What is the best course of treatment for a patient presenting with dyspepsia, flatulence, and vomiting?

Management of Dyspepsia with Flatulence and Vomiting

For a patient presenting with dyspepsia, flatulence, and vomiting, test for H. pylori infection and provide eradication therapy if positive; if negative or symptoms persist after eradication, initiate empirical proton pump inhibitor therapy with omeprazole 20 mg once daily before meals. 1, 2, 3

Initial Clinical Assessment

Begin by determining the patient's age and screening for alarm symptoms, as these dictate the urgency of endoscopic evaluation. 1

Alarm symptoms requiring urgent action include: 1, 2

• Weight loss (objective evidence required)
• Recurrent or persistent vomiting
• Dysphagia
• Evidence of gastrointestinal bleeding (melena, hematemesis)
• Anemia or raised platelet count
• Palpable abdominal mass
• Family history of gastro-oesophageal cancer

Age-based endoscopy thresholds: 1

• Patients ≥55 years with new-onset dyspepsia require urgent 2-week wait endoscopy if weight loss is present 1
• Patients ≥55 years with treatment-resistant dyspepsia, nausea, vomiting, or raised platelet count warrant non-urgent endoscopy 1
• Patients <55 years without alarm symptoms can be managed empirically without immediate endoscopy 1, 2

Primary Management Strategy: Test and Treat H. pylori

The test-and-treat approach ranks first among all management strategies for uninvestigated dyspepsia. 1 This strategy is logical because approximately 5% of community dyspepsia is attributable to H. pylori, and eradication therapy is extremely efficacious for peptic ulcer disease while preventing future gastroduodenal complications. 1, 2

Testing methods: 1

• Use faecal antigen testing or carbon-urea breath testing (similar accuracy to endoscopic rapid urease testing)
• Do NOT use H. pylori serology due to lower specificity 1

If H. pylori positive, provide eradication therapy: 1, 2

• Triple therapy: Omeprazole 20 mg + Amoxicillin 1000 mg + Clarithromycin 500 mg, all twice daily for 10 days 3
• Alternative dual therapy: Omeprazole 40 mg once daily + Clarithromycin 500 mg three times daily for 14 days 3
• If ulcer present at therapy initiation, continue omeprazole 20 mg once daily for additional 18 days 3

Important caveat: Repeat testing to confirm eradication is not recommended in primary care dyspepsia patients, as most will have functional dyspepsia and may not achieve complete symptom resolution despite successful eradication. 1

Empirical Acid Suppression Therapy

For H. pylori-negative patients or those with persistent symptoms after eradication, initiate proton pump inhibitor therapy. 1, 2

Specific dosing regimen: 3

• Omeprazole 20 mg once daily taken before meals for 4-8 weeks
• For symptomatic GERD (if heartburn/regurgitation predominate): up to 4 weeks initially 3
• Antacids may be used concomitantly 3

This approach is rational because approximately 20% of dyspepsia patients have peptic ulcer or erosive oesophagitis, conditions for which PPIs are highly efficacious. 1 Additionally, PPIs demonstrate efficacy in functional dyspepsia itself. 1

The 2022 British Society of Gastroenterology guidelines demonstrate that empirical PPI therapy is effective, though test-and-treat ranks slightly higher in network meta-analysis. 1 The choice between these strategies depends on local H. pylori prevalence, with test-and-treat remaining cost-effective above 20% prevalence. 1

Symptom-Based Treatment Considerations

For patients with predominant fullness, bloating, or early satiety (dysmotility-like symptoms), prokinetic agents represent an alternative first-line option. 1 However, metoclopramide carries risk of extrapyramidal side effects and requires careful patient counseling. 4

Documentation of the patient's most bothersome symptom may guide treatment selection: 1

• Epigastric pain/burning: PPI therapy preferred 1, 2
• Postprandial fullness/early satiety: Consider prokinetic agents 1
• Nausea/vomiting: Antiemetic agents (prochlorperazine 5-10 mg or ondansetron 8 mg) can be added as needed 4

Management Algorithm for Treatment Failures

If symptoms are controlled after initial therapy, attempt withdrawal with therapy repeated only if symptoms recur. 1 On-demand therapy with the successful agent represents an alternative maintenance approach. 1

If initial therapy fails: 1

1. Switch treatment class (e.g., from prokinetic to PPI or vice versa) 1
2. Consider high-dose PPI therapy (omeprazole 40 mg once daily) for 4-8 weeks 1, 3
3. If symptoms persist after treatment switching, refer for endoscopy if not already performed 1, 2

For resistant functional dyspepsia after endoscopy confirms no structural disease: 1

• Re-evaluate the diagnosis to exclude misclassified GERD or other conditions 1
• Provide additional reassurance 1
• Consider behavioral therapy, psychotherapy, or low-dose tricyclic antidepressants 1, 4
• Refer to gastroenterology for specialized management 2

Critical Pitfalls to Avoid

Do not subgroup patients with uninvestigated dyspepsia by symptom clusters (ulcer-like, reflux-like, dysmotility-like) to predict underlying structural disease, as this has proven to be of little value due to significant symptom overlap. 1 However, symptom subgrouping may predict response to PPI therapy in patients with confirmed functional dyspepsia. 1

Do not perform endoscopy while patients are taking antisecretory therapy—wait minimum one month after stopping these medications. 1 Endoscopy should be conducted when symptoms are present. 1

Do not dismiss vomiting as benign functional dyspepsia without proper evaluation, as recurrent vomiting constitutes an alarm symptom requiring endoscopic investigation. 1, 2

Avoid extensive diagnostic testing in young patients without alarm symptoms, as this is not cost-effective compared to empirical management strategies. 1, 5