Functional

Dyspepsia
MD, PhD Boldbaatar Gantuya
Department of Gastroenterology and Hepatology

1
 Definition
• Persistent or recurrent pain or discomfort
centered in the upper abdomen:
including pain,  early satiety, nausea, vomiting,
abdominal distension, bloating, and anorexia
• Evidence of organic disease likely to
explain the symptoms is absent.
Without detectable structural or biochemical
abnormalities

2
 Epidemiology

• The prevalence of functional dyspepsia

ranges from 5 to 11 percent worldwide
• Approximately 25 percent of patients
with dyspepsia have an underlying
organic cause. However, up to 75 percent
of patients have functional (idiopathic or
nonulcer) dyspepsia with no underlying
cause on diagnostic evaluation
3
 Classification
( classified by anatomic region)
(A) Esophageal

(B) Gastroduodenal
(C) Bowel (IBS)
(D) Functional abdominal pain
(E) Biliary
(F) Anorectal

4
 Social Impact of Dyspepsia
70

60

50

40

30

20

10

0
Not At All Slightly Moderately Quite A Lot Extremely

(DIGEST, 1996)
 Pathophysiological
mechanisms
1. Gastrointestinal motor
abnormalities
2. Altered visceral sensation
3.Psychosocial factors
4. Gut microbe, Helicobacter
pylori infection ? 6
Putative Pathogenesis of Dyspepsia
Stress

Autonomic
Nervous System
Increased Sensitivity Imbalance
Sensory Inhibition
. Sensitivity
Increased
Low Grade
..
Afferent
Activity Inflammation
± HP InfectionImpaired Motor Activity
Accommodation

Altered Motor & Sensory Function

7
DYSPEPSIA
1. Alterations in Motility

• Delayed emptying
• Impaired accommodation to a
meal
• Antral hypomotility
• Gastric dysrhythmias
• Altered duodenojejunal motility
8
2. Altered visceral sensation
• Hypersensitivity to gastric balloon distention:
suggesting abnormal afferent function
• Reflex hyporeactivity:
suggesting either abnormal afferent or abnormal
efferent function

9
 3. Psychosocial factors

• The personality profile impacts on

patients with functional dyspepsia.
• Higher levels of anxiety and
depression have been found.
• A link between childhood abuse
and functional gastrointestinal
disorders.
10
 4. Altered gut
microbiome 

• Alterations in the upper

gastrointestinal tract microbiome
• It has also been hypothesized that
the efficacy of H. pylori therapy in
improving symptoms of functional
dyspepsia
11
 Clinical Features

Dyspepsia:
• Pain or Discomfort centered in the
upper abdomen
• The symptoms may be intermittent
or continuous, and may or may not
be related to meals.

12
 Definitions of the
symptom
Pain: a subjective, unpleasant sensation
Discomfort: a subjective, unpleasant
sensation or feeling that is not interpreted as
pain according to the patient, including upper
abdominal fullness, early satiety, bloating, or
nausea
Centered in the upper abdomen: the pain or
discomfort is mainly in or around the midline

13
Dyspepsia subgroup
classification
based on the predominant single
symptom

• Ulcer-like dyspepsia
(epigastric pain syndrome
(EPS)
• Dysmotility-like dyspepsia
(postprandial distress
syndrome (PDS)
14
1. Ulcer-like dyspepsia

Pain centered in the upper

abdomen is the predominant
(most bothersome) symptom.

15
 2. Dysmotility-like
dyspepsia
• An unpleasant or troublesome non-
painful sensation (discomfort)
centered in the upper abdomen
is the
predominant symptom; this sensation
may be characterized by or associated
with upper abdominal fullness, early
satiety, bloating, or nausea.
16
 Diagnosis
Rome criteria: Multinational Working Teams
Symptom-based diagnostic criteria:
Rome I 1994
Rome II 1999
Rome III 2006
Rome IV 2018

 
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 Rome IV Criteria:
• Use in patients with recurrent upper GI symptoms
on average once weekly in the last 3 months with
symptom onset ≥6 months ago and no abnormalities
on diagnostic testing, including upper endoscopy.
• Do NOT use in patients with alarm symptoms such
as GI bleeding, unexplained iron deficiency anemia,
unintentional weight loss, palpable abdominal mass,
family history of colon cancer or symptom onset ≥50
years of age and not yet screened for colon cancer,
or sudden/acute onset of new change in bowel habit.

18
 Must have ≥1 of the
following:
• Bothersome postprandial fullness
• Bothersome early satiation
• Bothersome epigastric pain
• Bothersome epigastric burning
AND
• No evidence of structural disease (including at upper
endoscopy) that is likely to explain the symptoms

19
 Postprandial distress
syndrome
Must include one or both of the following at least 3 days
per week:
•Bothersome postprandial fullness (ie, severe enough to
impact on usual activities)
•Bothersome early satiation (ie, severe enough to
prevent finishing a regular-size meal)
•No evidence of organic, systemic, or metabolic disease
that is likely to explain the symptoms on routine
investigations (including at upper endoscopy)

20
 Epigastric pain syndrome
Must include at least 1 of the following symptoms at
least 1 day a week:
•Bothersome epigastric pain (ie, severe enough to
impact on usual activities)
AND/OR
•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).

21
 Diagnostic process

FD remains a diagnosis of exclusion:

• Careful history and physical examination
• Upper endoscopy is necessary
• The others: exclusion of chronic peptic
ulcer disease, gastroesophageal reflux
disease, esophagitis, pancreatico-biliary
disease, malignancy
22
23
 Differential Diagnosis

• Upper endoscopy
• Prolonged esophageal pH
monitoring
• Twenty-four hour esophageal
pH monitoring
24
 Treatment Strategy

• General treatment approach

Establish therapeutic relationship education
and reassurance dietary and lifestyle
modifications
• Pharmacological therapies
Symptomatic treatment and antidepressant
• Psychological therapies
Cognitive-behavioral treatment hypnosis

25
Pharmacological therapies

• H. pylori therapy ?
controversial
• Acid suppression
• Prokinetic agents
• Gut analgesics
• Antidepressant
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Management of Ulcer-like
Functional Dyspepsia
Ulcer-like Symptoms
Dominant
Education/lifestyle
Education/lifestyle
modification
modification

Test
Test Hp
Hp

+
+ --

Eradicate
Eradicate Hp
Hp Acid
Acid suppression
suppression
Reassess
Reassess

Success
Success Failure
Failure
Investigate 27
Trial
Investigate Trial of
of
prokinetic
prokinetic
Management of Dysmotility-like Functional
Dyspepsia
Dysmotility-like Symptoms Dominant

Educate/lifestyle
Educate/lifestyle
modification
modification

Trial
Trial of
of prokinetic
prokinetic
medication
medication
Success
Success ((mosapride and Failure
Failure
acotiamide))

Continue
Continue with
with Investigate
Investigate
cyclic
cyclic therapy
therapy
Test
Test H.
H. pylori
pylori
Gastroscopy
Gastroscopy or
or UGI
UGI
+
+ --

Eradicate
Eradicate
Consider
Consider H H22 28
Success
Success Failure
Failure antagonists,
antagonists,
tricyclics
tricyclics