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'I feel full so quickly!' - managing functional dyspepsia

Gastroenterologists Dr Ben Shandro and Dr Andrew Poullis discuss this case of a man with epigastric discomfort

Case

A 40-year-old male non-smoker presents to his GP with recurrent epigastric discomfort and early satiety. He reports the symptoms first began five years ago, at which point he underwent an endoscopy and ultrasound abdomen, both of which were normal. He has been managing his symptoms with Gaviscon and found some improvement with reduction in alcohol intake. There are no red flag symptoms such as weight loss.

His GP diagnoses functional dyspepsia, explains the benign nature of the condition, and reassures the patient that further endoscopic assessment is not required in the absence of red flag symptoms. She checks H. pylori faecal antigen, which is negative, and prescribes omeprazole 40mg once daily for four weeks. She also counsels him on lifestyle changes. She advises him to return if symptoms have not improved or recur.

Definitions and diagnosis

Dyspepsia is a common problem seen by GPs, thought to affect 20% of adults and costing the UK economy £1 billion per year.1 Dyspepsia describes a combination of symptoms, thought to arise from the stomach and duodenum that include epigastric discomfort, pain or burning and post-prandial symptoms such as early satiety, nausea and bloating. Various organisations have put definitions forward, but a practical definition for GPs is the presence of any of the above symptoms for longer than three months.1

The term functional dyspepsia describes these symptoms in the absence of organic disease, and is synonymous with the older terms ‘non-ulcer dyspepsia’ and ‘essential dyspepsia’. The pathophysiology is thought to be multifactorial, and may include altered gastric accommodation and emptying, visceral hypersensitivity, and psychological factors.2

In theory, the diagnosis of functional dyspepsia requires a negative endoscopy, but this is not cost-effective in patients under 60 years of age.3 The primary role of endoscopy in dyspepsia is to exclude gastric cancer, which is rare in younger patients. In these patients, the diagnosis can be made based on symptoms alone in the absence of red flag symptoms or family history of gastric cancer. There is considerable overlap with non-erosive reflux disease and irritable bowel syndrome, which can complicate making the diagnosis, but rarely alters the management.

Investigations

Patients aged over 60 years old should be offered an endoscopy and abdominal imaging with either CT or ultrasound. Endoscopic examination and abdominal imaging are not routinely indicated in patients under 60 years old, but should be determined on a case-by-case basis.3 All patients should be tested for H. pylori using the faecal antigen assay. Patients with H. pylori whose symptoms respond to eradication treatment can be said to have H. pylori-associated dyspepsia.4 Most patients will not respond to eradication treatment, and can be diagnosed with functional dyspepsia.4 An ultrasound to exclude gallstone disease should be requested for patients whose symptoms suggest biliary pathology. Blood tests to exclude coeliac disease, diabetes and thyroid dysfunction, all of which may present with dyspepsia, can be considered in selected patients.

Table 1: Routine investigations for dyspepsia without red flag symptoms

Blood tests

Stool tests

Imaging

Endoscopy

FBC

H. pylori faecal antigen

CT or US abdomen (>60)

OGD (>60)

U&E, LFTs, Glucose, TFTs

Coeliac serology

Management

All patients should be tested for H. pylori and undergo eradication treatment if present. In patients without H. pylori infection, or who fail to respond to eradication therapy, a four-week trial of oral PPI therapy should be offered.3,5 Some patients may respond better to H2 antagonists than PPIs6, and it would be reasonable to offer a four-week trial of an H2 antagonist in PPI non-responders. If symptoms recur following cessation of treatment, patients should be offered ongoing PPI or H2 antagonist therapy at the lowest dose that relieves their symptoms.5 Alginates such as Gaviscon should not be overlooked, and there is some evidence for their use in functional dyspepsia.7 They can be used instead of or in addition to PPI therapy, and are useful as a step-down option for patients on long term PPI.

Lifestyle factors should also be addressed. Smoking cessation and alcohol reduction is recommended.2 Healthy eating and weight loss, if indicated, should be discussed. Reducing portion size and the intake of fat, caffeine and gluten have all been shown to improve symptoms.8 However, there is no ‘one size fits all’ approach and patients should be encouraged to keep a food and symptom diary to help identify their individual triggers. Elevation of the head off the bed may help in patients with coexisting reflux symptoms.

