Dyspepsia Xử trí

EMPIRIC THERAPY

Acid Suppression

Acid suppression, given for 4-8 weeks, is reasonable in most patients with functional dyspepsia, regardless of subtype. Patients should be treated with a 4-week trial of acid suppression before deciding whether or not therapy has been effective.

Proton Pump Inhibitors (PPIs)

Example drugs: Esomeprazole, Lansoprazole, Omeprazole, Pantoprazole, Rabeprazole

Proton pump inhibitors (PPIs) are the recommended first-line treatment in patients with EPS-subtype functional dyspepsia. These were shown to be more effective than other agents as an initial therapeutic strategy at reducing dyspeptic symptoms in trials of patients with uninvestigated dyspepsia when patients were not adequately excluded for GERD. For patients with uninvestigated dyspepsia, offer PPI for 4-8 weeks; a prokinetic may be added for 1 week. This is the preferred acid suppression for H pylori-negative patients or those who continue to be symptomatic despite H pylori eradication therapy. Patients with heartburn symptoms may be treated initially with PPIs then step-down therapy with low-dose PPIs or H₂RAs once their symptoms improve. Discontinue PPI treatment after 12 weeks if without response.

Histamine₂-Receptor Antagonists (H₂RAs) 







Example drugs: Cimetidine, Famotidine, Nizatidine, Ranitidine

Histamine₂-receptor antagonists have been shown to be significantly more effective than placebo. Individual patients may respond to H₂RA therapy. These may be more effective for functional dyspepsia in Asian populations, likely due to their generally lower acid secretion compared to Western populations, making acid inhibition by H₂RAs sufficient to improve symptoms. These may be given to patients who had an inadequate response to or were unable to tolerate proton pump inhibitor therapy. Histamine₂-receptor antagonists may also be used as step-down therapy.

Prokinetic Agents 







Example drugs: Clebopride, Domperidone, Itopride, Metoclopramide, Mosapride

Patients with dysmotility-like symptoms (eg PDS subtype), may respond to prokinetics though current evidence suggests it may benefit patients across all subtypes. Although prokinetics may help relieve symptoms in patients with functional dyspepsia, existing data show that complete symptom resolution is often not achieved. For patients with dysmotility-like dyspepsia, offer a prokinetic for one week; a PPI may be added and continued for 4-8 weeks. Treatment should be at the lowest effective dose for the shortest duration possible to reduce the risk of adverse effects.

Fundic Relaxants 







Example drugs: Acotiamide, Buspirone, Tandospirone

Fundic relaxants may be effective in improving functional dyspepsia, especially PDS. These aim to improve relaxation of the upper stomach enhancing gastric accommodation in patients with functional dyspepsia, particularly those experiencing postprandial fullness. Acotiamide provides symptom relief and has been shown to improve quality of life, work productivity and long-term safety in patients with functional dyspepsia. Further trials are needed before anxiolytics such as Buspirone and Tandospirone can be recommended for the management of functional dyspepsia.

Neuromodulators

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Neuromodulators may be considered for patients who show minimal response to first-line therapies. Tricyclic antidepressants (TCAs) (eg Amitriptyline, Desipramine, Imipramine, Nortriptyline) may be used as second-line therapy (if appropriate) in patients with functional dyspepsia (eg EPS subtype) if dyspeptic symptoms fail to improve with the initial 4-8 weeks of proton pump inhibitor or H pylori eradication therapy; if unresponsive to TCAs, offer treatment with prokinetic agents. This is initially given at a low dose for 8-12 weeks, continued for 6 months if effective, tapered gradually when discontinuing and may be restarted if symptoms recur. Mirtazapine, an oral tetracyclic antidepressant, has been found effective in improving early satiety, nutrient tolerance and GI-related anxiety, and in managing unintentional weight loss. Antipsychotics (eg Sulpiride, Levosulpiride) may be used as second-line therapy for functional dyspepsia. Pregabalin may be effective in patients with functional dyspepsia, but additional studies are needed to confirm its definitive role in treatment.

Adjunctive Therapy

Antacids and Gastroprotective Agents 







Self-treatment with antacids with or without alginates may be continued as needed for immediate symptom relief but additional therapy is appropriate to manage persistent or more severe symptoms. These may be used as add-ons to standard pharmacologic therapy with proton pump inhibitor, Histamine₂-receptor antagonists or prokinetics. Antacids, alginates, and gastroprotective agents (eg Rebamipide, Sucralfate) effectively reduce acid and improve symptoms, but evidence of a healing effect has not been demonstrated.

