Functional Dyspepsia

Background

• Functional dyspepsia (FD) is characterized by persistent or recurrent epigastric pain and/or early or uncomfortable postprandial fullness without obvious structural or motility abnormality of the gastrointestinal tract.
• Rome IV criteria are the most useful classification system to make the diagnosis.
• FD may be subclassified into 2 syndromes, which often overlap.
  • Epigastric pain syndrome (EPS) characterized by recurrent pain, discomfort, or burning in upper abdominal region.
  • Postprandial distress syndrome (PDS) characterized by feeling of fullness that is uncomfortable or interferes with ingestion of normal-sized meal.

Evaluation

• Guidelines are inconsistent regarding indication of upper endoscopy in patients less than 60 years old with dyspepsia and 1 or more alarm symptoms.
  • Rome IV criteria recommend prompt endoscopy for all patients with dyspepsia and any alarm symptom.
  • American College of Gastroenterology (ACG) and Canadian Association of Gastroenterology (CAG) joint guideline does not recommend offering endoscopy to most patients less than 60 years of age who have only 1 alarm symptom, unless alarm symptom is prominent, such as weight loss of more than 20 lbs (9 kg) or progressive dysphagia (Weak recommendation).
• Consider upper endoscopy if any of the following:
  • age ≥ 60 years (Weak recommendation)
  • ≥ 1 alarm symptoms, including unintentional weight loss, dysphagia, odynophagia, blood in stool or vomit, persistent vomiting, anemia, palpable abdominal mass, or adenopathy
  • family history of upper gastrointestinal malignancy
• Test for Helicobacter pylori infection in patients with dyspepsia.
  • For patients with uninvestigated dyspepsia, offer noninvasive test for H. pylori infection, such as urea breath test or fecal antigen test (Strong recommendation).
  • For patients undergoing endoscopy who have not had previous noninvasive testing for H. pylori infection, collect gastric biopsies at time of endoscopy (Strong recommendation).
• Consider blood tests to assess for anemia, hepatobiliary disease, or celiac disease, depending on the clinical presentation.

Management

• Offer Helicobacter pylori eradication therapy to all patients who test positive for H. pylori infection (Strong recommendation).
• For patients who tested negative for H. pylori infection or who remain symptomatic despite eradication therapy, offer proton pump inhibitor (PPI) (Strong recommendation).
• For patients who do not respond to PPIs or H. pylori eradication therapy, consider tricyclic antidepressants (Weak recommendation).
• For patients who do not respond to PPI, H. pylori eradication therapy, or tricyclic antidepressants, consider prokinetic agent (Weak recommendation).
• Consider other therapies with some evidence for improving symptoms, including:
  • psychological therapies (Weak recommendation)
  • herbal combinations that include ginger and artichoke leaf extracts
  • acupuncture
• Although evidence on efficacy of dietary interventions for functional dyspepsia is limited, consider suggesting the following:
  • avoiding foods that precipitate symptoms, such as alcohol, caffeine, or high-fat foods
  • eating a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs)
  • eating probiotic yogurt