An additional practical step is to review drug history and withdraw NSAIDs, corticosteroids, calcium channel blockers, nitrates, theophyllines, and bisphosphonates where possible.5

In patients who fail to respond to antacid therapy, second-line medical therapy with either a low-dose tricyclic antidepressant or a short course of prokinetic is warranted.3 We suggest that a tricyclic antidepressant is favoured in patients with epigastric pain as the dominant symptom, and a prokinetic in patients with predominantly post-prandial symptoms.

Patients with symptoms that are refractory to the above therapies, or those who prefer not to take medication, can explore complementary and alternative therapies. There is limited evidence supporting the use of peppermint oil, the herbal remedies Iberogast and Rikkunshito, and acupuncture.9,10 Psychological interventions can be offered to patients struggling to manage long-term symptoms, including hypnotherapy, cognitive behaviour therapy, and stress management.10,11

This can be a frustrating condition for both patient and physician. There are many therapeutic options available, but it can take some time to optimise response. Patients should be reassured about the benign nature of the condition and encouraged to manage their own symptoms, ideally stepping down from PPI to lifestyle measures and as-required alginate therapy over time. For patients requiring long-term management of their symptoms, an annual review with their GP should be offered.5

 

Dr Ben Shandro is a gastroenterology research fellow at St George’s Hospital, London.

Dr Andrew Poullis is a gastroenterology consultant at St George’s Hospital, London.

The authors have no competing interests to declare.

 

References

  1. Ford AC, Moayyedi P. Dyspepsia. BMJ. 2013;347:f5059
  2. Stanghellini V, Chan FK, Hasler WL, Malagelada JR, Suzuki H, Tack J, Talley NJ. Rome IV - Gastroduodenal disorders. Gastroenterology. 2016;150(6):1380-92
  3. Moayyedi P, Lacy BE, Andrews CN, Enns RA, Howden CW, Vakil N. ACG and CAG clinical guideline: management of dyspepsia. Am J Gastroenterol. 2017;112(7):988-1013
  4. Sugano K, Tack J, Kuipers EJ, Graham DY, El-Omar EM, Miura S, Haruma K, Asaka M, Uemura N, Malfertheiner P. Kyoto global consensus report on Helicobacter pylori gastritis. Gut. 2015;64:1353-1367.
  5. National Institute for Health and Care Excellence. Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management (CG184). London: NICE; 2014
  6. Talley NJ, Vakil NB, Moayyedi P. American gastroenterological association technical review on the evaluation of dyspepsia. Gastroenterology. 2005;129(5):1756-80
  7. Corsetti M, Fox M. The management of functional dyspepsia in clinical practice: what lessons can be learnt from recent literature? F1000Research. 2017;6:1778
  8. Duncanson KR, Talley NJ, Walker MM, Burrows TL. Food and functional dyspepsia: a systematic review. J Hum Nutr Diet. 2018;31(3):390-407
  9. Shams R, Oldfield EC, Copare J, Johnson DA. Peppermint oil: clinical uses in the treatment of gastrointestinal diseases. JSM Gastroenterol Hepatol. 2015;3(1):1036.
  10. Chiarioni G, Pesce M, Fantin A, Sarnelli G. Complementary and alternative treatment in functional dyspepsia. United European Gastroenterology Journal. 2018;6(1):5-12
  11. Soo S, Moayyedi P, Deeks J, Delaney B, Lewis M, Forman D. Psychological interventions for non-ulcer dyspepsia. Cochrane Database Syst Rev. 2004;(3):CD002301

 

 

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Readers' comments (1)

  • To the list of bloods I would add B12 & folate - B12 deficiency is associated with nausea, bloating and loss of appetite. I saw a lad in his 20's a few years ago who had been 'fully investigated' with nothing found and put down to functional dyspepsia. Normocytic, but B12 around 130. 2 weeks of B12 injections later and fully cured after 12 months of struggling....

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