DR

MEDICINE II
DYSPEPSIA
- Greek: “Dys” – Bad; “Pepse” – Digestion - Epidemiology
- Symptom referable to upper GI tract o Annual prevalence: 15-40%
- “Kinakabag”, “Impatso”, “Sinisikmura”, “Nabubunsol”, “Mabigat ang o Annual incidence: 1-6%
tiyan” o Women > Men
- Rome I & II o Accounts for 2-5% primary care consults
o Pain / discomfort centered on upper abdomen o Tends to follow relapsing
- Rome III o Normal life expectancy
o Presence of symptoms considered by the physician to originate - Causes
from the gastroduodenal region o Organic
o Postprandial fullness, early satiety, epigastric pain and o Non-organic / Functional
epigastric burning o Uninvestigated Dyspepsia
o Other symptoms may occur § Dyspeptic symptoms
§ No diagnostic investigations yet

Organic Causes
Luminal GIT Systemic Conditions Medications Pancreaticobiliary
Chronic gastric volvulus Adrenal insufficiency Acarbose Biliary Pain
Gastric infections (HIV) Diabetes Mellitus Antibiotics (Macrolides) (Cholelithiasis: Not related with
Gastroparesis Heart Failure, MI Aspirin / Other NSAIDs dyspepsia)
GERD Hyperparathyroidism Steroids Acute / Chronic Pancreatitis
Infiltrative gastric disorders Intraabdominal Malignancy Iron Pancreatic Neoplasms
IBS Metabolic Disturbances Narcotics
Food intolerance Pregnancy KCl
Parasites Renal Insufficiency Sildenafil
PUD Thyroid disease
Gastric or Esophageal cancer

- Luminal GIT § But may aggravate dyspepsia (Sensorimotor response)

o Upper GI endoscopy - Medications
§ Erosive esophagitis: Diagnostic for GERD; 20-25% o Direct gastric mucosal injury
§ Non-erosive GERD o Changes in GI sensory function
• Negative endoscopy reflux disease: 20% o Provocation of GERD
§ Peptic Ulcer Disease: 10% o Idiosyncratic mechanisms
§ Barrett’s Esophagus: 2% o Aspirin
§ Malignancy: <1% § 20% of persons with dyspepsia
o Acute gastritis does not correlate with dyspepsia § Occurrence of dyspepsia correlates with the presence of
o Intolerance to food ulcers
§ Ingestion of specific foods / excess amount of food has
not been established as cause

Non-Organic Cause / Functional Dyspepsia

- >70% of the cases § GERD & IBS may coexist with postprandial distress
Rome IV Criteria syndrome
Presence of 1 or more symptoms - Epigastric Pain Syndrome
Ø Bothersome postprandial fullness o At least 1 day per week
Postprandial Pain
Ø Early satiety Syndrome o (-) endoscopy
Ø Epigastric pain o Last three months symptom onset 6 months prior diagnosis
Epigastric Pain Syndrome
Ø Epigastric burning o Remarks
No evidence of structural disease (neg. endoscopy) § May be induced by ingestion or occur while fasting
Must fulfill criteria for postpartum distress syndrome and/or epigastric § Pain does not fulfill biliary pain criteria
pain syndrome § IBS, GERD, Heartburn can coexist
For the last 3 months with symptom onset of at least 6 months
before diagnosis
- Postprandial Distress Syndrome
o At least three days per week
o (-) endoscopy
o Supportive Remarks
§ More in fullness
§ Vomiting: Warrants consider another disorder
§ Heartburn may often coexist
§ Symptoms relieved by evacuation of feces or gas should
generally not be considered of dyspepsia
 DR
PATHOPHYSIOLOGY
- Impaired Gastric Accommodations o Empiric anti-secretory drug (PPI), Prokinetic
o Fundus dilates - High Risk
o 40% of Functional dyspepsia o Prompt endoscopy
o Increase intragastric pressure and activation of tension o NSAID use
sensitive mechanoreceptors in the gastric wall o 45-55 years
- Delayed Gastric Emptying o Alarm symptoms
o 20-50% of Functional dyspepsia - Lifestyle
o No convincing relationship o Small, frequent diets
- Visceral Hypersensitivity o Low fat diet
o Abnormally enhanced perception of visceral stimuli o Avoid spicy food, coffee
o Tension sensitive mechanoreceptors o Cessation of smoke and alcohol
o Alterations at level of visceral afferent nerves and CNS o Avoid NSAIDs
- Duodenal Hypersensitivity to Lipids/Acids o Treat psychological disorder
o Impaired acid clearance of acid from duodenum - Pharmacological Treatment
o Increased sensitivity of duodenum to lipids or acids o PPI: OD x 8 weeks
o pH monitor o H. pylori eradication
- Small Intestinal Dysmotility o Prokinetic agents
o Hypermotility o Tricyclic antidepressants
o Increased duodenal retrograde contractions o Buspirone: enhance gastric accommodation
- CNS Dysfunction o Acotiamide: release of acetylcholine
- Genetic Predisposition o Kappa opioid receptor agonist: visceral
o Increased frequency in first degree relatives
o GNB3 gene associated with functional dyspepsia
- Infection
o H. pylori: also associated with organic dyspepsia
o Post infection functional dyspepsia
o Salmonella gastroenteritis
- Psychosocial Factors
o Clear association with Functional dyspepsia
o Visceral hypersensitivity
o Anxiety, depression, sexual abuse

APPROACH TO DYSPEPSIA
- History
o Nature, frequency
o Chronicity, relationship to meals
o Alarm symptoms
§ Anemia
§ Chronic GI Bleed
§ Dysphagia
§ Weight loss
- Physical Examination
o Abdominal mass
o Organomegaly
o Ascites
o DRE
- Differential Diagnosis
o GERD
o IBS
o Peptic Ulcer Disease
- Laboratory Tests
o CBC
o Blood chemistry
o Thyroid
o Giardia, Parasites
o Pregnancy
- Factors to consider in work up
o Missing abdominal cancer in young patients
o Alarm symptoms
o Cost
- Low risk for organic cause
o Endoscopy
o H. pylori test