Traditional, Complementary and Integrative Medicines (TCIM)

Traditional, complementary and integrative medicines may be used alone or as an adjunct to conventional treatment at any point in the therapeutic process. Iberogast has effects on gastric motility and spasms, Motilitone enhances gastric accommodation, Rikkunshito promotes GI motility and Zhizhu Kuanzhong reduces postprandial fullness and early satiety. These should be selected based on clinical evidence, availability and regulatory status within specific healthcare systems.

Other Therapies

Rifaximin has demonstrated emerging therapeutic potential, with a clinical trial showing that a 2-week course of this gut-specific antibiotic effectively relieved global dyspeptic symptoms. Probiotics may play a role in functional dyspepsia, but their effectiveness appears to be strain-dependent, highlighting the need for further research on specific formulations. 

Lifestyle Modifications

There is no clear evidence of a specific association between lifestyle factors and dyspepsia, but some individuals may be helped by these measures. Advise patients to avoid known precipitants that they associate with dyspeptic symptoms (eg alcohol, coffee, chocolate, spicy and fatty foods, carbonated drinks, dairy products [especially in the Asian context], red meat, vegetables [eg cabbage, onion], wheat, citrus) and to avoid fast and irregular eating. Alcohol, coffee, and chocolate have pharmacological effects that may reduce the tone of the lower esophageal sphincter (LES). Fatty foods delay gastric emptying time, which may also predispose to gastroesophageal reflux disease. High carbohydrate, low protein and fat, and increased fruit intake are associated with a lower risk of functional dyspepsia. Dietary recommendations for functional dyspepsia should be individualized based on the patient-specific factors.

Encourage the patient to stop smoking. Smoking has pharmacological effects that may reduce the tone of the LES. Weight reduction should be advised for overweight and obese patients.  Obesity may disrupt the LES due to mechanical pressure on the diaphragm. Regular aerobic exercise is recommended for patients with functional dyspepsia.

Suggest to patients on having a main meal well before going to bed (preferably 3 hours before). Some patients may benefit from raising the head of the bed when sleeping. Lying in a left lateral decubitus position is also advised, as lying flat may increase reflux episodes since gravity does not prevent acid regurgitation. Advise patients to avoid tight-fitting undergarments (eg corsets and girdles).

Behavioral Therapies

Psychotherapy may be a treatment option for patients with functional dyspepsia who are unresponsive to initial treatments. Patients with refractory functional dyspepsia have a high rate of accompanying depression and psychiatric illness. Gut-brain behavioral interventions that have received focus in functional dyspepsia include psychodynamic therapy, cognitive behavioral therapy (CBT), stress management and mindfulness, and hypnotherapy. Consider psychological therapies (eg CBT and psychotherapy) or antidepressants to reduce dyspeptic symptoms especially in functional dyspepsia. Stress management and hypnotherapy may also be effective in reducing anxiety and depression as well as global symptoms in patients with functional dyspepsia. Cognitive behavioral therapy and stress management enable patients to increase their coping skills and improve social support. Metacognitive therapy bears many similarities to CBT, but rather than challenging intrusive thoughts and dysfunctional beliefs, it addresses ways of responding to these thoughts and preventing their persistence.

Other Considerations

To reduce anxiety in cases where there are no indications of organic disease, reassurance is an important part of initial therapy. Patients with severe or refractory functional dyspepsia presenting with weight loss and food restriction may be evaluated for eating disorders and disordered eating, including avoidant restrictive food intake disorder. If there is concurrent use of NSAIDs, evaluate for risk of GI complications and consider alternative strategies if risk is a concern (eg use of enteric-coated NSAIDs).

Please see Peptic Ulcer Disease disease management chart for further information.

Acupuncture, electroacupuncture, moxibustion, transcutaneous auricular vagus nerve stimulation and yoga have shown benefit in patients with functional dyspepsia, although more research is required to determine its effectiveness.

Patient Education 

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A holistic, multidimensional approach combined with strong doctor-patient communication is essential to build trust, empower decision-making, enhance treatment adherence, and improve symptom management and quality of life. Educate patients about the nature of the disorder, set long-term care expectations and advise them to promptly report alarm symptoms that may require further evaluation. Discuss the patient’s medication regimen, including dosage, timing, purpose and possible side effects, and the importance of adherence to therapy. Functional dyspepsia significantly impairs quality of life; explain to the patient that treatments aim to improve quality of life and are likely to be needed long-term. Advise the patient to replace or discontinue dyspepsia-causing medications. Provide patients with access to educational materials to support the care they receive.