How can I differentiate between functional dyspepsia and gastroesophageal reflux disease (GERD) in a patient presenting with upper gastrointestinal sy

Functional dyspepsia and gastroesophageal reflux disease (GERD) can be differentiated primarily based on symptom patterns and response to treatment.

Functional dyspepsia typically presents with recurrent epigastric pain or discomfort, which may be accompanied by bloating, nausea, or vomiting, but without evidence of acid reflux or oesophagitis on endoscopy. It is a diagnosis of exclusion after ruling out organic causes and GERD. In contrast, GERD is characterized by symptoms of heartburn and acid regurgitation, and may show endoscopic evidence of oesophagitis or be endoscopy-negative reflux disease.

Initial management in primary care involves offering empirical full-dose proton pump inhibitor (PPI) therapy for 4 weeks to both conditions, but GERD symptoms usually respond better to acid suppression therapy. If symptoms are predominantly reflux-like (heartburn, acid regurgitation), GERD is more likely. If symptoms are mainly epigastric pain or discomfort without typical reflux symptoms, functional dyspepsia is more probable.

Additional differentiation includes reviewing medication history and excluding other causes such as cardiac or biliary disease. Endoscopy is reserved for patients with alarm features or those aged 55 and over with treatment-resistant symptoms. Helicobacter pylori testing and 'test and treat' strategy is recommended for dyspepsia but not specifically for GERD.

Lifestyle advice and symptom management strategies overlap but should be tailored to the predominant symptoms. Psychological therapies may help in functional dyspepsia. Long-term management involves stepping down medication to the lowest effective dose and encouraging self-treatment where appropriate.

In summary, differentiation relies on symptom characterization (reflux symptoms vs epigastric pain), response to PPI therapy, and exclusion of organic disease by endoscopy when indicated.

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