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Dyspepsia
Functional Non-GI
Dyspepsia Causes of Symptoms
(cardiac disease,
muscular pain, etc.)
Structural Dyspepsia
(GERD, PUD, pancreatic
disease, gallstones, etc.)
What is Dyspepsia?
Epigastric pain
Indigestion
Fullness
Early satiety
Bloating
Belching
Nausea
Retching
Symptoms of Functional
Dyspepsia
Ulcer-like Dominant Dysmotility-like Dominant
Nocturnal
pain Nausea
Localized Heartburn Bloating
epigastric
Retrosternal Early satiety
burning
burning Worse
Better with food
with food
Why is Dyspepsia
Important?
Prevalence is 25% - 40% per year
Accounts for 5% of all PCP referrals
Accounts for 50% of gastroenterologists
workload
$2 Billion is spent on acid-suppressing
drugs each year in the US
Pathophysiology of
Functional
Dyspepsia
What are the possible
causes of functional
dyspepsia?
Altered enteric visceral perception
(hyperalgesia)
Altered enteric motor function
Altered CNS function
Helicobacter pylori
Pathogenesis &
Pathophysiology of Dyspepsia
Behavioural factors
Gastritis
H. pylori infection
Increased
visceral Altered
perception motility
Mechanisms Underlying
Increased Sensory Perception
Reduced
descendin
g inhibition
Increased
sensory
input
Mechanisms Underlying
Altered Motility in Dyspepsia
Stress
Behavioural
Factors
Local Factors:
Gastritis
H. pylori infection
Abnormal Motility
Decreased antral motility
Impaired fundal relaxation
Putative Pathogenesis of
Dyspepsia
Stress
ANS Imbalance
Increased Sensitivity
Sensory Inhibition
.
Increased
Low Grade
.. Sensitivity
Afferent
Activity Inflammation
HP Infection Impaired Motor Activity
Accommodation
DYSPEPSIA
Helicobacter pylori
in Functional
Dyspepsia
Is H. pylori a Factor in
Functional Dyspepsia?
Controversial
Some evidence
- biological plausibility
- prevalence (45% to 70% in
dyspeptics, 13% to 60% in controls)
- eradication studies
H. pylori Eradication
Studies
in Functional Dyspepsia
No Benefit from Length of Benefit from Length of
H. pylori Follow-up H. pylori Follow-up
Eradication (yr) Eradication (yr)
Veldhuyzen van Zanten, 1995 0.5 Lazzaroni, 1996 0.5
Elta, 1996 3 Trespi, 1994 0.5
Schutze, 1996 1 McCarthy, 1995 1
Sheu, 1996 1
Testing for H. pylori
Test Sensitivity Specificity Cost Comments
C13 or C14 90% to 100% 96% to 100% ++ Limited - requires
urease breath hospital nuclear
test medicine department
Serology 91% to 98% 75% to 80% + Widely available
through commercial
labs and Public Health
Capillary 85% to 90% 75% to 80% + Office test, must be
blood serology purchased by doctor administered
Alarm Symptoms:
Weight loss
Progressive
dysphagia
Recurrent vomiting
Evidence of GI bleed
Family history of
malignancy
AGA Guidelines Step 3
AGA Guidelines Step 4
Proposed Mechanisms of
Hyperalgesia
Central Hyperalgesia
Pain Loss of
Descending
Inhibition
Peripheral Signals
Proposed Mechanisms of
Hyperalgesia
Drug Effects on the CNS-Enteric Nervous System
Pain Perception
Cortex
Pharmacological
Options
Spinal Cord opiates, tricyclics
Descending inhibitory fibres 5HT3 antagonists
Substance P
Dorsal root ganglion CGRP antagonists
Sensory
NSAIDs
nerve endings in gut opiates
5HT3 antagonists
Altered Enteric
Motor Function in
Functional
Dyspepsia
Upper GI Motility in
Functional Dyspepsia
Impaired reflex fundal relaxation
Impaired gastric compliance/receptive relaxation
to food ingestion
Weak postprandial antral contractions
