What is the management approach for a patient with dyspepsia characterized by predominantly bloating?

Management of Dyspepsia with Predominantly Bloating

For dyspepsia with predominantly bloating and fullness (dysmotility-like dyspepsia), a prokinetic agent is the preferred first-line symptomatic therapy after H. pylori testing and eradication if positive. 1, 2

Initial Diagnostic Steps

• Test all patients for H. pylori using non-invasive methods and provide eradication therapy if positive, regardless of predominant symptom pattern 3, 2
• Perform urgent endoscopy if patient is ≥55 years with weight loss, or >40 years with family history of gastro-oesophageal cancer 3
• Consider non-urgent endoscopy for patients ≥55 years with treatment-resistant symptoms or associated nausea/vomiting 3

Treatment Algorithm for Bloating-Predominant Dyspepsia

First-Line Therapy

• After H. pylori eradication (or if negative), initiate a prokinetic agent as the primary treatment for patients whose predominant symptoms are fullness, bloating, or early satiety 1, 2
• Note that cisapride can no longer be recommended due to cardiac toxicity 1, 2
• Alternative prokinetic options include levosulpiride (25 mg three times daily) or sulpiride (100 mg four times daily), though these should be used cautiously and not combined with medications that prolong the QT interval 2, 4

If Prokinetic Therapy Fails

• Switch to a different treatment class—specifically, trial full-dose PPI therapy (omeprazole 20 mg once daily) for 4-8 weeks, as patients may have been misclassified and could have acid-related symptoms 1, 4
• If symptoms persist after switching from prokinetic to PPI, consider high-dose PPI therapy before proceeding to endoscopy 1

Second-Line Therapy

• Low-dose tricyclic antidepressants (e.g., amitriptyline 10 mg once daily, gradually increasing to 30-50 mg once daily) are effective second-line treatment, particularly for epigastric pain syndrome subtype 2, 4
• This approach is supported when both prokinetic and PPI trials have failed 2

Lifestyle and Non-Pharmacological Management

• Strongly recommend regular aerobic exercise for all patients with functional dyspepsia 3, 2
• Advise avoiding specific foods that trigger symptoms, but avoid overly restrictive diets that could lead to malnutrition or eating disorders 3, 2
• There is insufficient evidence to recommend specialized diets including low-FODMAP for functional dyspepsia 3, 2

Critical Communication Strategy

• Establish an empathic doctor-patient relationship and explain that functional dyspepsia is a disorder of gut-brain interaction affected by diet, stress, and emotional responses—not a psychological condition or "all in their head" 3, 2
• This communication approach reduces healthcare utilization and improves quality of life 3

Management of Refractory Cases

• If symptoms remain severe or refractory after first and second-line therapies, refer to gastroenterology for multidisciplinary management including primary care physicians, dietitians, gastroenterologists, and psychologists 2
• Screen patients with severe symptoms, weight loss, and food restriction for eating disorders including avoidant restrictive food intake disorder (ARFID) 2
• Refer to dietitian early in refractory cases to prevent excessively restrictive diets 2

Common Pitfalls to Avoid

• Do not use PPIs as first-line therapy for bloating-predominant dyspepsia—the symptom pattern suggests dysmotility rather than acid-related pathology, making prokinetics the more appropriate initial choice 1, 2
• Avoid opioids and surgery in patients with severe or refractory functional dyspepsia to minimize iatrogenic harm 2
• Do not continue ineffective therapy indefinitely; if initial treatment fails after 4-8 weeks, switch medication classes 1, 4
• Consider on-demand therapy rather than continuous daily use if symptoms are controlled, to minimize medication exposure 4

Key Distinction from Other Dyspepsia Subtypes

The management differs significantly from ulcer-like dyspepsia (predominant epigastric pain), where full-dose PPI therapy is the first-line symptomatic treatment 1, 4. For bloating-predominant symptoms, the pathophysiology suggests impaired gastric motility and accommodation rather than acid hypersecretion, making prokinetic agents the rational first choice after addressing H. pylori 1, 5, 6.