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 loss
- Progressive dysphagia
- Persistent vomiting
- GI bleeding
- Family history of cancer
- Age >55 years
PHYSICAL EXAM
- 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
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 techniques
- Physical exercise
- Reflux 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.