What is functional dyspepsia

Functional dyspepsia, also known as nonulcer dyspepsia or “irritable stomach syndrome”, is a medical term for recurring symptoms of an upset stomach or indigestion (dyspepsia) that cannot be fully explained by another medical condition and when no cause can be found after a thorough physical examination and appropriate investigations ¹, ², ³, ⁴, ⁵, ⁶, ⁷, ⁸, ⁹, ¹⁰, ¹¹. Functional dyspepsia symptoms resemble those of an upset stomach or indigestion. Functional dyspepsia is one of the most common functional gastrointestinal disorders and affects more than 20% of the population ¹², ⁹. Functional dyspepsia is more common in women than in men. This difference is due to inherent sex-specific differences in gastrointestinal function. For example, sex-specific variation exists in hormone mechanisms, pain signaling, and healthcare maintenance ⁷.

Functional dyspepsia symptoms include:

• upper abdominal pain or discomfort
• frequently include symptoms of burning, pressure, or fullness often, but not necessarily, related to meals.
• early feeling of fullness (satiety)
• nausea
• belching
• bloating

Functional dyspepsia is common. It is a constant condition but symptoms don’t happen all the time.

Functional dyspepsia can be divided into 3 categories ¹³:

1. Ulcer-like functional dyspepsia,
2. Dysmotility-like functional dyspepsia,
3. Unspecified.

Ulcer-like functional dyspepsia has upper abdominal pain as its predominant symptom. This pain is accompanied by several other symptoms, including ¹³:

• hunger pain that is sometimes relieved by eating,
• pain relieved by antacids,
• night pain,
• periodic pain, and
• pain which may be very localized in the upper middle region of the abdomen.

Dysmotility-like functional dyspepsia has upper abdominal discomfort, not pain, as its predominant symptom. It is accompanied by several other symptoms, including ¹³:

• early feeling of having enough to eat,
• fullness after a meal,
• nausea,
• recurrent retching and/or vomiting,
• upper abdominal bloating, and
• upper abdominal discomfort aggravated by food.

No one knows what causes functional dyspepsia. Experts consider it a functional disorder. That means it can’t be explained by a medical condition, so routine testing may not show any problems or causes. As a result, the diagnosis is based on your symptoms. However, care must be taken not to confuse functional dyspepsia with other common gastrointestinal (GI) disorders that may cause upper gastrointestinal distress, like heartburn, irritable bowel syndrome (IBS), gastroesophageal reflux disease (GERD), functional abdominal bloating, and functional biliary disorders.

Confirmation of the diagnosis of functional dyspepsia rests on ¹⁴, ¹⁵, ¹⁶:

• The typical symptoms and the patient’s history
• The exclusion of other diseases of the upper gastrointestinal tract and upper abdominal organs that may present with similar dyspeptic symptoms.

Functional dyspepsia is diagnosed based on the Rome IV (4) criteria. The diagnosis of functional dyspepsia must include one or more of the following for at least 4 days per month ¹⁷, ¹⁴:

• Bothersome after eating a meal fullness (satiety)
• Bothersome early satiation
• Bothersome epigastric pain not associated with defecation
• Bothersome epigastric burning not associated with defecation
• After appropriate evaluation, the symptoms cannot be fully explained by another medical condition

These criteria should be fulfilled for the last two months before diagnosis ¹⁷.

The current Rome IV (4) criteria divide functional dyspepsia into two subgroups according to the cardinal symptoms (Figure 2) ¹⁷, ¹⁴:

1. Epigastric pain syndrome (EPS)  — predominant epigastric pain or burning.
2. Postprandial distress syndrome (PDS) — feeling of fullness and early satiation.

Functional dyspepsia that can’t be managed with lifestyle changes may need treatment. Functional dyspepsia may be treated with changes in your diet or with medications. Although studies have not proven that dietary changes help, individual dietary experimentation may prove helpful for some.

• Avoiding spicy and fatty food may reduce symptoms of fullness after eating.
• Eating six small, low-fat meals per day may reduce early feelings of fullness, bloating after a meal, or nausea.
• Avoidance of caffeine, alcohol or smoking may also help.

