Gut–brain axisdysfunction

Alterations in gastrointestinal

microbiota

Immunedysfunction

Gastrointestinal sensory & motor

dysfunction

Pathophysiology

Management

Treatment

Testing

Abnormalendoscopy

Normal endoscopy

Trial of TCA orprokinetics

Non-invasive test for H pylori H pylori-positive

H pylori-positive

H pylori-negative

Aged <55 years without alarm

symptoms

H pylori-negative

Eradicationtherapy

Symptoms persist: review diagnosis,

consider endoscopySymptoms resolve

Treat relevant pathology

Symptomsresolve

Aged ≥55 years or alarm symptoms

present

Evidence qualityVery low Moderate High

Symptoms resolve

Discharge.Continued monitoring appropriate if still TCA

still in use

DischargeWean PPI to lowest

possible dose anddischarge

Considerpsychological

therapy

Oesophagitis, peptic ulcer, orgastro-oesophageal cancer

Symptoms persist: review diagnosis,

consider endoscopy

Symptoms persist: review diagnosis,

consider endoscopyPPI therapy

Management

Endoscopy with biopsies for

H pylori

Age/symptomcheck

Prokinetics might be more beneficial in postprandial distress syndrome and TCAs in epigastric pain syndrome.

Urgent endoscopy: dysphagia or aged ≥55 years with weight loss and upper abdominal pain/reflux/dyspepsia

Non-urgent endoscopy: haematemesis, treatment-resistant dyspepsia, upper abdominal pain with low haemoglobin, raised

platelet count with nausea/ vomiting/weight loss/reflux/dyspepsia/upper abdominal pain, or nausea and

vomiting with weight loss/reflux/dyspepsia/upper abdominal pain.

Stool antigen/13-carbon UBT

Functional Dyspepsia

Epigastric pain syndrome

Postprandial distress

syndrome

Epigastricpain

Epigastricburning

Postprandialfullness

Earlysatiety

SymptomsBothersome symptoms in past 3 months, onset ≥6 months before diagnosis. Patient needs to have a

structurally normal endoscopy.

Female sex

Risk factors

Helicobacter pylori infection

Psychological comorbidity

Smoking

Non-steroidal anti-inflammatory drugs

Acute gastroenteritis

Functional Dyspepsia

For full details, read the Lancet Series: Functional Gastrointestinal disorders 2, Functional Dyspepsia