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

Treatment Approach for Dyspepsia

For patients presenting with dyspepsia, test for Helicobacter pylori using a non-invasive test (urea breath test or stool antigen) and provide eradication therapy if positive; if H. pylori is negative or symptoms persist after eradication, start omeprazole 20 mg once daily taken 30-60 minutes before breakfast for 4-8 weeks. 1

Initial Risk Stratification and When to Perform Endoscopy

Immediate endoscopy is required for:

• Patients ≥55 years with alarm symptoms (weight loss, recurrent vomiting, bleeding, anemia, dysphagia, jaundice, palpable mass) 2, 3
• Patients >40 years from high gastric cancer risk areas 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 1, 3

Non-urgent endoscopy is indicated for:

• Patients ≥55 years with treatment-resistant dyspepsia, elevated platelet count, nausea, or vomiting 1, 3

Additional baseline testing:

• Complete blood count in all patients ≥55 years 4, 3
• Celiac serology in patients with overlapping irritable bowel syndrome symptoms 4, 3

First-Line Treatment: H. pylori Test-and-Treat Strategy

All patients without alarm features should undergo non-invasive H. pylori testing first. 4, 1 The urea breath test or stool antigen test are the validated non-invasive options. 1, 5

If H. pylori positive:

• Provide triple therapy: omeprazole 20 mg + amoxicillin 1000 mg + clarithromycin 500 mg, all twice daily for 10 days 1
• Eradication is effective because it cures underlying peptic ulcer disease and prevents future gastroduodenal complications 4, 3
• Confirmation of successful eradication is only necessary in patients at high risk of gastric cancer 4

Empirical Acid Suppression for H. pylori-Negative Patients

If H. pylori is negative or symptoms persist after eradication, start omeprazole 20 mg once daily taken 30-60 minutes before breakfast for 4-8 weeks. 4, 1

This approach is particularly effective for:

• Patients with epigastric pain or burning (ulcer-like dyspepsia) 2, 4
• Full-dose PPI therapy confirms the acid-related nature of symptoms 2
• Use the lowest dose that controls symptoms, as there is no evidence of dose-response benefit 4

Symptom-Based Treatment Alternatives

For patients with predominant postprandial fullness, bloating, or early satiety (dysmotility-like symptoms), consider a prokinetic agent instead of or in addition to PPI therapy. 2, 4, 3 Note that cisapride is no longer recommended due to cardiac toxicity. 2

If symptoms are controlled with initial therapy:

• Trial withdrawal of therapy and repeat if symptoms recur 2
• On-demand therapy with the successful agent is an option 2

If no response to first-line therapy:

• Switch treatment (e.g., from prokinetic to PPI or vice versa) as patients may have been misclassified 2
• Consider high-dose PPI therapy if not already attempted 2, 3
• Refer for endoscopy if not previously performed 2

Second-Line Treatment for Refractory Symptoms

For patients who fail empirical therapy, start amitriptyline 10 mg once daily at bedtime as the most effective second-line treatment. 1 Titrate slowly to a maximum of 30-50 mg once daily based on response and tolerability. 1

Alternative neuromodulators include other tricyclic antidepressants or selective serotonin reuptake inhibitors. 2, 3

Essential Non-Pharmacological Management

Establish an empathic doctor-patient relationship and explain that functional dyspepsia is a disorder of gut-brain interaction, not a psychological problem. 2, 4, 3 This reduces healthcare utilization and improves quality of life. 2, 4

Lifestyle interventions:

• Recommend regular aerobic exercise for all patients 4, 3
• Advise avoiding foods that trigger symptoms 4, 3
• Involve a dietitian early in severe or refractory cases to prevent excessively restrictive diets 4, 3
• Screen for eating disorders (including avoidant restrictive food intake disorder) in patients with weight loss and dietary restriction 4, 1

Management of Severe or Refractory Functional Dyspepsia

For patients with persistent symptoms despite optimal medical therapy:

• Re-evaluate the diagnosis to ensure functional dyspepsia is correct 2
• Consider behavioral therapy, psychotherapy, or antidepressants 2, 4
• Involve a multidisciplinary team including dietitians, gastroenterologists, and psychologists 1, 3

Critical Safety Warnings and Pitfalls to Avoid

Never prescribe opioids for chronic dyspepsia—they cause harm without benefit. 1, 3

Do not refer for surgery—there is no surgical treatment for functional dyspepsia. 1, 3

Avoid routine gastric emptying studies or 24-hour pH monitoring in typical functional dyspepsia, as they have low diagnostic yield and delay appropriate treatment. 3

Do not pursue additional endoscopy unless new alarm features develop. 1

Important clinical context: Approximately 20-25% of patients with dyspepsia will have organic disease, so maintain clinical vigilance. 3, 6 Most patients (70-80%) will have functional dyspepsia after investigation. 2, 5, 7 Symptom clusters (ulcer-like, reflux-like, dysmotility-like) have limited value in predicting underlying structural disease but may guide initial treatment selection. 2