> Table of Contents > Dyspepsia, Functional
Dyspepsia, Functional
Kristina Burgers, MD, FAAFP
Matthew W. Short, MD, FAAFP
image BASICS
DESCRIPTION
  • The presence of bothersome postprandial fullness, early satiety, or epigastric pain/burning in the absence of causative structural disease (to include normal upper endoscopy) for the preceding 3 months with initial symptom onset at least 6 months prior to diagnosis (Rome III criteria)
  • Rome III criteria divide patients into two subtypes:
    • Postprandial distress syndrome
    • Epigastric pain syndrome
  • System(s) affected: GI
  • Synonym(s): idiopathic dyspepsia; nonulcer dyspepsia; nonorganic dyspepsia; postprandial distress syndrome; and epigastric pain syndrome
EPIDEMIOLOGY
Incidence
Unknown, accounts for 70% of patients with dyspepsia, and ˜5% of primary care visits
Prevalence
  • 15-30% prevalence in developed countries (3-10% when strict Rome III criteria are used)
  • Predominant age: adults but can be seen in children
  • Predominant gender: female > male
ETIOLOGY AND PATHOPHYSIOLOGY
Unknown, but proposed mechanisms or associations include gastric motility disorders, visceral pain hypersensitivity, Helicobacter pylori infection, alteration in upper GI microbiome, medications, anxiety, and depression
Genetics
Possible link to G-protein &bgr;-3 subunit 825 CC genotype and serotonin transport genes
Pediatric Considerations
Be alert for family system dysfunction.
Pregnancy Considerations
Pregnancy may exacerbate symptoms.
Geriatric Considerations
Patients >50 years with new-onset dyspepsia should have an upper endoscopy.
RISK FACTORS
  • Other functional disorders
  • Anxiety/depression psychosocial factors: divorce, unemployment
  • Smoking
GENERAL PREVENTION
Avoid foods and habits known to exacerbate symptoms.
COMMONLY ASSOCIATED CONDITIONS
Other functional bowel disorders
image DIAGNOSIS
PHYSICAL EXAM
  • Document weight status and vital signs.
  • Examine for signs of systemic illness.
    • Murphy sign for cholelithiasis
    • Rebound and guarding for ulcer perforation
    • Palpation during muscle contraction for abdominal wall pain
    • Jaundice
    • Thyromegaly
DIFFERENTIAL DIAGNOSIS
  • Peptic ulcer disease; gastroesophageal reflux disease
  • Cholecystitis
  • Gastric or esophageal cancer; esophageal spasm
  • Malabsorption syndromes; celiac disease
  • Pancreatic cancer; pancreatitis
  • Inflammatory bowel disease; carbohydrate malabsorption; gastroparesis
  • Ischemic bowel disease
  • Intestinal parasites
  • Irritable bowel syndrome
  • Ischemic heart disease
  • Diabetes mellitus; thyroid disease
  • Connective tissue disorders
  • Conversion disorder
  • Medication effects
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
  • Functional dyspepsia is a diagnosis of exclusion. Order labs are based on clinical suspicion (3)[C].
  • CBC (if anemia or infection are suspected)
  • LFT (if hepatobiliary disease is suspected)
  • Test for H. pylori (stool antigen or urea breath test) in areas of high H. pylori prevalence (3,4)[A].
  • Upper endoscopy for patients >55 years or those with alarm symptoms (weight loss, signs of blood loss, dysphagia, concern for cancer) (3)[C]
  • Perform upper endoscopy if patient does not respond to gastric acid suppression trial (3)[C].
  • A self-report questionnaire can help assess and track symptoms (3)[C].
Diagnostic Procedures/Other
Esophageal manometry or gastric accommodation studies are rarely needed (3)[C].
Test Interpretation
None (by definition this a functional disorder)
image TREATMENT
GENERAL MEASURES
  • Few effective treatment options are available (5).
  • Reassurance and physician support are helpful (3)[C].
  • Treatment is based on presumed etiologies.
  • Discontinue offending medications (3)[C].
P.325

MEDICATION
First Line
  • Treat H. pylori if confirmed on testing (3,4)[A].
  • Trial of once daily proton pump inhibitor (PPI) medication (e.g., omeprazole 20 mg PO QD) or H2RA (e.g., ranitidine 150 mg BID) for up to 8 weeks in patients without alarm symptoms (3,5)[A]
Second Line
  • Trial of low-dose tricyclic antidepressant (TCA) medication is helpful in epigastric pain syndrome but not postprandial distress syndrome (amitriptyline 10 mg at bedtime); consider doubling dose after a few days (2,5)[A],(6)[B]; caution in elderly.
  • Trazodone 25 mg at bedtime is an alternative (2,5) [A]. Consider a 1-month trial of prokinetic medication (metoclopramide) or buspirone if no response to TCA (2,5)[B]. Caution with metoclopramide in elderly due to side effects of tardive dyskinesia and parkinsonian symptoms.
