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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Functional dyspepsia and disorders of gut-brain interaction

Gastroenterology and hepatology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

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Escalate

Functional dyspepsia cannot explain haemodynamic instability, haematemesis, melaena, rigid peritonism, acute coronary features, jaundice with sepsis or persistent vomiting with severe dehydration. Stabilise and investigate these presentations urgently. Progressive dysphagia, iron-deficiency anaemia, an upper-abdominal mass, persistent vomiting or qualifying weight loss requires the current urgent endoscopy or suspected-cancer pathway, even when earlier endoscopy was normal.

Synopsis

Diagnose functional dyspepsia positively after appropriate assessment, distinguish meal-related and pain phenotypes from dangerous structural disease, and deliver integrated gut-brain treatment without invalidating symptoms.

  • Functional dyspepsia is a disorder of gut-brain interaction producing epigastric pain or burning, early satiation or postprandial fullness without structural disease that adequately explains the symptoms.
  • Postprandial distress syndrome is dominated by meal-related fullness and early satiation; epigastric pain syndrome centres on pain or burning, and overlap is common.
  • Ask separately about retrosternal heartburn, biliary attacks, pancreatic pain, exertional pressure, vomiting and dysphagia because these imply different tests and pathways.
  • Use Helicobacter pylori test-and-treat and a time-limited full-dose proton-pump inhibitor strategy for suitable uninvestigated dyspepsia, sequencing them according to NICE and local practice.
  • A urea breath or stool-antigen test needs a two-week PPI washout and the required interval after antibiotics; a poorly prepared negative result is not reassuring.
  • Normal endoscopy supports a functional diagnosis only after the indication, quality, biopsies and alternative biliary, pancreatic, metabolic or motility questions are reconsidered.
  • Explain visceral hypersensitivity, impaired accommodation and gut-brain signalling as plausible mechanisms while making clear that psychological distress may modify symptoms but does not fabricate them.
  • Use regular smaller meals, exercise and selective acid suppression or low-dose tricyclic neuromodulation; avoid broad unsupported food bans and repetitive investigations.

Key red flags

Upper gastrointestinal alarm

Progressive dysphagia, haematemesis, melaena, iron-deficiency anaemia, persistent vomiting, palpable mass or qualifying unexplained weight loss activates urgent structural and cancer assessment rather than routine functional treatment.

Biliary or pancreatic alternative

Discrete prolonged right upper-quadrant or epigastric attacks with back or shoulder radiation suggest gallstone disease; continuous severe pain, vomiting and systemic illness raise pancreatitis and require targeted testing.

Cardiac mimic

Exertional epigastric pressure with dyspnoea, sweating, radiation or cardiovascular risk demands ECG-led acute coronary assessment. Meal association and temporary antacid response cannot safely exclude myocardial ischaemia.

Investigation priorities

01
Helicobacter pylori breath or stool-antigen testFirst step

Detect active infection and select eradication treatment in uncomplicated uninvestigated dyspepsia.

Management branches

TriageSeparate functional from urgent structural disease

A person presents with epigastric pain, burning, early satiation or post-meal fullness.

  1. Assess physiology and exclude bleeding, perforation, cardiac ischaemia, pancreatitis and biliary sepsis before considering a routine dyspepsia pathway.
  2. Ask about dysphagia, vomiting, weight loss, anaemia, mass, family history, NSAIDs and age-linked onset, then apply current NG12 and endoscopy criteria.
  3. Define whether symptoms are meal distress, epigastric pain, reflux, vomiting or discrete biliary attacks and select investigations that address that phenotype.
  4. Record the intended review interval and specific triggers for urgent reassessment even when initial management remains in primary care.
Initial dyspepsiaTest and treat in a deliberate sequence

Uninvestigated dyspepsia is stable and has no urgent endoscopy indication.

  1. Review NSAIDs and other offending medicines, provide regular-meal advice and choose H pylori test-and-treat or a four-week full-dose PPI trial under NICE and local practice.
  2. If testing for H pylori, arrange appropriate PPI and antibiotic washout, use a validated active-infection assay and establish who will action the result.
  3. Treat confirmed infection with the locally recommended resistance-aware regimen, checking allergy, interactions and previous antibiotic exposure.

Key medicines

Proton-pump inhibitorUse a current NICE full-dose preparation for a four-week empirical dyspepsia course, then step down to the lowest effective or intermittent strategy after review.Stop for two weeks before H pylori breath or stool testing when safe. Review interactions, infection risk and long-term indication, and never let symptomatic response override alarm features.
Helicobacter pylori eradication regimenUse the locally recommended seven-day combination selected for penicillin allergy, prior macrolide or metronidazole exposure and regional resistance information.Confirm active infection, allergies, pregnancy considerations and interactions. Failed treatment requires adherence and resistance-aware review; do not repeat the same antibiotics blindly or use serology to confirm cure.
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Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • BSG functional dyspepsia guidelinePositive diagnosis, subtypes, explanation and evidence-based treatment sequence.
  • NICE CG184 dyspepsia and refluxH pylori preparation and treatment, empirical PPI care, endoscopy and long-term review.
  • NICE NG12 upper gastrointestinal cancerCurrent symptom combinations and urgent referral routes for oesophageal, gastric and pancreatic cancer.
  • NICE QS96 dyspepsia quality standardQuality statements on testing, urgent endoscopy and acid-suppression review.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom
  • Review symptom response after the planned intervention, step down PPI treatment where safe and revisit the diagnosis rather than renewing empirically forever.