Brooks D. Cash, MD, FACP, FACG


December 12, 2002

In This Article


The optimal treatment of dyspepsia has yet to be determined ( Table 1 ). Initial evaluation should focus on easily reversible etiologies, such as iatrogenic causes, and the establishment of an empathetic and realistic patient-physician relationship.

When patients fulfill Rome II criteria for dyspepsia and do not exhibit alarm features, a reasonable approach is to begin empiric antisecretory therapy or to test for HP infection and, if positive, treat with an appropriate course of antimicrobial therapy. Until HP infection becomes less prevalent, this latter approach has a high probability of curing dyspepsia that is due to HP-mediated peptic ulcer disease or HP-mediated mucosal inflammation, and has the additional benefit of possibly reducing the risk of future peptic ulcers and neoplastic conditions.[41] If there is no response to the first therapy employed, the clinician should switch to the alternative. Any patient with alarm features or persistent symptoms after HP testing or an adequate trial of antisecretory therapy should proceed to upper endoscopy with subsequent therapy directed toward any abnormalities detected. The majority of patients with dyspepsia will not have organic disease and will ultimately be diagnosed with functional dyspepsia. There is some evidence to suggest that upper endoscopy may confer a therapeutic benefit in these latter patients through the inherent reassurance value associated with a negative diagnostic test. However, most patients with functional dyspepsia will continue to experience symptoms after the initial empiric therapy trials and diagnostic tests.

Subsequent therapeutic options for functional dyspepsia are numerous but largely unproven. Several trials support the use of enteric nervous system mediators such as tricyclic antidepressants and serotonin receptor agonists, but this evidence is limited by methodologic inconsistencies. Other promotility agents are limited by dose-related and idiosyncratic adverse reactions or are not currently available in the United States. Antispasmodic agents have not been shown to be beneficial for patients with functional dyspepsia. Other strategies, such as psychotherapy, biofeedback, and alternative medicine therapies, require more rigorously controlled trials before they can be routinely recommended or discouraged.