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DYSPEPSIA
Prinoj Varghese DEFINITION • Dyspepsia is derived from the Greek words δυς- (dys-) and • πέψη (pepse) and means “difficult digestion.” • Dyspepsia is often broadly defined as pain or discomfort centered in the upper abdomen but may include varying symptoms like – Epigastric pain – Postprandial fullness – Early satiation – Anorexia – Belching – Nausea and vomiting – Upper abdominal bloating The Rome IV Consensus Committee defined dyspepsia as the presence of symptoms considered by the physician to originate from the gastroduodenal region. • Postprandial fullness
• Early satiation
• Epigastric pain
• Epigastric burning Functional dyspepsia
• Also known as non ulcer dyspepsia
• No organic abnormality is identified by routine clinical evaluation
• Commonest cause of dyspepsia in Western countries
Uninvestigated dyspepsia
• The term uninvestigated dyspepsia refers to dyspeptic symptoms in
persons in whom no diagnostic investigations have yet been performed and a specific diagnosis that explains the dyspeptic symptoms has not been determined. Functional Dyspepsia According to the Rome IV criteria, FD is defined as presence of early satiation,
postprandial fullness,
epigastric pain,
epigastric burning
absence of organic, systemic, or metabolic disease that is likely to explain
the symptoms Epidemiology • Frequency 10% to 45%
• Higher in women than men
• In the initial study from Mumbai, approximately one third of 2549 healthy subjects complained of dyspepsia once a month. • Around 12% of subjects experienced significant symptoms (pain, fullness, or both at least once a week). • A recent survey on the prevalence of Rome IV functional gastrointestinal disorders (FGIDs) among 1309 college students in northern India identified FD as the most common FGID, with a prevalence of 15.2%, followed by IBS (6.2%) STRESS
SMOKING & ELDERLY AGE ALCOHOL
SPICY FOOD NSAIDs ABUSE
LOW INCOME ANXIETY &
STATUS DEPRESSION
Epidemiology of Functional Dyspepsia SUPPLEMENT TO JAPI • march 2012 • VOL. 60
Pathophysiology
• Delayed gastric emptying
• Impaired gastric accommodation to a meal
• Hypersensitivity to gastric distention
• Altered duodenal sensitivity to lipids or acid
• Abnormal intestinal motility
Proposed Pathophysiological Mechanisms Involved in Functional Dyspepsia
Visceral
hypersensitivity
• abnormal
sensitivity to acid
Disrupted Altered brain– gut–immune gut interactions interactions
Saad Saad RJ RJ et et al. al. Aliment Aliment Pharmacol Pharmacol Ther. Ther. 2006;24:475-492. 2006;24:475-492. Tack Tack JJ et et al. al. Gastroenterology. Gastroenterology. 2006;130:1466-1479. 2006;130:1466-1479. Pathogenic Factors
• Genetic Predisposition – Polymorphisms of the G-protein beta polypeptide 3 (GNB3) gene have been associated with the risk of functional dyspepsia • Infection -Hp-associated dyspepsia as dyspepsia in an Hp-infected person with the absence of an alternative cause of dyspepsia on endoscopy and sustained control of symptoms after eradication of Hp. • Psychosocial factors – psychiatric comorbidities in patients with functional dyspepsia are anxiety, depressive or somatoform disorders, and a recent or remote history of physical or sexual abuse. – The presence of psychosocial comorbidities is also associated with greater symptom severity in patients with FD, and this association may be mediated in part by visceral hypersensitivity. APPROACH TO UNINVESTIGATED DYSPEPSIA History and physical examination
• The nature, frequency, and chronicity of the symptoms
• Relationship to meals
• Influence of specific dietary factors
• Medications
• The presence and degree of weight loss, if present
• Family history of gastrointestinal cancers
• Alarm symptoms • Assessment of symptoms or signs of a systemic disorder (e.g., diabetes mellitus, cardiac disease, thyroid disorders) • Physical findings such as an
• Stool testing for ova and parasites and for Giardia antigen
• pregnancy test Initial management strategies
Prompt diagnostic endoscopy
Noninvasive testing for Hp infection, treatment based on the result ( Test
