01. Dyspepsia

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Transcript of 01. Dyspepsia

  • DYSPEPSIA

    Centre of Gastroentero-Hepatology, Wahidin Sudirohusodo Hospital Teaching

    Department of Internal Medicine, Medical Faculty , Hasanuddin University

    Upper & Lower GI Diseases Lecture of Gastroentero-Hepatology System, FKUH 2009

    Level of competent : 4

  • DEFINITION

    The term dyspepsia derives from

    the Greek dys meaning badand pepsis meaning digestion

    A board spectrum of symptoms consist of pain or discomfort

    centered in the upper abdomen (UGI tract), for at least 12

    weeks in the last 12 months (ROME II Criteria)

  • The term of dyspepsia are not used if the symptoms

    occur outside of UGI disorders, such as :

    Biliary disease

    Pancreatitis

    Malabsorbsion syndrome

    Metabolic syndrome

  • EPIDEMIOLOGY85%

    56.50%

    0%

    20%

    40%

    60%

    80%

    100%

    2007 2008

    Prevalence of Dyspepsia

    Prevalence of the population :

    25%

    Incidence : 9% per year

  • CLASSIFICATION

    1. ORGANIC DYSPEPSIA

    Peptic ulcer, GERD,

    Gastroduodenitis, UGI cancer

    2. FUNCTIONAL DYSPEPSIA/

    NON-ULCER DYSPEPSIA

    The absence of any organic,systemic, or metabolic disease(include upper endoscopy) thatcould explain the symptoms.2 subtype (Rome III criteria) :

    1. Post-prandial distress syndrome(bothersome post-prandialfullness, early satiation)

    2. Epigastric pain syndrome(pain & burning intermitten-localized to the epigastrium)

  • MULTIFACTORIAL

    Visceral hypersensitivity :

    epigastric pain, belching, weight loss

    Altered gastric accomodation :

    early satiety, weight loss

    Other mechanisms :

    - H.pylori infection : epigastric pain

    - Dietary factor : altered eating,food intolerance

    - Psychological factor : hypersensity to gastric distention

    Altered gastrointestinal

    motility :

    postprandial fullness, nausea,

    vomiting

    PATHOGENESIS

  • DIAGNOSIS

    Anamnesis : chronic/recurrentpain/discomfort centered inupper abdomen

    Diagnostic study : EndoscopyUGI as gold standard

    ENDOSCOPIC examination was using an

    Alarm Symptoms as criteria guide

    Discomfort refers a subjective

    sensation not interpret as pain which

    may characterized by or associated

    w/ abdominal fullness, early satiety,

    bloating, belching, nausea, vomiting.

    Centered refers to pain or discomfort

    in or around the midline

  • Age treshold 45 years oldPersistent anorexia/ vomitingBleeding UGI (haematemesis/melena) or anemia without knowing thesourceUnintentional weight lossDysphagia-odynophagiajaundiceAbdominal mass or lymphadenopathyPatients anxious because of the symptoms appearing off and on orpersistent (psychoneurosis)

    ALARM SYMPTOMS

  • 9DIFFERENTIAL DIAGNOSIS

    1. GERD and Nonerosive reflux disease

    2. Peptic ulcer disease

    3. Upper GI malignancy

    4. Chronic intestinal ischemia

    5. Pancreatobiliary disease

    6. Motility disorders

  • MANAGEMENT

    GENERAL MEASURES

    1. Education & reassurance2. Diet alteration and lifestyle modification

    - avoid fatty or heavilly spiced food & excessively large meal- smaller, more frequent meals- minimize alcohol and caffein intake- reguler exercise & adequate restful sleep- cognitive behavioral therapy (CBT), psychotherapy

    10

  • PHARMACOTHERAPY

    - Antisecretory agents (4-8 weeks)

    H2 receptor antagonis (ranitidine, cimetidine, famotidine)

    Proton Pump Inhibitor (omeprazole,lansoprazole, rabeprazole,

    pantoprazole, esomeprazole) >> H2RA

    block acid secretion, suppress acid production

    - Promotility agents (Prokinetic)

    Metoclopramide, domperidone, cisapride, tegaserodhelp increase stomach emptying or relaxation.

    - Low-dose Antidepressants

    Tricyclic antidepressant (amytriptylin, fluoxetin, desipramine) affect how the brain and nerves process pain, improve stomach emptying and expansion to accommodate food (these potential effects are being studied).

    11

  • 13

    PROGNOSIS

    - Clinical course :

    1.5-10 years prospective study

    5-27 years retrospective study

    - Asymptomatic or improve after 1 to several years

    - Poor prognosis :

    history of GERD treatment, peptic ulcer, use of aspirin, longer clinical

    course (>2 years), lower education, psychological vulnerebility

    - Functional dyspepsia + H.pylori infection, less likely to be symptoms free at

    2 years

  • FOLLOW UP

    Offer low dose w/limited number of prescriptions or stopping

    treatment

    dyspepsia is remitting & relapsing disease, continuous medication is not necessary

    after eradication of symptoms unless there is an underlying condition requiring

    treatment

    Continue to avoid known precipitants of dyspepsia including

    smoking, alcohol, coffee,chocolate, fatty food and weight

    bearing

    Monitor for appearance of alarm sign/symptoms

  • GUIDELINES FOR

    MANAGING DYSPEPSIA IN

    PRIMARY CARE

    Dyspepsia, without heartburn

    Hp test and treat

    Or empirical therapy

    Empirical therapy,

    a. Lifestyle modification

    b. Empiric therapy :

    PPI or H2RA x2-4 wk

    Adequate respons

    Follow up

    No adequate respons

    Modify therapy

    - Step up therapy : Increase dose or shift

    to another drug class

    - Prokinetic therapy

    Adequate respons :

    Follow up

    No adequate respons

    Specialist referral

    Endoscopy

    Hp test and treat

    Hp negative

    Hp +ve

    (Eradication)

    Follow up

    treatment

    succesfull

    Follow up not

    succesfull

    Alternative

    regimen

    Succesfull

    treatment

    No succesfull :

    Specialist

    referral

    Alarm symptoms

    Or > 45 y.o

    Specialist referral

    Endoscopy

  • If prompt investigation is required (such as recent onset of alarm symptoms)

    Severe pain Failure of symptoms to resolve or substantially

    improve after appropriate treatment

    Progressive symptoms

    When to consider referring a

    dyspeptic patient to a specialist