Functional Dyspepsia: Evaluation and Management
Am Fam Physician. 2020 Jan 15;101(2):84-88.
Patient information: A handout on this topic is available at https://familydoctor.org/condition/indigestion-dyspepsia/.
Author disclosure: No relevant financial affiliations.
Functional dyspepsia is defined as at least one month of epigastric discomfort without evidence of organic disease found during an upper endoscopy, and it accounts for 70% of dyspepsia. Symptoms of functional dyspepsia include postprandial fullness, early satiety, and epigastric pain or burning. Functional dyspepsia is a diagnosis of exclusion; therefore, evaluation for a more serious disease such as an upper gastrointestinal malignancy is warranted. Individual alarm symptoms do not correlate with malignancy for patients younger than 60 years, and endoscopy is not necessarily warranted but should be considered for patients with severe or multiple alarm symptoms. For patients younger than 60 years, a test and treat strategy for Helicobacter pylori is recommended before acid suppression therapy. For patients 60 years or older, upper endoscopy should be performed. All patients should be advised to limit foods associated with increased symptoms of dyspepsia; a diet low in FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) is suggested. Eight weeks of acid suppression therapy is recommended for patients who test negative for H. pylori, or who continue to have symptoms after H. pylori eradication. If acid suppression does not alleviate symptoms, patients should be treated with tricyclic antidepressants followed by prokinetics and psychological therapy. The routine use of complementary and alternative medicine therapies has not shown evidence of effectiveness and is not recommended.
Dyspepsia affects up to 30% of the general population in the United States, Canada, and the United Kingdom, with 70% of these patients having functional dyspepsia.1 The American College of Gastroenterology (ACG) and the Canadian Association of Gastroenterology (CAG) broadly define functional dyspepsia as at least one month of epigastric discomfort without evidence of organic disease on endoscopy.2 The more detailed Rome IV diagnostic criteria define functional dyspepsia as one to three days per week of symptoms of postprandial fullness, early satiety, epigastric pain, or epigastric burning without evidence of structural disease (Table 1).3 A calculator using the Rome IV criteria is available to aid with diagnosis at https://www.mdcalc.com/rome-iv-diagnostic-criteria-dyspepsia. Historically, Rome criteria have been used primarily for research, but the update to Rome IV attempts to increase its usefulness in clinical practice.4 The superseded Rome III criteria specifically excluded patients with heartburn and gastroesophageal reflux disease, but the definition of functional dyspepsia has now been broadened to include these patients. A cross-sectional study using the Rome IV criteria estimated the prevalence of functional dyspepsia to be 12% in the United States and was the most common cause of dyspepsia.1
WHAT'S NEW ON THIS TOPIC
A cross-sectional study using the Rome IV diagnostic criteria for functional dyspepsia estimated the prevalence to be 12% in the United States, making it the most common cause of dyspepsia.
A systematic review of 15 observational studies and one randomized controlled trial found that foods high in fat, wheat, FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols), and naturally occurring food chemicals, such as caffeine, were associated with symptoms of functional dyspepsia.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
|Clinical recommendation||Evidence rating||Comments|
Expert opinion based on the low prevalence of malignancy in younger patients and economic modeling
Systematic review of seven retrospective cohort studies showing a positive predictive value of less than 1% for malignancy
Consistent evidence from high-quality meta-analysis of 25 RCTs and one high-quality RCT
Meta-analysis of seven high-quality RCTs
RCT = randomized controlled trial.
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
|Clinical recommendation||Evidence rating||Comments|
Expert opinion based on the low prevalence of malignancy in younger
Referencesshow all references
1. Aziz I, Palsson OS, Törnblom H, et al. Epidemiology, clinical characteristics, and associations for symptom-based Rome IV functional dyspepsia in adults in the USA, Canada, and the UK: a cross-sectional population-based study. Lancet Gastroenterol Hepatol. 2018;3(4):252–262....
2. Moayyedi P, Lacy BE, Andrews CN, et al. ACG and CAG clinical guideline: management of dyspepsia. Am J Gastroenterol. 2017;112(7):988–1013.
3. Stanghellini V, Chan FK, Hasler WL, et al. Gastroduodenal disorders. Gastroenterology. 2016;150(6):1380–1392.
4. Drossman DA. Functional gastrointestinal disorders: history, pathophysiology, clinical features and Rome IV. Gastroenterology. 2016;150(6):1262–1279.
5. Rahman MM, Ghoshal UC, Sultana S, et al. Long-term gastrointestinal consequences are frequent following sporadic acute infectious diarrhea in a tropical country: a prospective cohort study. Am J Gastroenterol. 2018;113(9):1363–1375.
6. Sha W, Pasricha PJ, Chen JD. Correlations among electrogastrogram, gastric dysmotility, and duodenal dysmotility in patients with functional dyspepsia. J Clin Gastroenterol. 2009;43(8):716–722.