In patients who fail to respond to treatment, specialized diagnostic procedures should be carried out on an individual basis. In the presence of accompanying symptoms of reflux, 24-h monitoring of esophageal pH/impedance may be helpful ¹⁸. C13 Urea Breath tests and gastric emptying scintigraphy may detect an underlying gastric emptying disorder or gastroparesis ⁹.

In the case of accompanying severe flatulence, further breath tests for carbohydrate intolerance and abnormal bacterial colonization may be useful ⁹. Patients whose symptoms do not respond to treatment should be screened for mental disorders such as anxiety, depression, and stress ⁷, ¹⁹, ²⁰, ²¹.

Figure 1. Digestive system

Footnotes: Your digestive system processes nutrients in foods that you have eaten and helps pass waste material out of your body. Food moves from your throat to your stomach through a tube called the esophagus. After food enters your stomach, it is broken down by stomach acid and muscles that mix the food and liquid with digestive juices. After leaving your stomach, partly digested food passes into your small intestine and then into your large intestine. The end of the large intestine, called the rectum, stores the waste from the digested food until it is pushed out of the anus during a bowel movement.

Figure 2. Functional dyspepsia

Footnote: Rome IV criteria for functional dyspepsia and its subclassifications.

Abbreviations: EPS, epigastric pain syndrome; PDS, postprandial distress syndrome.

[Source ⁵ ]

Figure 3. Functional dyspepsia types

Footnote: Definition of functional dyspepsia according to the Rome IV criteria. Functional dyspepsia is divided into two subgroups according to the cardinal symptoms ¹⁴:

• Epigastric pain syndrome (EPS): predominant epigastric pain or burning
• Postprandial distress syndrome (PDS): feeling of fullness and early satiation.

[Source ⁹ ]

Figure 4. Functional dyspepsia diagnostic algorithm

Abbreviations: H.p. = Helicobacter pylori; EGD = esophagogastroduodenoscopy

[Source ⁹ ]

Functional dyspepsia cause

The causes of functional dyspepsia are largely unknown and likely involving or dependent on a number of factors (multifactorial), especially genetic or environmental factors ⁵. Functional dyspepsia is currently considered to be a bio-psychosocial disorder with disturbances of motor function, heightened visceral sensitivity, and possibly a central nervous system disturbance ²², ²³. Psychosocial factors can alter motility and/or enhance sensation and influence the timing of patients’ presentation to physicians ²², ²³. Some evidence exists to implicate a genetic predisposition. Although Helicobacter pylori (H. pylori) infection may produce dyspeptic symptoms in a small subset of patients, there is little data to support this bacteria as a cause of symptoms in a majority of patients. Psychological factors may influence the symptom experience in some patients with functional dyspepsia.

Changes in gastric function have been identified in many patients with functional dyspepsia. In approximately 40% of patients with dyspepsia, the stomach does not relax normally in response to a meal ²⁴, ²⁵, ²⁶. This is known as “impaired accommodation” and may be associated with symptoms of fullness and pressure in some patients. Impaired stomach contractions and abnormal stomach emptying may also be seen in a similar percentage of patients.

Impaired stomach emptying has been associated with symptoms of bloating and early feeling of fullness. As many as two-thirds of patients with functional dyspepsia have heightened perception of stomach activity, which is termed visceral hypersensitivity. While frequently seen, visceral hypersensitivity in functional dyspepsia has not been strongly associated with any specific symptoms.

Both with an empty stomach and after a meal, patients with functional dyspepsia suffer from visceral hypersensitivity when the gastric fundus is expanded ²⁷, ²⁸. The proportion of patients found to have this hypersensitivity depends on the diagnostic criteria and on whether hypersensitivity is defined as abnormal pain projection, allodynia, and/or hyperalgesia. In any case the hypersensitivity correlates with the severity of the symptoms ²⁹. Even patients with normal fundus accommodation may react hypersensitively to expansion of the stomach ³⁰ and some patients with functional dyspepsia also react hypersensitively to expansion of the duodenum, jejunum, or rectum ³¹. This finding points to generalized rather than local visceral sensitization of the efferent or afferent enteric nerves or of the sensory nerves connecting the gut with the central nervous system (gut–brain axis). The hypersensitivity following stomach expansion is ameliorated by inhibition of cholinergic tone but not by active muscle relaxation by means of the NO donor nitroglycerin ³². This shows the predominant role of the cholinergic enteric innervation in the origin of hypersensitivity.

