Managing dyspepsia as a generalist

Opening Vignette

Tom, a 38-year-old business executive, presents to your clinic with a 6-month history of dyspepsia. The symptoms have persisted despite frequent use of over-the-counter antacids. He is concerned about the cause of his symptoms having heard that they can be linked to ulcers and cancer.

WHAT IS DYSPEPSIA?

Dyspepsia is a broad term used to describe a range of epigastric symptoms, such as pain, burning, postprandial fullness and early satiety. Dyspepsia can be caused by structural disease or functional conditions. Box 1 shows a non-exhaustive list of structural causes of dyspepsia. Functional (or non-ulcer) dyspepsia (FD) makes up the majority of cases of dyspepsia (up to 70%–80%).[1,2] The Rome IV criteria, shown in Box 2, describe the features that are suggestive of this condition.[3]

Box 1.

Structural causes of dyspepsia.

• Peptic ulcer disease (including that caused by Helicobacter pylori infection or NSAID use)

• Gastro-oesophageal reflux disease

• Biliary colic

• Chronic pancreatitis

• Malignancy (oesophageal, gastric, hepatoma, pancreatic)

• Others: Crohn’s disease, mesenteric ischaemia, hypercalcaemia

NSAID: nonsteroidal anti-inflammatory drug

Box 2.

Rome IV criteria for functional dyspepsia.

Functional dyspepsia (FD)
Diagnostic criteria
1. Fulfilled at least one of the following bothersome symptoms for the last 3 months with symptom onset at least 6 months prior to diagnosis:
• Post-prandial fullness
• Early satiety
• Epigastric pain
• Epigastric burning
AND
2. No evidence of organic, systemic, or metabolic disease that is likely to explain the symptoms on routine investigations (including at upper endoscopy).
Supportive criteria
1. Pain may be induced by ingestion of a meal, relieved by ingestion of a meal or may occur while fasting.
2. The pain does not fulfil biliary pain criteria. 3. Post-prandial bloating, belching, and nausea can also be present.
4. Vomiting warrants consideration of another disorder.
5. Other digestive symptoms (such as from GERD and IBS) may coexist.
Two subtypes of functional dyspepsia
1. Postprandial distress syndrome: Must have one or both of the following bothersome symptoms at least 3 days a week, for the last 3 months with symptom onset at least 6 months prior to diagnosis.
• Post-prandial fullness (severe enough to impact on usual activities)
• Early satiety (severe enough to prevent finishing a regular size meal)
2. Epigastric pain syndrome: Must have bothersome epigastric pain or burning (severe enough to impact on usual activities) at least 1 day a week, for the last 3 months with symptom onset at least 6 months prior to diagnosis.

GERD: gastroesophageal reflux disease, IBS: irritable bowel syndrome

HOW RELEVANT IS THIS TO MY PRACTICE?

Dyspepsia is a common presenting complaint of patients at general practitioner clinics and hospitals. The prevalence of dyspepsia is approximately 20% worldwide,[4] while local data on FD show a prevalence of 4%–8%.[5,6]

Functional dyspepsia affects patients and the healthcare system in various ways. Patients with FD have significantly higher healthcare utilisation than those without it.[7] They also report lower physical and mental well-being, as well as lower work output due to absenteeism and decreased productivity while at work.[8,9] Subsequent referrals to tertiary healthcare and further investigations add to this burden, with patients and the healthcare system bearing the costs of investigations that often do not identify a secondary pathology.[10] The interplay between the physical and psychosocial aspects of one’s health was apparent during the coronavirus disease 2019 pandemic. A survey of 5000 subjects in Japan showed that anxieties about contracting the disease, coupled with changes to everyday life (e.g. social distancing, stay-at-home orders), were associated with an increase in gastrointestinal (GI) symptoms.[11] Because FD is a common condition, understanding the broad principles — such as excluding organic disease and addressing both the physical and psycho-emotional aspects — is important in managing the condition well.

WHAT CAN I DO IN MY PRACTICE?

Establishing the diagnosis

A comprehensive clinical history should be taken. This includes duration of symptoms, associated upper GI symptoms (including alarm signs and symptoms as shown in Box 3), and family history of upper GI malignancy.[12] Depending on the local epidemiological risk for gastric cancer, the recommended age for endoscopy in patients with new-onset dyspepsia varies between 40 and 50 years. Previous studies have suggested an age cut-off of 45 years for Singapore.[13,14] Other relevant history includes use of medications such as nonsteroidal anti-inflammatory drugs, steroids, certain traditional medications, metformin, acarbose, iron and bisphosphonates, use of medications that alter gut motility, excessive alcohol consumption, and recent changes in diet.[15] Without the presence of alarm symptoms and signs, the majority of patients are likely to have FD. Subjecting these patients to extensive, and sometimes repeated, investigations is unlikely to change the diagnosis.

Box 3.

Alarm symptoms and signs.

• Unintentional weight loss

• Dysphagia

• Odynophagia

• Unexplained iron deficiency anaemia

• Persistent vomiting

• Gastrointestinal bleeding (melaena or haematemesis)

• Palpable mass or lymphadenopathy

• Family history of upper gastrointestinal malignancy

Other than epigastric tenderness, which may be present, clinical examination should be normal. The patient should not have clinical signs such as cachexia, conjunctival pallor, jaundice, supraclavicular lymphadenopathy, abdominal mass or any organomegaly.[16] Non-invasive testing (carbon urea breath test) and treatment for Helicobacter pylori should be offered if not previously done.[17]

Management

Our approach to the management of FD is shown in Figure 1.[1,13] We recommend that, in the absence of alarm symptoms or signs [Box 3], clinicians should diagnose FD in the presence of bothersome epigastric pain, early satiety or postprandial fullness lasting longer than 3 months. Management of FD involves a two-pronged approach, comprising both pharmacological and non-pharmacological methods. Lifestyle changes include regular aerobic exercises[18] and the avoidance of dietary food triggers. Commonly reported triggers include dairy products, fatty foods, spicy foods, alcohol, coffee, carbonated drinks, red meat, carbohydrates, wheat and citrus.[19]

Figure 1.

