Initial assessment
In patients with symptoms suggestive of dyspepsia, the first step is to confirm that the presentation corresponds predominantly to epigastric symptoms — epigastric pain or discomfort, early satiety and postprandial fullness — and to distinguish them from gastro-oesophageal reflux disease, in which heartburn and regurgitation predominate. At this stage, the duration and temporal pattern of symptoms, functional and psychosocial impact, relevant medical history and regular medication should be reviewed.
Exclusion of drugs and non-gastrointestinal causes
Before assuming a primary gastrointestinal cause, it is essential to exclude iatrogenic and non-gastrointestinal causes. Drugs with dyspeptic potential should be identified, such as non-steroidal anti-inflammatory drugs, acetylsalicylic acid, oral bisphosphonates, corticosteroids, anticholinergics and calcium channel blockers, considering discontinuation or substitution whenever possible. In atypical presentations, relevant non-digestive disease should also be excluded, particularly cardiac or vascular causes of epigastric pain.
Age stratification and alarm features
Age and the presence of alarm features guide the need for endoscopic investigation. In patients aged 55 years or older, or in the presence of features such as dysphagia, odynophagia, anaemia, gastrointestinal bleeding, unintentional weight loss, persistent vomiting, jaundice or abdominal mass, early upper gastrointestinal endoscopy is indicated, and empirical treatment should not delay diagnostic clarification.
Initial approach without alarm features
In patients aged ≤55 years and without alarm features, an initial conservative approach is acceptable. Valid options include a test-and-eradicate strategy for Helicobacter pylori, particularly in settings of moderate or high prevalence, or empirical treatment with a proton pump inhibitor for 4–8 weeks. The choice should be individualised according to the clinical and epidemiological context, and response should always be reassessed.
Reassessment after initial treatment
After eradication of H. pylori or after an adequate course of PPI therapy, the patient should be reassessed. Resolution or significant improvement of symptoms allows treatment discontinuation to be planned. Persistent symptoms, despite adequate adherence and correction of aggravating factors, justify considering upper gastrointestinal endoscopy, even in the absence of alarm features.
Upper gastrointestinal endoscopy
Upper gastrointestinal endoscopy allows exclusion of relevant organic disease, such as peptic ulcer, malignancy or inflammatory disease. When peptic ulcer is identified, H. pylori should be eradicated if present, combined with PPI therapy for 4–8 weeks and review of NSAID or acetylsalicylic acid use. Other endoscopic findings should be managed according to the identified condition.
Functional dyspepsia
A normal endoscopy in a patient with persistent symptoms supports the diagnosis of functional dyspepsia, according to Rome criteria. This is a clinical diagnosis of exclusion and should be clearly explained to the patient to reduce anxiety and unrealistic expectations. Treatment should be directed according to the predominant symptom phenotype.
Alternative therapy in functional dyspepsia
When early satiety and postprandial fullness predominate, prokinetics may be used for limited periods. In cases where epigastric pain and visceral hypersensitivity predominate, low-dose tricyclic antidepressants have an important role as pain modulators. Psychological or cognitive-behavioural approaches may be particularly useful in patients with chronic symptoms or significant psychosocial impact.
Discontinuation of proton pump inhibitor therapy
Whenever there is clinical response to PPI therapy, discontinuation should be planned. Equivalent strategies may be used, such as gradual dose reduction, spacing doses in an intermittent regimen, or combining both over two to three weeks, in order to minimise acid rebound symptoms.
Referral and follow-up
Referral to Gastroenterology is indicated in the presence of alarm features, age above the threshold defined for endoscopy, failure of a structured therapeutic approach or significant impact on quality of life. Follow-up should be individualised, focusing on patient education, therapeutic optimisation and prevention of unnecessary investigations and treatments.
