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FUNCTIONAL DYSPEPSIA
DEFINITION The term dyspepsia derives from the Greek “dys,” meaning bad, and “pepsis,” meaning digestion. Dyspepsia refers to pain or discomfort centered in the upper abdomen Dyspepsia is a common symptom having either an organic or a functional cause; distinguishing between the two can be a challenge. Clinical features of functional dyspepsia, gastroesophageal reflux disease, and gastrointestinal motility disorders overlap, making diagnosis difficult. Most patients with functional dyspepsia have normal esophagogastroduodenoscopy (EGD) findings. Endoscopy is indicated for patients with new-onset symptoms who are > 55 years of age or have alarm features. Functional dyspepsia remains a diagnosis of exclusion Centered implies that the pain or discomfort is mainly in or around the midline.
Pain in the right or left
hypochondrium is not considered to be representative of dyspepsia Dyspepsia
Discomfort may be characterized by or
associated with upper abdominal fullness, early satiety, bloating , or nausea
These symptoms typically are
accompanied by a component of upper abdominal distress Dyspepsia
The painful or uncomfortable symptoms
may be intermittent or continuous , and may or may not be related to meals Differential Diagnosis
GERD Most common organic causes, Gastric cancer according to AGA Medications (ASA/NSAIDS, Abx) Gastroparesis Cholelithiasis, Choledocholithiasis Pancreatitis (acute or chronic) Carbohydrate malabsorption Ischemic bowel Other GI malignancy (ep. Pancreatic cancer) Systemic disease (DM, Thyroid, Parathyroid, CTD) Intestinal parasite FUNCTIONAL DYSPEPSIA FD is a clinical syndrome which is defined by chronic or recurrent upper abdominal symptoms without a cause that is identifiable by conventional diagnostic means such as endoscopy, radiology or histology. Risk Factors and Past Hx Risk Factors Smoker, NSAID use, Heavy EtOH, FHx ulcer Personal Hx Previous ulcer, GI bleed DM, hypo/hyperthyroidism, parathyroid dis. Colitis, diverticulosis, liver disease Anxiety, stress, depression Previous Upper GI series, OGD, Abdo U/S Diagnostic approach Symptom alone are unable to discriminate organic dyspepsia from non organic dyspepsia Patients need to have further examination to rule out relevant organic disease Functional dyspepsia is a diagnosis of exclusion Definition of Functional Dyspepsia FUNCTIONAL DYSPEPSIA
Dyspepsia is a very common
complaint. In western country: The prevalence rate of FD :10-40%. The remission rate :10-20% annually The recurrence rate :20-55% PATHOPHYSIOLOGY OF FUNCTIONAL DYSPEPSIA Pathophysiology of FD is poorly understood The symptoms can be associated with
Motility abnormality of the stomach
Visceral hyperalgesia/hypersensitivity
Hp gastritis
Psychosocial factor PATHOPHYSIOLOGY OF FUNCTIONAL DYSPEPSIA
In such a group of patient the symptoms
are associated with abnormal motor function of the stomach: Impairment of gastric accommodation Delayed gastric emptying Antral hypomotility Bradygastria / Tachygastria Intragastric maldistribution of solid and liquid food small bowel dysmotility (Malagelada etal.1985;Camilleri etal.1986;Waldron etal.1991;Hveem etal.1996;Stanghellini etal.1996) Disorders of gastric neuromuscular function: myoelectrical and contractile abnormalities Impaired fundic relaxation Abnormal fundic emptying
Weak 3 cpm rhythm
Gastric dysrhythmias
Dilated gastric antrum
Small bowel Antral hypomotility dysmotility Gastroparesis DIAGNOSTIC APPROACH Careful history taking and Physical examination Alcohol,smoking, drugs (NSAID), weight loss, abdml surgery , intractable pain,dysphagia, recurrent vomiting GI bleeding, pallor, jaundice abdominal mass, abdominal scar. Laboratory examination CBC, Liver function test, Renal function test, ECG, Test for Hp X ray examination and USG upper abdomen Endoscopy examination and biopsy EGG, Gastric emptying study, Manometry, 24 h pH monitoring History & Physical
PUD Past history of ulcers, NSAIDs, Smoking GERD Heartburn or regurg symptoms, aggravated when supine, chronic cough Gastric Cancer Older (>50), wt. loss, dysphagia, smoker, long- standing GERD History & Physical
Biliary Tract disease
Episodic RUQ pain > 1 hr, associated with meals, post- prandial Meds iron,NSAIDs, bisphosphonates, antibiotics, etc. Metabolic disorder/Gastroparesis DM, Hyper or Hypo - Thyroidism, Hyperparathyroidism History & Physical
IBS Pain relieved with defectation more freq stools at onset of pain abdominal distention passage of mucus sense of incomplete evacuation Examination
Fever, weight loss, Signs anemia
hypotension, Brittle nails tachycardia Cheilosis Abdo Pallor palpebral Epigastric mucosa or nail beds tenderness Other Palpable mass Teeth (loss enamel) Distention Lymphadenopathy - Colon tenderness Virchow’s node Jaundice Acanthosis nigrans
Murphy’s sign Hypo/Hyperthyroid.
