How should functional dyspepsia be initially evaluated and managed, including Helicobacter pylori testing, lifestyle modifications, acid suppression, prokinetics, and criteria for endoscopic investigation?

Functional Dyspepsia: Initial Evaluation and Management

Diagnostic Approach Based on Age and Alarm Features

In patients under 55 years without alarm symptoms, perform non-invasive H. pylori testing ("test and treat") rather than endoscopy, followed by empirical acid suppression if H. pylori is negative or symptoms persist after eradication. 1

Age-Based Endoscopy Thresholds

• Urgent endoscopy is warranted for:

  • Patients ≥55 years with dyspepsia and weight loss 1
  • Patients >40 years from high gastric cancer risk areas or with family history of gastro-oesophageal cancer 1

• Non-urgent endoscopy should be considered for:

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

• Urgent abdominal CT scanning:

  • Patients ≥60 years with abdominal pain and weight loss to exclude pancreatic cancer 1

Initial Laboratory Testing

• Perform full blood count in patients ≥55 years with dyspepsia 1
• Order coeliac serology in all patients with overlapping IBS-type symptoms 1

H. Pylori Testing and Treatment

Testing Strategy

All patients under 55 years without alarm features should receive non-invasive H. pylori testing using either 13C-urea breath test or stool antigen test (avoid IgG/IgM serology due to lower specificity). 2

• The test-and-treat approach is equally effective as prompt endoscopy and reduces endoscopy workload by approximately 62% 2
• This strategy is most cost-effective in populations with H. pylori prevalence >10% 1, 3

Eradication Therapy

• If H. pylori positive: Provide eradication therapy (triple therapy: amoxicillin, clarithromycin, and PPI for 14 days) 2
• Eradication provides modest but significant long-term symptom improvement and reduces risk of peptic ulcer disease, atrophic gastritis, and gastric cancer 2

Post-Eradication Confirmation

• Only confirm successful eradication in patients with increased gastric cancer risk (not routinely in all patients) 1, 2
• Use breath test or stool antigen test for confirmation, not serology 2

Empirical Acid Suppression

For H. pylori-negative patients or those with persistent symptoms after eradication, prescribe empirical PPI therapy for 4-8 weeks. 1

PPI Prescribing Details

• Use the lowest effective dose that controls symptoms (no dose-response relationship demonstrated) 1
• Take 30-60 minutes before meals for optimal effect 4
• PPIs are well-tolerated and have strong evidence for efficacy in functional dyspepsia 1

Alternative Acid Suppression

• H2-receptor antagonists may be efficacious but are less strongly recommended than PPIs 1
• Consider these as second-line options if PPIs are not tolerated 1

Prokinetic Therapy

Prokinetics have variable efficacy and should be considered when meal-related symptoms (early satiation, postprandial fullness) predominate. 1

• Acotiamide, itopride, and mosapride show modest benefit but availability varies by region 1
• Most prokinetics are well-tolerated 1
• Not recommended as first-line therapy for uninvestigated dyspepsia 3

Lifestyle Modifications

All patients with functional dyspepsia should be advised to take regular aerobic exercise. 1

• Insufficient evidence exists to recommend specific dietary therapies, including low-FODMAP diets 1
• Avoid routine recommendations for dietary restrictions without individualized assessment 1

Patient Education and Communication

Establish an empathic doctor-patient relationship and explain functional dyspepsia as a disorder of gut-brain interaction. 1

• Discuss the gut-brain axis and how diet, stress, cognitive, behavioral, and emotional responses impact symptoms 1
• Explain the natural history and common symptom triggers 1
• This approach may reduce healthcare utilization and improve quality of life 1

When to Refer to Gastroenterology

Referral is appropriate when:

• Diagnostic doubt exists 1
• Symptoms are severe or refractory to first-line treatments 1
• Patient requests specialist opinion 1

Testing NOT Recommended

Do not routinely perform gastric emptying testing or 24-hour pH monitoring in patients with typical functional dyspepsia symptoms. 1

Treatment Algorithm Summary

1. Age <55 without alarm features: Non-invasive H. pylori test → eradicate if positive → empirical PPI if negative or symptoms persist 1, 2

2. Age ≥55 or alarm features present: Proceed directly to endoscopy → test for H. pylori during endoscopy → eradicate if positive → targeted treatment based on findings 1

3. Failed initial therapy: Consider changing PPI dose or class, add prokinetic for meal-related symptoms, or refer for specialist evaluation 1

Common Pitfalls to Avoid

• Do not use serological H. pylori testing as the primary diagnostic method (lower specificity than breath or stool tests) 2
• Do not routinely confirm H. pylori eradication in low-risk patients (only in those at increased gastric cancer risk) 1, 2
• Do not perform endoscopy in young patients without alarm features who fail empirical therapy unless clinical judgment strongly suggests organic disease 1
• Alarm symptoms in younger patients have limited predictive value and should be assessed case-by-case rather than automatically triggering endoscopy 5