What is the initial management approach for a patient diagnosed with functional dyspepsia?

Management of Functional Dyspepsia

Initial Management Approach

Begin with establishing an empathic doctor-patient relationship and explain that functional dyspepsia is a disorder of gut-brain interaction, then proceed with H. pylori testing and empirical therapy based on symptom pattern. 1

Step 1: Risk Stratification and Appropriate Investigation

Before initiating treatment, determine if urgent investigation is needed:

Patients Requiring Urgent Endoscopy (2-week wait):

• Age ≥55 years with dyspepsia AND weight loss 1
• Age >40 years from high gastric cancer risk area OR family history of gastro-esophageal malignancy 1, 2

Patients Requiring Non-Urgent Endoscopy:

• Age ≥55 years with treatment-resistant dyspepsia 1, 2
• Age ≥55 years with raised platelet count, nausea, or vomiting 1, 2

Patients Requiring Urgent CT Scan:

• Age ≥60 years with abdominal pain AND weight loss (to exclude pancreatic cancer) 1, 2

Baseline Laboratory Testing:

• Full blood count in all patients aged ≥55 years 1, 2
• Coeliac serology in patients with overlapping IBS-type symptoms 1

Step 2: Patient Education and Therapeutic Relationship

Establishing an effective and empathic doctor-patient relationship is fundamental, as this reduces healthcare utilization and improves quality of life. 1

Key Educational Points:

• Explain FD as a disorder of gut-brain interaction, NOT a psychological problem 3, 2
• Discuss the gut-brain axis and how it is impacted by diet, stress, cognitive, behavioral, and emotional responses 1
• Explain the natural history and common symptom triggers 1
• Reassure that most patients with dyspepsia (approximately 80%) will have functional dyspepsia after investigation 1

Step 3: First-Line Pharmacological Management

Test and Treat for H. pylori:

All patients without alarm features should receive non-invasive H. pylori testing (breath or stool test), and if positive, receive eradication therapy. 1, 3, 2

• H. pylori eradication is an effective treatment and prevents future gastroduodenal disease 3, 2
• Confirmation of successful eradication is only necessary in patients at high risk of gastric cancer 1, 3

Empirical Therapy Based on Symptom Pattern:

For Epigastric Pain or Burning (Ulcer-like Dyspepsia):

Prescribe full-dose proton pump inhibitor (PPI) as first-line therapy. 3, 2

• Omeprazole 20 mg once daily is effective and can confirm the acid-related nature of symptoms 3
• Use the lowest dose that controls symptoms, as there is no evidence of dose response 3

For Postprandial Fullness, Early Satiety, or Bloating:

Prescribe a prokinetic agent such as domperidone or itopride as first-line therapy. 3, 2

Common Pitfall:

Do NOT order routine gastric emptying studies or 24-hour pH monitoring in typical functional dyspepsia, as they have low diagnostic yield and delay appropriate treatment. 2, 4

Step 4: Non-Pharmacological Interventions

Recommend regular aerobic exercise for all patients with functional dyspepsia. 3, 2

Advise patients to avoid foods that trigger symptoms. 3

Involve a dietitian early in patients with severe or refractory FD to prevent excessively restrictive diets. 3

Evaluate patients with severe FD who present with weight loss and dietary restriction for eating disorders. 3

Step 5: Management of Refractory Symptoms

If symptoms persist after initial empirical therapy:

Second-Line Options:

• Trial high-dose PPI therapy if not already attempted 2
• Perform endoscopy if not previously done to confirm diagnosis 2
• Consider low-dose tricyclic antidepressants (TCAs) or selective serotonin reuptake inhibitors (SSRIs) for refractory cases 2, 5, 6

Severe or Refractory FD:

Establish a multidisciplinary support team for patients with severe or refractory FD. 3

Consider behavioral therapy, psychotherapy, or antidepressants after reevaluating the diagnosis and providing reassurance. 3, 7

Critical Pitfall:

AVOID opioids and surgery in patients with severe or refractory FD to minimize iatrogenic harm. 3, 2

Step 6: Referral to Gastroenterology

Refer to gastroenterology when there is diagnostic doubt, severe symptoms, refractoriness to first-line treatments, or patient request for specialist opinion. 1

Remember that approximately 20% of dyspepsia patients will have organic disease, so maintain clinical vigilance. 2, 4, 6