Functional Dyspepsia
This care pathway can guide primary care providers in the management of patients with functional dyspepsia and does not include those with organic, systemic, or metabolic causes for dyspepsia symptoms. This care pathway follows the guidelines for the management of functional dyspepsia (FD) from the American College of Gastroenterology (ACG) & Canadian Association of Gastroenterology (CAG), and the Rome IV criteria for functional dyspepsia.
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This care pathway provides information on:
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A summary of dyspepsia
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A checklist for primary care providers
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Algorithm for functional dyspepsia
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Explanation of the algorithm
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Treatment for functional dyspepsia
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Additional Resources
DIAGNOSITIC CRITERIA FOR FUNCTIONAL DYSPEPSIA
Functional dyspepsia (FD) is a disorder of gut-brain interaction (DGBI) characterized by one or more of the following symptoms: postprandial fullness, early satiety, epigastric pain, and/or epigastric burning with no identifiable structural or metabolic cause. Symptoms of FD can be similar to other gastrointestinal disorders such as gastroesophageal reflux disease, peptic ulcer disease, or gastroparesis.
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The pathophysiology of FD is complex and multifactorial. Gastroduodenal motor and sensory dysfunction, impaired mucosal integrity, low-grade immune activation, and dysregulation of the gut-brain axis have all been described as possible mechanisms.
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Dyspepsia is more common in women, people who smoke, and those who use nonsteroidal anti-inflammatory drugs.
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The Rome Foundation developed diagnostic criteria for FD to differentiate functional dyspepsia from GERD and heartburn. In addition to the four cardinal symptoms of dyspepsia, the patient may also report other symptoms such as: bloating, belching, nausea, and vomiting.
One or more of the following:
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Bothersome postprandial fullness
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Bothersome early satiety
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Bothersome epigastric pain
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Bothersome epigastric burning
AND​​
No evidence of structural disease (including upper endoscopy) that is likely to explain the symptoms
Criteria fulfilled for the last 3 months with symptom onset at least 6 months before diagnosis.
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Functional dyspepsia can be subtyped based on the patient's predominate symptom:
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Postprandial Distress Syndrome
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Epigastric Pain Syndrome
POSTPRANDIAL DISTRESS SYNDROME
Must include one or both of the following at least three days per week:
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Bothersome postprandial fullness (i.e. severe enough to impact usual activities)
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Bothersome early satiation (i.e. severe enough to prevent finishing a regular-sized meal)
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No evidence of organic, systemic, or metabolic disease that is likely to explain the symptoms on routine investigations (including upper endoscopy)
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Criteria fulfilled for the last three months with symptom onset at least six months before diagnosis.
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Supportive remarks:
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Postprandial epigastric pain or burning, epigastric bloating, excessive belching, and nausea can be present
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Vomiting warrants consideration of another disorder
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Heartburn is not a dyspeptic symptom but may coexist
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Symptoms relieved by a bowel movement or gas are generally not considered as a part of FD
EPIGASTRIC PAIN SYNDROME
Must include at least 1 of the following symptoms at least once a week:
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Bothersome epigastric pain (i.e. severe enough to impact usual activities)
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AND/OR
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Bothersome epigastric burning (i.e. severe enough to impact usual activities)
No evidence of organic, systemic, or metabolic disease that is likely to explain the symptoms on routine investigations (including upper endoscopy)
Criteria fulfilled for the last three months with symptom onset at least six months before diagnosis.
Supportive remarks:
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Pain may be induced by ingestion of a meal, relieved by ingestion of a meal, or may occur while fasting
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Postprandial epigastric bloating, belching, and nausea can also be present
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Persistent vomiting likely suggests another disorder
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Heartburn is not a dyspeptic symptom but may coexist
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The pain does not fulfill biliary pain criteria
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Symptoms relieved by a bowel movement or gas are generally not considered as a part of FD
PRIMARY CARE CHECKLIST
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History and physical examination to determine other causes for dyspepsia
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Absence of alarm features:
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anemia, iron deficiency, GI bleeding
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acute or unintentional weight loss
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dysphagia, vomiting
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family history of upper GI cancers
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abnormality on physical exmaination
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Exclude medications that can cause dyspepsia (NSAIDs, corticosteroids, iron, bisphosphonates)​
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Patients > 60 years old, refer to GI for upper endoscopy investigation
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Patients < 60 years old with no multiple alarm features/risk factors, test for H. Pylori
ALGORITHIM FOR FUNCTIONAL DYSPEPSIA
Patient with dyspepsia
≥60 years old
≤60 years old
Refer to GI for consideration of endoscopy
YES
ALARM FEATURES?
NO
Abnormal endoscopy
Manage according to relevant guidelines
Normal endoscopy
Establish diagnosis of functional dyspepsia & manage accordingly
Test for H. pylori
POSITIVE
Treat HP
HP eradicated
NEGATIVE
Establish diagnosis for FD
Dyspepsia not resolved
PPI
TCA
No response
Symptoms resolved
No response
Prokinetic
No response
Consider psychotherapy
ACRONYMS:
FD: functional dyspepsia
TCA: tricyclic antidepressants
No response
Consider referral to GI
EXPLANATION OF ALGORITHIM FOR FUNCTIONAL DYSPEPSIA
PHYSICAL & HISTORY ASSESSMENT
A careful history and abdominal examination are important to determine other causes for dyspeptic symptoms. Assessment should focus on chronicity, frequency, and nature of symptoms, especially their relationship to meals. Exclude alarm features as listed above. Review all current medications that may cause dyspepsia and, if possible, discontinue, decrease, or alter therapy.
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For patients 60 years or older, it is recommended they be referred to a specialist for endoscopy to exclude upper gastrointestinal neoplasia.
For patients <60 years old with no alarm features or risk factors, the risk of malignancy is typically very low, and endoscopy is not recommended. However, if the assessment reveals significant alarm features and/or risk factors (i.e. family history of gastric cancer), a referral to a specialist should be considered.
INVESTIGATIONS
Routine laboratory testing may be considered. Baseline laboratory tests may include CBC, electrolytes, calcium, liver enzymes to identify if the source of pain is hepatobiliary or pancreatic, and thyroid function tests.
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Patients < 60 years old with no alarm features should undergo non-invasive H. pylori (HP) testing. The urea breath test has excellent sensitivity and specificity and is relatively accessible. If the test results are positive, follow current guidelines for HP treatment. Retest for infection at least four weeks post-treatment and evaluate dyspepsia symptoms. If test results are negative, establish a diagnosis for FD. Once FD diagnosis has been established, it is helpful to review the gut-brain axis with the patient to help them understand their condition and establish realistic treatment goals.
TREATMENT FOR FUNCTIONAL DYSPEPSIA
Any recommended regimen should be trialed for 4 to 8 weeks before considering a step-up or change in therapy.
Medication | Recommended Dose | Side Effects | Patient Education |
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If there is no response after 8 weeks, there is value in doubling the PPI dose and treatment should be discontinued. Consider a neuromodulator.
Medication | Recommended Dose | Side Effects | Patient Education |
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Discontinue TCA if there is an inadequate response after 12 weeks. Prokinetics may be considered to improve impaired gastric motility, which has been associated with functional dyspepsia.
Medication | Recommended Dose | Side Effects | Patient Education |
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PSYCHOLOGICAL TREATMENT
Cognitive-behavioural therapy (CBT) and mindfulness-based therapy (MBT) have shown to be successful in managing other DGBI. They may be an option for patients willing to participate in therapy.
If the patient does not respond to therapy, a referral to a gastroenterologist should be considered.