DYSPEPSIA

dr. Arif Nur Widodo Sp.PD

Divisi Gastroentero-hepatologi RSUD Ulin/FK ULM Banjamasin
Definition
• The term dyspepsia derives from the Greek “dys,” meaning bad,
and “pepsis,” meaning digestion
• Dyspepsia is a symptom, not a diagnosis
• It encompasses a broad spectrum of symptoms that include
upper abdominal pain or discomfort, bloating, early satiety,
postprandial fullness, nausea with or without vomiting,
anorexia, symptoms of GERD, regurgitation, and belching
Organic Dyspepsia
1. Esophagitis
2. Gastritis
3. Peptic ulcer disease
4. Benign esophageal strictures
5. Upper gastrointestinal malignancies
6. Chronic intestinal ischemia
7. Small intestinal bacterial overgrowth or dysbiosis
8. Underlying dysmotility
9. Pancreaticobiliary disease
Organic Dyspepsia (Drugs related)
1. Acarbose 1. Narcotics
2. Aspirin, Nonsteroidal Anti- 2. Niacin
Inflammatory Drugs 3. Nitrates
3. Colchicine 4. Orlistat
4. Digitalis preparations 5. Potassium chloride
5. Estrogens 6. Quinidine
6. Gemfibrozil 7. Sildenafil
7. Glucocorticoids 8. Theophylline
8. Iron
9. Levodopa
Functional Dyspepsia

“The presence of symptoms thought to originate from the

gastroduodenal region, in the absence of any organic, systemic,

or metabolic disease that is likely to explain the symptoms.”

(Rome III)
 Rome III
Criteria for
Functional
Dyspepsia
Epidemiology
• 20-30% of dyspeptic symptoms
• 1% as first onset
• 40% may have an organic cause
• 12-15% functional dyspepsia
• 5-7% new cases at primary care visit
• 40-70% gastroenterology practice visit
Pathogenesis
a) Altered Gastrointestinal
Motility
b) Altered Accommodation
c) Visceral Hypersensitivity
d) Dietary Factors
e) Helicobacter pylori Infection
f) Duodenal Eosinophilia
g) Psychological Factor
Symptoms and Signs
• Identify possible etiologies such as GERD, gallstones,
medications' side effects (particularly NSAIDs), chronic
pancreatitis, diabetic gastroparesis, or obstruction
• Comorbidities, surgical history, family history of upper
gastrointestinal malignancy, alcohol and tobacco use, dietary
changes or allergies, stressful life events, and psychological
factors
 ALARMS
1. Unintentional weight loss 1. Jaundice
2. Anorexia 2. Abdominal mass
3. Early satiety 3. Lymphadenopathy
4. Vomiting 4. Family history of upper GI
5. Odynophagia malignancy
6. Dysphagia 5. History of peptic ulcer disease
7. History  of  gastrointestinal  6. Previous history of GI surgery
(GI)  bleeding 7. History of previous GI
8. Iron deficiency anemia malignancy
Diagnostic
Evaluation
• Adapted, with permission, from Talley
NJ; American Gastroenterological
Association. American
Gastroenterological Association medical
position statement: evaluation of
dyspepsia. Gastroenterology. 2005
Nov;129(5):1753–1755
Diagnostic
Evaluation
• Adapted, with permission, from
Talley NJ; American
Gastroenterological
Association. American
Gastroenterological Association
medical position statement:
evaluation of dyspepsia.
Gastroenterology. 2005
Nov;129(5):1753–1755
Esophagogastroduodenoscopy

