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Dyspepsia, Functional

Basics

Description

  • Postprandial fullness, early satiety, or epigastric pain/burning without identifiable structural cause

  • Rome IV Criteria: symptoms present 1–3 days/week for β‰₯3 months, onset β‰₯6 months prior to diagnosis

  • Subtypes:

    • Postprandial Distress Syndrome (PDS)

    • Epigastric Pain Syndrome (EPS)

Systems Affected

  • Gastrointestinal

Synonyms

  • Idiopathic dyspepsia, nonulcer dyspepsia, PDS, EPS

Epidemiology

  • Accounts for 70% of dyspepsia cases

  • ~5% of primary care visits

  • 10–20% prevalence worldwide

  • PDS: more common in Eastern cultures

  • Female > male

Etiology and Pathophysiology

  • Multifactorial:

    • Visceral hypersensitivity

    • Delayed gastric emptying

    • Gut-brain axis disturbance

    • H. pylori infection

    • Microbiome alterations

  • Genetic links: G-protein Ξ²3, serotonin transporter, cholecystokinin-A receptor

Risk Factors

  • Functional syndromes (IBS, fibromyalgia)

  • Psychological: anxiety, depression, trauma

  • Smoking

  • NSAID use

  • Female gender

Associated Conditions

  • Other functional GI disorders

Diagnosis

History

  • Symptoms: postprandial fullness, early satiety, epigastric pain/burning β‰₯3 months

  • Alarm features:

    • Weight loss

    • Progressive dysphagia

    • GI bleeding

    • Vomiting

    • Age β‰₯60

    • Family history of GI cancer

Physical Exam

  • Vital signs, weight

  • Abdominal exam:

    • Murphy’s sign, rebound/guarding

    • Carnett sign

  • Look for jaundice, thyromegaly

Differential Diagnosis

  • GERD, peptic ulcer, IBD, celiac

  • Pancreatitis, cancer, gastroparesis

  • Ischemia, thyroid disease, medications

Diagnostic Tests

Initial

  • H. pylori testing: stool antigen or urea breath test

  • CBC, LFTs, pancreatic enzymes as indicated

  • Upper endoscopy:

    • Indicated if age β‰₯60 or alarm features

    • Not routinely recommended in age <60 without red flags

Other

  • Motility or accommodation studies rarely needed

  • Functional tests not routinely useful

Treatment

General Measures

  • Reassurance, stress management

  • Discontinue offending drugs

  • Avoid unnecessary tests in low-risk patients

First Line

  • Treat H. pylori if positive

  • PPI (e.g., omeprazole 20 mg QD) or H2 blocker Γ— 8 weeks

  • Prokinetics (e.g., metoclopramide 5–10 mg TID) for PDS (use cautiously)

Second Line

  • TCAs (e.g., amitriptyline 25–50 mg QD) for EPS

  • Trazodone, buspirone, or mirtazapine as alternatives

  • Gabapentin 300 mg BID for refractory pain

Adjunct Therapies

  • Cognitive-behavioral therapy (CBT)

  • Stress reduction techniques

  • Positive diagnosis + reassurance of benign prognosis

Complementary & Alternative Medicine

  • STW-5 (Iberogast): promising but needs more data

  • Probiotics: inconsistent evidence

  • Hypnotherapy, electroacupuncture: may help

Ongoing Care

Follow-Up

  • Monitor every 4–6 weeks

  • Re-evaluate if no improvement after 4 weeks

  • Stop meds once symptoms resolve

Diet

  • Limit FODMAPs, fatty foods

  • Avoid spicy, coffee, tea, alcohol, milk/wheat

Patient Education

  • Emphasize stress reduction

  • Discuss good prognosis

Prognosis

  • Chronic with intermittent symptom-free periods

Complications

  • Iatrogenic from over-testing

Clinical Pearls

  • Functional dyspepsia = diagnosis of exclusion

  • PPI trial is first step in most patients

  • Avoid extensive testing unless alarm features present

  • Prokinetics help with PDS; TCAs help EPS

  • Supportive care and reassurance are essential for long-term success