Symptoms of functional dyspepsia occur after infusion of acid into the duodenum ³³ and probably result from sensitized pH sensors or insufficient removal of the acid due to impaired motor function of the proximal duodenum ³⁴. This is in accordance with the elevated sensitivity to capsaicin ³⁵. Capsaicin is a TRPV1 agonist (transient receptor potential cation channel subfamily V member 1) that is stimulated by, among other factors, decreased pH.

The presence of fat in the duodenum triggers the symptoms of functional dyspepsia due to direct neural action, increased sensitivity of enteroendocrine cells, systemic or local elevation of cholecystokinin concentration, and/or increased sensitivity of the cholecystokinin-A receptors ³⁶.

Risk factors for functional dyspepsia

Some factors can increase the risk of functional dyspepsia. They include:

• Being female.
• Using certain pain relievers that are available without a prescription. These include aspirin and ibuprofen (Advil, Motrin IB, others), which can cause stomach problems.
• Smoking.
• Anxiety or depression.
• History of childhood physical or sexual abuse.
• Helicobacter pylori infection.

Functional dyspepsia pathophysiology

Although the exact mechanism is not well understood, the pathophysiology of functional dyspepsia is complex. Several different mechanisms are thought to contribute to each subtype. Traditionally, functional dyspepsia has been attributed to disturbances in gastric physiologic factors divided into macroscopic and microscopic mechanisms.

• Macroscopic mechanisms include the following:
  • Gastroesophageal reflux (GERD)
  • Delayed gastric emptying, rapid gastric emptying, gastric dysrhythmias, and antral hypomotility ³⁷
  • Visceral hypersensitivity alterations in the nervous system ³⁸:
    • Lower threshold for pain in the presence of normal gastric compliance
    • Contributed to abnormal processing of afferent input in the spinal cord or brain as well as dysfunction of mechanoreceptors.
• Microscopic mechanisms include the following:
  • Impaired barrier function
    • Altered sensitivity to duodenal acid or lipids impairs mucosal integrity.
  • Gastroduodenal inflammation ³⁹
    • Characterized by altered lymphocytes, including “gut-homing” lymphocytes, increased eosinophils, and mast cells ⁴⁰
  • Altered gut microbiome and Helicobacter pylori infection ⁴¹

Additional mechanisms include environmental insults like food-inducing gastroduodenal physiologic changes, infections causing inflammation, and allergen exposure can lead to eosinophil recruitment in genetically predisposed patients.

Psychological factors like anxiety and depression can cause increased activation of the amygdala, and the dysregulation of the hypothalamic–pituitary–adrenal (HPA) axis suggests that there is central processing of visceral stimuli from sensations in the gastrointestinal tract ⁴². Acute stress also increases salivary cortisol levels and intestinal permeability in healthy individuals ⁴³. A higher prevalence of functional gastrointestinal disorders is present in patients with a history of childhood abuse ⁴⁴.

Functional dyspepsia symptoms

When you have indigestion or dyspepsia, you may have one or more of the following symptoms:

• Pain or burning in the stomach, bloating, excessive belching, or nausea after eating
• An early feeling of fullness when eating. The feeling of fullness also is called satiety.
• Stomach pain that occurs unrelated to meals or goes away when eating.
• Feeling uncomfortably full after eating a meal
• Bloating
• Burping

Other symptoms may include:

• burping up food or liquid
• loud growling or gurgling in your stomach
• nausea
• gas

Sometimes when you have indigestion, you may also have heartburn. However, heartburn and indigestion are two separate conditions.

Functional dyspepsia types

Functional dyspepsia is divided into two subgroups according to the cardinal symptoms ¹⁴:

• Epigastric pain syndrome (EPS): predominant epigastric pain or burning
• Postprandial distress syndrome (PDS): feeling of fullness and early satiation.

Epigastric pain syndrome

Epigastric pain syndrome with no evidence of systemic, organic, or metabolic disease is diagnosed with at least one of the following symptoms (severe enough to impact usual activities) occurring at least once per week, for 3 or more months with onset at least 6 months before diagnosis: epigastric burning (severe enough to impact usual activities) or epigastric pain.