ADDITIONAL THERAPIES
  • Stress reduction (2,5)[A]
    • Relaxation techniques
    • Physical exercise
    • Reflux precautions where applicable
  • Psychotherapy effective in some patients (2)[A],(3)[B]
COMPLEMENTARY & ALTERNATIVE MEDICINE
Alternative approaches need further study.
  • Peppermint oil +/− caraway oil
  • Probiotics have theoretical benefit but few controlled trials (5)[B].
  • Hypnotherapy may help (3)[B].
  • Transcutaneous electroacupuncture may help (3)[B].
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
  • Provide ongoing support and reassurance.
  • Upper endoscopy if persistent symptoms
  • Change medications if no change after 4 weeks (3)[C].
  • Discontinue drug therapy after symptom resolution (3)[C].
DIET
  • Limited data to support dietary modification
  • Consider limiting fatty foods (2,5)[C].
  • Avoid foods that exacerbate symptoms: wheat and cow milk proteins, peppers or spices, coffee, tea, and alcohol (2,5)[C].
PATIENT EDUCATION
Reassurance and stress reduction techniques
PROGNOSIS
Long-term/chronic symptoms with symptom-free periods
REFERENCES
1. Tack J, Talley NJ. Functional dyspepsia—symptoms, definitions and validity of the Rome III criteria. Nat Rev Gastroenterol Hepatol. 2013;10(3):134-141.
2. Vanheel H, Tack J. Therapeutic options for functional dyspepsia. Dig Dis. 2014;32(3):230-234. doi:10.1159/000358111.
3. Miwa H, Kusano M, Arisawa T, et al. Evidence-based clinical practice guidelines for functional dyspepsia. J Gastroenterol. 2015;50(2):125-139. doi:10.1007/s00535-104-1022-3.
4. Zhao B, Zhao J, Cheng WF, et al. Efficacy of Helicobacter pylori eradication therapy on functional dyspepsia: a meta-analysis of randomized controlled studies with 12-month follow-up. J Clin Gastroenterol. 2014;48(3):241-247.
5. Stein B, Everhart KK, Lacy BE. Treatment of functional dyspepsia and gastroparesis. Curr Treat Options Gastroenterol. 2014;12(4):385-397. doi:10.1007/s11938-014-0028-5.
6. Talley NJ, Locke GR, Saito Y, et al. Effect of amitriptyline and escitalopram on functional dyspepsia: a multicenter, randomized controlled study. Gastroenterology. 2015;149(2):340.e2-349.e2. doi:10.1053/j.gastro.2015.04.020.
Additional Reading
&NA;
  • Amini M, Ghamar Chehreh ME, Khedmat H, et al. Famotidine in the treatment of functional dyspepsia: a randomized double-blind, placebo-controlled trial. J Egypt Public Health Assoc. 2012;87(1-2):29-33.
  • Ford AC, Moayyedi P. Dyspepsia. Curr Opin Gastroenterol. 2013;29(6):662-668. doi:10.1097/MOG.0b013e328365d45d.
  • Ganesh M, Nurko S. Functional dyspepsia in children. Pediatr Ann. 2014;43(4):e101-e105. doi:10.3928/00904481-20140325-12.
  • Graham D, Rugge M. Clinical practice: diagnosis and evaluation of dyspepsia. J Clin Gastroenterol. 2010;44(3):167-172.
  • Kaminski A, Kamper A, Thaler K, et al. Antidepressants for the treatment of abdominal pain-related functional gastrointestinal disorders in children and adolescents. Cochrane Database Syst Rev. 2011;(7):CD008013.
  • Lacy BE, Talley NJ, Locke GR III, et al. Review article: current treatment options and management of functional dyspepsia. Aliment Pharmacol Ther. 2012;36(1):3-15.
  • Lan L, Zeng F, Liu GJ, et al. Acupuncture for functional dyspepsia. Cochrane Database Syst Rev. 2014;(10):CD008487.
  • Loyd RA, McClellan DA. Update on the evaluation and management of functional dyspepsia. Am Fam Physician. 2011;83(5):547-552.
  • Oustamanolakis P, Tack J. Dyspepsia: organic versus functional. J Clin Gastroenterol. 2012;46(3):175-190.
  • Overland MK. Dyspepsia. Med Clin North Am. 2014;98(3):549-564.
  • Tack J, Masaoka T, Janssen P. Functional dyspepsia. Curr Opin Gastroenterol. 2011;27(6):549-557.
See Also
&NA;
  • Irritable Bowel Syndrome
  • Algorithms: Dyspepsia
Codes
&NA;
ICD10
K30 Functional dyspepsia
Clinical Pearls
&NA;
  • Dyspepsia without underlying organic disease is termed functional or idiopathic.
  • Consider empiric treatment with acid suppression as first-line therapy for functional dyspepsia.
  • Extensive diagnostic testing is not recommended unless alarm symptoms are present.