1. MANAGEMENT OF
DYSPEPSIA SYNDROME
dr. Abimanyu,Sp.PD, KGEH, FINASIM
DIVISI GASTROENTEROHEPATOLOGY
DEPARTEMEN ILMU PENYAKIT DALAM
FK ULM – RSUD ULIN BANJARMASIN
2. Outline
• Definition of Dyspepsia
• Symptoms of Dyspepsia
• Differential Diagnosis
• Organic Causes of Dyspepsia
• Functional Dyspepsia
• Approach to Uninvestigated Dyspepsia
• Management of Dyspepsia
3. Dyspepsia
Definition:
Chronic or recurrent pain or discomfort
centered in the upper abdomen
Talley NJ, Vakil N. Practice Parameters Committee of the American College of Gastroenterology. Guidelines for the
management of dyspepsia. Am J Gastroenterology 2005
4. DYSPEPSIA – ROME III
Definition
Dyspepsia Is Defined As The Presence Of 1 Or More Dyspepsia
Symptoms That Are Considered To Originate From The
Gastroduodenal Region
One Or More Of The Following Symptoms:
1. Post Prandial Fullness
2. Early Satiety
3. Epigastric Pain
4. Epigastric Burning
5. DYSPEPSIA – ROME IV
Definition
Dyspepsia as any combination of 4 symptoms: postprandial
fullness, early satiety, epigastric pain, and epigastric burning
that are severe enough to interfere with the usual activities.
Stanghellini, Vincenzo. (2017). Functional Dyspepsia and Irritable Bowel Syndrome: Beyond Rome IV. Digestive Diseases
6. Dyspepsia symptoms
• Epigastric pain:
• A subjective, unpleasant sensation; some patients may feel that tissue damage is
occurring. Other symptoms may be extremely bothersome without being interpreted
by the patient as pain.
• Epigastric burning:
• An unpleasant subjective sensation of heat.
• Postprandial fullness:
• An unpleasant sensation perceived as the prolonged persistence of food in the
stomach
• Early satiation:
• A feeling that the stomach is overfilled soon after starting to eat, out of proportion to
the size of the meal being eaten, so that the meal cannot be finished.
7. Epidemiology
• Difficult to assess given variability in definition
• Reported that ~20% of the population has symptoms of dyspepsia
globally
• Annual incidence of 1% - 6%
• More common in women, smokers, and those taking non-
steroidal antinflammatory drugs
Moayyedi, Paul M MB, et al, ACG and CAG Clinical Guideline: Management of Dyspepsia, American Journal of Gastroenterology: July 2017
8. Differential Diagnosis Dyspepsia
There are 5 major causes:
1. Gastroesophageal reflux (with or without esophagitis)
2. Medications
3. Functional dyspepsia
4. Chronic peptic ulcer disease (PUD)
5. Malignancy
Less likely causes :
1. Pancreatic or hepatobiliary tract disease,
2. Motility disorders,
3. Infiltrative diseases of the stomach (e.g., eosinophilic gastritis, Crohn’s
disease, sarcoidosis)
4. Celiac disease
5. Intestinal angina
6. Small intestine bacterial overgrowth (SIBO)
7. Irritable bowel syndrome (IBS)
8. Metabolic disturbances (e.g., hypercalcemia, heavy metal)
9. Diabetic radiculopathy
10. Hernia,
11. Abdominal wall pain
Harmon RC, Peura DA. Evaluation and management of dyspepsia. Therap Adv Gastroenterol. 2010
10. Organic Causes
1. Peptic Ulcer Disease
2. GERD
3. Intolerance to food or drugs
4. Gastric and Esophageal Cancer
5. Pancreatic and Biliary Tract Disorders
6. Other
11. Peptic Ulcer Disease and Dyspepsia
• 5-15% of patients with dyspepsia
• Declining in prevalence
Risk Factors:
1. Increasing Age
2. NSAID use
3. H pylori infection
Hsu, et al . Gut. 2002; 51: 15-20
12. PUD and Dyspepsia
• H pylori and NSAID - synergistic role in PUD
• Serious ulcer related complications in 1-4% of NSAID
Huang ES, Strate LL, Ho WW, et al Am J Med 2011; 124(5):426-433
13. GERD and Dyspepsia
• Approximately 20% of dyspeptic pts
• 15-20% of patients with dyspepsia have erosive esophagitis
• 20% of patients have endoscopy negative GERD (i.e., NERD)
• 40% of patients with Barrett’s had no symptoms
Ronkainen J. Aliment Pharmacol Ther 2006
14. Malignancy and Dyspepsia
• Estimated to be about 1% of dyspeptic pts (gastric and esophageal)
• Declining incidence of gastric cancer
• Presence of symptoms indicative of advanced disease (32%)
• Alarm features and age limited predictive value
