After several guidelines published, including the ACG (American Collegue of Gastroenterology) in 2017, the BSG has released one of the most comprehensive and extended guidelines in this matter.
The defitinion of dyspepsia is usually extracted from the Rome Foundation
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- One or more of the following:
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- Bothersome postprandial fullness
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- Bothersome early satiation
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- Bothersome epigastric pain
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- Bothersome epigastric burning
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- One or more of the following:
AND
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- No evidence of structural disease (including at upper endoscopy) that is likely to explain the symptoms
This symptoms are usually >8 weeks in order to diagnose the condition. The condition can be classified in 2 main subtypes : Epigastric pain syndrome (mostly epigastric ulcerous type of pain, burning: This responds well to PPI) or postprandial distress syndrome (usually early satiety, postprandial fullness, belching: This can respond to PPI but also prokinetics that facilitate gastric emptying and enhance motility)
The guidelines emphasise in the need to consider endoscopy in cases of >55yo (note in the American guidelines it is 60 yo) and urgent endoscopy is only warranted in patients aged ≥55 years with dyspepsia with weight loss, or those aged >40 years from an area at an increased risk of gastric cancer or with a family history of gastro-oesophageal cancer.
Elective non-urgent endoscopy can be considered in patients aged ≥55 years with treatment-resistant dyspepsia or dyspepsia with either a raised platelet count or nausea or vomiting
On top of EGD, a CT scanning should be considered in patients aged ≥60 years with abdominal pain and weight loss to exclude pancreatic cancer
For the rest of cases, (Most patients) They should be offered non-invasive testing for Helicobacter pylori (‘test and treat’) and, if infected, given eradication therapy (recommendation: strong; quality of evidence: high). Interestingly, they do not recommend checking eradication of H. pylori after ‘test and treat’ ,except in patients with an increased risk of gastric cancer (Family history)
With regards of the treatment, basic lifestyle advice and trying to avoid specific triggers (some patient can identify spicy food -some cohorts show up to 50% sensitivity to capsaicin in functional dyspepsia) . It is important to explain to the patient how this is impacted by diet, stress, cognitive, behavioural and emotional responses to symptoms, as well as sometimes a sign of postinfective changes (ie, viral infection ). Obviously, we need to exclude dyspepsia related to medication -NSAIDs are the typical expample, which can contribute to mucosal damage, ulceration, and bleeding complications. Other associated medications include iron, antibiotics, antihypertensives, narcotics, estrogens, theophylline, selective serotonin reuptake inhibitors (SSRIs), niacin, digoxin, corticosteroids, levodopa, and hypoglycemic agents.
Once this is discussed and patient is started on acid suppresion medication (PPI preferable, however antiH2 may be an efficacious therapy in those which do not respond or tolerate PPI)- response can be assesed after a few weeks, and dose of medication should be maintained to the minimum possible.
The second line therapies for those still symptomatic are usually about Tricyclic antidepressants (TCAs) used as gut–brain neuromodulators- those are known to be efficacious . They can be initiated in primary or secondary care, but careful explanation as to the rationale for their use is required, and patients should be counselled about their side effect profile. They should be commenced at a low dose (eg, 10 mg amitriptyline once daily) and titrated slowly to a maximum of 30–50 mg once daily. Others like pregabalin or mirtazapine, or levosulpiride, could be considered. There is not enough evidence of selective serotonin reuptake inhibitors (SSRIs) being effective in functional dyspepsia, contrary to what we know in IBS.
There is insufficient evidence to support the role of FODMAP or low gluten diet, however some patient can improve by reducing ultraproccessed foods, dairy or citric, most of them food are banned in lowFODMAP diet or could contain higher amount of gluten