Functional dyspepsia
Ermias D. (MD)
Diagnosis
• Functional, idiopathic, non ulcer
• Rome III criteria
– Bothersome post prandial fullness
– Early satiety
– Epigastric pain
– Epigastric burn
– No evidence of structural diseases
• Three – six months duration
subcategorize nonulcer dyspepsia
• Reflux-like dyspepsia - heartburn, regurgitation, or both, with
dyspeptic symptoms and no endoscopic evidence of
esophagitis.
• ulcer-like dyspepsia - Epigastric pain.
• Dysmotility-like dyspepsia - nausea, vomiting, early satiety,
and abdominal bloating or distention.
• Non specific dyspepsia
• The usefulness of this subclassification under question,
because of marked overlap among the subtypes.
• Also, provides little information about the underlying
pathophysiologic abnormality, such as gastroduodenal ulcer
or gastroparesis.
pathophysiology
• Gastric motor fn
–
–
–
–
–
Gastroparesis
Antral hypomotility
Low fasting gastric volume
Faster gastric emptying (10%)
Lower gastric compliance, early satiety, wt loss
• Tx – sumatryptan – fundal relaxation
• Visceral sensitivity – lower pain threshold
• H. Pylori infection - ??
• Psychosocial factors – multiple somatic complaints
Diagnosis
• Characteristic history
• Dx by exclusion
treatment
•
•
•
•
•
•
Controversial and disappointing
Aim – help pt to accept, and cope with sx
Patient counseling
Mx of psychosocial factors
Dietary advice
Discontinue contributory medications
Drug treatment
• Summaries of treatment trials
– Prokinetic agents > placebo (RRR 50%)
– H2 antagonists > placebo (RRR 30%)
– PPI and bismuth salts > placebo
– No benefit from antacids or sucralfate
• Limitation of trials: short duration,
heterogeneous syndrome, inclusion of
ass. disorders
60%
PPI
60%
49%
50%
40%
30%
Meta analysis
of six randomized trials
20%
10%
0%
good out come
Good out come
with PPI than placebo
PPI and H2RB comparable
40
3
8
%
36
%
sx relief
28
%
35
30
25
20
1262 patients,
randomized,
omeperazole vs placebo
for
four wks
More benefit in
omeperazole group
15
Greatest
benefit among ulcer like,
reflux like
than dysmotility like sx
10
5
0
20 mg
10 mg
omeperazole
placebo
H2 receptor antagonist
• Low methodological quality studies
– H2RB likely to improve symptoms
• Better quality studies
– Reduced efficacy of H2RB
• Studies differ in agent used, dose,
inclusion criteria, length of follow up and
outcome
Prokinetic agents
• Rationale - abnormal gastric emptying
• Cisapride, domperidone – showed benefit
over placebo
• Availability
• Metoclopramide – side effects with long
term use
• Tegaserod (5HT4 receptor agonist),
itopride (D2 antagonist) – on trial
antidepressants
• TCA (amitriptyline)
• Uncertain benefit
• Improve associated conditions
– Insomnia
– fibromyalgia
H. pylori
• Controversial pathogenetic roll
• Mixed results after eradication therapy
• Only small proportion of patients respond
after eradication therapy
• Long term benefit (AGA, ACG)
• Psychotherapy
• Visceral analgesia
– Serotonin receptor antagonist
– Somatostatin analogue - octreotide
• Alternative medicine
– Herbal and natural products (peppermint, caraway)
– acupuncture