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How to manage the difficult-to-treat dyspeptic patient

Nature Clinical Practice Gastroenterology & Hepatology volume 4, pages 35–42 (2007)Cite this article

Abstract

The main causes of dyspepsia are unexplained gastroduodenal symptoms (i.e. functional dyspepsia), peptic ulcer disease, reflux disease and, rarely, malignancy. A careful clinical evaluation and upper endoscopy will exclude most of the major causes of dyspepsia. The absence of alarm features is reassuring. The yield of other diagnostic tests in this clinical situation is low, and repeat endoscopy is unlikely to be cost-effective. By definition, the difficult-to-treat patient with functional dyspepsia has already had Helicobacter pylori infection excluded or eradicated, has failed to respond to an adequate trial of acid-suppression therapy that used appropriate doses and, therefore, seeks other solutions. It is likely that patients who have failed to respond to previous trials of a PPI will not experience therapeutic gains with high-dose PPI therapy. A major gastroduodenal motor disorder should be suspected if there is severe early satiation (inability to finish a normal-sized meal), postprandial fullness, or persistent nausea and vomiting; here, an assessment of gastric emptying or gastric accommodation can be considered, to tailor therapy. Antidepressants (especially low-dose tricyclic agents) and psychological therapies can be useful. Creation of a logical management plan that includes patient education and support remains key.

Key Points

  • When planning the management of a patient with dyspepsia, likely underlying etiologies should be ruled out; most of the major causes of dyspepsia (e.g. peptic ulcer disease, gastroesophageal reflux disease and malignancy) can be excluded by careful clinical evaluation and upper endoscopy

  • By definition, the difficult-to-treat dyspeptic patient has already had Helicobacter pylori infection excluded or eradicated and has failed to respond to an adequate trial of acid-suppression therapy

  • In patients who have failed to respond to previous trials of PPI therapy, the therapeutic gain with high-dose PPIs is likely to be minimal

  • A major gastroduodenal motor disorder should be suspected if there is severe, early satiation, postprandial fullness, or persistent nausea and vomiting; investigation of gastric emptying or gastric accommodation can be considered, to tailor therapy

  • Antidepressants (especially low-dose tricyclic agents) and psychological therapies might be useful, although the evidence of their benefit is limited

  • Patient education and support remain key to the logical management of difficult-to-treat dyspeptic patients

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Figure 1: Patient responses to acid-suppression therapy differ.
Figure 2: Functional dyspepsia: symptom severity and gastric accommodation of a meal.
Figure 3: A comparison of the efficacy of hypnotherapy, medical care (a H2-receptor antagonist) and supportive therapy in patients with functional dyspepsia.

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Author notes

  1. Mayo Clinic, 200 First Street SW, Plummer 6–56, Rochester, MN 55905, USA talley.nicholas@mayo.edu

Authors and Affiliations

  1. NJ Talley is a Professor of Medicine and the Director of the Motility Interest Group in the Division of Gastroenterology and Hepatology at the Mayo Clinic, Rochester, MN, USA.,

    Nicholas J Talley

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Competing interests

The author has been a consultant for Altana, AstraZeneca, Axcan, Chugai, EBMed, Gianconda, GlaxoSmithKline, Kosan, KV Pharmaceuticals, Medscape, ProEd Communications, Renovis Inc, Solvay, Strategic Consultants International, Takeda Pharmaceuticals Inc, TAP Pharmaceutical Products Inc, Therapeutic Gastrointestinal Group, Theravance, and Yamanouchi. The author has received research support from Axcan, Bohringer-Ingelheim, Forest, Merck, Novartis, and TAP Pharmaceutical Products Inc.

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Talley, N. How to manage the difficult-to-treat dyspeptic patient. Nat Rev Gastroenterol Hepatol 4, 35–42 (2007). https://doi.org/10.1038/ncpgasthep0685

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