Dyspepsia

2. Dyspepsia Dr.NasserE.Daryani Professor of Tehran Medical University

3. سوء هاضمه در واقع یک بیماری نیست بکه مجموعه ای از شکایاتی است که احتمال وجود بیماریهای دستگاه گوارش فوقانی را مطرح می کند درد شکم سنگيني بعد از غذا سوزش سر دل احساس پري بعد از غذا خوردن نفخ قبل يا بعد از غذا خوردن گرسنگي غير عادي (دل غشه) مالش سر دل زود سيرشدن با حجم معمولی غذا تهوع و استفراغ کاهش اشتها آروغ زدن مکرر

6. تعریف سوء هاضمه بر اساس آخرین معیارهای تشخیصی روم ـ۳ چهار شکايت مهم تر اند: ۱ـ سنگيني بعد از غذا ۲ـ-سيرشدن زودهنگام ۳ـ-درد شکم در بالاي ناف ۴ـ- سوزش سردل • در ۳ ماه گذشته • به صورت مکرر و حداقل هفته ای یک بار وجود داشته باشد • و شروع بیماری بیش از ۶ ماه باشد.

7. Epidemiology • It occurs in approximately 25 percent (range 13 to 40 percent) of the population each year. • but most affected people do not seek medical care.

8. Etiology?

9. Etiologies • Functional dydpepsia (up to 60%) • Dyspepsia caused by structural or biochemical disease

10. Differential Diagnosis Of Dyspepsia

11. 1) Functional Dyspepsia

13. Functional Dyspepsia • Functional dyspepsia, the cause of symptoms in 60% of dyspeptic pts • Defined as 3 months of bothersome postprandial fullness, early satiety, or epigastric pain or burning with symptom onset at least 6 months before diagnosis in the absence of organic cause • Some cases of functional dyspepsia result from prior gastrointestinal infection

14. Pathophysiology of functional dyspepsia: • Gastric motor function • Visceral sensitivity • Helicobacter pylori infection • Psychosocial factors

15. Gastric motor function  • Normal GI motor function requires: - Coordination of the sympathetic and parasym. nervous systems - Coordination of neurons within the stomach and intestine and the smooth muscle cells of the gut • Abnormalities in this process can lead to a delay in gastric emptying (gastroparesis)

16. Delayed gastric emptying found in 30% of pts with dyspepsia • Up to 10% of pts have fast gastric emptying, which may also be associated with dyspepsia • Gastric compliance is lower in pts with NUD

17. Visceral sensitivity • Visceral hyperalgesia: lowered threshold for induction of pain by gastric distension in the presence of normal gastric compliance • Pathophysiology of visceral hypersensitivity: - Mechanoreceptor dysfunction (peripheral mechanism) - Aberrant processing of afferent input in the spinal cord or brain (central mechanism)

18. Helicobacter Pylori

19. Helicobacter pylori infection • H. pylori is a well known cause of chronic active gastritis • Gastritis is probably not the cause of symptoms in most pts with NUD • A consistent link between findings on endoscopy and dyspepsia has not been found

20. H. pylori may cause altered smooth muscle dysfunction • Multiple studies have evaluated the benefit of eradicating H. pylori in pts with NUD, but results have been conflicting • In aggregate they suggest a small significant benefit

21. Psychosocial factors  •  No unique personality profile has been found in patients with functional dyspepsia • anxiety, somatization, neuroticism, and depression are increased in NUD pts compared with healthy controls • There is a link between self-reported childhood abuse and functional gastrointestinal disorders

22. 2) Gastroesophageal Reflux Disease • Most cases of heartburn occur because of excess acid reflux, although reflux of non-acidic fluid produce similar symptoms • Alkaline reflux esophagitis produces GERD-like symptoms most often in pts who had surgery for PUD • 10% of pts with heartburn of a functional nature exhibit normal degrees of esophageal acid exposure and no increase in nonacidic reflux

23. 3) Ulcer Disease • 15–25% of cases of dyspepsia stem from ulcers of the stomach or duodenum • The most common causes of ulcer disease are gastric infection with H. pyloriand use of NSAIDs • Rare causes of gastroduodenal ulcer include Crohn's disease and Zollinger-Ellison syndrome

24. 4) Malignancy • <2% of cases of dyspepsia result from GE malignancy • Between 8 and 20% of GERD pts exhibit intestinal metaplasia of the esophagus, termed Barrett's metaplasia • Gastric malignancies include adenocarcinoma, which is prevalent in certain Asian societies, and lymphoma

25. 5) Other Causes • Opportunistic fungal or viral esophageal infections may produce heartburn or chest discomfort but more often cause odynophagia • Other causes of esophageal inflammation include eosinophilicesophagitisand pill esophagitis • Biliary colic is in the differential diagnosis of dyspepsia

