Functional dyspepsia Ermias D. (MD)

Diagnosis Functional, idiopathic, non ulcer Rome III criteria –Bothersome post prandial fullness –Early satiety –Epigastric pain –Epigastric burn –No evidence of structural diseases Three – six months duration

subcategorize nonulcer dyspepsia Reflux-like dyspepsia - heartburn, regurgitation, or both, with dyspeptic symptoms and no endoscopic evidence of esophagitis. ulcer-like dyspepsia - Epigastric pain. Dysmotility-like dyspepsia - nausea, vomiting, early satiety, and abdominal bloating or distention. Non specific dyspepsia The usefulness of this subclassification under question, because of marked overlap among the subtypes. Also, provides little information about the underlying pathophysiologic abnormality, such as gastroduodenal ulcer or gastroparesis.

pathophysiology Gastric motor fn –Gastroparesis –Antral hypomotility –Low fasting gastric volume –Faster gastric emptying (10%) –Lower gastric compliance, early satiety, wt loss Tx – sumatryptan – fundal relaxation Visceral sensitivity – lower pain threshold H. Pylori infection - ?? Psychosocial factors – multiple somatic complaints

Diagnosis Characteristic history Dx by exclusion

treatment Controversial and disappointing Aim – help pt to accept, and cope with sx Patient counseling Mx of psychosocial factors Dietary advice Discontinue contributory medications

Drug treatment Summaries of treatment trials –Prokinetic agents > placebo (RRR 50%) –H2 antagonists > placebo (RRR 30%) –PPI and bismuth salts > placebo –No benefit from antacids or sucralfate Limitation of trials: short duration, heterogeneous syndrome, inclusion of ass. disorders

PPI Meta analysis of six randomized trials Good out come with PPI than placebo PPI and H2RB comparable 60% 49%

1262 patients, randomized, omeperazole vs placebo for four wks More benefit in omeperazole group Greatest benefit among ulcer like, reflux like than dysmotility like sx omeperazole 38%38% 36 % 28 %

H2 receptor antagonist Low methodological quality studies –H2RB likely to improve symptoms Better quality studies –Reduced efficacy of H2RB Studies differ in agent used, dose, inclusion criteria, length of follow up and outcome

Prokinetic agents Rationale - abnormal gastric emptying Cisapride, domperidone – showed benefit over placebo Availability Metoclopramide – side effects with long term use Tegaserod (5HT4 receptor agonist), itopride (D2 antagonist) – on trial

antidepressants TCA (amitriptyline) Uncertain benefit Improve associated conditions –Insomnia –fibromyalgia

H. pylori Controversial pathogenetic roll Mixed results after eradication therapy Only small proportion of patients respond after eradication therapy Long term benefit (AGA, ACG)

Psychotherapy Visceral analgesia –Serotonin receptor antagonist –Somatostatin analogue - octreotide Alternative medicine –Herbal and natural products (peppermint, caraway) –acupuncture