1. Dyspepsia Dr. Atakan Yeşil Yeditepe Unıversity Department of Gastroenterology

2. Dyspepsia 40% of all adults Aproximately 25 percent of patients with dyspepsia have an underlying organic cause.However, up to 75 percent of patients have functional (idiopathic or nonulcer) dyspepsia with no underlying cause on diagnostic evaluation

3. Gastroesophageal reflux disease (GERD), functional dyspepsia (FD) and irritable bowel syndrome (IBS) are common functional gastrointestinal conditions with significant impact on the daily lives of individuals. When diagnosing patients with GERD, FD and IBS, physicians should keep in mind that these patients could be suffering from more than one of these conditions Scand J Gastroenterol. 2014 Dec 19:Overlap of symptoms of gastroesophageal reflux disease, dyspepsia and irritable bowel syndrome in the general population. Rasmussen S Scand J Gastroenterol.Rasmussen S

5. Antrum: Pylor:G cells:gastrin:stimulates acid secretion D cells:somostatin:inhibits gastrin secretion, Goblet cells:secrete mucus to coat and protect the stomach from corozive injury Fundus:pariatal cells:secrete Hcl chief:secrete pepsinojen-pepsin by HCL, pepsin:can damage the gastric epitelium

16. Which One is not diagnostic criteria for functional dyspepsia? A.Postprandial fullness B.Early satiation C.Epigastric pain D.Epigastric burning E.Bloating

18. Which one dosn’t have a role ın dyspepsıa pathogenesis? A. Gastric motility and compliance B. Visceral hypersensitivity C. Helicobacter pylori infection D.Altered gut microbiome E.Malabsorpition

19. PATHOPHYSIOLOGY 1. Gastric motility and compliance Several motility disorders have been reported in patients with dyspepsia. These include delayed gastric emptying, rapid gastric emptying, antral hypomotility, gastric dysrhythmias, and impaired gastric accommodation in response to a meal

20. 2. Visceral hypersensitivity — Visceral hypersensitivity is characterized by a lowered threshold for induction of pain in the presence of normal gastric compliance.

21. 3. Helicobacter pylori infection — Although there are several hypotheses with regard to the role of Helicobacter pylori infection in the pathogenesis of functional dyspepsia, the mechanism remains unclear.

22. Helicobacter Pylori

23. 4.Altered gut microbiome — Alterations in the upper gastrointestinal tract microbiome may result in the development of dyspepsia, although this has not been directly, formally evaluated.

24. 5. Psychosocial dysfunction: Functional dyspepsia may result from a complex interaction of psychosocial and physiological factors. Dyspepsia has been associated with generalized anxiety disorder, somatization, and major depression

25. Which is most of underlying organic cause of dyspepsia? A.Reflux oesophagitis B.Duodenal ulcer C.Gastric ulcer D.Gastric carcinoma E.Oesophageal carcinoma

26. Causes Reflux oesophagitis 12% Duodenal ulcer 10% Gastric ulcer 6% Gastric carcinoma 1% Oesophageal carcinoma 0.5%

28. Which is not alarm symptom for dyspepsia? A.GI bleeding B.Persistent vomiting C.Weight loss Dysphagia D.Anaemia E.Reflux

29. Alarm Symptoms/ Signs* GI bleeding (same day referral) Persistent vomiting Weight loss (progressive unintentional) Dysphagia Epigastric mass Anaemia due to possible GI blood loss Thus all patients with new-onset dyspepsia should have abdominal examination and FBC

30. First Approach to Dyspepsia Consider possible causes outside upper GI tract -Heart, lung, liver, gall bladder, pancreas, bowel Consider drugs and stop if possible - Aspirin / NSAIDs, calcium antagonists, nitrates, theophyllines, etidronate, steroids

31. Refer if dyspepsia in 55+* year old Alarm symptoms/signs (2 week referral) GI bleeding (same day referral) Persistent vomiting Weight loss (progressive unintentional) Dysphagia Epigastric mass Anaemia due to possible GI blood loss

33. Routine Endoscopic Investigation Patients of any age, presenting with dyspepsia and without alarm signs, is not necessary. However, in patients aged 55 years and older with unexplained and persistent recent-onset dyspepsia alone, an urgent referral for endoscopy should be made.

34. Management of simple dyspepsia in those aged < 55 years Stress benign nature of dyspepsia Lifestyle advice – Healthy eating – Weight reduction – Stop smoking – Use of antacids

35. Helicobacter Pylori 95% Duodenal ulcers 70% Gastric ulcers 10% Non-ulcer dyspepsia Treatment benefits gastritis more than reflux symptoms

36. Which one is best for diagnosing H. pylori? A.Urea breath test B.Stool antigen test C.Serology D.Endoscopy – CLO test E.Hydogen breath test

37. Diagnosing H. pylori Urea breath test 95% sensitive & specific Stool antigen test 92% sensitive & specific Serology 80% sensitive & specific Endoscopy – CLO test 98% sensitive & specific (urea and phenol red, a dye that turns pink in a pH of 6.0 or greater)

38. H. pylori eradication Treatment failure may be due to - Resistance to antibacterial drugs - Poor compliance Drug Side effects Bismuth n&v, unpleasant taste, darkening of tongue & stools, caution in renal disease Metronidazole n&v, unpleasant taste, ↓ effectiveness OCP, care with lithium/warfarin Amoxicillin & tetracycline GI side effects, ↓ effectiveness OCP, pseudomenbranous colitis Lansoprazole ↓ effectiveness OCP

39. Rx of H. Pylori Use a carbon-13 urea breath test, stool antigen test or, when performance has been validated, laboratory based serology. If re-testing for H. pylori use a carbon-13 urea breath test.*