SIMPO-8 dr. Pieter FUNCTIONAL DYSPEPSIA Limas.pptx

penyakit dispepsia

1. FUNCTIONAL DYSPEPSIA Pieter Saragih​

2. Agenda 1 2 3 4 5 DEFINITION EPIDEMIOLOGY PATHOPHYSIOLOGY DIAGNOSIS MANAGEMENT 3 Functional dyspepsia 2023

3. DEFINITION 4

4. Functional Dypepsia 5 Funcional Dypepsia 2023 The term dyspepsia (Greek “ dys ” [bad], “ pepsis ” [digestion]) is used for a spectrum of symptoms localized by the patient to the epigastric region (between the navel and the xiphoid process) and the flanks C onsidered to originate from the gastroduodenal region. I n the absence of organic, systemic, or metabolic condition(s) that is (are) likely to explain symptoms

5. Two main subtypes of functional dyspepsia are distinguished which may overlap : postprandial distress syndrome (PDS) characterized by meal‐induced symptoms (early satiation, postprandial fullness) and epigastric pain syndrome (EPS), with epigastric pain and/or epigastric burning not necessarily associated with a meal. 6 Functional Dyspepsia 2023

6. ORG A N IC U N INV E ST I G A TED FUNCTIONAL INVESTIGATED Talley et al., Gut 1999; 45 (Suppl II): II37–42. Dyspepsia covers a range of symptoms DYSPEPSIA PAIN OR DISCOMFORT centred in upper abdomen IBS GERD

7. Yarandi SS and Christie J., Gastroenterol Res Pract 2013

8. EPIDEMIOLOGY 9 Presentation title 20XX

9. Using the Rome IV criteria, prevalence was estimated at 7% in the recent Rome Foundation global survey V aried between individual countries with the lowest reported prevalence 2.4% in Japan, and the highest 12.3% in Egypt The prevalence of dyspepsia in health care units reaches 30% of services offerec by general physicians and 50% of services by gastroenterologists. A multi-center Asian study comprising 1115 patients with un-investigated dyspepsia from nine countries including Indonesia revealed that 43% of the patients were shown to have FD. According to data from the Ministry of Health, Republic of Indonesia, dyspepsia was the ffth and sixth most prevalent disease in inpatients and outpatients in Indonesia 10 Black CJ, Paine PA,Agrawal A, et al . Gut 2022; 71 :1697–1723. Acta Med Indones - Indones J Intern Med • Vol 49 • Number 3 • July 2017 Syam  et al. Gut Pathogens (2023) 15:25

10. 11 Functional Dyspepsia 2023 Global prevalence of uninvestigated dyspepsia and functional dyspepsia World J Gastroenterol 2006 May 7; 12(17): 2661-2666

11. 12 Presentation title 20XX

12. RISK FACTORS Different studies have identi fi ed different risk factors for dyspepsia, including female sex, increasing age, high socioeconomic status H pylori infection, nonsteroidal antiin fl ammatory drug use, low educational level, renting accommodation, absence of central heating, sharing a bed with siblings, and being married 13 F unctional Dyspepsia 2023 Gastroenterology 2016;150:1380–1392

13. PATHOPHYSIOLOGY 14 Presentation title 2023

14. FD is a DGBI (Disorder of Brain Gut Interaction) Associated with abnormalities in motility, visceral sensitivity, central nervous system processing, psychopathology, immune function, changes in the gastric and small bowel microbiome, epithelial permeability, and genetics No studies have been carried out to establish which factors occur together or in isolation from one another. Not all of these abnormalities are present in all patients, and if and how they associate with each other, and with dyspeptic symptoms themselves, requires clarification. 15 Functional Dyspepsia 2023 Black CJ, et al. Gut 2022;71:1697–1723

15. Gut Brain Axis 16 Functional Dyspepsia 2023

16. 17 Functional Dyspepsia 2023 Deutsches Ärzteblatt International | Dtsch Arztebl Int 2018; 115: 222–32

17. DIAGNOSIS 18 Presentation title 20XX

18. FUNCTIONAL DYSPEPSIA (ROME IV) Diagnostic criteria** One or more  of the following: Bothersome postprandial fullness Bothersome early satiation Bothersome epigastric pain Bothersome epigastric burning   AND No evidence of structural disease (including at upper endoscopy) that is likely to explain the symptoms   *Must fulfill criteria for B1a. PDS and/or B1b. EPS          **Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis 19 Functional Dyspepsia 2023

