Functional dyspepsia: What can help?

Many people say their symptoms are affected by certain foods or eating habits. Studies show that functional dyspepsia symptoms are sometimes linked to wheat products, fatty foods and caffeine. A lot of people find that it helps to

• take their time when eating,
• eat in a pleasant and relaxed environment,
• chew slowly and thoroughly,
• eat smaller, more frequent meals rather than a few larger ones,
• avoid fatty or spicy foods, and
• keep an eye on whether hot drinks, alcohol, or coffee make the symptoms worse and, if so, avoid or reduce the number of these drinks.

There is no clear scientific proof that changing your diet can relieve symptoms. But experts recommend the options listed above, and they are easy to try out at no risk. Keeping a diary of what you eat and drink can help to find out what your stomach reacts to.

It can sometimes be helpful to reduce your stress levels and respect your own limits. Various relaxation and stress management techniques can help here. Examples include autogenic training and progressive muscle relaxation.

Being physically active in daily life can also improve your wellbeing and digestion – for instance, taking the stairs instead of the elevator whenever possible, or walking or cycling instead of driving. Functional dyspepsia is less common in people who integrate exercise and sport into their daily life.

If you take medications for other conditions, it can be a good idea to check whether they have an influence. Some things, like iron supplements and medication for rheumatoid arthritis, can cause functional dyspepsia symptoms or make them worse.

It can help to write down which medications you take and then talk to your doctor about whether the stomach problems might be side effects of the medications. Your doctor can then check whether you could take your medication differently, take a break or completely stop taking it, or take a different kind.

Many people try herbal products to relieve their symptoms. Known as phytotherapy products, these are available without a prescription. Essential oils and extracts of various plants can relieve cramping and prevent inflammation, and might also be able to increase movement in the digestive tract. But how effective are these kinds of products in the treatment of functional dyspepsia, and is it safe to use them?

• A summary of scientific studies suggests that a combination of peppermint and caraway oil can relieve symptoms of functional dyspepsia. These products aren't generally recommended for the treatment of functional dyspepsia. But they are considered to be well tolerated.
• Essential oils made from chamomile or fennel, and herbal active ingredients like dry artichoke leaf extracts, might also help some people. They are usually well tolerated.
• Some products contain extracts from various plants such as bitter candytuft, chamomile, peppermint, licorice root, lemon balm and caraway. It is still not clear what effects these products have, even if some smaller scale studies have shown that they can provide relief. They are usually well tolerated when taken for short periods of time. It is advisable to talk to your doctor before taking them because people who have certain pre-existing conditions and pregnant women might have to be especially careful.

Antacids containing mineral salts are often used to reduce feelings of fullness, heartburn and reflux. They are designed to protect the lining of the stomach by neutralizing excess stomach acid and binding to bile acid. There is hardly any research into whether these kinds of over-the-counter antacids can help reduce the symptoms of functional dyspepsia. If you have kidney disease or a metabolic disorder, it is important to talk to your doctor before taking any of them.

In some people with functional dyspepsia, the lining of the stomach is infected with bacteria called Helicobacter pylori. These bacteria are generally widespread: They are found in about 20 to 40 out of 100 adults, and are more common in older people. The infection can also cause symptoms such as gastritis and – more rarely – ulcers in the stomach and the duodenum (the first part of the small intestine).

If you have functional dyspepsia symptoms and you also have a Helicobacter pylori infection, treatment with antibiotics can kill the bacteria. That can relieve the symptoms, or even completely get rid of them in about 10 out of 100 affected people. The treatment lasts one to two weeks, but it can take six to twelve months for the symptoms to get better.

It is not clear how exactly the bacteria cause the symptoms. But the treatment certainly reduces the risk of stomach ulcers that can have serious consequences. Usually, two antibiotics are combined with a proton pump inhibitor.

If there are any side effects, they are nearly always mild. Typical side effects include the following:

• A metallic taste in the mouth
• Intolerance if alcohol is consumed
• Sometimes, black stool (poop) and constipation if the treatment includes bismuth
• Cramping and diarrhea with some treatment combinations

The treatment has to be repeated in about 20 out of 100 people because bacteria are still found in the mucous membrane lining the stomach. Because of this, it's a good idea to have a check-up to see if the bacteria are gone after the first treatment. This can be determined using gastroscopy, a breath test or a stool test.

Some medications reduce the production of stomach acid. The most commonly used ones are called proton pump inhibitors (PPIs). They include the active ingredients pantoprazole and omeprazole. These medications have not been approved for the treatment of functional dyspepsia, so they can only be used off-label. But studies have shown that PPIs can relieve the typical symptoms a little better than a placebo can. Treatment with PPIs can be particularly suitable for upper abdominal (belly) pain and heartburn. PPIs are considered to be well tolerated.

H2 blockers (H2-receptor antagonists) are sometimes taken instead. Like PPIs, they have not been approved for the treatment of functional dyspepsia ( off-label use). H2 blockers cause glands in the stomach lining to make less acid. The active ingredient famotidine is available over the counter in low doses, and on prescription in higher doses.

The active ingredient ranitidine, which is also an H2 blocker, should not be used because there are safety concerns. Ranitidine is not allowed to be sold anymore until these concerns have been investigated more closely.

PPIs are preferred because they are more effective and better tolerated. PPIs and H2 blockers are recommended for the temporary treatment of functional dyspepsia only (not for long-term treatment).

If medications like PPIs do not help, treatment with tricyclic antidepressants (TCAs) may be an option. Doctors particularly recommend the use of TCAs for functional dyspepsia if the main symptoms are pain and burning in the upper abdomen. If PPIs do not help enough when taken alone, TCAs and PPIs can be combined.

The TCA is taken in small doses at first, for example 10 to 25 mg of amitriptyline or 50 mg of imipramine per day. The dose can be gradually increased after several weeks. But a low dose is often enough because higher doses aren't necessarily more effective. Also, side effects like tiredness are more common with higher doses. If this treatment hasn't helped enough after eight to twelve weeks, the treatment will be stopped in agreement with your doctor.

Probiotic foods and dietary supplements contain certain microorganisms like lactic acid bacteria. The idea is that they will settle in the digestive tract and help with digestion. There are also prebiotic products that, when absorbed with food, can increase the amount of useful bacteria in the bowel. But it's not clear whether these products help in functional dyspepsia.

Prokinetics are thought to increase movement in the digestive tract and make sure that stomach contents are passed on to the bowel more quickly. This is meant to reduce nausea, reflux and feelings of fullness in the upper abdomen. Research suggests that prokinetics can relieve symptoms. But they can also have severe side effects: For instance, some prokinetics can lead to an irregular heartbeat. Long-term treatment with the prokinetics domperidone and metoclopramide is not generally recommended in Germany.

Apart from medication, there are various other treatments that can be offered in certain situations to treat functional dyspepsia. They include acupuncture and psychotherapy:

• A number of studies have looked into different kinds of acupuncture, such as manual acupuncture, moxibustion (applying heat to certain points on the body), and electroacupuncture. But no reliable conclusions can be drawn about their effectiveness. Some people say they have a positive effect, though.
• Psychotherapy helps in some people, especially if they also have psychological symptoms such as stress, anxiety or depression. Psychotherapy can also help if the functional dyspepsia symptoms themselves become a major psychological or everyday burden. Psychological approaches like cognitive behavioral therapy, psychodynamic psychotherapy and hypnosis are also an option if other treatments like medication don't provide enough relief.