Functional Dyspepsia

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Functional Dyspepsia

• Norbert Welkovics
• Heine van der Walt

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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 disorders E.      
  Billiary disorders
• A1. Globus E1. Gallbladder dysfunction
• A2. Rumination Syndrome E2. Sphincter of Odi
  dysfunction
• A3. Functional chest pain of presumed
  oesophageal origin
• A4. Functional heartburn
• A5. Functional dysphagia
• A6. Unspecified oesophageal disorder
• B.       Gastroduodenal disorders
  F.       Anorectal disorders
• B1. Functional dyspepsia F1. Functional
  faecal incontinence
• B1a. Ulcer like dyspepsia F2. Functional
  anorectal pain
• B1b. Dysmotility like dyspepsia
  F2a. 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

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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 disease 22
• Esophagitis 10
• Cancer 1
• Functional dyspepsia 67
• 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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Aetiology Postulates

• 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

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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 dont 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