Functional dyspepsia: a pragmatic approach.

Functional dyspepsia includes one or more of four cardinal symptoms: postprandial fullness, early satiety, pain or burning in the epigastrum. According to the Rome III diagnostic criteria for functional dyspepsia, these symptoms must be present for the last 3 months with symptom onset at least 6 months prior to diagnosis. Functional dyspepsia is not the result of an underlying structural abnormality, but rather the consequence of multiple pathophysiological mechanisms such as abnormal gastric motility, gastric and duodenal hypersensitivity to acid, Helicobacter pylori infection. Dyspeptic patients over 50 or those with alarm symptoms should be investigated to detect any structural abnormality such as cancer, peptic ulcer or esophagitis. After structural abnormalities and gastroesophageal reflux disease are excluded the management of functional dyspepsia consists of either a test and treat approach (non invasive detection of Helicobacter pylori infection followed by eradication therapy) or empirical therapy. Although endoscopy was traditionally reserved for those patients without symptom relief after 6-8 weeks of therapy, the significant percentage of patients with functional dyspepsia with symptom breakthrough or relapse after antisecretory or prokinetic therapy discontinuation makes an initial endoscopic study a logical choice. Therapy with proton pump inhibitors yields results especially in those patients with regurgitation and epigastric burning sensation, while prokinetic agents with no extrapyramidal side effects (such as Domperidone and Itopride) alleviate satiation, bloating and nausea by accelerating gastric emptying. Second-line drugs with encouraging results in clinical trials which can be used in functional dyspepsia are low-dose tricyclic antidepressants as well as selective serotonine reuptake inhibitors.