19. Postprandial Distress Syndrome (PDS) Diagnostic criteria*         Must include  one or both  of the following at least 3 days a week: Bothersome postprandial fullness (i.e., severe enough to impact on usual activities) Bothersome early satiation (i.e., severe enough to prevent finishing a regular size meal) No evidence of organic, systemic, or metabolic disease that is likely to explain the symptoms on routine investigations (including at upper endoscopy)         *Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis Supportive criteria Postprandial epigastric pain or burning, epigastric bloating, excessive belching, and nausea can also be present Vomiting warrants consideration of another disorder Heartburn is not a dyspeptic symptom but may often co-exist Symptoms that are relieved by evacuation of feces or gas should generally not be considered as part of dyspepsia Other individual digestive symptoms or groups of symptoms (e.g., from GERD and IBS) may co-exist with PDS 20 Functional Dyspepsia 2023

20. Epigastric Pain Syndrome (EPS) Diagnostic criteria*         Must include  one or both  of the following symptoms at least 1 day a week: Bothersome epigastric pain (i.e., severe enough to impact on usual activities) Bothersome epigastric burning (i.e., severe enough to impact on usual activities) No evidence of organic, systemic, or metabolic disease that is likely to explain the symptoms   on routine investigations (including at upper endoscopy).          *Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis Supportive criteria Pain may be induced by ingestion of a meal , relieved by ingestion of a meal, or may occur while fasting Postprandial epigastric bloating, belching, and nausea can also be present Persistent vomiting likely suggests another disorder Heartburn is not a dyspeptic symptom but may often co-exist The pain does not fulfill biliary pain criteria Symptoms that are relieved by evacuation of feces or gas generally should not be considered as part of dyspepsia Other digestive symptoms (such as from GERD and IBS) may co-exist with EPS 21 Functional dyspepsia 2023

21. Confirmation of the diagnosis of functional dyspepsia rests on: ● The typical symptoms and the patient’s history ● The exclusion of other diseases of the upper gastro -intestinal tract and upper abdominal organs that may present with similar dyspeptic symptoms Upper gastrointestinal endoscopy is not required to diagnose FD ( Uninvestigated dyspepsia) FD should be diagnosed on the basis of a comprehensive evaluation of symptoms, age, medical history, presence of H. pylori infection, and laboratory history. In patients who fail to respond to treatment, specialized diagnostic procedures should be carried 22 Functional Dyspepsia 2023

22. ALARM SYMPTOM The alarm features are as follows: unintended weight loss progressive dysphagia recurrent or persistent vomiting evidence of GI bleeding; anemia Fever family history of gastric cancer and new onset dyspepsia in a patient over 40 yearsof age in a population with high prevalence of upper GI malignancy, or over 45 or 50 years in a population with intermediate or low prevalence, respectively 23 Functional Dyspepsia 2023 Asian Consensus Report on Functional Dyspepsia, 2012

23. ENDOSCOPIC FINDING UNINVESTIGATED DYSPEPSIA 24 Functional Dyspepsia 2023 Faintuch et al. BMC Gastroenterology 2014, 14:19

24. 25 Functional Dyspepsia 2023 Journal of the Canadian Association of Gastroenterology, 2022, 5(1), 32–38

25. 26 Functional Dyspepsia 2023 World J Clin Cases 2021 May 26; 9(15): 3597-360

26. 27 Functional Dyspepsia 2023

27. Alarm symptoms and endoscopic finding Gastric cancer early stage of the disease is often asymptomatic, diagnosis is frequently made at an advanced stage of the disease, characterized by poor prognosis with a reported 5-year survival rate of less than 30% in most series Unlike Japan, where the screening programme resulted in a 5-year survival rate of 90%, in Western countries, despite the introduction of open-access gastroscopy, delays in diagnosis still seem to be common Alarm symptoms are not sufficiently sensitive to detect gastrointestinal cancer Sensitivity of 62.4%, a specificity of 70.5%, a positive predictive value of 2.6%, and a negative predictive value of 99.3% 28 Functional Dyspepsia 2023 World J Gastroenterol 2008 February 28; 14(8): 1149-1155

28. 29 Functional Dyspepsia 2023 To improve the diagnosis of gastro-intestinal cancer, age is considered an important factor. There is a gradual increase in the risk of gastric and oesophageal cancer with age, but, unfortunately, a clear cut-off is difficult to define The vast majority of the populations studied,almost 90% of patients with cancer are > 50 years

29. Endoscopy and anxiety 30 Functional Dyspepsia 2023 GHR | June 2021 | vol.3 | no.2 |

30. Management 31 Presentation title 20XX

31. First things first Establishing an effective and empathic doctor–patient relationship and a shared understanding is key to the management of FD This may reduce healthcare utilisation and improve quality of life the diagnosis of FD, Explain I ts underlying pathophysiology, and the natural history of the condition, including common symptom triggers FD should be introduced as a DGBI, together with a simple account of the gut–brain axis and how this is impacted by diet, stress, cognitive, behavioural , and emotional responses to symptoms, and postinfective changes 32 Functional Dyspepsia 2023 Black CJ et al. Gut 2022;71:1697–1723.

