Functional Dyspepsia

Functional dyspepsia is a chronic disorder of gastroduodenal symptoms (epigastric pain, burning, postprandial fullness, early satiety) without structural or metabolic explanation on investigation.

• Prevalence 10 to 20% of the population.
• Rome IV subtypes: postprandial distress syndrome (meal induced fullness and early satiety) and epigastric pain syndrome (pain or burning unrelated to meals), which commonly overlap.
• Pathophysiology: impaired gastric accommodation, delayed emptying, visceral hypersensitivity, duodenal eosinophilia and low grade inflammation, post infectious dysfunction, Helicobacter pylori, psychological factors, dysbiosis.
• Associations: irritable bowel syndrome, gastro oesophageal reflux disease, anxiety, depression.
• Chronic relapsing course with no increase in mortality.

• Epigastric pain or burning, postprandial fullness, early satiety, bloating, belching, nausea.
• Symptoms for at least 3 months with onset 6 months earlier.
• Normal physical examination aside from mild epigastric tenderness.
• Alarm features requiring endoscopy: age over 55 with new symptoms (or over 40 in regions with high gastric cancer risk), dysphagia, odynophagia, persistent vomiting, weight loss, anaemia, GI bleeding, family history of upper GI cancer, mass.

• Clinical diagnosis using Rome IV criteria.
• Test for Helicobacter pylori (urea breath test or stool antigen, off PPI for 2 weeks and antibiotics for 4 weeks).
• Upper endoscopy for patients over 55 years or with alarm features; biopsies for H. pylori.
• Exclude gastro oesophageal reflux, peptic ulcer, gastroparesis (scintigraphy when vomiting predominates), pancreatic and biliary disease (ultrasound, lipase), coeliac disease, medication effects (NSAIDs, iron, metformin).
• Full blood count, glucose, liver tests, TSH.

• Explain the benign nature and avoid trigger foods; small meals; reduce NSAIDs, alcohol, caffeine, smoking.
• Test and treat H. pylori: clarithromycin triple therapy or bismuth quadruple therapy (omeprazole 20 mg twice daily, bismuth subsalicylate 262 mg four times daily, metronidazole 500 mg three times daily, tetracycline 500 mg four times daily for 14 days). About 10% achieve lasting benefit.
• Acid suppression for epigastric pain syndrome: omeprazole 20 mg or esomeprazole 20 to 40 mg daily for 4 to 8 weeks, then step down to on demand.
• Prokinetics for postprandial distress: acotiamide 100 mg three times daily before meals, itopride 50 mg three times daily, metoclopramide 5 to 10 mg before meals short term, domperidone 10 mg three times daily.
• Neuromodulators: amitriptyline 10 to 50 mg at night (first line for epigastric pain), mirtazapine 15 mg at night (weight loss, early satiety), buspirone 10 mg three times daily (improves accommodation).
• Herbal preparations (peppermint, caraway, iberogast) and cognitive behavioural therapy, hypnotherapy.
• Review every 3 months. Repeat endoscopy only for new alarm features.