Functional DyspepsiaFunctional Dyspepsia

Norbert WelkovicsNorbert WelkovicsHeine van der WaltHeine van der Walt

Functional DyspepsiaFunctional DyspepsiaFunctional Dyspepsia

DefinitionDefinitionCharacteristics: – Central abdomen– Pain or discomfort– Not associated with bowel movements

No structural or biochemical abnormalty

Part of Gastroduodenal disorders (Rome II)

Functional DyspepsiaFunctional DyspepsiaFunctional Dyspepsia

Fx GastroFx Gastro--intstinal disordersintstinal disordersRome II (1999)Rome II (1999)

A. Esophagial disorders E. Billiary disordersA1. Globus E1. Gallbladder dysfunction

A2. Rumination Syndrome E2. Sphincter of Odi dysfunctionA3. Functional chest pain of presumed oesophageal originA4. Functional heartburnA5. Functional dysphagiaA6. Unspecified oesophageal disorder

B. Gastroduodenal disorders F. Anorectal disordersB1. Functional dyspepsia F1. Functional faecal incontinence

B1a. Ulcer like dyspepsia F2. Functional anorectal painB1b. Dysmotility like dyspepsia F2a. Levator ani syndromeB1c. Non-specific dyspepsia F2b. Proctalgia fugax

B2. AerophagiaB3. Functional vomiting

C. Bowel disordersC1. Irritable bowel syndromeC2. Functional abdominal bloatingC3. Functional constipationC4. Functional diarrhoeaC5. Unspecified functional bowel disorder

D. Functional abdominal painD1. Functional abdominal pain syndromeD2. Unspecified functional abdominal pain

Functional DyspepsiaFunctional DyspepsiaFunctional Dyspepsia

ClassificationClassificationOrganic dyspepsia– PUD, GERD, Pancreatico-billiry disease– Functional dyspepsia– Ulcer-like dyspepsiea

• Pain

– Dysmotility-like dyspepsia• Discomort; nausea, vomiting, postprandial fullness and upper

abdominal bloating

– Reflux-like dyspepsia• Heartburn but not the predominant symptom

Functional DyspepsiaFunctional DyspepsiaFunctional Dyspepsia

EpidemiologyEpidemiologyCommon complaint (15 – 25%)

On upper GIT endoscopy:– Peptic ulcer disease 22%– Esophagitis 10%– Cancer 1%– Functional dyspepsia 67%

Comparable to asymptomatics

Functional DyspepsiaFunctional DyspepsiaFunctional Dyspepsia

AetiologyAetiologyCause and effect difficult to establish1. Symptoms experienced are intermittent and

changing2. High placebo response rate (30%)3. No specific findings in all patients present4. Findings present in asymptomatic patients as well5. Symptoms and findings often do not correlate6. There is no universal effective treatment7. The response to treatment is difficult to predict

Functional DyspepsiaFunctional DyspepsiaFunctional Dyspepsia

Aetiology Aetiology PostulatesPostulates

UlcerUlcer--likelikeDyspepsiaDyspepsia

– Helicobacter pylori– Gastritis / Duodenitis– Missed PUD– Acid sensitivity– Occult GERD

DysmotilityDysmotility--likelikeDyspepsiaDyspepsia

– Gastroparesis– Abnormal relaxation– Visceral hypersensitivity– Brain-gut disorder– Psychological disorder

Functional DyspepsiaFunctional DyspepsiaFunctional Dyspepsia

Aetiology Aetiology Helicobacter pyloriHelicobacter pylori

Controversial:– Background infection rates increase with age– H.pylori gastritis equal in asymptomatics

Possible CagA+ strain

For treatment– WHO declared HP carcinogen– Response to treatment 20% at 1 year

Functional DyspepsiaFunctional DyspepsiaFunctional Dyspepsia

Aetiology Aetiology Helicobacter pyloriHelicobacter pylori

Against treatment– Response to PPI not to antibiotics– Low background infection rate in 1st world countries

MAASTRICHT CONSENSUSMAASTRICHT CONSENSUSTest and treat approach in uninvestigated dyspepsia in

patients younger than 45 in the absence of:1. Alarm symptoms

2. NSAID use

3. Predominant reflux symptoms

4. Family history of gastric carcinoma

Functional DyspepsiaFunctional DyspepsiaFunctional Dyspepsia

Aetiology Aetiology GastritisGastritis

NSAID gastropathy and functional dyspepsia can occur simultaniously– Stop NSAID– If symptoms don’t improve, treat as functional

dyspepsia

Functional DyspepsiaFunctional DyspepsiaFunctional Dyspepsia

Aetiology Aetiology DuodenitisDuodenitis

Presence of past PUD diagnosis– Manage as PUD even if endoscopy normal– Missed PUD?

Absence of past history– Treat as functional dyspepsia

Functional DyspepsiaFunctional DyspepsiaFunctional Dyspepsia

Aetiology Aetiology Acid sensitivityAcid sensitivity

Normal acid secretion

Acid sensitivity increased– 20% incidence in functional dyspepsia– Decreased acid clearance by duodenum

? H2 treatment response– 20% above placebo rate

Functional DyspepsiaFunctional DyspepsiaFunctional Dyspepsia

Aetiology Aetiology Occult GERDOccult GERD

Reflux s a normal phenominon

High positive predictive value– If dominant symptom = GERD– Might form part of functional dyspepsia