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Level of

competent : 4

DYSPEPSIA

Upper & Lower GI Diseases Lecture of Gastroentero-Hepatology System, FKUH 2009


Centre of Gastroentero-Hepatology, Wahidin Sudirohusodo Hospital Teaching
Department of Internal Medicine, Medical Faculty , Hasanuddin University

DEFINITION
The term dyspepsia derives
from the Greek dys
meaning bad and pepsis
meaning digestion

A board spectrum of symptoms consist of pain


or discomfort centered in the upper abdomen (UGI
tract), for at least 12 weeks in the last 12 months
(ROME II Criteria)

The term of dyspepsia are not used if the


symptoms occur outside of UGI disorders, such
as :
Biliary disease
Pancreatitis
Malabsorbsion syndrome
Metabolic syndrome

EPIDEMIOLOGY

Data from Centre of GastroenteroHepatology,


Wahidin Sudirohusodo General
Hospital.

Prevalence of the
population : 25%
Incidence : 9% per year

CLASSIFICATIO
N
1. ORGANIC
DYSPEPSIA

Peptic ulcer, GERD,


Gastroduodenitis, UGI
cancer

2. FUNCTIONAL
DYSPEPSIA/
NON-ULCER DYSPEPSIA
The
absence
of
any
organic,
systemic,
or
metabolic disease (include
upper endoscopy) that
could
explain
the
symptoms.
2
subtype
(Rome
III
criteria) :
1. Post-prandial distress
syndrome
(bothersome post-prandial
fullness, early satiation)
2.
Epigastric
pain

PATHOGENESIS of Functional
dyspepsia
Altered
gastrointesti
nal motility :
postprandial
fullness,
nausea,
vomiting

Visceral hypersensitivity :
epigastric pain, belching,
weight loss
MULTIFACTORI
AL

Other mechanisms :
- H.pylori infection : epigastric pain
- Dietary factor : altered eating,food
intolerance
- Psychological factor : hypersensity to
gastric distention

Altered
gastric
accomodati
on :
early
satiety,
weight loss

DIAGNOSIS
Anamnesis : chronic/recurrent
pain/discomfort centered in
upper abdomen
Diagnostic study : Endoscopy
UGI as gold standard

Discomfort
refers
a
subjective
sensation
not
interpret as pain which may
characterized
by
or
associated
w/
abdominal
fullness,
early
satiety,
bloating, belching, nausea,
vomiting.
Centered refers to pain or
discomfort in or around the
midline

ENDOSCOPIC examination was using an


Alarm Symptoms as criteria guide

ALARM
SYMPTOMS
Age treshold 45 years old
Persistent anorexia/ vomiting
Bleeding UGI (haematemesis/melena) or anemia without
knowing the source
Unintentional weight loss
Dysphagia-odynophagia
jaundice
Abdominal mass or lymphadenopathy
Patients anxious because of the symptoms appearing off
and on or persistent (psychoneurosis)

DIFFERENTIAL DIAGNOSIS
1.
2.
3.
4.
5.
6.

GERD and Nonerosive reflux disease


Peptic ulcer disease
Upper GI malignancy
Chronic intestinal ischemia
Pancreatobiliary disease
Motility disorders

MANAGEMENT
10

GENERAL MEASURES
1.
2.
-

Education & reassurance


Diet alteration and lifestyle modification
avoid fatty or heavilly spiced food & excessively large meal
smaller, more frequent meals
minimize alcohol and caffein intake
reguler exercise & adequate restful sleep
cognitive behavioral therapy (CBT), psychotherapy

PHARMACOTHERAPY
11

- Antisecretory agents (4-8 weeks)


H2 receptor antagonis (ranitidine, cimetidine, famotidine)
Proton Pump Inhibitor (omeprazole,lansoprazole, rabeprazole,
pantoprazole, esomeprazole) >> H2RA
block acid secretion, suppress acid production

- Promotility agents (Prokinetic)


Metoclopramide, domperidone, cisapride, tegaserod
help increase stomach emptying or relaxation.

- Low-dose Antidepressants
Tricyclic antidepressant (amytriptylin, fluoxetin, desipramine)
affect how the brain and nerves process pain, improve stomach emptying and expansion to
accommodate food (these potential effects are being studied).

PROGNOSIS
12

- Clinical course :
1.5-10 years prospective study
5-27 years retrospective study
- Asymptomatic or improve after 1 to several years
- Poor prognosis :
history of GERD treatment, peptic ulcer, use of aspirin,
longer clinical course (>2 years), lower education,
psychological vulnerebility
- Functional dyspepsia + H.pylori infection, less likely to be
symptoms free at 2 years

FOLLOW UP

Offer low dose w/limited number of prescriptions


or stopping treatment
dyspepsia is remitting & relapsing disease, continuous medication
is not necessary after eradication of symptoms unless there is an
underlying condition requiring treatment

Continue to avoid known precipitants of


dyspepsia including smoking, alcohol,
coffee,chocolate, fatty food and weight bearing
Monitor for appearance of alarm sign/symptoms

GUIDELINES FOR
MANAGING
DYSPEPSIA IN
PRIMARY CARE

Dyspepsia, without
heartburn
Hp test and
treat
Or empirical
therapy

Empirical
therapy,
a.
Lifestyle
modification
b. Empiric therapy
:
PPI or H2RA x24 wk
Adequate
respons
Follow up

No adequate
respons
Modify
therapy
Step up
therapy

:
Increase dose or shift
to another drug class
- Prokinetic therapy
No adequate
Adequate
respons
respons :
Specialist
Follow up
referral

Alarm
symptoms
Or > 45 y.o
Specialist
referral
Endoscopy

Hp test
and
treat
Hp
negati
ve

Hp +ve
(Eradicati
on)

Follow up
treatment
succesfull

Follow up
not
succesfull
Altern
ative
regime
No
Succesf n
succesful
ull
l:
treatme
Specialist
nt

When to consider referring a


dyspeptic patient to a specialist
If prompt investigation is
required (such as
recent onset
of alarm symptoms)
Severe pain
Failure of symptoms to resolve
or substantially improve after
appropriate
treatment
Progressive symptoms

Dyspepsia is not new and has been


known throughout history
(Indigestion by Cruickshank (17921872))