and treat strategy) Empirical antisecretory drug therapy OGD endoscopy • Detection of organic causes of dyspepsia, such as peptic ulcer, erosive esophagitis, or malignancy. • Age more than 45 years. • Younger than age 45 who have a family history of gastric cancer, emigrated from a country with a high rate of gastric cancer, or have undergone partial gastrectomy Endoscopy vs Noninvasive management
• A meta-analysis of 5 trials that compared initial endoscopy with a test-
and-treat strategy concluded that initial endoscopy may be associated with a small reduction in the risk of recurrent dyspeptic symptoms • This gain is not cost-effective
• Direct and indirect costs associated with prompt endoscopy are higher than those associated with empirical therapy • Available data, therefore do not support early endoscopy as a cost- effective initial management strategy for all patients with uncomplicated dyspepsia. Hp infection
• Because of the involvement of Hp in PUD several consensus panels have advocated
noninvasive testing for Hp in young patients (<45 to 55 years of age) with uncomplicated dyspepsia. • Fecal antigen test and urea breath test preferred. • Patients with a positive test result should receive eradication therapy • Patients with a negative test result should be treated empirically usually with a PPI for 1-2 months. • Failure to respond-OGD Additional investigation
• Testing for celiac disease and Giardia infection is useful for patients with refractory symptoms, and weight loss. • Abdominal US or CT can be used to rule out pancreaticobiliary disease and screen for mesenteric ischemia. • Severe postprandial fullness and refractory nausea and vomiting, a gastric emptying test using scintigraphy or a breath test • Refractory intermittent epigastric pain or burning, esophageal pH with impedance monitoring for atypical manifestations of GERD • Psychological or psychiatric assessment is recommended for patients with long-standing refractory or debilitating symptoms Treatment of functional dyspepsia • General measures
• Smaller, more frequent meals may benefit some patients.
• Low-fat diets may lessen symptoms in some patients with FD
• Monitor medications, especially NSAIDs, iron, and antibiotics.
Acid suppressing drugs H2 receptor blockers
Proton pump inhibitors
• PPIs are also likely to be more effective at relieving symptoms of
dyspepsia as compared with H2 receptor antagonists. • Studies have shown that a twice-daily PPI is not more effective than a once-daily PPI at relieving dyspeptic symptoms. Prokinetic Agents • Metoclopramide and domperidone are dopamine receptor agonists with a stimulatory effect on UGI motility. • Anxiolytic 5-HT1A agonist buspirone improved both symptoms of early satiation and gastric accommodation. • Acotiamide is both a presynaptic muscarinic autoreceptor inhibitor and a cholinesterase inhibitor and enhances both gastric emptying and accommodation. Centrally acting neuromodulators
• Psychotropic agents like antidepressants, anxiolytics, and antipsychotics
• Treatment of functional GI disorders that do not respond to initial
conventional approaches. • Alter pain-processing pathways in the brain • Tricyclic antidepressant-Amitriptyline effective second line therapy in FD
• Mirtazapine, an non adrenergic and serotonergic antidepressant -FD and
major weight loss Other agents • Simethicone
• Peppermint oil
• Duodenal and intestinal dysbiosis –Rifaximin
• Rifaximin 400 mg three times daily for 2 weeks -In a study from Hong Kong, , was well tolerated and superior to placebo in providing adequate relief of belching and postprandial fullness and bloating. • Probiotics Psychological Interventions
• Patients with functional dyspepsia have a higher prevalence of
psychosocial comorbidities • Group support with relaxation training,
• Cognitive therapy, psychotherapy, and hypnotherapy
• A systematic review of clinical trials of psychological interventions for
functional dyspepsia found that all published trials claimed benefit for psychological interventions, with effects persisting for over 1 year. Functional dyspepsia
