K14 IPD Dispepsia Fungsional

Functional
Dyspepsia
Division of Gastroentero - Hepatology
Departmen of Internal Medicine
Medical Faculty, North Sumatera University
Medan - Indonesia
Dyspepsia - Definition
A group of symptoms which alert
clinicians to consider disease of the
upper gastrointestinal tract
(British Society of Gastroenterology, 1996)
Functional Dyspepsia Definition

Chronic or recurrent upper GI symptoms not
explained by biochemical or structural abnormalities
(does not imply that there is no physiological basis)
Appropriate evaluation using standard diagnostic
tests reveals no abnormalities
Also known as nonulcer dyspepsia, essential
dyspepsia, idiopathic dyspepsia
(Talley N. Scand J Gastro 1991;182:7)
Dyspepsia
Functional
Dyspepsia
Non-GI
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
Nocturnal
pain
Localized
epigastric
burning
Better
with food
Dysmotility-like Dominant
Heartburn
Nausea
Bloating
Retrosternal Early satiety

burning
Worse
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
perception
Altered
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
Afferent
Activity
Low Grade
Inflammation
HP Infection
.
..
Sensitivity
Impaired Motor Activity

Accommodation
Altered Motor & Sensory Function
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
H. pylori
Eradication
Length of Benefit from Length of

Follow-up
H. pylori
Follow-up
(yr)
Eradication
(yr)
Veldhuyzen van Zanten, 1995 0.5
Lazzaroni, 1996
0.5
Elta, 1996
Trespi, 1994
0.5
Schutze, 1996
McCarthy, 1995
Sheu, 1996
Testing for H. pylori

Test
Sensitivity Specificity Cost
C13 or C14
urease breath
test
90% to 100% 96% to 100%

hospital nuclear
medicine department
Serology
91% to 98% 75% to 80%

through commercial
labs and Public Health
Comments
++
Limited - requires
Widely available
Capillary
85% to 90% 75% to 80%
+
blood serology purchased by doctor administered
Office test, must be
Endoscopic
biopsy
Requires specialist
99%
Invasive
99%
++++
(Cutler A. Gastro 1995;109:136.

Megraud F. Scand J Gastro 1996;215:57)
Suspected Functional
Dyspepsia - Who to
Investigate?
Over 50 years of age, with new onset
of symptoms
Failed therapy
Cancer fear
Symptoms that are severe as
perceived by patient or physician
AGA Guidelines Step 1

Alarm Symptoms:
Weight loss
Progressive
dysphagia
Recurrent vomiting
Evidence of GI bleed
Family history of
malignancy
Proposed Mechanisms of
Hyperalgesia
Central Hyperalgesia
Pain
Peripheral Signals
Loss of
Descending
Inhibition
Proposed Mechanisms of
Hyperalgesia
Drug Effects on the CNS-Enteric Nervous System
Cortex
Spinal Cord
Descending inhibitory fibres
- ANS. Input
2nd order neurons
Dorsal horn nucleus
Dorsal root ganglion
Sensory
nerve endings in gut
Pain Perception
Pharmacological
Options
opiates, tricyclics
5HT3 antagonists
Clonidine
opiates
5HT3 antagonists
Substance P
CGRP antagonists
NSAIDs
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
Functional
dyspepsia
Impaired fundic
accommodation
with a
redistribution of
food to antrum
(Gilja O. Dig Dis Sci 1996;41:689)
Delayed Gastric Emptying in

Studies have found delayed gastric
emptying for solids, in 30% to 82%
of patients with functional
dyspepsia
Small Bowel Motor

Dysfunction in Functional
Dyspepsia
In patients with more severe
symptoms
Hyperactive or uncoordinated
duodenal contractions
Absent or abnormal migrating
myoelectrical complexes
(Kerlin P. Gut 1989;30:54)
Altered CNS Function

in Functional
Dyspepsia
CNS Factors
Psychological factors to be considered
in
pathogenesis of functional
the
Anxiety
dyspepsia:
Depression
Sexual abuse
Sleep deprivation
Stressful events
The role of psychological factors in functional dyspepsia

is not as clearly established as it is in IBS
H. pylori Eradication
Regimens
(All given for one week)
Treatments of Choice
Regimen
PPI
Antibiotics
PPI - AC
BID
Amoxicillin 1 g bid
Clarithromycin 500 mg bid
PPI - MC
BID
Metronidazole 500 mg bid

Clarithromycin 250 mg bid
BID
Bismuth 2 tabs qid

Metronidazole 250 mg qid
Tetracycline 500 mg qid
Alternate
PPI - BMT
Choice of Investigation for

Ulcer-like Dyspepsia
Endoscopy
UGI Series
More expensive
Less expensive
Issues of access/waiting
lists can be a problem
Easy access, usually short

waiting time
Allows for biopsy

(cancer, Hp)
If cancer is found, endoscopy

will be needed
Allows diagnosis of
mucosal lesions (erosions)
Often misses mucosal lesions
Preferred investigation for

dyspepsia
Alternative, especially if
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
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
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
H2-receptor antagonist for 4 weeks
OR
Proton pump inhibitor for 2 weeks
Management of Dysmotility-like Functional

Dyspepsia
Dysmotility-like Symptoms Dominant
Educate/lifestyle
Educate/lifestyle modification
modification
Trial
Trial of
of prokinetic
prokinetic
medication
medication
Success
Success
Failure
Failure
Continue
Continue with
with
cyclic
cyclic therapy
therapy
Investigate
Investigate
Test
Test H.
H. pylori
pylori
Gastroscopy
Gastroscopy or
or UGI
UGI
+
+
--
Eradicate
Eradicate
Success
Success
Failure
Failure
Consider
Consider H
H22
antagonists,
antagonists, tricyclics
tricyclics
Differential Diagnosis
Functional Dyspepsia (60%)

PUD (25%)
GERD
Biliary Pain
Chronic Abdominal Wall Pain
Gastric CA
Esophageal CA
Other Abdominal Malignancy
Gastroparesis
Pancreatitis
Carbohydrate Malabsorption
Meds (NSAIDS, Narcotics,
etc.)
Infiltrative Diseases
Metabolic Disturbances
Hepatoma
Ischemic Bowel Disease
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

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Functional

(British Society of Gastroenterology, 1996)

Functional Dyspepsia Definition

(Talley N. Scand J Gastro 1991;182:7)

Retrosternal Early satiety

What are the possible

Impaired Motor Activity

Altered Motor & Sensory Function

Length of Benefit from Length of

Veldhuyzen van Zanten, 1995 0.5

Testing for H. pylori

Sensitivity Specificity Cost

90% to 100% 96% to 100%

91% to 98% 75% to 80%

Office test, must be

(Cutler A. Gastro 1995;109:136.

AGA Guidelines Step 1

AGA Guidelines Step 2

AGA Guidelines Step 3

AGA Guidelines Step 4

Upper GI Motility in Functional

Delayed Gastric Emptying in

Small Bowel Motor

Altered CNS Function

The role of psychological factors in functional dyspepsia

Metronidazole 500 mg bid

Bismuth 2 tabs qid

Choice of Investigation for

Easy access, usually short

Allows for biopsy

If cancer is found, endoscopy

Often misses mucosal lesions

Preferred investigation for

Lifestyle Modification for

Small frequent meals

Acid Suppression Therapy

Management of Dysmotility-like Functional

Functional Dyspepsia (60%)

Increased gastric acid

Psychological Treatment for

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