Functional DyspepsiaFunctional Dyspepsia

Yehudith Assouline-Dayan, MDYehudith Assouline-Dayan, MD

Functional Dyspepsia

Definition

Incidence

Pathophysiology

Management

Functional Dyspepsia (FD) is a clinical syndrome characterized by

• Chronic or recurrent upper abdominal pain or discomfort

• in the absence of underlying organ disease that can explain the symptoms

Rome IIIB. Functional Gastroduodenal Disorders

B1 Functional Dyspepsia

• B1a: postprandial distress syndrome (PDS)

• B1b: epigastric pain syndrome (EPS)

B2 Belching disorders

• B2a: Aerophagia

• B2b: Unspecific excessive belching 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

AND• No evidence of structural disease

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

Incidence Dyspepsia is common, and affects about ¼

individuals in the community

About 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 brain–gut 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 pts

Fewer 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 RCTs

10% relative risk reduction in the HP eradication group compared with placebo

NNTs =14

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

Moayyedi P, Cochrane Database Syst Rev 2006

Antidepressants Limited data

No 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 to placebo in 512 pts

Domperidone- not FDA proved in the US, poor evidence

Pharmacotherapy

Tegaserod- accelerates gastric emptying in some 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 eradicated

No 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