Chart shows the management of functional dyspepsia. ^aIdentify and avoid trigger foods and perform regular aerobic exercise. ^bLowest effective dose of proton pump inhibitors for acid suppression. Prolonged prokinetic agent use is not recommended due to side effects. Acid suppression and prokinetic agents can be used simultaneously. ^cLow-dose amitriptyline initiated at 10 mg at bedtime. Multidisciplinary team includes gastroenterologists, dietitians and clinical psychologists.

Acid suppression with a proton pump inhibitor (PPI) is recommended for managing FD. The lowest effective dose should be used as there is no apparent dose–response relationship. We recommend a treatment course of 8 weeks. If symptoms resolve or improve, PPIs can be discontinued with standby as-needed therapy or maintained at the lowest tolerated dose. The use of PPIs is most beneficial in patients with epigastric pain syndrome (EPS) who experience symptoms of burning and reflux-like pain. There is little data to support the use of antacids, alginates and sucralfate for the treatment of dyspepsia symptoms.[20] Prokinetics such as metoclopramide and domperidone can be considered in patients with FD who experience postprandial fullness and early satiety.[21] Acid suppression and prokinetic agents can be used concurrently. Due to the associated adverse effects such as cardiac arrhythmias and extrapyramidal side effects, it is recommended that these medications be used only for a short duration of time.

In patients with chronic and refractory symptoms, gut–brain neuromodulation is used as second-line treatment. It can be initiated in both primary and tertiary care settings, with patients counselled on the potential risks and benefits of these medications. Recommended agents include tricyclic antidepressants (TCAs) initiated at a low dose and titrated upwards slowly, e.g., 10 mg of amitriptyline at bedtime and gradually uptitrated to a maximum of 30–50 mg daily.[22] Side effects of TCAs include sleepiness, dizziness, dry mouth, urinary retention and sexual dysfunction. There is no evidence that selective serotonin reuptake inhibitors or serotonin–norepinephrine reuptake inhibitors are effective second-line gut–brain neuromodulators.

WHEN SHOULD I REFER TO A SPECIALIST?

Patients with severe symptoms that are affecting their quality of life should be referred to tertiary care with a multidisciplinary support team involving gastroenterologists, dietitians and clinical psychologists.[23]

Referral of patients with dyspepsia to gastroenterology in tertiary care is appropriate when (a) there are alarm symptoms and/or signs, (b) there is diagnostic doubt, (c) the symptoms are severe or refractory to first-line treatments, or (d) the individual patient requests a specialist opinion.

TAKE HOME MESSAGES

1. Most patients who present with dyspepsia have FD (70%–80%).

2. If alarm features are present, patients should be promptly referred to a gastroenterologist.

3. Functional dyspepsia can be managed via a pharmacological or non-pharmacological approach.

4. An effective and empathetic doctor–patient relationship is crucial for the optimal management of patients with FD.

Closing Vignette

After a urea breath test, you exclude H. pylori infection and prescribe the patient with an 8-week course of proton pump inhibitor. You advise him to reduce his intake of spicy food, alcohol, caffeine and carbonated drinks. His symptom of dyspepsia markedly improved on subsequent review.

Conflicts of interest

There are no conflicts of interest.

SMC CATEGORY 3B CME PROGRAMME

Online Quiz: https://www.sma.org.sg/cme-programme

Deadline for submission: 6 pm, 25 August 2025

Question: Answer True or False
1. Dyspepsia is a general term used to describe various epigastric symptoms.
2. Structural causes of dyspepsia are more common than functional causes.
3. The Rome IV criteria are used to diagnose only irritable bowel syndrome, and not functional dyspepsia.
4. A 3-month history of dyspepsia makes functional dyspepsia less likely.
5. Epigastric pain relieved by defaecation supports the diagnosis of functional dyspepsia.
6. Early satiety can be associated with functional dyspepsia.
7. Dyspepsia can lead to reduced mental well-being and decreased productivity at work.
8. Patients with dyspepsia have increased healthcare resource utilisation.
9. All patients with dyspepsia should be referred to a gastroenterologist for consideration of an upper gastrointestinal endoscopy at some stage.
10. All patients aged 40 years and above with dyspepsia need to be referred to a gastroenterologist.
11. Dysphagia associated with dyspepsia requires a referral to a gastroenterologist.
12. Vomiting associated with dyspepsia requires a referral to a gastroenterologist.
13. Iron deficiency anaemia associated with dyspepsia requires a referral to a gastroenterologist.
14. Helicobacter pylori should be excluded in patients with persistent dyspeptic symptoms.
15. Dairy products can exacerbate dyspeptic symptoms.
16. Acid suppression therapy is a cornerstone of the pharmacological management of dyspepsia.
17. Prokinetics can be used for patients with functional dyspepsia.
18. There is evidence for the use of tricyclic antidepressants in the pharmacological management of functional dyspepsia.
19. There is evidence for the use of selective serotonin reuptake inhibitors in the pharmacological management of functional dyspepsia.
20. Pharmacological therapy alone is effective in treating functional dyspepsia.

Funding Statement

Nil.