Functional dyspepsia-Approach

Approach to functional dyspepsia

1. DR.VADIVEL KUMARAN.,M.D.,DM CONSULTANT MEDICAL GASTROENTEROLOGIST KAUVERY HOSPITAL CHENNAI

2. DYSPEPSIA Greek word means “difficult digestion .” Symptoms located in upper abdomen

3. AGE DISTRIBUTION IN KAUVERY

4. HISTORY & EXAM ALARM Chronicity of the symptoms Nature Frequency Relationship to meals Influence of specific dietary factors Systemic disorders Family and personal history Medications Blood loss Anemia Dysphagia LOW Persistent vomiting Abdominal mass

5. TESTING After the age of 45 Complete blood count Serum electrolytes Calcium Liver biochemical tests Thyroid function Serum amylase Celiac disease Antibodies Stool for ova, parasites , Giardia antigen Pregnancy test

6. Endoscopy Erosive esophagitis Barrett’s esophagus Esophageal cancer Peptic ulcer-Gastric/Duodenal Mechanical obstruction(GOO) Duodenitis or gastritis- Minor findings

7. DRUGS

8. LUMINAL CAUSES

9. SYSTEMIC DISEASES

10. No evidence of structural disease on endoscopy or imaging or basic evaluation.

11. Functional Dyspepsia 1. Epigastric pain 2 . Epigastric burning 3. Early satiation 4 . Bothersome postprandial fullness 1 or more

12. Epigastric Pain Syndrome 1. Pain or burning - epigastrium -moderate severity, 1/week 2 . Intermittent 3. Not generalized or localized to other abdominal or chest regions 4. Not relieved by defecation or passage of flatus 5. Not fulfilling criteria for gallbladder or sphincter of Oddi disorders all the above. Supportive Criteria 1. Pain may be of a burning quality but without a retrosternal component 2 . Pain is commonly induced or relieved by ingestion of a meal but may occur while fasting 3 . Postprandial distress syndrome may coexist

13. Postprandial Distress Syndrome 1. Bothersome postprandial fullness , after ordinary sized meals , at least several times/week 2. Early satiation that prevents finishing regular meal, at least several times/week Supportive Criteria: 1 . Upper abdominal bloating or nausea or belching 2 . Epigastric pain syndrome may coexist

14. PATHOPHYSIOLOGY Hypersensitivity to gastric distention Delayed gastric emptying Impaired gastric accommodation to a meal Altered duodenal sensitivity to lipids or acid Abnormal intestinal motility Central nervous system dysfunction

15. GASTRIC EMPTYING Distal stomach-grinding and sieving until particles are small enough to pass through pylorus Delayed gastric emptying ranges from 20% to 50% Solid gastric emptying- 30-40% Postprandial fullness, nausea and vomiting

16. IMPAIRED GASTRIC ACCOMMODATION Impaired in 40% Proximal stomach-reservoir during and after ingestion of a meal. Relaxation- vagally mediated Rise in intragastric pressure Meal-induced satiation Activation of tension-sensitive mechanoreceptors

17. Antroduodenal Manometry EGG-2.5- to 3.7-cpm, frequency dip in 10 to 15 minutes-gastric relaxation and accommodation Barostat Tests Drink Tests

18. Hypersensitivity to Gastric Distension To isobaric gastric distention Tension-sensitive mechanoreceptors Altered visceral afferent nerves and the central nervous system

19. Altered Duodenal Sensitivity to Lipids or Acid Gastric distention- cholecystokinin Duodenal hypersensitivity to acid Increased postprandial duodenal acid exposure- impaired clearancE of acid

20. OTHERS Rapid gastric emptying Phasic fundic contractions Lack of suppression of phasic contractility of the proximal stomach Duodenal retrograde contractions Genetic predisposition-G -protein beta polypeptide 3 Hp Infection Postinfection Functional Dyspepsia-acute Salmonella gastroenteritis Anxiety, depressive,somatoform disorders, physical or sexual abuse

21. DIABETIC GASTROPARESIS Loss of ICCs Reduced receptive relaxation and accommodation Antral hypomotility . Isolated pyloric contractions- Pylorospasm . Gastric dysrhythmias -abnormal intragastric distribution of food. Antral dilation Impaired action of prokinetic drugs. Modifies upper GI sensations Gastric smooth muscle dysfunction

22. General measures Lifestyle and dietary measures Eat smaller, more frequent meals Avoiding meals with a high fat Avoid spicy foods- capsaicin Avoid- coffee Cessation of smoking and consumption of alcohol Avoidance of aspirin and other NSAIDs Treat- coexisting anxiety disorder or depression

23. APPROACHES (1) Prompt diagnostic endoscopy followed by targeted medical therapy (2) Noninvasive testing for Hp infection, followed by treatment based on the result (“test-and-treat” strategy) (3) Empirical anti- secretory drug therapy Not Recommended = empirical therapy with a prokinetic agent

24. Prompt Endoscopy and Directed Treatment Family history of gastric cancer High rate of gastric cancer country Had a partial gastrectomy Peptic ulcer, erosive esophagitis , or malignancy Reassures-patients and physicians Diagnosis of Hp infection- eradication therapy Functional dyspepsia and GERD recurs after discontinuing PPI

25. Test and Treat for Hp Infection Hp- associated with peptic ulcers & gastric cancer Young patients- noninvasive testing Eliminates chronic gastritis The test and- treat strategy= Hp infection rate is high

26. Empirical Antisecretory Drug Therapy Beneficial in 1/3 rd of functional dyspepsia Response usually within 2 weeks of therapy Economically- equally or more cost-effective than test & treat strategy

27. Acid-Suppressive Drugs Both therapeutic and diagnostic value H2RAs & PPI are effective Half-dose=full-dose=double-dose PPI therapy Hp status did not affect the response Most effective for GERD also. Less effective- epigastric pain & dysmotility

28. Eradication of Hp Infection Induce sustained remission of dyspepsia Low number of responder Delayed symptomatic benefit Protects against- peptic ulcer, gastric cancer Short duration and low cost of treatment.

29. Prokinetic Agents Dopamine receptor agonists-upper GI motility 5-hydroxytryptamine 4 (5-HT4) receptor agonism Motilin receptor agonist ABT-229 Mixed 5-HT4 receptor agonist and 5-HT3 receptor antagonist mosapride 5-HT4 receptor agonist tegaserod Dopamine D2 antagonist/ acetylcholinesterase inhibitor itopride

30. Antidepressants Functional GI disorders not initially responding Anxiolytics and antidepressants-TCA The effect- independent of the presence of depression, decrease visceral sensitivity SSRI- increased gastric accommodation

31. OTHERS M1 and M2 muscarinic receptor antagonist & inhibits cholinesterase- Acotiamide Bismuth salts Simethicone 5-HT1A, 5-HT3, 5-HT4- agonists-enhance gastric accommodation Neurokinin receptor antagonists and peripherally kappa opioid receptor agonists-Visceral hypersensitivity Alleviating postprandial fullness, early satiation and upper abdominal bloating.

32. Psychological Interventions Group support with relaxation training Cognitive therapy Psychotherapy Hypnotherapy

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