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Dyspepsia, Functional
Kristina Burgers, MD, FAAFP
Matthew W. Short, MD, FAAFP
image BASICS
  • 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
Unknown, accounts for 70% of patients with dyspepsia, and ˜5% of primary care visits
  • 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
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
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.
  • Other functional disorders
  • Anxiety/depression psychosocial factors: divorce, unemployment
  • Smoking
Avoid foods and habits known to exacerbate symptoms.
Other functional bowel disorders
  • 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
  • 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
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)
  • 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].

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.
  • Stress reduction (2,5)[A]
    • Relaxation techniques
    • Physical exercise
    • Reflux precautions where applicable
  • Psychotherapy effective in some patients (2)[A],(3)[B]
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].
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].
  • 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].
Reassurance and stress reduction techniques
Long-term/chronic symptoms with symptom-free periods
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
  • 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
  • Irritable Bowel Syndrome
  • Algorithms: Dyspepsia
K30 Functional dyspepsia
Clinical Pearls
  • 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.