Supportive criteria include the following ¹⁴:

• Postprandial epigastric bloating, nausea, and belching may also be present.
• Pain does not meet biliary pain criteria.
• Pain may be provoked or relieved by ingesting meals and can also occur while fasting.
• Persistent vomiting is suggestive of another condition.
• Heartburn may coexist.
• Symptoms relieved by flatus or defecation are typically not considered part of dyspepsia.

Postprandial distress syndrome

Postprandial distress syndrome with no evidence of systemic, organic, or metabolic disease is diagnosed with at least one of the following symptoms (severe enough to impact usual activities) occurring at least 3 days per week, for 3 or more months with onset at least 6 months before diagnosis: postprandial fullness (severe enough to impact usual activities) or early satiation that prevents finishing a regular-size meal.

Supportive symptoms include the following ¹⁴:

• Nausea
• Postprandial epigastric pain or burning
• Epigastric bloating
• Excessive belching
• Heartburn

Symptoms relieved by flatus or defecation are typically not considered part of dyspepsia. Persistent vomiting could be suggestive of a coexisting condition. Reflux symptoms and irritable bowel syndrome may also be present.

Functional dyspepsia complications

Although functional dyspepsia is not associated with increased mortality, it does cause physical and mental distress affecting the patient’s quality of life ¹². Patients with functional dyspepsia score higher on psychometric tests for symptoms of anxiety, depression, and somatization. About 10% to 25% of patients report the social impact of their symptoms is significant enough to seek a physician, leading to more healthcare visits, greater health impairment, and a worsening quality of life ¹².

Functional dyspepsia diagnosis

Your doctor will review your symptoms, medical history and perform a physical exam. He or she will ask you about your eating and drinking habits, your use of over-the-counter and prescription medicines, and whether you smoke.

Several tests can help find the cause of your discomfort and rule out other disorders. These may include:

• Blood tests. Blood tests may help rule out other diseases that can cause symptoms like those of functional dyspepsia.
• Laboratory tests for H. pylori. Your doctor may recommend tests to determine whether the bacterium H. pylori is present in your body. He or she may look for H. pylori using a blood, stool or breath test. The breath test is the most accurate.
  • Urea breath test. Doctors may use a urea breath test to check for H. pylori infection. For the breath test, you will swallow a capsule, liquid, or pudding that contains urea “labeled” with a special carbon atom (radioactive carbon). H. pylori breaks down the substance in your stomach. If H. pylori is present, the bacteria will convert the urea into carbon dioxide. After a few minutes, you will breathe into a bag, exhaling carbon dioxide, which is then sealed. If you’re infected with H. pylori, your breath sample will contain the radioactive carbon in the form of carbon dioxide (CO2). If you are taking an antacid prior to the testing for H. pylori, make sure to let your doctor know. Depending on which test is used, you may need to discontinue the medication for a period of time because antacids can lead to false-negative results.
  • Blood test. Doctors may use blood tests to check for signs of H. pylori infection or complications of peptic ulcers. For a blood test, a health care professional will take a blood sample from you and send the sample to a lab.
  • Stool test. Doctors may use stool tests to check for H. pylori infection. Your doctor will give you a container for catching and holding a stool sample. You will receive instructions on where to send or take the kit for testing.
• Upper gastrointestinal endoscopyy also called EsophagoGastroDuodenoscopy (EGD). Your doctor is more likely to recommend endoscopy if you are older, have signs of bleeding, or have experienced recent weight loss or difficulty eating and swallowing. Your doctor may use a scope to examine your upper digestive system (endoscopy). During upper endoscopy (EGD), your doctor passes a hollow tube equipped with a lens (endoscope) down your throat and into your esophagus, stomach and small intestine. Using the endoscope, your doctor looks for ulcers. If your doctor detects an ulcer, a small tissue sample (biopsy) may be removed for examination in a lab. A biopsy can also identify whether H. pylori is in your stomach lining. If the endoscopy shows an ulcer in your stomach, a follow-up endoscopy should be performed after treatment to show that it has healed, even if your symptoms improve.

The American College of Gastroenterology (ACG) recommends the routine use of upper endoscopy in patients older than 60 to rule out malignancy, especially in the setting of red flag signs ¹². If patients do not respond to treatment, pursuing more specialized testing specific to the symptoms is reasonable ⁹. Confirmation of the diagnosis is based on the patient’s history by excluding other diseases with similar presentations ⁹.

In some cases, you may have other tests to see how well your stomach empties its contents.