Delayed gastric emptying
Small bowel motor dysfunction
Upper GI Motility in Functional
Dyspepsia
Abnormal Fundic Relaxation in Response
Abnormal Fundic Relaxation in Response
to Meal in Functional Dyspepsia
Normal Fundic
accommodatio
n or receptive
relaxation
Meal
Impaired fundic
accommodation
Functional with a
dyspepsia redistribution of
food to antrum
(Gilja O. Dig Dis Sci 1996;41:689)
Delayed Gastric Emptying in
Functional Dyspepsia
Alternate
PPI - BMT BID Bismuth 2 tabs qid
Metronidazole 250 mg qid
Tetracycline 500 mg qid
Choice of Investigation for
Ulcer-like Dyspepsia
Endoscopy UGI Series
More expensive Less expensive
Issues of access/waiting Easy access, usually short
lists can be a problem waiting time
Allows for biopsy If cancer is found, endoscopy
(cancer, Hp) will be needed
Allows diagnosis of Often misses mucosal lesions
mucosal lesions (erosions)
Preferred investigation for Alternative, especially if
dyspepsia access is a concern
Investigation of
Dysmotility-like Dyspepsia
Investigations are frequently normal
Reserved for patients with severe
symptoms, vomiting dominant,
unresponsive to therapy
Solid-phase gastric emptying test
may be useful
Management of
Functional
Dyspepsia
Management of Functional
Dyspepsia
Functional Dyspepsia
General
General treatment
treatment and
and specific
specific
management
based
based on
on dominant
dominant symptom
symptom complex
complex
Ulcer-like
Ulcer-like Dysmotility-like
Dysmotility-like
Follow-up
Follow-up within
within 3
3 to
to 6
6
weeks
weeks
Management of Ulcer-like
Functional Dyspepsia
Ulcer-like Symptoms Dominant
Education/lifestyle
Education/lifestyle
modification
modification
Test
Test Hp
Hp
+
+ --
Eradicate
Eradicate Hp
Hp Trial
Trial of
of acid
acid suppression
suppression
Reassess
Reassess
Success
Success Failure
Failure
Investigate
Investigate Trial
Trial of
of prokinetic
prokinetic
Lifestyle Modification for
Patients with Functional
Dyspepsia
Small frequent meals
Stop smoking
Reduce alcohol
Reduce caffeine
Avoid irritating foodstuffs
Maintain an ideal weight
Review medications
Acid Suppression Therapy
for Ulcer-like Functional
Dyspepsia
Educate/lifestyle
Educate/lifestyle modification
modification
Trial
Trial of
of prokinetic
prokinetic
medication
medication
Success
Success Failure
Failure
Continue
Continue with
with Investigate
Investigate
cyclic
cyclic therapy
therapy
Test
Test H.
H. pylori
pylori
Gastroscopy
Gastroscopy or
or UGI
UGI
+
+ --
Eradicate
Eradicate
Consider
Consider HH22
Success
Success Failure
Failure antagonists,
antagonists, tricyclics
tricyclics
Differential Diagnosis
Functional Dyspepsia (60%) Pancreatitis
PUD (25%) Carbohydrate Malabsorption
GERD Meds (NSAIDS, Narcotics,
Biliary Pain etc.)
Chronic Abdominal Wall Pain Infiltrative Diseases
Gastric CA Metabolic Disturbances
Esophageal CA Hepatoma
Other Abdominal Malignancy Ischemic Bowel Disease
Gastroparesis Systemic Disorders
Parasites
Pathophysiology of FD
Increased gastric acid
H. pylori infection
GI dysmotility (antral hypocontractility)
Decreased perception threshold
Autonomic dysfunction
Decreased gastric accommodation
Gastric myoelectric activity
Psychological factors
Psychological Treatment for
FD
4 trials have evaluated CBT,
hypnotherapy, or psychotherapy
All show statistically improvement at 1
year
Cochrane Meta-analysis- insufficient
evidence as all trials likely underpowered