Dyspepsia 1

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Functional Dyspepsia

Yehudith Assouline-Dayan, MD

Functional Dyspepsia

DefinitionIncidence

PathophysiologyManagement

Functional Dyspepsia

(FD) is a clinical syndrome characterized by

Chronic or recurrent upper abdominal painor discomfort

in the absence of underlying organ

disease that can explain the symptoms

B. Functional Gastroduodenal Disorders

Rome III

B1 Functional Dyspepsia

B1a: postprandial distress syndrome (PDS) B1b: epigastric pain syndrome (EPS) B2a: Aerophagia B2b: Unspecific excessive belching

B2 Belching disorders

B3 Nausea and vomiting disorders B4 Rumination syndrome

B1 Functional Dyspepsia

Must Include one or more of the following:

Bothersome postprandial fullness Early satiation Epigastric pain/ burning No evidence of structural disease

AND

At the last 3 months and onset at least 6 months prior to diagnosis

Incidence

Dyspepsia is common, and affects about individuals in the communityAbout 25% of symptomatic people eventually present to their primary-care physician About 10% of these are referred because of refractory symptoms and unhelpful diagnostic tests

Pathophysiology of FGID

Abnormal motility Visceral hypersensitivity Psychosocial factors Mucosal inflammation Altered bacterial flora Disturbed braingut interactions

FD-Pathophysiological Mechanisms

GI motor abnormalities in FD

Delayed gastric emptying Impaired gastric meal distribution Impaired gastric accommodation Abnormal fundic phasic contractions Disturbed antroduodenal motility Abnormal duodenogastric refluxes

The mechanism and associated symptoms in FD

Prevalence of gastroduodenal dysmotility and relation with symptoms in FD patients

Mizuta Y, J of Gastroenterology, 2006

Algorithm for the management of uninvestigated dyspepsia

Initial management strategies for dyspepsia- Review, 2007

Early investigation vs acid suppression

Effectiveness: no difference in 1,125 ptsFewer dyspepsia-related and other sick leave days with early investigation Higher patient satisfaction with early investigation

HP test and treat vs endoscopy

No difference in outcome

Efficacy of PPI in FD

Moayyedi P, Gastroenterology, 2004

Eradication of HP NUD

21 RCTs10% relative risk reduction in the HP eradication group compared with placebo

NNTs =14HP eradication has a small but statistically significant effect in HP positive NUD

Moayyedi P, Cochrane Database Syst Rev 2006

Antidepressants

Limited dataNo RCTs

One study:

Good response to SSRI (depressive FD pts) No change in EGG

Pharmacotherapy

Metoclopramide- standard of care in the US: SE,efficacy is poorly documented

Cisapride- restricted in the US, not superior toplacebo in 512 pts

Domperidone- not FDA proved in the US, poorevidence

Pharmacotherapy

Tegaserod- accelerates gastric emptying insome but not all studies, efficacy in FD not established

Sumatriptan- 5-HT1- receptor agonist Buspirone (anti anxiety)- potential eficacy

Modulation of pain pathways

Psychological treatments: A meta-analysis insufficient evidence for a benefit Potential benefit (methodologic problems)

Applied relaxation therapy Psychodynamic psychotherapy

Antidepressants- no RCTs

Hypnotherapy

Calvert EL, Gastroenterology, 2002

Difficult-to-treat dyspeptic patient

HP infection was excluded or eradicatedNo response to acid suppression therapy Antidepressants and psychological therapies might be useful TLC = Patient education and support remain key to the logical management these patients