Confirmation of the diagnosis of functional dyspepsia rests on ¹⁴, ¹⁵, ¹⁶:

• The typical symptoms and the patient’s history
• The exclusion of other diseases of the upper gastrointestinal tract and upper abdominal organs that may present with similar dyspeptic symptoms.

Functional dyspepsia diagnostic criteria

Functional dyspepsia is diagnosed based on the Rome IV (4) criteria. The diagnosis of functional dyspepsia must include one or more of the following for at least 4 days per month ¹⁷, ¹⁴:

• Bothersome after eating a meal fullness (satiety)
• Bothersome early satiation
• Bothersome epigastric pain not associated with defecation
• Bothersome epigastric burning not associated with defecation
• After appropriate evaluation, the symptoms cannot be fully explained by another medical condition

These criteria should be fulfilled for the last two months before diagnosis ¹⁷.

Functional dyspepsia differential diagnosis

These conditions should be considered in functional dyspepsia differential diagnosis.

• GERD
• H. pylori infection
• Gastritis
• Peptic ulcer disease
• Celiac disease
• Irritable bowel syndrome
• Small intestinal bacterial overgrowth
• Chronic pancreatitis
• Gastroparesis
• Acute cholecystitis
• Gastric carcinoma

Functional dyspepsia treatment

Functional dyspepsia treatment depends on your symptoms. It may combine medicines and behavior therapy. Patients whose symptoms do not respond to treatment should be screened for mental disorders such as anxiety, depression, and stress ⁷, ¹⁹, ²⁰, ²¹.

Diet for functional dyspepsia

Most patients with functional dyspepsia have symptoms associated with the ingestion of food. As such, a variety of dietary recommendations are often made, although no clinical trials have formally evaluated specific dietary interventions for the treatment of functional dyspepsia ⁴⁵. There are limited data to suggest that dietary fat may induce or worsens symptoms and patients often report improvement by eating low-fat meals, and more frequent, smaller meals.

Changes to what you eat and how you eat might help control your symptoms. Try to:

• Eat smaller, more-frequent meals. Having an empty stomach sometimes contributes to functional dyspepsia. Nothing but acid in your stomach may make you feel sick. Try eating a small snack such as a cracker or a piece of fruit. Try not to skip meals. Avoid large meals and overeating. Eat smaller meals more often.
• Stay away from trigger foods. Some foods may trigger functional dyspepsia. These may include fatty and spicy foods, carbonated beverages, caffeine, and alcohol.
• Chew your food slowly and completely. Allow time to enjoy your meals.

Reduce stress in your daily life

Chronic stress can be bad for your body and mind. It can put you at risk for health problems such as high blood pressure, stomachaches, headaches, anxiety, and depression. Using stress-reduction techniques or relaxation therapy can help you feel calm and manage your symptoms.

When you feel stress, your body responds by releasing hormones that increase your blood pressure and raise your heart rate. This is called the stress response.

Relaxation techniques can help your body relax and lower your blood pressure and heart rate. This is called a relaxation response.

There are many healthy ways to manage stress. Try a few and see which ones work best for you.

Deep breathing

One of the simplest ways to relax is by practicing deep breathing. You can do deep breathing almost anywhere.

• Sit still or lie down and place one hand on your stomach. Put your other hand over your heart.
• Inhale slowly until you feel your stomach rise.
• Hold your breath for a moment.
• Exhale slowly, feeling your stomach fall.

There are also many other types of breathing techniques you can learn. In many cases, you do not need much instruction to do them on your own.

Meditation

Meditation involves focusing your attention to help you feel more relaxed. Practicing meditation may help you react in a calmer way to your emotions and thoughts, including those that cause stress. Meditation has been practiced for thousands of years, and there are several different styles.

Most types of meditation usually include:

• Focused attention. You might focus on your breath, an object, or a set of words.
• Quiet. Most meditation is done in a quiet area to limit distractions.
• Body position. Most people think meditation is done while sitting, but it can also be done lying down, walking, or standing.
• An open attitude. This means that you stay open to thoughts that come into your mind during meditation. Instead of judging these thoughts, you let them go by bringing your attention back to your focus.
• Relaxed breathing. During meditation, you breathe slowly and calmly. This also helps you relax.

Biofeedback

Biofeedback teaches you how to control some of your body’s functions, such as your heart rate or certain muscles.