Bai et al . GUT 2010
15. Risk Factors DYSPEPSIA
1. Female gender
2. Smoking
3. Non-steroidal
inflammatory drug use
4. Helicobacter pylori
infection
5. Alcohol
Ford AC, Marwaha A, Sood R, et al Global prevalence of, and risk
factors for, uninvestigated dyspepsia: a meta-analysis Gut 2015
16. Malignancy and Dyspepsia
1. Breast
2. Lung
3. Melanoma
4. Ovarian
5. Cervical
6. Pancreatic
7. Hepatocellular
Sites:
• Metastasis to stomach is rare (1%)
Symptoms:
1. Melena
2. Epigastric pain
3. Anemia
18. NSAIDS and Dyspepsia
• Chronic NSAIDS and ASA use – 20% dyspeptic symptoms
• Presence of dyspepsia correlates poorly with presence of ulcer
• Higher dosing Worse dyspepsia
• NSAIDS + PPI ( 66% RR) vs NSAIDCOX 2 vs NSAID ( 12% RR )
19. Functional Dyspepsia
Definition
Dyspepsia as any combination of 4 symptoms: postprandial
fullness, early satiety, epigastric pain, and epigastric burning
that are severe enough to interfere with the usual activities and
occur at least 3 days per week over the last 3 months with an
onset of at least 6 months in advance
Stanghellini, Vincenzo. (2017). Functional Dyspepsia and Irritable Bowel Syndrome: Beyond Rome IV. Digestive Diseases
20. Diagnostic Criteria for
Functional Dyspepsia (Rome IV)
• Complaints of recurrent or persistent dyspepsia for more than 3 months in
the last 6 months
• No organic abnormalities were found on endoscopic examination
• There is no sign that dyspepsia improves with defecation
• Epigastric pain syndrome (EPS):
• Dominant complaint is pain or heat in the
epigastric area
2 Subgrup, based on cardinal symptoms :
• Postprandial distress syndrome (PDS) :
• Characterized by complaints of bloating,
postprandial fullness and early satiety, nausea,
decreased appetite.
21. Harmon RC, Peura DA. Evaluation and management of dyspepsia. Therap Adv Gastroenterol. 2010
22.
23. Functional Dyspepsia Epidemiology
• Inggris and Skandinavia :
• Prevalensi : 7 – 41 %
• Only 10-20% are treated
• Indonesia :
– Nationally data (-)
24. For the purposes of therapy, the clinical picture of functional
dyspepsia is divided into:
1. Ulcer-like type, predominant complaint is epigastric pain
accompanied by night pain
2. Types such as dysmotility dominant complaints of bloating,
nausea, vomiting, feeling full, early satiety.
3. Non-specific type no dominant complaint
25.
26. Delayed Gastric Emptying
• 25-45% of all FD pts
• Waldron et al - Meta analysis 17 studies dyspeptic pts/397 controls
40% significant delay of gastric emptying
• Failed to find correlation between symptoms and DGE
Tack J, Bisschops R, Sarnelli G. Pathophysiology and Treatment of Functional Dyspepsia. Gastroenterology 2004
27. Infection and FD
• Mearin et al –Outbreak of Salmonella 271 affected – 335 controls,
• Compared development of FD between affected and non affected
over the course of 1 year
• 14% developed Post Infectious FD
• Prolonged abdominal pain and vomiting predictive of FD
Mearin et al. Gastroenterology 2005
28. Psychological Factors and FD
• Frequency of anxiety, depression , somatization, abuse increased
in FD pts
• Increased number of stressful life events 6 months prior to
development of symptoms
Talley et al. 2004
29. Duodenal Sensitivity
• Duodenal perfusion with lipids enhances perception of gastric distention
Ishii et al 2010 :
• 44 FD / 16 control
• 11 PDS / 9 EPS / 24 PDS and EPS
• Transnasal endoscopy after overnight fast with injection of acid
• Increase in symptom severity scale in FD patients
• Bloating , Early Satiety and Heavy sensation in stomach most commonly
reported in FD
Ishi et al : J Gastroenterol Hepatol 2011
30. Uninvestigated Dyspepsia
Definition
• Dyspeptic symptoms in persons in whom no diagnostic
investigations have yet been performed and in whom a specific
diagnosis that explains the dyspeptic symptoms has not been
determined
• Who can be treated empirically and who needs additional
diagnostic eval.
31. History and Physical
• Nature of symptoms
• Chronicity
• Relationship with meals
• Onset (recent infections?)
