What is the initial treatment approach for a patient with dyspepsia (functional dyspepsia) without underlying anxiety or depression?

Treatment of Dyspepsia Without Anxiety or Depression

The initial treatment approach for functional dyspepsia without anxiety or depression should be H. pylori "test and treat" using non-invasive testing (urea breath test or stool antigen test), followed by empirical proton pump inhibitor therapy if H. pylori is negative or symptoms persist after eradication. 1, 2

First-Line Management Algorithm

Step 1: H. pylori Testing and Eradication

• All patients with dyspepsia should undergo non-invasive H. pylori testing as the initial intervention, regardless of symptom subtype 1, 2, 3
• Use 13C urea breath test or stool antigen test; avoid serology due to lower specificity 1
• If positive, provide eradication therapy immediately, as this cures underlying peptic ulcer disease (present in ~20% of dyspepsia patients) and prevents future gastroduodenal complications 1
• Do not perform repeat testing after eradication in primary care functional dyspepsia, as most patients will not achieve symptom resolution from H. pylori treatment alone 1

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

• Initiate full-dose PPI therapy (e.g., omeprazole 20 mg once daily) for 4-8 weeks, particularly effective for epigastric pain syndrome subtype 1, 2, 3
• PPIs are superior to H2-receptor antagonists, antacids, and placebo for symptom relief in dyspepsia 1
• Use the lowest effective dose that controls symptoms to minimize long-term side effects 2

Step 3: Symptom-Based Tailoring

• For predominant epigastric pain or burning: Continue PPI as first-line therapy 1, 2, 3
• For predominant postprandial fullness, bloating, or early satiety: Consider switching to a prokinetic agent (where available) as these symptoms suggest dysmotility 2, 4

Non-Pharmacological Interventions

• Recommend regular aerobic exercise for all patients with functional dyspepsia 2, 3
• Advise avoiding specific foods that trigger symptoms, but caution against overly restrictive diets that may lead to malnutrition 2, 4
• Establish an empathic doctor-patient relationship and explain that functional dyspepsia is a disorder of gut-brain interaction, not a psychological condition 2, 4

Second-Line Treatment (if initial therapy fails)

• Trial high-dose PPI therapy if standard dosing was ineffective 1, 4
• Consider low-dose tricyclic antidepressants (e.g., amitriptyline 10 mg at bedtime, titrated to 30-50 mg daily) as the most effective second-line therapy, particularly for epigastric pain syndrome 2, 5
• Combination therapy (TCA + PPI) may be considered for augmentation effects in refractory cases 2

When to Refer or Escalate

• Urgent endoscopy is warranted for patients ≥55 years with weight loss, or those >40 years from high gastric cancer risk areas or with family history of gastro-esophageal cancer 2, 3, 4
• Non-urgent endoscopy should be considered for patients ≥55 years with treatment-resistant dyspepsia or with raised platelet count, nausea, or vomiting 3, 4
• Refer to gastroenterology when there is diagnostic doubt, severe symptoms, or treatment refractoriness 3, 4
• Severe refractory cases require multidisciplinary management including primary care physicians, dietitians, gastroenterologists, and psychologists 2, 4

Critical Pitfalls to Avoid

• Never prescribe opioids for functional dyspepsia, as they cause iatrogenic harm without benefit 2, 4
• Avoid empirical H. pylori eradication without prior testing, as this leads to overtreatment 3
• Do not routinely order gastric emptying studies or 24-hour pH monitoring in typical functional dyspepsia, as diagnostic yield is low 4
• Avoid cisapride due to fatal cardiac arrhythmias and QT prolongation 2
• Be cautious with overly restrictive diets that may lead to malnutrition or eating disorders 2, 4

Important Context

The "test and treat" strategy ranks first among all management approaches in network meta-analysis, reducing the relative risk of remaining symptomatic at 12 months and significantly decreasing endoscopy requirements compared to other strategies 1. However, physicians must recognize that H. pylori eradication provides symptom relief in only a minority of functional dyspepsia patients within one year, though it eliminates peptic ulcer mortality risk and prevents future gastroduodenal disease 1. The empirical therapies described (PPIs, prokinetics, TCAs) form the mainstay of treatment for H. pylori-negative patients or those with persistent symptoms after eradication 1.