In a typical session, a biofeedback therapist attaches sensors to different areas of your body. These sensors measure your skin temperature, brain waves, breathing, and muscle activity. You can see these readings on a monitor. Then you practice changing your thoughts, behaviors, or emotions to help control your body’s responses. Over time, you can learn to change them without using the monitor.

Progressive relaxation

This is another simple technique that you can do almost anywhere. Starting with your toes and feet, focus on tightening your muscles for a few moments and then releasing them. Continue with this process, working your way up your body, focusing on one group of muscles at a time.

Yoga

Yoga is an ancient practice rooted in Indian philosophy. The practice of yoga combines postures or movements with focused breathing and meditation. The postures are meant to increase strength and flexibility. Postures range from simple poses lying on the floor to more complex poses that may require years of practice. You can modify most yoga postures based on your own ability.

There are many different styles of yoga that range from slow to vigorous. If you are thinking about starting yoga, look for a teacher who can help you practice safely. Make sure to tell your teacher about any recent or past injuries.

Tai Chi

Tai chi was first practiced in ancient China for self-defense. Today, it is used mainly to improve health. It is a low-impact, gentle type of exercise that is safe for people of all ages.

There are many styles of tai chi, but all involve the same basic principles:

• Slow, relaxed movements. The movements in tai chi are slow, but your body is always moving.
• Careful postures. You hold specific postures as you move your body.
• Concentration. You are encouraged to put aside distracting thoughts while you practice.
• Focused breathing. During tai chi, your breathing should be relaxed and deep.

If you are interested in tai chi for stress relief, you may want to start with a class. For many people, it is the easiest way to learn the proper movements. You can also find books and videos about tai chi.

Exercise

Getting physical activity every day is one of the easiest and best ways to cope with stress. When you exercise, your brain releases chemicals that make you feel good. It can also help you release built-up energy or frustration. Find something you enjoy, whether it is walking, cycling, softball, swimming, or dancing, and do it for at least 30 minutes on most days.

Functional dyspepsia medication

Some medicines may help manage symptoms of functional dyspepsia. They include:

Gas-relieving medicine

Gas-relieving medicine that are available without a prescription. An ingredient called simethicone may provide some relief by reducing intestinal gas. Simethicone is used to relieve painful pressure caused by excess gas in the stomach and intestines. Simethicone is a silicone compound that functions as a non-systemic surfactant, decreasing the surface tension of gas bubbles in the gastrointestinal (GI) tract ⁴⁶. This action results in coalescence and dispersion of the gas bubbles allowing their removal from the gastrointestinal tract as flatulence or belching. Simethicone causes the gas bubbles to accumulate and therefore pass more easily either through the upper gastrointestinal or lower gastrointestinal opening ⁴⁶. Simethicone does not appear to reduce the actual production of gas in the GI tract ⁴⁷  Examples of gas-relieving medicines include Mylanta, Maalox, Alka-Seltzer Anti-Gas and Gas-X.

Medications to reduce acid production

Acid blockers also called H2-receptor blockers (Histamine Type-2 Receptor Antagonists) reduce the amount of stomach acid released into your digestive tract, which relieves ulcer pain and encourages healing. Available by prescription or over the counter, acid blockers include the medications famotidine (Pepcid AC), cimetidine (Tagamet HB) and nizatidine (Axid AR). Stronger versions of these medicines also are available by prescription.

Medications that block acid production and promote healing. Proton pump inhibitors (PPIs) reduce stomach acid by blocking the action of the parts of cells that produce acid. These drugs include the prescription and over-the-counter medications omeprazole (Prilosec, Zegerid), lansoprazole (Prevacid), rabeprazole (Aciphex), esomeprazole (Nexium), dexlansoprazole (Dexilant) and pantoprazole (Protonix). There are very few medical differences between these drugs. However, long-term use of proton pump inhibitors (PPIs), particularly at high doses, may increase your risk of hip, wrist and spine fracture. Ask your doctor whether a calcium supplement may reduce this risk.

