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Dyspepsia, Functional

- Document weight status and vital signs. - Examine for signs of systemic illness. - Murphy sign for cholelithiasis - Rebound and guarding for ulcer perforation - Palpation during muscle contraction for abdominal wall pain - Jaundice - Thyromegaly

para>Be alert for family system dysfunction.

Pregnancy Considerations

Pregnancy may exacerbate symptoms.

Geriatric Considerations

Patients >50 years with new-onset dyspepsia should have an upper endoscopy.

RISK FACTORS

  • Other functional disorders
  • Anxiety/depression psychosocial factors: divorce, unemployment
  • Smoking

GENERAL PREVENTION

Avoid foods and habits known to exacerbate symptoms.

COMMONLY ASSOCIATED CONDITIONS

Other functional bowel disorders

DIAGNOSIS

HISTORY

  • Post-prandial fullness (1)[B]
  • Early satiety (1)[B]
  • Epigastric pain (1)[B]
  • Epigastric burning (1)[B]
  • Symptoms for 3 months (1)[C]
  • Warning signs that necessitate endoscopy include (2,3)[C]:Unintended weight lossProgressive dysphagiaPersistent vomitingGI bleedingFamily history of cancerAge >55 years

PHYSICAL EXAM

  • Document weight status and vital signs.
  • Examine for signs of systemic illness.Murphy sign for cholelithiasisRebound and guarding for ulcer perforationPalpation during muscle contraction for abdominal wall painJaundiceThyromegaly

DIFFERENTIAL DIAGNOSIS

  • Peptic ulcer disease; gastroesophageal reflux disease
  • Cholecystitis
  • Gastric or esophageal cancer; esophageal spasm
  • Malabsorption syndromes; celiac disease
  • Pancreatic cancer; pancreatitis
  • Inflammatory bowel disease; carbohydrate malabsorption; gastroparesis
  • Ischemic bowel disease
  • Intestinal parasites
  • Irritable bowel syndrome
  • Ischemic heart disease
  • Diabetes mellitus; thyroid disease
  • Connective tissue disorders
  • Conversion disorder
  • Medication effects

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)

  • Functional dyspepsia is a diagnosis of exclusion. Order labs are based on clinical suspicion (3)[C].
  • CBC (if anemia or infection are suspected)
  • LFT (if hepatobiliary disease is suspected
  • Test for H. pylori (stool antigen or urea breath test) in areas of high H. pylori prevalence. (3,4)[A]
  • Upper endoscopy for patients >55 years or those with alarm symptoms (weight loss, signs of blood loss, dysphagia, concern for cancer) (3)[C]
  • Perform upper endoscopy if patient does not respond to gastric acid suppression trial. (3)[C].
  • A self-report questionnaire can help assess and track symptoms. (3)[C].

Diagnostic Procedures/Other

Esophageal manometry or gastric accommodation studies are rarely needed. (3)[C].

Test Interpretation

None (by definition this a functional disorder)

TREATMENT

GENERAL MEASURES

  • Few effective treatment options are available (5).
  • Reassurance and physician support are helpful (3)[C].
  • Treatment is based on presumed etiologies.
  • Discontinue offending medications (3)[C].

MEDICATION

First Line

  • Treat H. pylori if confirmed on testing. (3,4)[A]
  • Trial of once daily proton pump inhibitor (PPI) medication (e.g., omeprazole 20 mg PO QD) or H2RA (e.g., ranitidine 150 mg BID) for up to 8 weeks in patients without alarm symptoms (3,5)[A]

Second Line

  • Trial of low dose tricyclic antidepressant (TCA) medication is helpful in epigastric pain syndrome but not postprandial distress syndrome (amitriptyline 10 mg at bedtime); consider doubling dose after a few days. (2,5)[A],(6)[B] Caution in elderly.
  • Trazodone 25 mg at bedtime is an alternative (2,5)[A]. Consider a 1-month trial of prokinetic medication (metoclopramide) or buspirone if no response to TCA (2,5)[B]. Caution with metoclopramide in elderly due to side effects of tardive dyskinesia and parkinsonian symptoms.

ADDITIONAL THERAPIES

  • Stress reduction (2,5)[A]Relaxation techniquesPhysical exerciseReflux precautions where applicable
  • Psychotherapy effective in some patients (2)[A],(3)[B]

COMPLEMENTARY & ALTERNATIVE MEDICINE

Alternative approaches need further study.

  • Peppermint oil +/- caraway oil
  • Probiotics have theoretical benefit but few controlled trials (5)[B].
  • Hypnotherapy may help (3)[B].
  • Transcutaneous electroacupuncture may help (3)[B].

