Dr Lacy provides guidance for diagnosing and managing treatment of functional dyspepsia in the gastroenterology practice.

Brian Lacy, MD, is a professor of medicine at the Mayo Clinic in Jacksonville, Florida.

TRANSCRIPT:

Hi, I'm Brian Lacy, Professor of Medicine at Mayo Clinic in Jacksonville, Florida. Welcome from Chicago, we're at DDW 2023. I just gave a presentation on the management of functional dyspepsia for the busy provider, and I wanted to summarize a few key tips I think that help busy providers make the diagnosis and then manage this very prevalent problem. And I think a first key tip is to remember the distinction between uninvestigated dyspepsia and functional dyspepsia.

And uninvestigated dyspepsia are those patients with symptoms thought to arise from the gastroduodenal region. And we know that there are really 4 key symptoms of dyspepsia. Early satiety, that sensation of feeling full, postprandial fullness or pressure, and epigastric pressure or discomfort.

And I'll put that together. So those are really the cardinal symptoms of dyspepsia. Now when you hear those symptoms, you want to think, is this an organic process? Significant gastritis, peptic ulcer disease, maybe ongoing esophagitis, which can sometimes mimic dyspeptic symptoms, or more likely is this functional dyspepsia.

And that's where we then perform some limited testing to translate those patients from uninvestigated dyspepsia to investigated and more likely functional dyspepsia. And that's really 80% of the patient population.

How do you do that? It generally involves some simple blood work, a blood count, a basic metabolic profile, maybe a CRP, and then an upper endoscopy, likely including biopsies of the stomach to eliminate the possibility of H. pylori playing a role, and duodenal biopsies as well. So we think about this problem too, because it's so common. So when we think about these patients with symptoms, remember the differential diagnosis.

But when you think about those 4 cardinal symptoms, dyspepsia is really on the top of the list. And we recently did the study at Mayo Clinic Jacksonville, looking at 400 patients with symptoms thought to represent gastroparesis, which is part of the differential diagnosis. But 80% of those patients who were thought to have gastroparesis by their local providers actually had functional dyspepsia. So that's an important teaching point.

What else is on the list? Of course, you can think about small intestine bacterial overgrowth, celiac disease, peptic ulcer disease, which I mentioned, and of course, malignancy, which is worrisome for the possibility to both patients and providers, but actually not very common at all. So now you're thinking about this patient with these dyspeptic symptoms, you've made the diagnosis of functional dyspepsia, what are your management options? So remember that in the United States there are no FDA approved medications. So technically everything we do is off-label.

So let's think simply about diet, although we don't have great data, think about a small, frequent meal low in fat. Then we think about the first step, and for the majority of patients, a proton pump inhibitor, a PPI, is the first step because many patients pathophysiologically are sensitive to acid. And so a PPI makes sense.

But another great teaching point is high-dose PPIs are no better than lower dose, and double dose PPIs are definitely not better than single dose. So start a single dose PPI. If patients feel better, great, you're on your pathway to success. But if they continue to have dyspeptic symptoms, then think about either a tricyclic antidepressant, a neuromodulator. Remember, functional dyspepsia is a disorder of gut-brain interaction, that bidirectional pathway. So a neuromodulator, such as a tricyclic makes great sense, or consider a prokinetic agent.

Unfortunately, we don't have head-to-head trials, so I think listen to your patient, understand their symptoms, and either a low dose neuromodulator such as a tricyclic or a low dose prokinetic agent would be very reasonable. If they fail one of those options, then I would reverse the course and substitute the other medication.

Many patients and providers ask about alternative therapies. Don't forget, because this is a disorder of brain-gut interaction, cognitive behavioral therapy may be very effective. Hypnotherapy has been shown to be effective as well. In terms of over-the-counter agents, Iberogast is a combination of 9 different herbal products, and peppermint oil may be helpful as well.

So I think the take-home message today is, don't forget about functional dyspepsia. This is much more common than other disorders of the upper GI tract such as gastroparesis. We do have a number of different treatment options available. Try to understand your patient's symptoms, recognize that this causes significant patient distress, reduces quality of life. So intervening with either diet or medications can really improve patient's quality of life. Thanks so much for joining us, and again, welcome from Chicago.