• Systemic disorders
• Alarm features
• Abdominal pain
• Abdominal mass
• Organomegaly
• Ascites
• FOB
32. Heartburn or Dyspepsia?
• Dyspepsia – burning pain confined to epigastrum
• Klauser et al – 304 pts referred for 24 hour pH monitoring
1. Heartburn (68% vs 48%) and acid regurgitation (60% vs 48%) correlated
with GERD ( pH monitoring)
2. High specificity (89% and 95%, respectively)
3. Low sensitivity (38% and 6%)
Klauser, et al. Lancet, 1990
33. Heartburn or Dyspepsia
• Considerable overlap noted b/w GERD and Dyspepsia
• Up to 27 % of pts with GERD have associated dyspepsia
• Patients suffering from both GERD and Dyspepsia had higher
symptom intensity scores
Lee et al : Digestion 2009
Piessevaux et al : Neurogastroenterol Motility 2009
34. Alarm Features
• Progressive dysphagia
• Odynophagia
• Persistent vomiting
• Previous PUD
• Lymphadenopathy
• Abdominal Mass
• Family hx of UGI malignancy
• Unexplained weight loss (>10%)
• Overt Bleeding
• Anemia
• Early satiety
• Previous hx of gastric surgery
• Jaundice Talley,
Talley et al. Gastroenterology, 2005
35. Alarm Features
• Meta analysis of 15 studies
• 57,363 pts / 458 with malignancy
1.Low positive predictive value <10
2.High negative predictive value 97%
3.Varying thresholds to determine whether alarm feature present
Vakil N, Moayyedi P, Fennerty MB, Talley NJ. Limited value of alarm features in the diagnosis of upper gastrointestinal malignancy:
systematic review and meta-analysis. Gastroenterology 2006
36. AGE
• “Age threshold should be assessed locally based on known regional correlation
between age and incidence of upper GI malignancies”
• Breslin et al – retrospective study of 3634 pts
• Less than 45 yrs old with no alarm features
• 3 Gastric cancers, 10 Barrets, 1 moderate dysplasia
• Prevalence 1.05/1000
• Liou JM et al – retrospective study of 17894 pts with dyspepsia
• 225 (Gastric cancer), 111 (alarm symptoms), 11 (age<45) (9.9%)
Breslin et al. Gut, 2000
Liou et al : Gastrointest Endos 2005
38. Harmon RC, Peura DA. Evaluation and management of
dyspepsia. Therap Adv Gastroenterol. 2010
39. Moayyedi, Paul M MB, et al, ACG and CAG Clinical Guideline: Management
of Dyspepsia, American Journal of Gastroenterology: July 2017
40. Moayyedi, Paul M MB, et al, ACG and CAG Clinical Guideline: Management
of Dyspepsia, American Journal of Gastroenterology: July 2017
41. Harmon RC, Peura DA. Evaluation and management of dyspepsia. Therap Adv Gastroenterol. 2010
42. TREATMENT OF DYSPEPSIA
Non Pharmacology :
* Avoid food/drink as triggers, stimulating foods such as:
- Spicy
- Sour
- High fat
- Contains gas
- Coffee
- Alcohol etc
* If vomiting is severe, don't eat first
* Eat regularly, not excessive, small portions but often
* Avoid stress, exercise
43. ANTACIDA:
• Momentary neutralizing acid factor, temporary pain relief
• Most commonly used
• Meta-analysis study benefit (-), effectiveness = placebo
H2 RECEPTOR BLOCKER
• Gastric acid secretion
• It is also commonly consumed
• Study: 20% benefit over placebo
• Generic: cimetidine, ranitidine, famotidine etc
MEDICAL THERAPY
44. • Proton pump inhibitors (PPIs) for acid production:
Omeprazole, lansoprazole, pantoprazole, rabeprazole,
esomeprazole
Effective and superior to placebo
Expensive
• Prokinetic (anti-nausea-vomiting):
Dimenhydrinate, metoclopramide, domperidone, cisapride,
ondansetron
Dopamine 2 and serotonin receptor antagonists
For the type of dysmotility effective than placebo
MEDICAL THERAPY
45. • OMAI (Obat Modern Asli Indonesia) – REDACID Has a
mechanism :
- PPI
- Proton Pump Down regulator
- Gastroprotector
REDACID has been included in
the National Consensus on the
Management of Dyspepsia and
Helicobacter Pylori Th infection.
2014
46. Cytoprotectors:
• sucralfate, teprenone, rebamipid
• Mucopromoter
• Increase prostaglandins
• Increase mucosal blood flow
Antibiotics:
• if proven involvement of H. pylori (+)
• Amoxicillin, clarithromycin, tetracycline, metronidazole, bismuth
Antianxiety tranguilizer, antidepressant
• If there are psychological factors
