Management of functional heartburn and functional dyspepsia

This topic describes the management of functional heartburn and functional dyspepsia. For general advice about managing functional gastrointestinal disorders, including patient support and psychiatric or psychological assessment, see Approach to managing functional gastrointestinal disorders.

Patients with functional heartburn or functional dyspepsia may benefit from dietary modification, such as avoiding foods that precipitate symptoms, reducing the size of meals or altering the time of the main meal. Referral to an accredited practising dietitian should be considered if symptoms are refractory or weight loss is present.

An initial trial of proton pump inhibitor (PPI) therapy is appropriate to manage the symptoms of functional dyspepsia and heartburn—see Initial therapy for gastro-oesophageal reflux (GORD) in adults.

A trial of acid suppression therapy also helps to distinguish functional heartburn from gastro-oesophageal reflux. Functional heartburn should be suspected in patients with heartburn that persists despite PPI therapy.

If initial acid suppression therapy provides adequate symptom control, gastro-oesophageal reflux may be contributing to symptoms. The need for acid suppression should be regularly reassessed, with the dose titrated down and maintained at the lowest dose and frequency that controls symptoms (see Maintenance and step-down therapy for GORD in adults). PPI therapy should be stopped if it does not significantly relieve symptoms.

If acid suppression is ineffective, consider a trial of neuromodulator therapy (eg a low-dose tricyclic antidepressant or selective serotonin reuptake inhibitor); see Neuromodulation using antidepressant drugs in functional gastrointestinal disorders for suitable regimens.

Other therapies for functional dyspepsia that may be effective include Helicobacter pylori eradication, prokinetic therapy and the herbal preparation Iberogast (also known as STW5).

Referral to a clinical psychologist or other suitably trained health professional for cognitive behavioural therapy or hypnotherapy may be indicated, particularly if features of anxiety or depression are present.