In patients whose symptoms improve with proton pump inhibitors (PPIs), PPI (proton pump inhibitor) therapy should be discontinued every 6 to 12 months to reduce the long-term risk of therapy. The standard dosages of orally administered proton pump inhibitors are as follows:

• Lansoprazole 30 mg daily
• Omeprazole 20 mg daily
• Pantoprazole 40 mg daily
• Rabeprazole 20 mg daily
• Esomeprazole 20 mg daily

Proton pump inhibitors (PPIs) require a meal to activate them. You should eat a meal within 30 minutes to 1 hour after taking this medication for the acid suppression therapy to work most effectively. Waiting later than this time can decrease the positive effect of this medication. This might delay healing or even result in the failure of the ulcer to heal.

Antibiotic medications to kill H. pylori

If H. pylori is found in your digestive tract, your doctor may recommend a combination of antibiotics to kill the bacterium. These may include amoxicillin (Amoxil), clarithromycin (Biaxin), metronidazole (Flagyl), tinidazole (Tindamax), tetracycline and levofloxacin. The antibiotics used will be determined by where you live and current antibiotic resistance rates. You’ll likely need to take antibiotics for two weeks, as well as additional medications to reduce stomach acid, including a proton pump inhibitor (PPI) and possibly bismuth subsalicylate (Pepto-Bismol). To find out if the antibiotics worked, your doctor may recommend testing you for H. pylori at least 4 weeks after you’ve finished taking the antibiotics ⁴⁸. If you still have an H. pylori infection, your doctor may prescribe a different combination of antibiotics and other medicines to treat the infection. Making sure that all of the H. pylori bacteria have been killed is important.

Low-dose antidepressants

Your doctor may prescribe low doses of tricyclic antidepressants (TCAs) and antidepressants known as selective serotonin reuptake inhibitors (SSRIs). These medicines may inhibit the activity of neurons that control intestinal pain.

In patients whose symptoms are refractory to the initial 8 weeks of proton pump inhibitor (PPI) therapy, a tricyclic antidepressant (TCA) is suggested ⁴⁹. For those who respond partially to proton pump inhibitors (PPIs), tricyclic antidepressants (TCAs) may be given in combination therapy with PPIs. The following approach is recommended:

• Start with either of the following low-dose tricyclic antidepressants (TCAs) at night:
  • Amitriptyline 10 mg ⁵⁰
  • Nortriptyline 10 mg
  • Desipramine 25 mg
• Doses may be titrated up modestly according to symptoms.
• Higher doses may cause sedation and still not be more effective.
• Tricyclic antidepressant (TCA) is initially administered for 8 to 12 weeks and then continued for 6 months if the patient responds appropriately.
• Doses are slowly tapered.
• Tricyclic antidepressants (TCAs) may be resumed if symptoms recur.

Mirtazapine has shown benefits in patients with functional dyspepsia and the associated weight loss that may be due to a central mechanism of action ⁵¹. As with tricyclic antidepressants (TCAs), an initial low dose is recommended. The dose is titrated from 7.5 mg an hour before bedtime to 45 mg daily.

Prokinetics

These medicines help your stomach empty faster and tighten the valve between your stomach and esophagus (the lower esophageal sphincter). This helps to reduce upper abdominal pain. Prescription prokinetics include bethanechol (Urecholine) and metoclopramide (Reglan). Metoclopramide 5 to 10 mg is usually given one-half hour before meals and at night.

A 4 to 8 week course is recommended and may be repeated when symptoms recur. However, in some patients, adverse effects may lead to discontinuation of therapy ¹⁵.

Medicines to relieve nausea or anti-emetics

If you feel like throwing up after eating, anti-emetics may help. These include promethazine, prochlorperazine and meclizine.

Psychological therapy

Patients with functional dyspepsia score higher than those without gastrointestinal symptoms for depression, anxiety, and somatization, which are more strongly associated with decreased quality of life than are the clinical symptoms themselves ⁹, ⁷. Your doctor may recommend a type of psychological therapy called “talk therapy” also called psychotherapy to help treat anxiety and depression that may be causing your indigestion. If stress is causing your indigestion, your doctor may recommend ways to help you reduce your stress, such as meditation, relaxation exercises or counseling. Talk therapy can also help you learn how to reduce your stress. A counselor or therapist can show you relaxation techniques to help you cope with your symptoms ⁵². You may also learn ways to reduce stress to help manage your symptoms.

Lifestyle and home remedies

Your doctor may recommend lifestyle changes to help you control your functional dyspepsia.

