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Functional Dyspepsia Guideline

CATEGORY: PURPOSE:

Clinical Practice, General GI Guidelines To assist MNGI physicians and NPPAs in the care of patients with functional dyspepsia.

RESPONSIBLE PARTIES: All MNGI physicians, nurse practitioners and physician assistants

GUIDELINE: The Rome III Criteria for functional dyspepsia is defined as: Must include one or more of the following symptoms: 1. Bothersome postprandial fullness 2. Early satiety 3. Epigastric pain 4. Epigastric burning AND 5. No evidence of structural disease (including at upper endoscopy) that is likely to explain the symptoms. *Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis I. Assessment A. History 1. Context a. When did symptoms start, new medications, illness, change in diet, or change in stress 2. Modifying factors a. Relationship to eating, fasting, medication, bowel movements, aggravating and alleviating factors 3. Severity a. Mild to severe based upon the frequency and intensity of the symptoms, the degree of psychosocial difficulties, and the frequency of need for health care assistance 4. Timing and duration a. When does it occur, how frequent, how long does it last, intermittent or constant, relationship to meals or events, and relationship to bowel movements 5. Associated symptoms a. Nausea, vomiting, postprandial fullness or pain, heartburn, regurgitation, dysphagia, odynophagia, abdominal bloating, constipation, diarrhea, anxiety, depression, weight loss, or fever. 6. Review of medications a. Prescription and nonprescription medications, including NSAIDs 7. Review any previous studies completed: a. EGD
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Functional Dyspepsia Guideline

Gastric biopsies for H. pylori b. Abdominal imaging c. Blood work CBC H. pylori serology 8. Presence or absence of alarm features a. Signs of GI bleeding: Melena, hematochezia, hematemesis b. Unintended weight loss c. Age older than 45 with new-onset dyspepsia d. Persistent vomiting e. Progressive dysphagia f. Odynophagia g. Family history of upper GI cancer h. Unexplained iron-deficiency anemia i. Jaundice j. Previous esophagogastric malignancy k. Palpable abdominal mass/lymphadenopathy. B. Past Medical and Surgical History 1. Other medical diagnoses a. Crohns disease, gastroparesis, diabetes mellitus, GERD, past gastrointestinal infections 2. Past abdominal surgeries 3. Psychiatric history a. Depression b. Anxiety c. Past history of abuse (emotional, sexual, physical) C. Social History 1. Alcohol consumption 2. Drug use 3. Tobacco use 4. Recent travel 5. Sick contacts 6. Change in diet 7. New stressors D. Physical Exam 1. Constitutional a. Fever, signs of dehydration, malnutrition 2. Abdomen a. Masses, tenderness, bloating, distention, tympanic or abnormal bowel sounds 3. Skin a. Rash, fever, jaundice II. Work Up A. Consider the following for patients with alarm features: 1. EGD a. With gastric biopsies to evaluate for H. pylori 2. CBC 3. Complete metabolic panel (CMP) B. Consider the following for the initial workup of a patient without alarm features:
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Functional Dyspepsia Guideline

1. 2. 3. 4.

H. pylori testing and treatment if positive Empiric PPI therapy EGD with gastric biopsies Bravo study off of medications (If symptoms consistent with possible GERD)

C. Consider the following for patients with associated abdominal pain: 1. Consider biliary etiology (i.e. choledocholithiasis, cholecystitis) a. Hepatic function panel b. RUQ ultrasound 2. Pancreatic etiology (i.e. acute pancreatitis, chronic pancreatitis, pancreatic malignancy) a. Amylase, lipase, and hepatic function panel b. CT scan of the abdomen D. Consider the follow for patients with history of Crohns disease: 1. MRI or CT of the abdomen E. Consider the following for patients with early satiety and/or nausea and vomiting: 1. Gastric emptying study III. Differential diagnosis A. Functional dyspepsia B. Peptic ulcer disease C. Gastroesophageal reflux disease (GERD) D. H. pylori infection E. Gastroparesis F. Pancreatitis G. Biliary pain (i.e. choledocholithiasis, cholecystitis) H. Gastric or esophageal malignancy I. Crohns disease J. Chronic abdominal wall pain K. Irritable bowel syndrome (IBS) L. Systemic disorders (diabetes mellitus, thyroid and parathyroid disorders, connective tissue disease) M. Medications (i.e. potassium supplements, iron, oral antibiotics, NSAIDs, bisphosphonates, niacin, estrogen, levodopa) N. Ischemic bowel O. Abdominal cancer (i.e. pancreatic cancer) IV. Treatment A. Treatment is dependent on the severity of the patients symptoms, which is determined by the frequency and intensity of the symptoms, the degree of psychosocial difficulties, and the frequency of need for health care assistance. 1. Most patients do not require chronic medications 2. Patients often benefit from reassurance, education to the condition, and recommendations regarding dietary and life style changes to help the patient accept and cope with their symptoms, rather than eliminate them B. Dietary recommendations: 1. Small frequent meals 2. Avoid foods high in fat content and foods that aggravate the patients symptoms C. Avoid NSAIDS D. Consider PPI therapy first

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Functional Dyspepsia Guideline

1. Meta-analysis has shown improvement with PPI over placebo in patients with GERD-type symptoms but not in those with unspecified dyspepsia 2. Recommend 4-8 week trial of once daily PPI E. Histamine 2 receptor antagonists (H2RAs) have not shown as great of efficacy as PPIs, but may be considered F. Consider a trial of Tricyclic antidepressants (TCAs) for patients whom failed PPI therapy 1. Amitriptyline 10 -25 mg at bedtime 2. Desipramine 10-25 mg at bedtime 3. Trazadone (only in women due to risk of priapism in men) starting at 25 to 50 mg at night 4. Does may be adjusted upward for all TCAs over a few weeks. If this is beneficial, continue the medication for a few months, and then stop. G. Treat H. pylori infection if present. 1. In patients whom symptoms persist after successful eradication, offer a one month course of PPI therapy H. Consider psychological therapy (i.e. cognitive behavioral therapy, hypnotherapy, or psychotherapy) as it has been shown to have some benefit. I. Consider prokinetic medications which may be effective, but are associated with potential side effects, especially with long term use. 1. Metoclopramide (Reglan) 5-10 mg four times daily one-half hour before meals and at night for four weeks REFERENCES/RELATED DOCUMENTS:
1. Rome III Diagnostic Criteria for Functional Gastrointestinal Disorders 2. American Gastroenterology Association. American Gastroenterological Association Medical Position Statement: Evaluation of Dyspepsia, Gastroenterology 2005; 129: 5, pages 1753-1755. 3. American Gastroenterology Association. American Gastroenterological Association Technical Review on the Evaluation of Dyspepsia, Gastroenterology 2005; 129: 5, pages 1756-1780 4. Talley NJ, Vakil N. Guidelines for the management of dyspepsia. Am J Gastroenterol 2005; 100:2324-2337. 5. Talley, NJ. Functional dyspepsia. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham.MA, 2012. 6. Talley, NJ. Approach to the patient with dyspepsia. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham.MA, 2012. 7. UNC Center for Functional GI and Motility Disorders www.med.unc.edu.

Person initiating original guideline or revision: Mikki Bjork, RN,CNP Original Date of guideline: 4/2012 Date of Revisions: ______________________________ Date of Review: ________________________________ APPROVAL:

______________________________ Douglas Nelson, MD Chair, Clinical Practice Committee

_______________________ Date

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