What is the best approach to manage symptoms of dyspepsia?

Management of Dyspepsia

Test all patients with dyspepsia for Helicobacter pylori using non-invasive methods and provide eradication therapy if positive; if H. pylori is negative or symptoms persist after eradication, treat with a proton pump inhibitor (PPI) at full dose for 4-8 weeks. 1, 2

Initial Risk Stratification and Red Flags

Immediate endoscopy is required for:

• Patients ≥55 years with dyspepsia and weight loss 3, 2
• Patients >40 years from high gastric cancer risk areas or with family history of gastro-esophageal malignancy 3, 2
• Alarm symptoms including dysphagia, persistent vomiting, gastrointestinal bleeding, or anemia 3, 1
• Regular NSAID users presenting with dyspepsia 3, 1

Non-urgent endoscopy should be considered for:

• Treatment-resistant dyspepsia in patients ≥55 years 3, 2
• Patients with raised platelet count, nausea, or vomiting 2

Additional urgent investigations:

• Urgent CT scan for patients ≥60 years with abdominal pain and weight loss to exclude pancreatic cancer 2
• Abdominal ultrasound for epigastric pain <1 year with characteristics of biliary colic 3

Baseline Laboratory Testing

Perform these tests before initiating treatment:

• Full blood count in all patients ≥55 years 3, 2
• Celiac serology in patients with overlapping IBS-type symptoms 3, 2
• Non-invasive H. pylori testing (breath or stool test) in all patients without alarm features 3, 1, 2

The yield of endoscopy in unselected dyspepsia patients is low—only 13% have erosive esophagitis, 8% have peptic ulcer, and less than 0.5% have gastro-esophageal malignancy, with 80% having functional dyspepsia 3. This justifies the empirical approach in younger patients without alarm features.

First-Line Treatment Algorithm

Step 1: H. pylori Testing and Eradication

• Test all patients for H. pylori using validated non-invasive methods 1, 2, 4
• If positive, provide eradication therapy with appropriate antibiotic regimen 1, 2, 4
• H. pylori eradication cures underlying peptic ulcer disease and prevents future gastroduodenal disease 2
• Confirmation of successful eradication is only necessary in patients at high risk of gastric cancer 4

Step 2: Empirical Acid Suppression (if H. pylori negative or symptoms persist)

• For epigastric pain or burning: prescribe full-dose PPI (e.g., omeprazole 20 mg once daily) for 4-8 weeks 1, 2, 4, 5
• Take PPI before meals 5
• Use the lowest effective dose that controls symptoms, as there is no evidence of dose-response benefit 4
• Antacids may be taken concurrently with PPIs 5

Step 3: Prokinetic Therapy (for postprandial symptoms)

• For predominant postprandial fullness, early satiety, or bloating: consider a prokinetic agent such as domperidone or itopride 2, 4

Patient Education and Therapeutic Relationship

Establishing an empathic doctor-patient relationship is essential and reduces healthcare utilization while improving quality of life 3, 2, 4. Explain the following to patients:

• Functional dyspepsia is a disorder of gut-brain interaction, not a psychological condition or "all in their head" 1, 2
• The condition involves altered communication between the gut and brain, affecting motility, visceral sensitivity, and gastrointestinal function 3, 4
• Common symptom triggers include specific foods, stress, and emotional responses 3, 4
• The natural history is typically chronic with fluctuating symptoms 3

Non-Pharmacological Interventions

Implement these lifestyle modifications:

• Regular aerobic exercise for all patients with functional dyspepsia 2, 4
• Avoid foods that trigger symptoms 2, 4
• Early involvement of a dietitian in severe cases to prevent excessively restrictive diets 2, 4

Management of Refractory Dyspepsia

If initial empirical therapy fails after 4-8 weeks:

Step 1: Optimize PPI therapy

• Trial high-dose PPI if not already attempted 2
• Ensure proper timing (before meals) and adherence 5

Step 2: Perform endoscopy if not previously done

• Confirm the diagnosis of functional dyspepsia by excluding organic disease 2

Step 3: Central neuromodulators

• Low-dose tricyclic antidepressants (TCAs) are the most effective second-line treatment, particularly for epigastric pain syndrome 1, 2
• Start with amitriptyline 10 mg daily at bedtime, slowly titrate up to 30-50 mg as tolerated 1
• Alternative: selective serotonin reuptake inhibitors (SSRIs) 2

Step 4: Multidisciplinary approach

• Refer patients with severe or refractory symptoms to a multidisciplinary team including gastroenterologists, dietitians, and psychologists 1, 2
• Assess patients with weight loss and food restriction for eating disorders, including avoidant restrictive food intake disorder (ARFID) 1, 2

Critical Safety Warnings and Pitfalls

Avoid these interventions:

• Never prescribe opioids or recommend surgery for severe or refractory functional dyspepsia to minimize iatrogenic harm 1, 2, 4
• Do not routinely order gastric emptying studies or 24-hour pH monitoring in typical functional dyspepsia, as they have low diagnostic yield and delay appropriate treatment 2

PPI-related precautions:

• Long-term PPI use (>3 years) may cause vitamin B-12 deficiency due to reduced stomach acid 5
• Monitor magnesium levels in patients on prolonged PPI therapy (≥3 months), especially those taking digoxin or diuretics 5
• PPI use increases risk of fundic gland polyps with long-term use, especially beyond one year 5
• Avoid concomitant use of omeprazole with clopidogrel, as it reduces clopidogrel's antiplatelet activity 5
• Temporarily stop PPI treatment at least 14 days before assessing serum chromogranin A (CgA) levels to avoid false positive results for neuroendocrine tumors 5

Drug interactions to monitor:

• Omeprazole may increase INR and prothrombin time in patients taking warfarin; monitor closely 5
• Concomitant use with high-dose methotrexate may elevate methotrexate levels and cause toxicity; consider temporary PPI withdrawal 5
• Avoid concomitant use with St. John's Wort or rifampin, which substantially decrease omeprazole concentrations 5

Clinical vigilance:

• Approximately 20% of dyspepsia patients will have organic disease, so maintain clinical vigilance throughout management 2
• Symptom subgroups (ulcer-like, reflux-like, dysmotility-like) have poor predictive value for underlying pathology and should not guide initial investigation decisions 3