Functional Dyspepsia

Prevalence

• Dyspepsia common at 20%

• Especially females, smokers and people on NSAIDs

• 80% of patients with symptoms of dyspepsia are eventually categorised as having functional dyspepsia

Epidemiology

• 5 to 10% worldwide

Pathophysiology

• Gastric emptying, accommodation and vagal function

  • Associated with motility disorders

• Visceral hypersensitivity

  • Lower threshold for the induction of pain in the presence of normal gastric compliance

• Helicobacter pylori

• Altered gut microbiome

• Duodenal inflammatory and immune activation

  • Increased eosinophils and mast cells

• HPA axis and stress

  • Increases salivary cortisol and intestinal permeability

• Psychosocial dysfunction

  • FD linked to GAD, somatisation and MDD

Clinical manifestations

• Postprandial fulness

• Early satiety

• Bloating

• Epigastric pain or burning

• Nausea

• Vomiting

• Heartburn

Diagnosis

• Rome IV criteria

• One or more of

  • postprandial fullness

  • early satiation

  • epigastric pain or epigastric burning

  • and no evidence of structural disease

• Criteria should be fulfilled for the last three months with symptoms onset at least six months before diagnosis

Subtypes

• Postprandial distress syndrome

  • Must include one or both of the following at least three days per week:

    1. Bothersome postprandial fullness (ie, severe enough to impact on usual activities)

    1. Bothersome early satiation (ie, severe enough to prevent finishing a regular-size meal)

    2. No evidence of organic, systemic, or metabolic disease that is likely to explain the symptoms on routine investigations (including at upper endoscopy)

• Epigastric pain syndrome

  • Must include at least one of the following symptoms at least one day a week:

    1. Bothersome epigastric pain (ie, severe enough to impact on usual activities)

    AND/OR

    1. Bothersome epigastric burning (ie, severe enough to impact on usual activities)

    No evidence of organic, systemic, or metabolic disease that is likely to explain the symptoms on routine investigations (including at upper endoscopy)

Differential

• Peptic ulcer disease

• Helicobacter pylori gastritis

• Gastroesophageal reflux disease (GERD)

• Biliary pain

• Chronic abdominal wall pain

• Gastric or esophageal cancer

• Gastroparesis

• Pancreatitis

• Carbohydrate malabsorption

• Medications (including potassium supplements, digitalis, iron, theophylline, oral antibiotics [especially ampicillin and erythromycin], nonsteroidal antiinflammatory drugs [NSAIDs], glucocorticoids, niacin, gemfibrozil, narcotics, colchicine, quinidine, estrogens, levodopa)

• Infiltrative diseases of the stomach (eg, Crohn disease, sarcoidosis)

• Metabolic disturbances (hypercalcemia, hyperkalemia)

• Hepatocellular carcinomaIschemic bowel disease, celiac artery compression syndrome, superior mesenteric artery syndrome

• Systemic disorders (diabetes mellitus, thyroid and parathyroid disorders, connective tissue disease)

• Intestinal parasites (Giardia, Strongyloides)

• Abdominal cancer, especially pancreatic cancer

Management

• The management of patients with functional dyspepsia is controversial and alleviates symptoms in only a small proportion of patients

• Test and treat H. Pylori

• PPI for 8 weeks

• Trial TCA as combination therapy

  • Amitriptyline 10mg at night, uptitrate weekly intervals, to 20-30mg

• Mirtazapine has evidence

• Prokinetics e.g. metoclopramide 5 to 10mg taken 30 minutes before meals