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

Functional Dyspepsia

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.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Endoscopy should be performed for all patients 60 years and older with at least one month of dyspepsia symptoms.2

C

Expert opinion based on the low prevalence of malignancy in younger patients and economic modeling

For patients younger than 60 years with a single, nonsevere alarm feature, endoscopy should not be the first diagnostic step.2,13

B

Systematic review of seven retrospective cohort studies showing a positive predictive value of less than 1% for malignancy

For patients younger than 60 years, a Helicobacter pylori test and treat strategy before acid suppression is effective.2,14,17,18

A

Consistent evidence from high-quality meta-analysis of 25 RCTs and one high-quality RCT

Proton pump inhibitor therapy is more effective than placebo for symptom relief.2,20

A

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 recommendationEvidence ratingComments

Endoscopy should be performed for all patients 60 years and older with at least one month of dyspepsia symptoms.2

C

Expert opinion based on the low prevalence of malignancy in younger

The Authors

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ANNE MOUNSEY, MD, is a professor in the Department of Family Medicine at the University of North Carolina, Chapel Hill....

AMIR BARZIN, DO, MS, is the director of the Family Medicine Center and an assistant professor in the Department of Family Medicine at the University of North Carolina, Chapel Hill.

ASHLEY RIETZ, MD, is a clinical assistant professor in the Department of Family Medicine at the University of North Carolina, Chapel Hill.

Address correspondence to Anne Mounsey, MD, 590 Manning Dr., Chapel Hill, NC 27514 (email: anne_mounsey@med.unc.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

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