32. Cure of FD is unlikely, and most treatments are of modest efficacy . An explanation of the relapsing and remitting natural history of FD, it is not associated with an increased risk of cancer or mortality, T reatment is offered with the aim of improving symptoms, social functioning, and quality of life 33 Functional Dyspepsia 2023

33. 34 Functional Dyspepsia 2023 JAMA Intern Med. 2021;181(6):825-833

34. The role of H Pylori Infection 5% of dyspepsia in the community is attributable to H. pylori,up to 80% of individuals with dyspepsia have FD Although the treatment effect is modest, cure of symptoms at 12 months. Is cost-effective, as it only needs to be taken for 1–2 weeks. Clinicians allow at least 4 weeks before reassessing symptomatic response to H. pylori eradication therapy (ACG 2017), Reduce future risk of gastric cancer and peptic ulcer disease and the benefi ts of this approach clearly outweigh the harms of antibiotic prescribing 35 Functional Dyspepsia 2023 Moayyedi et al. Am J Gastroenterol 2017; 112:988–1013 Black CJ et al. Gut 2022;71:1697–1723 .

35. The role of H Pylori Infection 36 Functional Dyspepsia 2023 Forest plot of randomized controlled trials comparing H. pylori eradication with placebo antibiotics in H. pylori –infected patients with functional dyspepsia Moayyedi et al. Am J Gastroenterol 2017; 112:988–1013

36. Role of PPI in Functional Dyspepsia Several studies have suggested a role for increased duodenal acid exposure or duodenal or gastric hypersensitivity to acid There is evidence that acid suppression therapy with H2RAs or PPIs is beneficial Increased duodenal permeability and duodenal inflammation in FD, with infiltration of eosinophils and mast cells seen, and in close proximity to submucosal plexus neurones . Pantoprazole led not only to symptom improvement in patients with FD, but also a reduction in duodenal eosinophilia and mast cell counts and reduced duodenal permeability. The ACG/CAG guidelines, based on an updated metaanalysis , propose PPI as first‐line therapy, irrespective of the Rome IV subgroupsEmpirical PPI therapy before a test-and-treat approach for Hp has alsobeen proposed in cases of low (<20%) Hp prevalence 37 Functional Dyspepsia 2023

37. Role of PPI in Functional Dyspepsia 38 Functional Dyspepsia 2023 Forest plot of randomized controlled trials comparing proton pump inhibitors with placebo in functional dyspepsia patients.

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39. Role of Prokinetic in Functional Dyspepsia A subset of patients with FD demonstrates abnormal gastric motility, hypersensitivity to gastric distension and impaired fundal accommodation. There is a relative paucity of data evaluating prokinetic therapy in the treatment of undiagnosed dyspepsia. With very low quality of evidence, However, studies on prokinetics in FD had limitations due to the high degree of heterogenicity and small sample size. Usually prokinetics are well tolerated (except for cisapride ) and effective in reducing dyspeptic symptom in all subtypes of FD (NNT =7; 95% CI 5 to 12). There is insuffcient evidence to conclude if one prokinetic is superior to another for FD treatment. No correlation between the acceleration of gastric emptying and symptom improvement. 40 Funtional Dyspepsia 2023

40. Role of Prokinetic in Functional Dyspepsia 41 Functional Dyspepsia 2023 Pittayanon et al..Am J Gastroenterol. 2018.

41. 42 Functional dyspepsia 2023

42. Role Psycothropic drug 43 Functional Dyspepsia 2023 Involvement of the brain–gut axis and abnormal central pain processing in functional gastrointestinal disorders is now established, and FD has been retermed a DGBI. Gut–brain neuromodulators, including low-dose antidepressants, have been suggested as a therapy for many years, due to their peripheral pain-modifying properties. Amitriptyline appeared to derive its benefit predominantly through improving abdominal pain, since no change in psychological distress measures nor gastric emptying rates was found

43. 44 Functional Dyspepsia 2023 Role Psycothropic drug Ford AC, et al. Gut 2015; Forest plot of efficacy of psychotropic drugs versus placebo in randomised controlled trials in functional dyspepsia.

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45. 46 Functional Dyspepsia 20 23 Forest plot of adverse events with psychotropic drugs versus placebo in randomised controlled trials in functional dyspepsia

46. 47 Functional Dyspepsia 2023 Talley et al.Gastroenterology. 2015149(2):340-9.e2

47. 48 Functional Dyspepsia 2023 Syam et al. Gut Pathogens (2023) 15:25

48. 49 Presentation title 20XX