1. Case A 48 year old man presented with post prandial epigastric pain for 6 months. Omeprazole 20 mg/D is effective in relieving pain but pain recurs when the drug is stopped Heavy smoker Mild epigastric tenderness

2. Dyspepsia

3. Definition Group of symptoms consisting mostly upper abdominal or epigastric pain or discomfort, heartburn, or acid regurgitation.Often associated with belching, bloating, nausea or vomiting

4. Dyspepsia is a common symptom with an extensive differential diagnosis and a heterogeneous pathophysiology. 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.

5. Dyspepsia FunctionalDyspepsia Non-GI Causes of Symptoms (cardiac disease, muscular pain, etc.) Structural Dyspepsia (GERD, PUD, pancreatic disease, gallstones, etc.)

6. common causes of dyspepsia 1- Functional (nonulcer) dyspepsia Up to 70% 2- Peptic ulcer disease 15 to 25 % 3- GERD 5 to 15 % 4-Gastric or esophageal cancer < 2 %.

7. Less common causes of upper abdominal pain Abdominal cancer, especially pancreatic cancer Biliary tract disease Carbohydrate malabsorption (lactose, sorbitol, fructose, mannitol) Gastroparesis Hepatoma Infiltrative diseases of the stomach (Crohn disease, sarcoidosis) Intestinal parasites (Giardia, Strongyloides) Ischemic bowel disease Medication Metabolic disturbances (hypercalcemia, hyperkalemia) Pancreatitis Systemic disorders (diabetes mellitus, thyroid and parathyroid disorders, connective tissue disease)

8. Drugs associated with dyspepsia NSAIDs including cox-2 inhibitors Iron. Metformin Codiene Antibiotics Orlistat Corticosteroids theophyllin Digoxin. Colchicine Alendronate. Nitrates Quinidine Gemfibrozil Niacin Acarbose

9. Functional dyspepsia Functional dyspepsia Definition (Rome III criteria) One or more of: Bothersome postprandial fullness Early satiation Epigastric pain Epigastric burning AND No evidence of structural disease (including at upper endoscopy) that is likely to explain the symptoms.

10. These criteria should be fulfilled for the last three months with symptom onset at least six months before diagnosis.

11. Alarm features for MGN Age older than 55 Unintended weight loss Persistent vomiting Progressive dysphagia Odynophagia GIB Palpable abdominal mass or lymphadenopathy Unexplained iron deficiency anemia Family history of upper gastrointestinal cancer Previous gastric surgery Jaundice

12. Diagnostic strategies Alarm features Age Local prevalence of H pylori

13. Initial managment Patients with GERD and NSAID induced dyspepsia PPI for eight weeks and NSAIDs should be discontinued

14. Initial managment Patient with alarm features or age ≥ 55 Early upper endoscopy (within two weeks) & rule out H. pylori. further evaluation to exclude other etiologies. If the upper endoscopy is normal optimal age cut-off for endoscopic evaluation in patients with dyspepsia (without alarm features) is controversial

15. yield of upper endoscopy in patients with dyspepsia most prevalent findings in patients with dyspepsia were erosive esophagitis and peptic ulcer disease (pooled prevalence 6 and 8 percent increases with age

16. Initial managment Patient without alarm features and age <55 years test and treat (efficacy varies based on used in primary or secondary care settings and the local prevalence)- prevalence of H. pylori is >20 percent empiric antisecretory therapy- prevalence <5 percent prevalence of 5 to 20% the strategies may be equivalent in terms of dyspepsia resolution, patient satisfaction, and cost

17. PPI therapy is more effective in relieving symptoms of dyspepsia as compared with H2 antagonists Upper endoscopy reserved for patients with persistent symptoms despite antisecretory therapy and H. pylori testing/treatment

18. EVALUATION OF PERSISTENT SYMPTOMS persistent H. pylori infection patients with an alternate diagnosis patients with functional dyspepsia carefully reassessed, paying specific attention to the type of ongoing symptoms, the degree to which symptoms have improved or worsened, and compliance with medications

19. Delayed gastric emptying has been found in 30 to 50

20. Pathophysiology unclear Research has focused upon the following factors: Gastric motor function Visceral sensitivity Helicobacter pylori infection Psychosocial factors

21. functional dyspepsia altered gastric motility in up to 80 percent Gastroparesis gastric dysrhythmias abnormal fundus accumulation pyloric sphincter dysfunction the degree of dysmotility does not correlate with symptoms.

22. TREATMENT — Treatment of patients with functional dyspepsia is controversial and often disappointing, a sharp contrast to the therapy of peptic ulcer disease [ 40]. The goal is to help patients accept, diminish, and cope with symptoms rather then eliminate them [ 40].40 Similar to patients with irritable bowel syndrome, the most important aspects of the therapy of functional dyspepsia include explanation, validation that the symptoms are not imaginary, evaluation and management of relevant psychosocial factors, and dietary advice

23. . Medications that might contribute to symptoms (such as NSAIDs) should be substituted or discontinued whenever possible. Drug therapy, which is based upon the putative pathogenetic mechanisms described above, may help some patients. Several systematic reviews

24. antidepressant -PPI therapy has failed

25. Prokinetics