Dyspepsia: A stepwise approach to evaluation and management
Let a patient’s age and specific symptoms steer your initial investigation. Consider treatment options beyond antibiotics for H pylori gastritis and PPIs.
PRACTICE RECOMMENDATIONS
› Test for Helicobacter pylori in patients who are < 60 years of age or who have no alarm symptoms. If results are negative, consider a trial of proton pump inhibitor therapy. C
› Arrange for esophagogastroduodenoscopy in individuals ≥ 60 years of age and all patients with alarm symptoms, to identify or rule out a structural cause. C
› Consider a diagnosis of functional dyspepsia if the work-up is negative. Supportive therapy, including the use of tricyclic antidepressants, prokinetics, and a holistic approach to lifestyle changes in select patients have shown encouraging results. C
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
A shortcoming of the established guidelines is that they do not provide guidance as to long-term management of those patients who respond to prescription medications. Our practice has been to continue medications for a minimum of 3 months, then begin a slow taper in order to establish the lowest efficacious dose. Some patients may relapse and require full dosage for a longer period of time.
Adjunctive therapies are worth considering
Complementary and alternative medicines. Products containing ginger, carraway oil, artichoke leaf extract, turmeric, and red pepper are readily available without prescription and have long been used with variable results for dyspepsia.22 The 9-herb combination STW-5 has demonstrated superiority over placebo in a number of studies and has a favorable safety profile.23 The recommended dose is 10 to 20 drops tid. The European manufacturer has recently modified the package insert noting rare cases of hepatotoxicity.24
A commercially available formulation (FDgard) containing L-menthol (a key component of peppermint oil) and caraway has been found to reduce the intensity of symptoms in patients with FD. Potential adverse effects include nausea, contact dermatitis, bronchospasm, and atrial fibrillation. Cayenne, a red pepper extract, is available over the counter for the benefit for epigastric pain and bloating. Begin with a 500-mg dose before breakfast and a 1000-mg dose before dinner, increasing to 2500 mg/d as tolerated. Cayenne preparations may trigger drug toxicities and are best avoided in patients taking antihypertensives, theophylline, or anticoagulants.
Cognitive behavioral therapy, acupuncture, and hypnosis. These modalities are time consuming, are often expensive, are not always covered by insurance, and require significant motivation. A systematic review found no benefit.25 Subsequent studies summarized in the ACG guidelines2 reported benefit; however, a lack of blinding and significant heterogeneity among the groups detract from the quality of the data. It remains unclear whether these are effective strategies for FD, and therefore they cannot be recommended on a routine basis.
CORRESPONDENCE
Norman H. Gilinsky, MD, Division of Digestive Diseases, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267-0595; norman.gilinsky@ uc.edu
