This 2022 guideline, last updated in 1996, was based on a series of systematic reviews and network meta-analyses. The authors recommend urgent evaluation of patients with upper gastrointestinal alarm symptoms, such as anyone with dysphagia, or persons 55 years or older with weight loss and either dyspepsia, upper abdominal pain, or reflux. They also recommend urgent evaluation for patients 40 years or older who are either from a region where gastric cancer is common or who have a family history of gastroesophageal cancer. Other alarm symptoms warranting a less urgent evaluation include hematemesis; and in persons 55 years or older, treatment-resistant dyspepsia, dyspepsia, or upper abdominal pain with elevated platelet count, low hemoglobin, nausea or vomiting, or nausea or vomiting with any weight loss, reflux, dyspepsia, or upper abdominal pain. Patients without alarm symptoms who present with at least 2 months of epigastric burning or pain, early satiety, and/or postprandial fullness should be given a diagnosis of functional dyspepsia and be told that it is a disorder of gut-brain interaction. As part of the initial evaluation, all patients 55 years or older should have a complete blood count with platelets, those with overlapping irritable bowel symptoms should have celiac serology, and those 60 or older with abdominal pain and weight loss should have an abdominal CT to evaluate for pancreatic cancer.
All patients with dyspepsia should be evaluated for the presence of helicobacter pylori (HP) using a stool or breath test, and if the results are abnormal the patient should be treated to eradicate HP (another recent study confirms that eradication not only reduces the risk of ulcer but is also effective for functional dyspepsia). Confirmation of HP eradication is only recommended for patients at increased risk of gastric cancer, although it should also be considered in patients whose symptoms persist. The guidelines recommend against the routine use of gastric emptying tests or 24-hour pH monitoring. For patients who are HP negative, first-line therapy includes acid-suppressive therapy with a histamine antagonist or proton pump inhibitor and regular aerobic exercise; the guidelines do not recommend specific diets such as a FODMAPS diet. Prokinetics may be an effective treatment, with the strongest evidence supporting tegaserod. Second-line therapies include low-to-moderate dose tricyclic antidepressants (eg, amitriptyline 10 mg once daily, titrating to 30 mg to 50 mg). The authors recommend against selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and buspirone. Finally, cognitive behavioral therapy, psychodynamic interpersonal psychotherapy, stress management, and hypnotherapy may be effective. Patients with refractory or persistent symptoms should be referred to a gastroenterologist. It is important to note that approximately half of the 35 recommendations in the guidelines are based on low- or very low–certainty evidence.