What is the recommended work‑up and treatment for an adult presenting with dyspepsia?

Management of Adult Dyspepsia

Initial Risk Stratification and Urgent Referral

Patients ≥55 years with new-onset dyspepsia and weight loss, or those >40 years from high gastric cancer risk areas or with family history of gastro-oesophageal malignancy, require urgent endoscopy within 2 weeks. 1

• Consider urgent abdominal CT scanning in patients ≥60 years presenting with abdominal pain and weight loss to exclude pancreatic cancer 1
• Non-urgent endoscopy should be considered for patients ≥55 years with treatment-resistant dyspepsia or dyspepsia accompanied by raised platelet count, nausea, or vomiting 1
• Alarm features in younger patients (<55 years) should be evaluated case-by-case rather than automatically triggering endoscopy 2

Baseline Investigations

Perform the following before initiating treatment:

• Full blood count in all patients ≥55 years 1
• Coeliac serology in patients with overlapping IBS-type symptoms 1
• Non-invasive H. pylori testing (13C urea breath test or stool antigen test preferred over serology) 1, 3

First-Line Treatment Algorithm

For Patients <55 Years Without Alarm Features:

All patients must undergo non-invasive H. pylori testing as the initial step, with eradication therapy if positive, followed by empirical PPI therapy if negative or symptoms persist. 1, 3

1. Test for H. pylori using breath or stool antigen test 1, 3

   • If positive: Provide eradication therapy (standard triple therapy: PPI + clarithromycin + amoxicillin or metronidazole for 7 days) 4
   • Do not routinely confirm eradication in primary care functional dyspepsia 3

2. If H. pylori negative or symptoms persist after eradication:

   • Initiate full-dose PPI therapy (e.g., omeprazole 20 mg once daily) for 4-8 weeks 1, 3
   • PPIs are superior to H2-receptor antagonists, antacids, and placebo for symptom relief 3, 5
   • Use the lowest effective dose for maintenance 3

For Patients ≥55 Years:

Proceed directly to endoscopy before empirical therapy to exclude malignancy and other organic pathology. 1

• Test for H. pylori at endoscopy with biopsy specimens 1
• Offer eradication therapy if positive to reduce risk of peptic ulcer disease and gastric malignancy 1
• After negative endoscopy (functional dyspepsia confirmed), follow the same treatment algorithm as younger patients 1

Second-Line Treatment for Refractory Symptoms

Low-dose tricyclic antidepressants are the most effective second-line therapy, particularly for epigastric pain syndrome. 3, 2

• Start amitriptyline 10 mg once nightly at bedtime 3
• Titrate slowly to 30-50 mg daily based on response and tolerability 3
• Counsel patients that TCAs work through gut-brain neuromodulation, not as antidepressants 3

Alternative Second-Line Options:

• Prokinetic agents for postprandial distress syndrome (predominant bloating, fullness, early satiety) 3, 5
• Antipsychotic agents (sulpiride 100 mg four times daily or levosulpiride 25 mg three times daily) with careful counseling about side effects 3
• Avoid cisapride due to fatal cardiac arrhythmias and QT prolongation 3, 5

Symptom Subtype-Specific Approach

Epigastric Pain Syndrome (EPS):

• First-line: PPI therapy 3
• Second-line: Low-dose TCA 3

Postprandial Distress Syndrome (PDS):

• First-line: Prokinetic agent 3, 5
• If prokinetic fails, switch to full-dose PPI (patients may have been misclassified) 3
• Second-line: Low-dose TCA if prokinetic and PPI both fail 3

Lifestyle and Dietary Modifications

• Recommend regular aerobic exercise for all patients 3
• Advise avoiding specific foods that trigger symptoms, but do not prescribe overly restrictive diets that risk malnutrition or eating disorders 3
• Early dietitian referral is recommended for refractory cases 3
• There is insufficient evidence to recommend specialized diets, including low FODMAP diets 3

Management of Refractory or Severe Cases

Refer to gastroenterology when there is diagnostic doubt, symptoms are severe or refractory to first-line treatments, or the patient requests specialist opinion. 1, 3

• Multidisciplinary management including primary care physicians, dietitians, gastroenterologists, and psychologists is mandatory for severe cases 3
• Screen patients with severe symptoms, weight loss, and food restriction for eating disorders, including avoidant restrictive food intake disorder (ARFID) 3
• Consider combination therapies (e.g., TCA + PPI) for augmentation effects 3

Critical Safety Warnings

Never prescribe opioids or recommend surgery for functional dyspepsia—these cause iatrogenic harm without benefit. 3

• Discontinue NSAIDs if possible, or switch to COX-2 selective agents 1
• If NSAIDs must be continued, consider prophylactic PPI therapy, especially in patients >60 years or with previous peptic ulcer disease 1
• Avoid combining prokinetic agents with medications that prolong QT interval 3

Investigations NOT Routinely Recommended

• Gastric emptying testing or 24-hour pH monitoring should not be performed routinely in patients with typical functional dyspepsia symptoms 1, 3
• Upper gastrointestinal radiography is inferior to endoscopy and should not be used 1

Doctor-Patient Communication

Establish an empathic relationship and explain that functional dyspepsia is a disorder of gut-brain interaction, not a psychological condition or "all in their head." 1, 3

• Discuss the underlying pathophysiology, natural history, and common symptom triggers 1
• This approach reduces healthcare utilization and improves quality of life 1
• Set realistic expectations: functional dyspepsia is typically chronic with fluctuating symptoms 6