APPROACH TO DYSPEPSIA

Resultanti
INTRODUCTION
Dyspepsia is a common problem worldwide.
In the United States, the point prevalence is
approximately 25%, excluding those people who
have typical GERD symptoms.
Dyspepsia is a clinical problem of considerable
magnitude for the health care system due to the
high prevalence and the chronic or recurrent
nature of symptoms.

1. Tack J, et al. Gastroenterology 2004;127:1239-55.

2. Talley NJ, et al. Am J Gastroenterol 2005;100:2324-37.
DEFINITION
Dyspepsia is defined as chronic or recurrent pain or
discomfort centered in the upper abdomen.
Discomfort is defined as a subjective negative feeling
that is nonpainful, and can incorporate a variety of
symptoms including early satiety or abdominal
fullness.
Patients presenting with predominant or frequent
(more than once a week) heartburn or acid
regurgitation should be considered to have
gastroesophageal reflux disease (GERD) until proven
otherwise.
1. Tack J, et al. Gastroenterology 2004;127:1239-55.
2. Talley NJ, et al. Am J Gastroenterol 2005;100:2324-37.
DIFFERENTIAL DIAGNOSIS OF DYSPEPSIA
Functional dyspepsia Intestinal parasites
Peptic ulcer disease Carbohydrate

GERD malabsorptioin
Gastroparesis Drugs

Gastric neoplasm Ischemic bowel

disease
Cholelithiasis or
choledocholithiasis Abdominal cancer,
especially pancreatic
Acute or chronic
relapsing pancreatitis cancer

Fisher RS, et al. NEJM 1998;339 (19):1376-81

AGENTS COMMONLY ASSOCIATED WITH
DYSPEPSIA

Loyd RA, et al. Am Fam Physician 2011;83 (5):547-52.

American Gastroenterological Association. Gastroenterology 2005;129:1753-55.
American Gastroenterological Association. Gastroenterology 2005;129:1753-55.
ALARM SYMPTOMS
Unexplained weight Jaundice
loss An abdominal mass
Anorexia Lymphadenopathy
Early satiety A family history of
Vomiting upper gastrointestinal
Progressive dysphagia tract cancer
Odynophagia History of peptic ulcer

Bleeding Previous gastric

surgery or malignancy
Anemia

Talley NJ, et al. Am J Gastroenterol 2005;100:2324-37.

TREATMENT REGIMENS FOR H. PYLORI

Harmon RC, et al. Ther Adv Gastroenterol 2010;3 (2):87-98.

American Gastroenterological Association. Gastroenterology 2005;129:1753-55.
American Gastroenterological Association. Gastroenterology 2005;129:1753-55.
ADVANTAGES AND DISADVANTAGES
OF ENDOSCOPY

Advantages Disadvantages

Improvement in Very unlikely to

symptoms score identify an
and quality of life unexpected
Reduction in the structural cause
use of PPI in a young
patient with no
alarm features
Very costly

Talley NJ, et al. Am J Gastroenterol 2005;100:2324-37.

FUNCTIONAL DYSPEPSIA
DEFINITION
The presence of dyspeptic symptoms (early
satiation, postprandial fullness, epigastric pain
or burning) thought to originate from the
gastroduodenal region, in the absence of any
organic disease that is likely to explain the
symptoms.
Consists of two main diagnostic categories:
Meal-induced dyspeptic symptoms (postprandial
distress syndrome, PDS)
Epigastric pain syndrome (EPS)

Karamanolis GP, et al. Annals of Gastroenterology 2012;25:96-9.

PATHOPHYSIOLOGY

Tack J, et al. Gastroenterology 2004;127:1239-55.

CLINICAL MANIFESTATION
Mechanism Associated symptoms
Delayed gastric emptying Postprandial fullness, nausea,
vomiting
Hypersensitivity to gastric Epigastric pain, belching, weight
distention loss
Impaired accommodation Early satiety, weight loss
H. pylori infection Epigastric pain
Duodenal lipid hypersensitivity Nausea
Duodenal acid hypersensitivity Nausea
Unsuppressed phasic contractility Bloating, absence of nausea
Atypical nonerosive reflux disease Epigastric pain

Tack J, et al. Gastroenterology 2004;127:1239-55.

