01. Dyspepsia
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Transcript of 01. Dyspepsia
DYSPEPSIA
Centre of Gastroentero-Hepatology, Wahidin Sudirohusodo Hospital Teaching
Department of Internal Medicine, Medical Faculty , Hasanuddin University
“Upper & Lower GI Diseases” Lecture of Gastroentero-Hepatology System, FKUH 2009
Level of competent : 4
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
EPIDEMIOLOGY85%
56.50%
0%
20%
40%
60%
80%
100%
2007 2008
Prevalence of Dyspepsia
•Prevalence of the population :
25%
•Incidence : 9% per year
CLASSIFICATION
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) thatcould explain the symptoms.2 subtype (Rome III criteria) :
1. Post-prandial distress syndrome(bothersome post-prandialfullness, early satiation)
2. Epigastric pain syndrome(pain & burning intermitten-localized to the epigastrium)
MULTIFACTORIAL
Visceral hypersensitivity :
epigastric pain, belching, weight loss
Altered gastric accomodation :
early satiety, weight loss
Other mechanisms :
- H.pylori infection : epigastric pain
- Dietary factor : altered eating,food intolerance
- Psychological factor : hypersensity to gastric distention
Altered gastrointestinal
motility :
postprandial fullness, nausea,
vomiting
PATHOGENESIS
DIAGNOSIS
Anamnesis : chronic/recurrentpain/discomfort centered inupper abdomen
Diagnostic study : EndoscopyUGI as gold standard
ENDOSCOPIC examination was using an
Alarm Symptoms as criteria guide
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
Age treshold 45 years oldPersistent anorexia/ vomitingBleeding UGI (haematemesis/melena) or anemia without knowing thesourceUnintentional weight lossDysphagia-odynophagiajaundiceAbdominal mass or lymphadenopathyPatients anxious because of the symptoms appearing off and on orpersistent (psychoneurosis)
ALARM SYMPTOMS
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DIFFERENTIAL DIAGNOSIS
1. GERD and Nonerosive reflux disease
2. Peptic ulcer disease
3. Upper GI malignancy
4. Chronic intestinal ischemia
5. Pancreatobiliary disease
6. Motility disorders
MANAGEMENT
GENERAL MEASURES
1. Education & reassurance2. 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
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PHARMACOTHERAPY
- 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, tegaserodhelp 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).
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PROGNOSIS
- 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 x2-4 wk
Adequate respons
Follow up
No adequate respons
Modify therapy
- Step up therapy : Increase dose or shift
to another drug class
- Prokinetic therapy
Adequate respons :
Follow up
No adequate respons
Specialist referral
Endoscopy
Hp test and treat
Hp negative
Hp +ve
(Eradication)
Follow up
treatment
succesfull
Follow up not
succesfull
Alternative
regimen
Succesfull
treatment
No succesfull :
Specialist
referral
Alarm symptoms
Or > 45 y.o
Specialist referral
Endoscopy
• 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
When to consider referring a
dyspeptic patient to a specialist