You are more likely to get indigestion (dyspepsia) if you:

• drink too many alcoholic beverages
• drink too much coffee or too many drinks containing caffeine
• eat too fast or too much during a meal
• eat spicy, fatty, or greasy foods
• eat foods that contain a lot of acid, such as tomatoes, tomato products, and oranges
• feel stressed
• have certain health problems or digestive tract diseases
• smoke
• take certain medicines e.g., nonsteroidal anti-inflammatory drugs (NSAIDs), antibiotics

In addition to making changes in what you eat and drink, you can help prevent indigestion by making lifestyle changes such as: ⁵³

• avoiding exercise right after eating
• chewing food carefully and completely
• losing weight
• not eating late-night snacks
• not taking a lot of nonsteroidal anti-inflammatory drugs
• quitting smoking
• trying to reduce stress in your life
• waiting 2 to 3 hours after eating before you lie down

Get enough sleep

Getting a good night’s sleep can help you think more clearly and have more energy. This will make it easier to handle any problems that crop up. Aim for about 7 to 9 hours each night.

Maintain a healthy diet

Eating healthy foods helps fuel your body and mind. Skip the high-sugar snack foods and load up on vegetables, fruits, whole grains, low-fat or nonfat dairy, and lean proteins.

Avoid stressful situations

When you can, remove yourself from the source of stress. For example, if your family squabbles during the holidays, give yourself a breather and go out for a walk or drive.

Do something you enjoy

When stress has you down, do something you enjoy to help pick you up. It could be as simple as reading a good book, listening to music, watching a favorite movie, or having dinner with a friend. Or, take up a new hobby or class. Whatever you choose, try to do at least one thing a day that’s just for you.

Complementary and alternative treatments

People with functional dyspepsia often turn to complementary and alternative medicines to help them cope. Further studies are needed before complementary and alternative medicines can be recommended. But they may provide some symptom relief when used with other approaches suggested by your health care provider.

If you’re interested in complementary and alternative treatments, talk to your doctor about:

• Herbal supplements. A combination of peppermint and caraway oils may offer some benefit for functional dyspepsia. Together, they relieved pain symptoms in a l-week trial. Iberogast contains extracts of nine herbs. It may relieve gastrointestinal spasms and improve the intestine’s ability to move food. A Japanese herbal remedy called rikkunshito (a kampo herbal medicine) also may be helpful ³. Researchers found it improved abdominal pain, heartburn and bloating better than placebo ⁵⁴, ⁵⁵. A placebo is a treatment with no therapeutic effect that looks the same as, and is given the same way as, the medicine or treatment being tested in a study. Preliminary studies have suggested that rikkunshito (TJ-43, Tsumura and Co) promotes gastric accommodation and expedites gastric emptying time ⁵⁶, ⁵⁷, ⁵⁸. Three randomized control trials have also demonstrated that rikkunshito (a kampo herbal medicine) improves dyspepsia symptoms, including abdominal pain, postprandial fullness, and bloating ⁵⁹, ⁶⁰, ⁵⁵. Artichoke leaf extract may reduce symptoms of functional dyspepsia.

Functional dyspepsia prognosis

Functional dyspepsia is a benign common gastrointestinal disorder ¹². Functional dyspepsia is relapsing and remitting ⁶¹. In a European study of patients with functional dyspepsia, dyspepsia symptoms recurred within 3 months in 20% of the patients whose symptoms had disappeared after 4 weeks of treatment with a proton pump inhibitor (PPI) or placebo ⁶². Similarly, in a Japanese study of patients with functional dyspepsia whose symptoms improved with a prokinetic drug called acotiamide, functional dyspepsia was found to have recurred in 25% of the patients at 1 year ⁶³.

Population studies have shown that 15% to 20% of patients have persistent symptoms during extended follow-up, while 50% have complete resolution of symptoms ¹². In a population-based cohort study in the United States of the impact of functional gastrointestinal disorders (FGIDs) on survival with over 30,000 person-years of follow-up, no association with overall survival was detected for dyspepsia, IBS, chronic diarrhea, or abdominal pain ⁶⁴. Likewise, a population-based cohort study in the United Kingdom with over 84,000 person-years of follow-up also found that dyspepsia did not increase mortality ⁶⁵. Taken together, these studies indicate that functional dyspepsia does not appear to increase mortality.

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