TREATMENT
H. pylori eradication

Acid-suppressive drugs

Prokinetic drugs

Fundic relaxant drugs

Antidepressants

Psychological therapies
H. PYLORI ERADICATION
Eradication of H. pylori infection plays only a
limited role in the treatment of functional
dyspepsia.
The subgroup of infected functional dyspepsia
patients is expected to become progressively
smaller as the prevalence of H. pylori infection is
steadily declining in Western population.

Karamanolis GP, et al. Annals of Gastroenterology 2012;25:96-9.

ACID-SUPPRESSIVE DRUGS
Frequently used as first line treatment
Proton pump inhibitor
Meta-analysis of placebo-controlled, randomized
trials showed a significant benefit of 13% over
placebo.
H2-receptor antagonist

Patient with concomitant symptom of heartburn

are best candidates for acid suppression therapy.

1. Karamanolis GP, et al. Annals of Gastroenterology 2012;25:96-9.

2. Talley NJ, et al. Am J Gastroenterol 2005;100:2324-37.
PROKINETIC DRUGS
Stimulate gastric smooth muscle contraction.
Showing their most convincing efficacy in
patients with meal-related symptoms.
Domperidone: butyrophenone derivative that
exerts antidopaminergic effects on peripheral
dopamine2 receptors (D2).
Cisapride: accelerates gastric emptying by
stimulating 5-HT4 receptors and releasing
acethylcholine in the myenteric plexus
withdrawn due to cardiac safety concerns.
Karamanolis GP, et al. Annals of Gastroenterology 2012;25:96-9.
PROKINETIC DRUGS
Metoclopramide: dopamine receptor antaginist that readily
crosses the blood-brain barrier and has a high incidence of
dose-related side effects restlessness, tremor, fatigue,
Parkinsonism.
Erythromycin: acts on the motilin receptor to increase
gastric emptying in patients with gastroparesis
tachyphylaxis and side effects limits its clinical utility.
Tegaserod: partial 5-HT4 receptor agonists withdrawn
for a putative increased risk of cardiovascular ischemic
events.

1. Karamanolis GP, et al. Annals of Gastroenterology 2012;25:96-9.

2. Harmon RC, et al. Ther Adv Gastroenterol 2010;3 (2):87-98.
FUNDIC RELAXANT DRUGS
Impaired fundic accommodation is one of the
major pathophysiological mechanisms linked to
functional dyspepsia.
Nitrates, sildenafil, and sumatriptan which are
able to relax the proximal stomach, seem less
suitable for functional dyspepsia patients for
reasons of cost and lack of selectivity.
Buspirone: nonselective 5-HT1 receptor agonist
used in treatment of panic attack superior to
placebo in alleviating dyspeptic symptoms.
1. Karamanolis GP, et al. Annals of Gastroenterology 2012;25:96-9.
2. Tack J, et al. Gastroenterology 2004;127:1239-55.
ANTIDEPRESSANTS
Tricyclic antidepressants showed a significant
benefit over placebo with a relative risk reduction
by 45%, but the available trials were small and
poor quality.
The mechanism is unclear, although there is
some evidence that the drugs affect gastric
sensitivity.
Paroxetine (SSRI) enhanced gastric
accommodation in healthy volunteers, but clinical
studies in functional dyspepsia are lacking.

Karamanolis GP, et al. Annals of Gastroenterology 2012;25:96-9.

PSYCHOLOGICAL THERAPIES
Hypnotherapy, psychotherapy, and cognitive-
behavioral therapy showed clinical benefits that
persist for almost 1 year.
The studies included were small, with high
dropout rates, and biased patient recruitment.

1. Karamanolis GP, et al. Annals of Gastroenterology 2012;25:96-9.

2. Talley NJ, et al. Am J Gastroenterol 2005;100:2324-37.
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