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Functional Dyspepsia. Norbert Welkovics Heine van der Walt. Definition. Characteristics: Central abdomen Pain or discomfort Not associated with bowel movements No structural or biochemical abnormalty Part of Gastroduodenal disorders (Rome II).

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Functional Dyspepsia

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Functional dyspepsia l.jpg

Functional Dyspepsia

Norbert Welkovics

Heine van der Walt


Definition l.jpg

Definition

  • Characteristics:

    • Central abdomen

    • Pain or discomfort

    • Not associated with bowel movements

  • No structural or biochemical abnormalty

  • Part of Gastroduodenal disorders

    (Rome II)


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Fx Gastro-intstinal disordersRome II (1999)

A. Esophagial disordersE.Billiary disorders

A1. GlobusE1. Gallbladder dysfunction

A2. Rumination SyndromeE2. Sphincter of Odi dysfunction

A3. Functional chest pain of presumed oesophageal origin

A4. Functional heartburn

A5. Functional dysphagia

A6. Unspecified oesophageal disorder

B.Gastroduodenal disordersF.Anorectal disorders

B1. Functional dyspepsiaF1. Functional faecal incontinence

B1a. Ulcer like dyspepsiaF2. Functional anorectal pain

B1b. Dysmotility like dyspepsiaF2a. Levator ani syndrome

B1c. Non-specific dyspepsia F2b. Proctalgia fugax

B2. Aerophagia

B3. Functional vomiting

C.Bowel disorders

C1. Irritable bowel syndrome

C2. Functional abdominal bloating

C3. Functional constipation

C4. Functional diarrhoea

C5. Unspecified functional bowel disorder

D.Functional abdominal pain

D1. Functional abdominal pain syndrome

D2. Unspecified functional abdominal pain


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Classification

  • Organic 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


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Epidemiology

  • Common complaint (15 – 25%)

  • On upper GIT endoscopy:

    • Peptic ulcer disease22%

    • Esophagitis10%

    • Cancer 1%

    • Functional dyspepsia67%

  • Comparable to asymptomatics


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Aetiology

  • Cause and effect difficult to establish

    1.Symptoms experienced are intermittent and changing

    2.High placebo response rate (30%)

    3.No specific findings in all patients present

    4.Findings present in asymptomatic patients as well

    5.Symptoms and findings often do not correlate

    6.There is no universal effective treatment

    7.The response to treatment is difficult to predict


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Ulcer-like

Dyspepsia

Helicobacter pylori

Gastritis / Duodenitis

Missed PUD

Acid sensitivity

Occult GERD

Dysmotility-like

Dyspepsia

Gastroparesis

Abnormal relaxation

Visceral hypersensitivity

Brain-gut disorder

Psychological disorder

Aetiology Postulates


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Aetiology Helicobacter 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


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Aetiology Helicobacter pylori

  • Against treatment

    • Response to PPI not to antibiotics

    • Low background infection rate in 1st world countries

  • MAASTRICHT CONSENSUS

  • Test and treat approach in uninvestigated dyspepsia in

  • patients younger than 45 in the absence of:

    • Alarm symptoms

    • NSAID use

    • Predominant reflux symptoms

    • Family history of gastric carcinoma


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Aetiology Gastritis

  • NSAID gastropathy and functional dyspepsia can occur simultaniously

    • Stop NSAID

    • If symptoms don’t improve, treat as functional dyspepsia


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Aetiology Duodenitis

  • Presence of past PUD diagnosis

    • Manage as PUD even if endoscopy normal

    • Missed PUD?

  • Absence of past history

    • Treat as functional dyspepsia


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Aetiology Acid sensitivity

  • Normal acid secretion

  • Acid sensitivity increased

    • 20% incidence in functional dyspepsia

    • Decreased acid clearance by duodenum

  • ? H2 treatment response

    • 20% above placebo rate


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Aetiology Occult GERD

  • Reflux s a normal phenominon

  • High positive predictive value

    • If dominant symptom = GERD

    • Might form part of functional dyspepsia


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