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 bad

and “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

9

DIFFERENTIAL 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