Dyspepsia Centre of Gastroentero-Hepatology, Wahidin Sudirohusodo Hospital TeachingDepartment of Internal Medicine, Medical Faculty , Hasanuddin University

Upper & Lower GI Diseases Lecture of Gastroentero-Hepatology System, FKUH 2009Level of competent : 41DEFINITIONThe 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)2

The term of dyspepsia are not used if the symptoms occur outside of UGI disorders, such as : Biliary disease PancreatitisMalabsorbsion syndromeMetabolic syndrome

3EPIDEMIOLOGY

Data from Centre of Gastroentero-Hepatology, Wahidin Sudirohusodo General Hospital.Prevalence of the population : 25%Incidence : 9% per year4CLASSIFICATION1. ORGANIC DYSPEPSIAPeptic ulcer, GERD, Gastroduodenitis, UGI cancer2. FUNCTIONAL DYSPEPSIA/NON-ULCER DYSPEPSIAThe 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 syndrome(pain & burning intermitten-localized to the epigastrium)

5PATHOGENESIS of Functional dyspepsia 6DiagnosisAnamnesis : chronic/recurrent pain/discomfort centered in upper abdomen Diagnostic study : Endoscopy UGI 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

7Age treshold 45 years oldPersistent anorexia/ vomiting Bleeding UGI (haematemesis/melena) or anemia without knowing the sourceUnintentional weight loss Dysphagia-odynophagia jaundiceAbdominal mass or lymphadenopathy Patients anxious because of the symptoms appearing off and on or persistent (psychoneurosis)Alarm Symptoms89DIFFERENTIAL DIAGNOSIS1. GERD and Nonerosive reflux disease2. Peptic ulcer disease3. Upper GI malignancy4. Chronic intestinal ischemia5. Pancreatobiliary disease6. Motility disorders

9MANAGEMENTGENERAL MEASURES1. Education & reassurance 2. 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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10PHARMACOTHERAPY

- Antisecretory agents (4-8 weeks)H2 receptor antagonis (ranitidine, cimetidine, famotidine) Proton Pump Inhibitor (omeprazole,lansoprazole, rabeprazole, pantoprazole, esomeprazole) >> H2RAblock acid secretion, suppress acid production- Promotility agents (Prokinetic) Metoclopramide, domperidone, cisapride, tegaserodhelp increase stomach emptying or relaxation.- Low-dose AntidepressantsTricyclic 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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1112PROGNOSISClinical course :1.5-10 years prospective study5-27 years retrospective studyAsymptomatic or improve after 1 to several yearsPoor 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 years12FOLLOW UPOffer low dose w/limited number of prescriptions or stopping treatmentdyspepsia is remitting & relapsing disease, continuous medication is not necessary after eradication of symptoms unless there is an underlying condition requiring treatmentContinue to avoid known precipitants of dyspepsia including smoking, alcohol, coffee,chocolate, fatty food and weight bearingMonitor for appearance of alarm sign/symptoms13GUIDELINES FOR MANAGING DYSPEPSIA IN PRIMARY CARE14 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 symptomsWhen to consider referring adyspeptic patient to a specialist

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Dyspepsia is not new and has been known throughout history(Indigestion by Cruickshank (1792-1872))16Chart10.8470.565

Prevalence of Dyspepsia

Sheet1Prevalence of Dyspepsia200785%200856.50%To resize chart data range, drag lower right corner of range.