Functional Dyspepsia

Maggie Abbassi, Ph.D.

Clinical Pharmacy Department
 Functional Dyspepsia
• A clinical syndrome in which there is no
evidence of mucosal damage related to PUD,
GERD, or malignancy found at endoscopy.
• Specific types:
– nonulcer dyspepsia (NUD), which describes
“ulcerlike” symptoms,
– nonerosive reflux disease (NERD), which describes
“GERD-like” symptoms in an endoscopy-negative
patient.
Epidemiology
 Pathophysiology

• No definitive pathophysiologic mechanism

suggesting that it is a heterogeneous group of
disorders.
• Patients commonly have coexisting symptoms of
irritable bowel syndrome or other functional GI
disorders.
• In one 10-year follow-up study of patients with
dyspepsia or irritable bowel syndrome, 40
percent of symptomatic patients switched
subgroups over the study period.
 Pathophysiology

• Several studies implicate gastric dysmotility:

bloating, early satiation, nausea, and
vomiting.
• Studies have documented altered gastric
motility (e.g., gastroparesis, gastric
dysrhythmias, abnormal fundus accumulation,
pyloric sphincter dysfunction) in up to 80
percent of patients with functional dyspepsia.
 Rome III Diagnostic Criteria for
Functional Dyspepsia
Presence of at least one of the following for the past
three months, with symptom onset at least six months
before diagnosis
• Bothersome postprandial fullness
• Early satiation
• Epigastric pain
• Epigastric burning
and
• No evidence of structural disease (including at upper
endoscopy) that is likely to explain the symptoms
 Diagnosis
• By exclusion: focus on excluding serious or
specifically treatable diseases, without spending
too much time investigating symptoms
• Diverse differential diagnosis: detailed history
and physical examination at the initial
presentation, noting any findings that point to a
diagnosis other than functional dyspepsia (e.g.,
right upper-quadrant pain with cholelithiasis,
exercise association with coronary artery disease,
radiation to the back with pancreatitis).
 Diagnosis
• The AGA recommends proceeding directly to endoscopy in patients
with warning signs and in those older than 55 years
• Warning Signs:
– Unintended weight loss (>10%)
– Progressive dysphagia
– Persistent vomiting
– Evidence of GI bleeding
– Family history of cancer
– Odynophagia
– Previous esophagogastric malignancy
– Previous documented peptic ulcer
– Lymphadenopathy
– An abdominal mass
 Treatment
Few treatment options have proven effective
• Gastric acid suppression
• Prokinetics
• H. Pylori eradication
• Psychotropic and psychological interventions
 Gastric Acid Suppression
• No evidence to support the use of antacids,
sucralfate, and misoprostol.
• H2 blockers : less quality evidence than for
PPI’s
 Gastric Acid Suppression
• PPI’s: 4-8 weeks
• If no response: endoscopy
• If symptoms stop: assess every 6 to 12 months
for recurrence of symptoms
• There appears to be no difference in efficacy
between full-dose or double-dose PPIs.
 Prokinetics
• Effectiveness tended to be targeted at patients with
symptoms suggestive of motility disorders, raising the
question of their effectiveness in cases of isolated
epigastric pain.
• Most studies showing effectiveness used cisapride, which
has been removed from the U.S. market because of
concerns about cardiac arrhythmias.
• Metoclopramide may cause tardive dyskinesia and
parkinsonian symptoms in older persons, limiting its use.
• Erythromycin has some prokinetic effects and is used to
treat gastroparesis. However, erythromycin has not been
studied as a treatment for functional dyspepsia, so its
effectiveness is unknown.
 Psychotropic and psychological
interventions
• Because of the high rate of coexisting
depression and psychiatric illness in patients
with refractory functional dyspepsia, many
physicians prescribe antidepressants
• Tricyclic antidepressants: amitriptyline
• Other psychological treatment effects were
not confirmed (e.g. cognitive therapy)