• EGD is the gold standard for evaluating

the upper gastrointestinal tract, as it can
provide direct visualization and allows the
endoscopist to obtain a biopsy specimen
of the mucosa if needed
• Cost-effectiveness of early endoscopy in
patients older than 50 years has been
studied in the United Kingdom, with
findings of improvement in symptom
scores, quality of life, and 48% reduction
in use of PPIs
 Helicobacter pylori testing
• For patients younger than 55 years and without alarm features
• The optimal test for H pylori is a 13C-urea breath test or stool
antigen test
• As the prevalence of H pylori varies widely among different
population, this strategy of H pylori test-and-treat followed by
PPI trial is particularly recommended for patients from
backgrounds with high prevalence of H pylori (>10%)
 C-UREA Breath Test (UBT)
13
HP Eradication
 Differential Diagnosis
1. GERD and Nonerosive 1. Motility Disorders
Reflux Disease 2. Systemic Disorders
2. Peptic Ulcer Disease 3. Infections
3. Upper Gastrointestinal 4. Other Considerations
Malignancy
4. Chronic Intestinal
Ischemia
5. Pancreaticobiliary
Disease
 Treatment
• The physician-patient relationship is crucial to the treatment of
functional dyspepsia
• Fears of having cancer or a life-threatening condition, anxiety
levels, and stressful factors in the patient's life should be
assessed and addressed early in the evaluation
• It is important to recognize the variability of symptoms,
exacerbators and alleviators, and response to treatment in
patients with dyspeptic symptoms
Lifestyle Modifications
• The efficacy of dietary or lifestyle modifications in functional
dyspepsia has not been well studied, often showing conflicting results
• Foods generally reported to cause symptoms include onions,
peppers, citrus fruit, coffee, carbonated beverages, and spices
• General dietary recommendations are to avoid fatty or heavily spiced
foods and excessively large meals
• Smaller, more frequent meals are beneficial in patients with GERD,
impaired gastric accommodation, and delayed gastric emptying
• Regular exercise and adequate restful sleep are also important and
can be helpful in alleviating stress
Antisecretory agents
• A systematic review of eight studies with a total of 3293 patients who received
PPI therapy for 2–8 weeks found a significant effect over placebo. PPI therapy
relieved or eliminated symptoms in 33% of patients compared with 23% of
those receiving placebo. The relative risk (RR) of remaining symptomatic on
PPI versus placebo was significantly protective (RR = 0.86; 95% CI, 0.78–0.95;
P = .003; NNT = 9)
• Similarly, another meta analysis of seven randomized placebo-controlled trials
of PPIs with a total of 3725 patients found PPIs to be effective for patients with
ulcer-like dyspepsia (RRR = 12.8%; 95% CI, 7.2–18.1%) and reflux-like
dyspepsia (RRR = 19.7%; 95% CI,1.8–34.3%), but not dysmotility-like
dyspepsia and unspecified dyspepsia
• Systematic reviews on H2-blockers versus placebo have shown improvement
in epigastric pain, but not global symptoms
Promotility
agents • A systematic review of 14 randomized controlled trials reported
prokinetics to be more effective than placebo in functional dyspepsia
• Another systematic review of 17 studies looked at cisapride and
domperidone and found both agents to be superior to placebo
• Metoclopramide was found to be more effective than placebo in two
older studies
• Tegaserod has been shown to increase gastric emptying and mildly
improve symptoms in functional dyspepsia in phase III randomized
controlled trials
• A study of itopride in healthy subjects found that it reduces total
postprandial volume without significantly accelerating gastric
emptyingor altering gastric motor or sensory function
Antidepressants and anxiolytic agents
• Low-dose tricyclic anti-depressants (TCAs), such as
amitriptyline or desipramine, have been used in patients with
various functional disorders, including functional dyspepsia and
irritable bowel syndrome
• As TCAs can slow gastric emptying due to their anticholinergic
effect, they should be avoided in patients with gastroparesis-
functional dyspepsia overlap syndrome
Other drugs
• Antacids and bismuth have each been evaluated in a few trials
for functional dyspepsia and have been consistently found to be
no better than placebo
• Sucralfate has been studied in several limited trials and found to
be no more effective than placebo
• In a recent randomized, double-blind, placebo-controlled trial of
patients with functional dyspepsia, treatment with buspirone for
4 weeks led to significant improvement in gastric
accommodation and reduction in symptoms compared to
placebo
Other drugs
• Antinociceptive agents such as gabapentin or pregabalin have
been suggested as potential agents for management of
discomfort or distress related to functional gastrointestinal
disorder
Recommendations for pharmacotherapy
• Providing reassurance and basic dietary and lifestyle interventions
first
• If H pylori testing (+) treatment is recommended with the
understanding that eradication may or may not improve symptoms
• Antisecretory medications can then be added, such as H2-
blockers (ranitidine, 150 mg twice daily; cimetidine, 400 mg twice
daily; or famotidine, 20 mg twice daily) or PPIs (omeprazole, 20
mg daily; esomeprazole, 40 mg daily; pantoprazole, 40 mg daily;
lansoprazole, 30 mg daily; or rabeprazole, 20 mg daily)
Recommendations for pharmacotherapy
• If there is a response, a course of 2–6 weeks PPI can be tried,
with assessment of resolution of symptoms
• If prokinetics are used, short courses of metoclopramide can be
considered (5–10 mg prior to meals)
• If symptoms are refractory and persist, low-dose TCAs
(amitriptyline, imipramine, nortriptyline, or desipramine at 10–25
mg at bedtime) can be tried even in those without depression
• In patients with symptoms suggestive of poor gastric
accommodation, such as those with postprandial bloating and
discomfort, buspirone represents a potential new treatment option
Psychological
Therapy
• A systematic review of
randomized controlled trials of
psychological therapies found
four eligible trials on applied
relaxation therapy,
psychodynamic psychotherapy,
cognitive therapy, and
hypnotherapy that all reported
symptomatic improvement at 1
year
Complementary and Alternative
Medical Therapy
• Safety and efficacy are also not regulated
• A systematic review of herbal remedies
was published examining 17 studies that
evaluated agents such as angelica,
artichoke, boldo, gentian, ginger, lemon
balm, milk thistle, peppermint, and
turmeric  the symptom improvement
scores ranged from 60% to 90% favoring
treatment over placebo
• Short-term use is likely safe
Course & Prognosis
• The clinical course of functional dyspepsia has been evaluated
in retrospective and prospective studies, with follow-up of 1.5–
10 years for prospective studies and 5–27 years for
retrospective studies  a significant number of patients with
functional dyspepsia became asymptomatic or improved overall
after 1 to several years
• History of GERD treatment during follow-up, prior history of
peptic ulcer disease, use of aspirin, longer clinical history (>2
years), lower education, and psychological vulnerability were
found to be associated with poorer prognosis in these studies
THANK YOU
Any questions?