern 3

Considerations for Specialist Referral

Referral to gastroenterology is appropriate when:

• Diagnostic uncertainty exists 1
• Symptoms are severe or refractory to first-line treatments 1
• Patient requests specialist opinion 1
• Ideally, patients should be managed in specialist clinics with access to dietetic support, efficacious drugs, and gut-brain behavioral therapies 1