Stool for OB Alarm symtoms Weight loss Anaemia Dysphagia Recurrent vomiting Haematemesis and or maelena Abdominal mass From AGA Guidelines
patient with uninvestigated dyspepsia without alarm symptoms. The treatment should be individualize First line treatment is prokinetic agent or anti secretory drug. However the placebo response is high (20-60%) Some patients should be avoid precipitating food or drink Other patients may be need anti anxiety or anti depressant drugs Pharmacologic Treatment for FD Prokinetic agent Dopaminergic ( Metoclopramid , Domperidone) Serotonergic ( Cisapride, Ondansetron, Granisetron) Anti secretion H2 blockers(Cimetidin,Ranitidin,Nizatidin,Famotidin,Roxatidin) PPI ( Omeprazole,Mesomeprazole,Lansoprazole,Rabeprazole, Pantopprazole) Antacid Cytoprotector agent Sucralfate Rebamipide Trepenon Anti anxiety or Anti depression ANTACIDS Drug Side effect Magnesium severe osmotic •MOA: Weak bases that diarrhoea react with gastric acid to (therefore form H20+salt. ↓pepsin combined with activity as pepsin inactive AlOH) at pH>4 ↓ drug absorption
1) Sulcralfate MOA: Binds to positively charged proteins present on damaged mucosa forming a protective coat
Useful in “stress ulceration”
As effective as H2-R antagonists/high dose antacids
SE: Constipation
↓absorption of cimetidine, digoxin, phenytoin & tetracycline
2) Bismuth MOA: Antimicrobial action. Also inhibit pepsin activity, ↑mucus secretion & interact with proteins in necrotic mucosal tissue to coat & protect the ulcer crater H2-RECEPTOR ANTAGONISTS
Drug Side effects
Cimetidine -reversible impotence, gynaecomastia & ↓ sperm count (high doses) (nonsteroidal antiandrogen) -mental status abnormalities-confusion, hallucinations (elderly/renal impairment) -leukopenia & thrombocytopenia (rare) -cytochrome P450 inhibitor (e.g. impairs metabolism of warfarin, theophylline & phenytoin) Ranitidine,famotidi -Impotence, gynaecomastia & confusion less ne frequently than cimetidine. -Little interference with cytochrome P450 -Reversible drug-induced hepatitis with all H2- antagonists PROTON-PUMP INHIBITORS (PPI)
• MOA: block parietal cell H+/K+ ATPase enzyme
system (proton pump) ↓ secretion of H+ ions into gastric lumen
• More effective than H2-antagonists or antacids
• Used in antimicrobial regimens to eradicate H. pylori
• SE: n&v, diarrhoea, dizziness, headaches,
gynaecomastia & impotence (rare), thrombocytopenia, rashes H. PYLORI ERADICATION
1st line eradication tx 2nd line tx
for H. pylori Preferred tx= PPI PO + PPI + Bismuth 120mg QDS PO Clarithromycin 500mg BD PO + + Metronidazole 500mg TDS Amoxicillin 1 gm BD PO for 7 PO + Tetracycline 500mg QDS days PO for 7 days
If Penicillin allergic= PPI +
Clarithromycin 500mg BD PO + Metronidazole 400mg BD PO for Subsequent failures handled 7 days on individual basis with advice from gastro/micro E.g. of PPI: Lansoprazole 30mg BD PO H. PYLORI ERADICATION
1 week triple-therapy regimens eradicate H. Pylori
in >90% cases. Usually no need for continued antisecretory tx unless ulcer complicated by bleeding/perforation
2 week triple-therapy offer higher eradication
rates cf 1 week but SE common & poor compliance
2-week dual-therapy with PPI & antibacterial
produce low rates of H. pylori eradication & not recommended H. PYLORI ERADICATION Treatment failure may be due to - Resistance to antibacterial drugs - Poor compliance
Drug Side effects
Bismuth n&v, unpleasant taste, darkening of tongue & stools, caution in renal disease Metronidazol n&v, unpleasant taste, ↓effectiveness OCP, care e with lithium/warfarin Amoxicillin GI side effects, ↓ effectiveness OCP, & tetracycline pseudomenbranous colitis Lansoprazole ↓ effectiveness OCP
