Guideline sources The following summarized guidelines for the evaluation and management of functional dyspepsia are prepared by our editorial team based on guidelines from the British Society of Gastroenterology (BSG 2022), the American College of Gastroenterology (ACG/CAG 2017), and the Maastricht V/Florence Consensus Report (Maastricht V/Florence 2017). 1 2 3 Guidelines 1. Screening and diagnosis Differential diagnosis: exclude H. pylori gastritis before making a reliable diagnosis of functional dyspepsia. A Diagnosis: Recognize that most patients with dyspepsia will have functional dyspepsia as the underlying cause of their symptoms after investigation. B Diagnose functional dyspepsia in the presence of bothersome epigastric pain or burning, early satiation and/or postprandial fullness of > 8 weeks duration in the absence of upper gastrointestinal alarm symptoms or signs. B 2. Diagnostic investigations https://web.pathway.md/diseases/recZHCBG24opDw9BU 1/4 6/29/23, 4:08 AM Functional dyspepsia Pathway Testing for Helicobacter pylori: obtain noninvasive testing for H. pylori ('test and treat') in all patients with dyspepsia in the absence of alarm features. A Laboratory tests: Obtain a CBC in 55 years old patients with dyspepsia. B Obtain celiac serology in all patients with functional dyspepsia and overlapping IBS-type symptoms. B Diagnostic imaging: consider obtaining urgent abdominal CT to exclude pancreatic cancer in 60 years old patients with abdominal pain and weight loss. B Motility testing: Do not obtain routine motility studies in patients with functional dyspepsia. D Consider obtaining motility studies in selected patients with functional dyspepsia with a strong suspicion of gastroparesis. C Gastric emptying testing: do not obtain routine gastric emptying testing in patients with typical symptoms of functional dyspepsia. D pH monitoring: do not obtain routine 24-hour pH monitoring in patients with typical symptoms of functional dyspepsia. D 3. Diagnostic procedures Upper gastrointestinal endoscopy: Perform urgent endoscopy only in the following patients if no other upper gastrointestinal alarm symptoms or signs are reported: age 55 years, dyspepsia and weight loss age > 40 years, coming from an area at an increased risk of gastric cancer or having a family history of gastroesophageal cancer. B Consider performing non-urgent endoscopy in 55 years old patients with treatment- resistant dyspepsia or dyspepsia with either a raised platelet count or nausea or vomiting. C 4. Medical management Setting of care: Manage patients with functional dyspepsia referred to secondary care ideally in a specialist clinic with access to an interested clinician, dietetic and lifestyle support with access to efficacious drugs and gut-brain behavioral therapies. B Refer patients with functional dyspepsia to gastroenterology in secondary care in the following situations: diagnostic doubt severe symptoms symptoms refractory to first-line treatments individual patient requesting a specialist opinion. B Helicobacter pylori eradication: https://web.pathway.md/diseases/recZHCBG24opDw9BU 2/4 6/29/23, 4:08 AM Functional dyspepsia Pathway As per BSG 2022 guidelines: Initiate eradication therapy for the treatment of H. pylori-positive patients with functional dyspepsia. A Confirm successful eradication of H. pylori after 'test and treat' only in patients with an increased risk of gastric cancer. B As per ACG 2017 guidelines, initiate treatment for H. pylori infection in H. pylori-positive patients with functional dyspepsia. A Acid suppression therapy: As per BSG 2022 guidelines, offer empirical acid suppression therapy with PPIs at the lowest dose A or histamine-2-receptor antagonists in patients without H. pylori infection. B As per ACG 2017 guidelines, offer empirical PPIs in H. pylori-negative patients with functional dyspepsia or in patients remaining symptomatic despite eradication of the infection. B Prokinetics: As per BSG 2022 guidelines, consider offering certain prokinetics, such as tegaserod, B acotiamide, itopride, and mosapride, for the treatment of patients with functional dyspepsia. C As per ACG 2017 guidelines, offer prokinetics in patients with functional dyspepsia not responding to PPIs, H. pylori eradication therapy or TCAs. B Tricyclic antidepressants: As per BSG 2022 guidelines, consider offering TCAs as gut-brain neuromodulators as second-line therapy in patients with functional dyspepsia providing a careful explanation as to the rationale for their use and counseling patients about their side effect profile. Initiate TCAs at a low dose (such as 10 mg amitriptyline once daily) and titrate slowly to a maximum of 30-50 mg once daily. B As per ACG 2017 guidelines, offer TCAs in patients with functional dyspepsia not responding to PPIs or H. pylori eradication therapy (if appropriate). B Other antidepressants: insufficient evidence to support the use of SSRIs I or SNRIs as gut- brain neuromodulators as second-line therapy for global symptoms in patients with functional dyspepsia. I Show 2 more Antipsychotics: consider offering antipsychotics, such as sulpiride 100 mg QID or levosulpiride 25 mg TID, as second-line therapy in patients with functional dyspepsia providing a careful explanation as to the rationale for their use and counseling patients on their side effect profile. C Anticonvulsants: consider offering pregabalin 75 mg once daily as second-line therapy in patients with functional dyspepsia only in specialist settings. C 5. Nonpharmacologic interventions Dietary modifications: insufficient evidence to recommend dietary therapies, including a diet low in FODMAP, in patients with functional dyspepsia. I https://web.pathway.md/diseases/recZHCBG24opDw9BU 3/4 6/29/23, 4:08 AM Functional dyspepsia Pathway Physical activity: advise practicing regular aerobic exercise in all patients with functional dyspepsia. B Psychological interventions: As per BSG 2022 guidelines, consider offering the following interventions for global symptoms in patients with functional dyspepsia: interpersonal psychodynamic-informed psychotherapy cognitive-behavioral therapy and metacognitive therapy stress management approaches hypnotherapy. C As per ACG 2017 guidelines, consider offering psychological therapies in patients with functional dyspepsia not responding to drug therapy. C Alternative and complementary medicine: do not use complementary or alternative medicines in patients with functional dyspepsia. D 6. Patient education General counseling: Establish an effective and empathic doctor-patient relationship and a shared understanding as the cornerstone of the management of functional dyspepsia, which may also reduce healthcare utilization and improve quality of life. B Educate patients with functional dyspepsia about the diagnosis, its underlying pathophysiology, and the natural history of the condition including common symptom triggers. Introduce functional dyspepsia as a disorder of gut-brain interaction together with a simple account of the gut-brain axis and how this is impacted by diet, stress, cognitive, behavioral and emotional responses to symptoms and post-infective changes. B 7. Follow-up and surveillance Management of severe or refractory disease: involve a multidisciplinary support team in the management of patients with severe or refractory functional dyspepsia. B Show 3 more References 1. Christopher J Black, Peter A Paine, Anurag Agrawal et al. British Society of Gastroenterology guidelines on the management of functional dyspepsia. Gut. 2022 Sep;71 9 1697 1723. Open 2. Paul Moayyedi, Brian E Lacy, Christopher N Andrews et al. ACG and CAG Clinical Guideline: Management of Dyspepsia. Am J Gastroenterol. 2017 Jul;112 7 988 1013. Open 3. P Malfertheiner, F Megraud, C A O'Morain et al. Management of Helicobacter pylori infection-the Maastricht V/Florence Consensus Report. Gut. 2017 Jan;66 1 6 30. Open https://web.pathway.md/diseases/recZHCBG24opDw9BU 4/4