26. Intestinal lactase deficiency produces gas, bloating, discomfort, and diarrhea after lactose ingestion • Intolerance of other carbohydrates (e.g., fructose, sorbitol) produces similar symptoms • Small-intestinal bacterial overgrowth produce dyspepsia, often with bowel dysfunction, distention, and malabsorption

27. Eosinophilic infiltration of the duodenal mucosa is described in some cases of dyspepsia • Extraperitoneal etiologies of indigestion include congestive heart failure and tuberculosis

28. Pancreatic disease (chronic pancreatitis and malignancy) • Hepatocellular carcinoma • Celiac disease • Ménétrier's disease • Infiltrative diseases (sarcoidosis and eosinophilic gastroenteritis) • Mesenteric ischemia • Thyroid and Parathyroid disease • Abdominal wall strain

29. Approach to the Patient

30. History: • Three common patterns of dyspepsia have been recognized in a number of studies: • Ulcer-like or acid dyspepsia (eg, burning, epigastric hunger pain with food, antacid, and antisecretory agent relief) • Dysmotility-like dyspepsia (with predominant nausea, bloating, and anorexia) • Unspecified dyspepsia

32. weight loss dysphagia anemia Alarm features early satiety odynophagia recurrent vomiting bleeding FH of GI cancer

34. Questions to ask in patients with dyspepsia

35. Peptic ulcers • Does the patient have a previous history of ulcers? • Does the patient take nonsteroidal antiinflammatory drugs? • Is the patient a smoker?

36. Gastroesophageal reflux disease • Does the patient complain of heartburn or regurgitation? • Are symptoms worse when the patient is lying down? • Does the patient have a chronic cough or hoarseness?

37. History • Heartburn often is exacerbated by meals and may awaken the patient • Associated symptoms include: - Regurgitation of acid or nonacidic fluid - Water brash, the reflex release of salty salivary secretions into the mouth • Atypical symptoms include pharyngitis, asthma, cough, bronchitis, hoarseness, and chest pain

38. Biliary tract disease • Does the patient have episodic upper abdominal pain lasting at least one hour? • Does pain occur after meals? • Is the pain associated with meals or belching?

39. (a)Frontal upper right spot image from initial oral cholecystography shows bowel gas superimposed over the lower aspect of the gallbladder.(b) Oral cholecystogram obtained after repositioning the patient clearly shows a large gallstone in the fundus of the gallbladder (arrow).

40. Pancreatitis • Does the pain radiate to the patient's back? • Is the pain abrupt, is it unbearable in severity, or does it last for many hours without relief? • Does the patient have a history of heavy alcohol use? • Is there a family history of pancreatitis?

41. Cancer • Is the patient over 50 years of age? • Has the patient had a recent significant weight loss? • Does the patient have trouble swallowing? • Is the patient a smoker? • Does the patient have longstanding gastroesophageal reflux disease?

42. Irritable bowel syndrome • Does the patient fulfill the Rome or Manning criteria for irritable bowel syndrome (eg, pain relieved with defecation, more frequent stools at the onset of pain, loose stools at the onset of pain, visible abdominal distention, passage of mucus, sensation of incomplete evacuation)?

43. Overlap Among GI Disorders Bloating • 29% with GERD have chronic constipation* • Diagnoses can shift over time† • May share common patho-physiology†‡ Constipation Chronic Constipation Belching Dyspepsia IBS Discomfort Abdominal Pain GERD Regurgitation Heartburn *Locke GR. Neurogastroenterol Motil. 2004;16:1†Corazziari E. Best Prac Res Clin Gastroenterol. 2004;18:613‡Talley NJ. Am J Gastroenterol 2003;98:2454

44. Metabolic disorders/delayed gastric emptying Does the patient have a medical history of: • diabetes mellitus • hypothyroidism • Hyperthyroidism • hyperparathyroidism

45. Medications Is the patient currently taking medications commonly associated with dyspepsia: • iron • NSAIDs • Bisphosphonates • some antibiotics

46. drugs

47. Diagnostic testing

48. Routine laboratory tests • Routine blood counts and blood chemistry determinations are commonly obtained. • These tests help to identify patients with "alarm symptoms" (eg, anemia) who require endoscopy or other diagnostic testing.

49. Diagnostic Testing • Once alarm factors are excluded, pts with typical GERD do not need further evaluation and are treated empirically • Upper endoscopy is indicated to exclude mucosal injury in cases with atypical symptoms, symptoms unresponsive to acid suppressing drugs, or alarm factors

50. For heartburn <5 years in duration, especially in pts <50 years old, endoscopy is recommended to screen for Barrett's metaplasia • Ambulatory esophageal pH testing is considered for drug-refractory symptoms and atypical symptoms like unexplained chest pain • Esophageal manometry most commonly is ordered when surgical treatment of GERD is considered