7. B Biomed GB, Carroll G, Mathe A, et al. Evidence for local and systemic immune activation in functional dyspepsia and the irritable bowel syndrome: a systematic review. Am J Gastroenterol. 2019;114(3):429–436.
8. Du L, Chen B, Kim JJ, et al. Micro-inflammation in functional dyspepsia: a systematic review and meta-analysis. Neurogastroenterol Motil. 2018;30(4):e13304.
9. Henningsen P, Zimmermann T, Sattel H. Medically unexplained physical symptoms, anxiety, and depression: a meta-analytic review. Psychosom Med. 2003;65(4):528–533.
10. Kaji M, Fujiwara Y, Shiba M, et al. Prevalence of overlaps between GERD, FD and IBS and impact on health-related quality of life. J Gastroenterol Hepatol. 2010;25(6):1151–1156.
11. Loyd RA, McClellan DA. Update on the evaluation and management of functional dyspepsia. Am Fam Physician. 2011;83(5):547–552. https://www.aafp.org/afp/2011/0301/p547.html
12. Moayyedi P, Talley NJ, Fennerty MB, et al. Can the clinical history distinguish between organic and functional dyspepsia? JAMA. 2006;295(13):1566–1576.
13. Vakil N, Moayyedi P, Fennerty MB, et al. Limited value of alarm features in the diagnosis of upper gastrointestinal malignancy: systematic review and meta-analysis. Gastroenterology. 2006;131(2):390–401.
14. Delaney B, Ford AC, Forman D, et al. Initial management strategies for dyspepsia. Cochrane Database Syst Rev. 2005;(4):CD001961.
15. van Kerkhoven LA, van Rossum LG, van Oijen MG, et al. Upper gastrointestinal endoscopy does not reassure patients with functional dyspepsia. Endoscopy. 2006;38(9):879–885.
16. Duncanson KR, Talley NJ, Walker MM, et al. Food and functional dyspepsia: a systematic review. J Hum Nutr Diet. 2018;31(3):390–407.
17. Du LJ, Chen BR, Kim JJ, et al. Helicobacter pylori eradication therapy for functional dyspepsia: systematic review and meta-analysis. World J Gastroenterol. 2016;22(12):3486–3495.
18. Mazzoleni LE, Sander GB, Francesconi CF, et al. Helicobacter pylori eradication in functional dyspepsia: HEROES trial. Arch Intern Med. 2011;171(21):1929–1936.
19. Malfertheiner P, Megraud F, O’Morain CA; European Helicobacter and Microbiota Study Group and Consensus panel. Management of Helicobacter pylori infection-the Maastricht V/Florence consensus report. Gut. 2017;66(1):6–30.
20. Wang WH, Huang JQ, Zheng GF, et al. Effects of proton-pump inhibitors on functional dyspepsia: a meta-analysis of randomized placebo-controlled trials. Clin Gastroenterol Hepatol. 2007;5(2):178–185.
21. Talley NJ, Vakil NB, Moayyedi P. American Gastroenterological Association technical review on the evaluation of dyspepsia. Gastroenterology. 2005;129(5):1756–1780.
22. Kia L, Kahrilas PJ. Therapy: risks associated with chronic PPI use - signal or noise? Nat Rev Gastroenterol Hepatol. 2016;13(5):253–254.
23. Moayyedi P, Soo S, Deeks J, et al. Pharmacological interventions for non-ulcer dyspepsia. Cochrane Database Syst Rev. 2006;(4):CD001960.
24. Ford AC, Luthra P, Tack J, et al. Efficacy of psychotropic drugs in functional dyspepsia: systematic review and meta-analysis. Gut. 2017;66(3):411–420.
25. Tack J, Janssen P, Masaoka T, et al. Efficacy of buspirone, a fundus-relaxing drug, in patients with functional dyspepsia. Clin Gastroenterol Hepatol. 2012;10(11):1239–1245.
26. Pittayanon R, Yuan Y, Bollegala NP, et al. Prokinetics for functional dyspepsia: a systematic review and meta-analysis of randomized control trials. Am J Gastroenterol. 2019;114(2):233–243.
27. von Arnim U, Peitz U, Vinson B, et al. STW 5, a phytopharmacon for patients with functional dyspepsia: results of a multicenter, placebo-controlled double-blind study. Am J Gastroenterol. 2007;102(6):1268–1275.
28. Lan L, Zeng F, Liu GJ, et al. Acupuncture for functional dyspepsia. Cochrane Database Syst Rev. 2014;(10):CD008487.
29. Wang C, Zhu M, Xia W, et al. Meta-analysis of traditional Chinese medicine in treating functional dyspepsia of liver-stomach disharmony syndrome. J Tradit Chin Med. 2012;32(4):515–522.
30. Dickerson LM, King DE. Evaluation and management of nonulcer dyspepsia. Am Fam Physician. 2004;70(1):107–114. https://www.aafp.org/afp/2004/0701/p107.html
Copyright © 2020 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact firstname.lastname@example.org for copyright questions and/or permission requests.
Want to use this article elsewhere? Get Permissions