Evidence-based clinical practice guidelines for functional dyspepsia

Key points

• Functional dyspepsia (FD) is diagnosed from chronic upper abdominal symptoms without organic, systemic or metabolic disease; endoscopy is no longer required for every patient and is reserved for suspected organic disease.
• Alarm signs such as new onset at an advanced age, weight loss, recurrent vomiting, bleeding, dysphagia, an abdominal mass, fever or a family history of oesophageal or gastric cancer call for further investigation.
• First-line treatment: lifestyle and dietary modification, proton pump inhibitors (PPIs) or H2-receptor antagonists, the acetylcholinesterase inhibitor acotiamide and the Japanese herbal medicine rikkunshito.
• Second-line treatment: dopamine receptor antagonists, 5-HT4 receptor agonists, other herbal medicines, tricyclic antidepressants and anxiolytics such as tandospirone.
• FD can recur but does not appear to increase mortality.

Overview

These are the 2021 revised guidelines of the Japanese Society of Gastroenterology (JSGE) for FD, created with the GRADE system from 24 background questions, 9 future research questions and 7 clinical questions. Their two main changes are a new, limited role for endoscopy in diagnosis and updated drug recommendations that divide acid suppressants and prokinetics into classes, each with its own recommendation grade.

Definition and epidemiology

FD is defined by chronic symptoms centred in the upper abdomen, such as epigastric pain or discomfort, with no organic, systemic or metabolic disease likely to explain them. Unlike the Rome IV criteria, the guidelines set no specific symptom duration and leave the meaning of 'chronic' to the treating physician. Dyspepsia with Helicobacter pylori infection is treated as H. pylori-associated dyspepsia. In Japan, the prevalence of FD is 11–17% among people attending medical checkups and 45–53% among those seeking care for upper gastrointestinal symptoms.

Diagnosis

FD is diagnosed from a comprehensive evaluation of symptoms, age, medical history, H. pylori status and laboratory findings. If there are no alarm signs and no suspicion of organic disease, endoscopy is not needed and treatment should be started. The absence of alarm signs does not exclude organic disease, so patients who do not respond to initial treatment or relapse after stopping it should be examined thoroughly. Self-reporting questionnaires are recommended, while gastrointestinal function tests are not a routine clinical procedure.

Treatment

A good patient-physician relationship is useful, and placebo can have a strong effect (5–90%, average 56% in a meta-analysis). PPIs and H2-receptor antagonists are strongly recommended; a 2017 Cochrane review found a response rate of 31.1% with PPIs versus 25.8% with placebo. The efficacy of potassium-competitive acid blockers cannot yet be evaluated. Acotiamide and rikkunshito are first-line drugs because their evidence is much stronger than that for other prokinetics and herbal medicines. Patients who do not respond to these regimens are regarded as having refractory FD.

Frequently asked questions

Is endoscopy needed to diagnose functional dyspepsia?

No; it is performed when organic disease is suspected, for example because of an alarm sign, and the decision is left to the physician.

How often does FD recur?

In a European study symptoms recurred within 3 months in 20% of patients whose symptoms had disappeared, and in a Japanese study FD recurred in 25% at 1 year after improvement with acotiamide.

Which conditions often overlap with FD?

Irritable bowel syndrome (66.9% of FD cases diagnosed by the Rome IV criteria), gastroesophageal reflux disease, chronic constipation, anxiety and depression.

Source

Miwa H, Nagahara A, Asakawa A, Arai M, Oshima T, Kasugai K, et al. Evidence-based clinical practice guidelines for functional dyspepsia 2021. Journal of Gastroenterology 2022;57(2):47-61. DOI: 10.1007/s00535-021-01843-7. Open access. Guidelines of the Japanese Society of Gastroenterology. This page is a summary prepared by Medpresso from the original publication and is not a substitute for the full text or for medical advice.