British Society of Gastroenterology guidelines on the management of functional dyspepsia

Abstract

In 2022, the British Society of Gastroenterology released guidelines on the management of functional dyspepsia (FD), providing a long-anticipated evidence-based approach to the diagnosis, classification and management of patients with FD. This review summarises the key recommendations of the recent guidelines on the management of FD.

What is already known on this topic

• Functional dyspepsia is a common disorder of gut-brain interaction which can be challenging to manage.

What this study adds

• The last BSG guideline for the management of functional dyspepsia was published in 1996. In the past 26 years, there have been new advances in the diagnosis, classification and management of functional dyspepsia. This review summarises the key recommendations made by the 2022 British Society of Gastroenterology guidelines on the management of FD.

How this study might affect research, practice or policy

• While there have been substantial advances in the understanding of functional dyspepsia this century, the BSG guidelines on the management of FD highlights many areas which require further exploration in future research.

Introduction

Functional dyspepsia (FD) is a disorder of gut-brain interaction (DGBI) affecting 6.8% of the population in the UK.¹ FD is associated with abnormalities in visceral sensitivity to stimuli, motility, processing within the central nervous system, immune function, inflammation, epithelial permeability, genetics, psychology and the microbiome. The definition of FD has evolved over time and is best defined according to the diagnostic criteria developed by the Rome Foundation, which is now in its fourth iteration.² This review summarises the key recommendations made by the 2022 British Society of Gastroenterology (BSG) guidelines on the management of FD.³

Definition of FD

The guidelines recommend that the Rome IV criteria should be used for the diagnosis of FD. These are found in box 1.

Box 1. Rome IV diagnostic criteria for functional dyspepsia² .

Must include ≥1 of the following for the past 3 months with symptom onset at least 6 months prior to diagnosis:

• Bothersome epigastric pain.

• Bothersome epigastric burning.

• Bothersome postprandial fullness.

• Bothersome early satiation.

AND

• No evidence of structural disease (including at upper endoscopy) that is likely to explain the symptoms.

• Must fulfil criteria for postprandial distress syndrome and/or epigastric pain syndrome.

Postprandial distress syndrome diagnostic criteria

Must include one or both of the following symptoms at least 3 days per week:

• Bothersome postprandial fullness.

• Bothersome early satiation.

Epigastric pain syndrome diagnostic criteria

Must include at least 1 of the following symptoms at least 1 day per week:

• Bothersome epigastric pain.

• Bothersome epigastric burning.

Approach to the evaluation and management of FD

An approach to evaluate and manage FD is summarised in figure 1.

Figure 1.

Algorithm to evaluate and manage FD (adapted from associated British Society of Gastroenterology guideline).³ CBT, cognitive behavioural therapy; FD, functional dyspepsia; IPIP, interpersonal psychodynamic informed psychotherapy.

Management

All patients with symptoms consistent with FD should be tested for Helicobacter pylori. Up to 5% of dyspepsia in society can be attributed to H. pylori infections.⁴ H. pylori infections are organic causes of dyspepsia and should not be considered as FD. H. pylori should be eradicated if detected and FD symptoms should be reassessed after eradication.

There are numerous lifestyle modifications which should be considered in the management of FD. A systematic literature review showed that smoking was associated with a 50% increased risk of FD compared with never smokers, suggestive that smoking cessation is a lifestyle modification which should be considered.⁵ There is insufficient evidence to recommend dietary modification, which is perhaps attributable to the multifactorial nature of FD and difficulty conducting randomised controlled dietary trials. Patients with FD are recommended to regularly exercise, as aerobic exercise is a cost-effective adjunct to conventional treatment which can reduce stress levels and in turn reduce the severity of FD symptoms.⁶

First line management

There are two main pharmacological agents recommended for first line therapy of FD which include acid suppression with proton pump inhibitors (eg, pantoprazole 40 mg daily) and the use of prokinetics. Prokinetics such as domperidone and metoclopramide, have potential to be an effective treatment option for patients who have delayed gastric emptying as prokinetics enhance gastroduodenal motility and improve gastric accommodation. It is however unclear if prokinetics are useful in managing FD as there is a lack of placebo-controlled trials of easily accessible prokinetics and there is a risk of extrapyramidal side effects and risk of cardiac arrhythmias associated with the use of prokinetics.⁷

Second line management

FD has been identified as a DGBI and there is a subset of research directed towards identifying neuromodulator therapies for the treatment of FD. A significant association between FD with depression and anxiety was shown in a systematic review. In patients with refractory FD, the prevalence of depression was 63.3% and the prevalence of anxiety was 61.5%. In patients with non-refractory FD, the prevalence of depression was 20.9% and the prevalence of anxiety was 23.3%. The prevalence of depression and anxiety was 10% in healthy patients.⁸ There is moderate quality of evidence for treatment of FD with tricyclic antidepressants such as amitriptyline. Amitriptyline can be commenced at a low dose such as 10 mg daily and slowly up-titrated to minimise side effects. These drugs may be continued for 6–12 months if found to be beneficial. There is low-quality evidence to support the use of pregabalin 75 mg daily or antipsychotics such as sulpiride 100 mg four times a day as second-line treatment of FD. There is no evidence that serotonin selective receptor inhibitors or serotonin-norepinephrine reuptake inhibitors are efficacious treatments for FD.

Management of severe or refractory FD

Interestingly, despite the prevalence of FD, there is no consensus definition for severe or refractory FD. There is a lack of strong evidence for the management of severe FD as most randomised control trials (RCTs) do not classify patients by severity.

Patients with severe or refractory FD presenting with dietary restriction or weight loss should be assessed for eating disorders. Involvement of dietitians also appears to have better outcomes for refractory FD especially in formulating clinically assisted nutrition for patients when indicated and assisting with avoidance of over-restrictive diets. While pharmacological agents may be necessary in the treatment of FD, evidence has suggested that a multidisciplinary team and multimodal management has better outcomes in managing refractory FD.

Role of psychological therapies and other therapies

Non-pharmacological options were also explored in this guideline with a focus on psychological therapies. The guidelines highlighted that although evidence is limited, it is important to consider the impact that FD can have on the quality of life of patients. Patients with FD are more likely than those with organic dyspepsia to have moderate to severe depression or anxiety. There are four main gut-brain behavioural interventions which may have efficacy in treating global symptoms of FD: hypnotherapy, stress management, interpersonal psychodynamic informed psychotherapy and cognitive behavioural therapy.⁹

Drugs in development

In the era of biologics and immunomodulators, it is important to appreciate the evolving literature on the role of these agents in the management of FD. Steroids are one of the most widely used immunosuppressive agents and budesonide is an appealing agent to consider in the management of FD. Most formulations however are not designed to deliver budesonide in the upper gastrointestinal system. Talley et al performed a RCT with 162 patients for 8 weeks which showed a drop in duodenal eosinophil count was significantly correlated with a reduction in both early satiety severity and postprandial fullness severity. The results of the study do not strongly support the use of budesonide in FD, however highlight the possibility that a decrease in duodenal eosinophil counts may be associated with symptomatic improvement of FD.¹⁰

Conclusion

FD is a complex DGBI affecting 6.8% of the population in the UK. The BSG guidelines on the management of FD provides a framework for clinicians to use to diagnose and manage patients with FD. The recommendations are consistent with the most current evidence available at the time of publication; however the evidence base is limited. It is expected that these guidelines will be updated regularly with emerging evidence on the pathophysiology and emerging novel agents that can be used to manage FD. Regardless of the pharmacological therapies available, a holistic approach using a biopsychosocial framework is beneficial when managing patients with FD.

Ethics statements

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