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Am Fam Physician. 2023;108(1):online

Clinical Question

What are the latest evidence-based guidelines for the management of functional dyspepsia?

Bottom Line

The thoughtful, evidence-based guidelines provide a helpful framework for evaluating and treating patients with dyspepsia. The guidance regarding imaging and the use of upper endoscopy may be conservative for U.S. physicians. The authors acknowledge that approximately half of the recommendations are based on low- or very low-quality evidence. (Level of Evidence = 1a)


The 2022 guideline, last updated in 1996, was based on a series of systematic reviews and network meta-analyses. The authors recommend urgent evaluation of patients with upper gastrointestinal alarm symptoms, such as dysphagia in all patients, weight loss with dyspepsia, upper abdominal pain, or reflux in patients 55 years and older. Urgent evaluation is recommended for patients 40 years and older who are from a region where gastric cancer is common or have a family history of gastroesophageal cancer. Other alarm symptoms warranting a less urgent evaluation include hematemesis; treatment-resistant dyspepsia; dyspepsia; upper abdominal pain with elevated platelet count, low hemoglobin, and nausea or vomiting; and nausea or vomiting with weight loss, reflux, dyspepsia, or upper abdominal pain in patients who are 55 years and older. Patients without alarm symptoms who present with at least two months of epigastric burning or pain, early satiety, or postprandial fullness should be given a diagnosis of functional dyspepsia and told that it is a disorder of gut-brain interaction. As part of the initial evaluation in patients 55 years and older, a complete blood count with platelets should be obtained and those with overlapping irritable bowel symptoms should have celiac serology. Those 60 years and older with abdominal pain and weight loss should have abdominal computed tomography to evaluate for pancreatic cancer.

All patients with dyspepsia should be evaluated for the presence of Helicobacter pylori by obtaining a stool or breath test. If the results are abnormal, the patient should be treated to eradicate H. pylori (a recent study confirms that eradication not only reduces the risk of ulcer but is effective for functional dyspepsia). Confirmation of H. pylori eradication is recommended only for patients at increased risk of gastric cancer, although it should be considered in patients whose symptoms persist. The guidelines recommend against the routine use of gastric emptying tests or 24-hour pH monitoring. For patients who are negative for H. pylori, first-line treatment includes acid-suppressive therapy with a histamine H2 antagonist or proton pump inhibitor and regular aerobic exercise; the guidelines do not recommend specific diets such as a FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) diet. Prokinetics may be an effective treatment, and the strongest evidence supports tegaserod. Second-line therapies include low to moderate dosages of tricyclic antidepressants (e.g., amitriptyline, 10 mg once daily, titrating to 30 to 50 mg). The authors recommend against selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and buspirone. Cognitive behavior therapy, psychodynamic interpersonal psychotherapy, stress management, and hypnotherapy may be effective. Patients with refractory or persistent symptoms should be referred to a gastroenterologist.

Study design: Practice guideline

Funding source: Foundation

Setting: Outpatient (any)

Reference: Black CJ, Paine PA, Agrawal A, et al. British Society of Gastroenterology guidelines on the management of functional dyspepsia. Gut. 2022;71(9):1697-1723.

Editor's Note: Dr. Ebell is deputy editor for evidence-based medicine for AFP and cofounder and editor-in-chief of Essential Evidence Plus, published by Wiley-Blackwell.

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POEMs (patient-oriented evidence that matters) are provided by Essential Evidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, see Copyright Wiley-Blackwell. Used with permission.

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