Functional Dyspepsia

Pt <55 y/o with h/o GERD, IBS, anxiety/depression presents with chronic, paroxysmal epigastric pain associated with early satiety. Symptoms started 6 months ago and have been persistent during past 3 months. Abdominal pain does not radiate to chest/back/RUQ and is not relieved by flatus. Pt cannot finish normal size meals multiple times per seek due to sensation of bloating/nausea. Denies excessive alcohol use and red flags including unintended weight loss, progressive dysphagia, persistent vomiting, dark tarry stools, BRBPR. No family h/o GI malignancy. Pain with palpation of epigastric region on exam.

• Obtain CBC, BMP, H. pylori fecal antigen testing

• Treatment

  • CrCl >50 mL/min: Start ranitidine 150 mg BID

  • Positive H. pylori fecal antigen test: Triple therapy with omeprazole 20 mg BID, amoxicillin 1 g BID, and clarithromycin 500 mg BID x 14 days

  • Refractory symptoms

    • Negative H. pylori fecal antigen testing: Consider starting metoclopramide 5 mg TID; pt counseled that medication should not be taken for greater than 12 weeks due to risk for tardive dyskinesia

    • H. pylori fecal antigen testing and s/p triple therapy: Consider quadruple therapy vs. referral for EGD (see PUD)

• Pt advised to schedule follow-up appointment to address anxiety/depression

Notes

• Affects 40 percent of adults yearly

• Responsible for 70% of dyspepsia cases; differential also includes

  • Peptic ulcer disease (~20%)

  • Reflux esophagitis (~10%)

  • Esophageal/gastric CA (~2%)

• Diagnosis

  • CBC screens for anemia that may occur due to GI bleed

  • Rome III criteria separates condition into disorders of epigastric pain and postprandial fullness

• Intervention

  • Ranitidine

    • If not already documented, calculate creatinine clearance before starting BID

    • CrCl <50 mL/min: Start 150 mg qd

  • Metoclopramide (Reglan): Use with caution in older adults

  • Consider endoscopy and/or colonoscopy for patients older than 55 years and/or those with red flag symptoms