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Patient Monitoring

  • Provide ongoing support and reassurance.
  • Upper endoscopy if persistent symptoms
  • Change medications if no change after 4 weeks (3)[C].
  • Discontinue drug therapy after symptom resolution (3)[C].

DIET

  • Limited data to support dietary modification
  • Consider limiting fatty foods (2,5)[C].
  • Avoid foods that exacerbate symptoms: wheat and cow milk proteins, peppers or spices, coffee, tea, and alcohol (2,5)[C].

PATIENT EDUCATION

Reassurance and stress reduction techniques

PROGNOSIS

Long-term/chronic symptoms with symptom-free periods

COMPLICATIONS

Iatrogenic, from evaluation to rule out serious pathology

REFERENCES

11 Tack J, Talley NJ. Functional dyspepsia-symptoms, definitions and validity of the Rome III criteria. Nat Rev Gastroenterol Hepatol. 2013;10(3):134-141.22 Vanheel H, Tack J. Therapeutic options for functional dyspepsia. Dig Dis. 2014;32(3):230-234. doi:10.1159/000358111.33 Miwa H, Kusano M, Arisawa T, et al. Evidence-based clinical practice guidelines for functional dyspepsia. J Gastroenterol. 2015;50(2):125-139. doi:10.1007/s00535-104-1022-3.44 Zhao B, Zhao J, Cheng WF, et al. Efficacy of Helicobacter pylori eradication therapy on functional dyspepsia: a meta-analysis of randomized controlled studies with 12-month follow-up. J Clin Gastroenterol. 2014;48(3):241-247.55 Stein B, Everhart KK, Lacy BE. Treatment of functional dyspepsia and gastroparesis. Curr Treat Options Gastroenterol. 2014;12(4):385-397. doi:10.1007/s11938-014-0028-5.66 Talley NJ, Locke GR, Saito Y, et al. Effect of amitriptyline and escitalopram on functional dyspepsia: a multicenter, randomized controlled study. Gastroenterology. 2015;149(2):340.e2-349.e2. doi:10.1053/j.gastro.2015.04.020.

ADDITIONAL READING

  • Amini M, Ghamar Chehreh ME, Khedmat H, et al. Famotidine in the treatment of functional dyspepsia: a randomized double-blind, placebo-controlled trial. J Egypt Public Health Assoc. 2012;87(1-2):29-33.
  • Ford AC, Moayyedi P. Dyspepsia. Curr Opin Gastroenterol. 2013;29(6):662-668. doi:10.1097/MOG.0b013e328365d45d.
  • Ganesh M, Nurko S. Functional dyspepsia in children. Pediatr Ann. 2014;43(4):e101-e105. doi:10.3928/00904481-20140325-12.
  • Graham D, Rugge M. Clinical practice: diagnosis and evaluation of dyspepsia. J Clin Gastroenterol. 2010;44(3):167-172.
  • Kaminski A, Kamper A, Thaler K, et al. Antidepressants for the treatment of abdominal pain-related functional gastrointestinal disorders in children and adolescents. Cochrane Database Syst Rev. 2011;(7):CD008013.
  • Lacy BE, Talley NJ, Locke GRIII, et al. Review article: current treatment options and management of functional dyspepsia. Aliment Pharmacol Ther. 2012;36(1):3-15.
  • Lan L, Zeng F, Liu GJ, et al. Acupuncture for functional dyspepsia. Cochrane Database Syst Rev. 2014;10:CD008487.
  • Loyd RA, McClellan DA. Update on the evaluation and management of functional dyspepsia. Am Fam Physician. 2011;83(5):547-552.
  • Oustamanolakis P, Tack J. Dyspepsia: organic versus functional. J Clin Gastroenterol. 2012;46(3):175-190.
  • Overland MK. Dyspepsia. Med Clin North Am. 2014;98(3):549-564.
  • Tack J, Masaoka T, Janssen P, et al. Functional dyspepsia. Curr Opin Gastroenterol. 2011;27(6):549-557.

SEE ALSO

  • Irritable Bowel Syndrome
  • Algorithms: Dyspepsia

CODES

ICD10

K30 Functional dyspepsia

ICD9

536.8 Dyspepsia and other specified disorders of function of stomach

SNOMED

3696007 Nonulcer dyspepsia (disorder)

CLINICAL PEARLS

  • Dyspepsia without underlying organic disease is termed functional or idiopathic.
  • Consider empiric treatment with acid suppression as first-line therapy for functional dyspepsia.
  • Extensive diagnostic testing is not recommended unless alarm symptoms are present.