Delta Sem (6) - GIT Lecture (3) - Dyspepsia

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Questions and Answers

List four symptoms that dyspepsia-related pain or discomfort may manifest as.

Chronic or recurrent epigastric pain/burning, postprandial fullness/early satiety, gastro-esophageal reflux symptoms, nausea/vomiting/belching.

What is the key distinction in the location of abnormalities between functional and organic dyspepsia?

Functional dyspepsia shows no structural abnormalities in the GIT, while organic dyspepsia involves structural abnormalities.

Identify two broad categories of conditions that can lead to organic dyspepsia.

Structural abnormalities like peptic ulcers or cancer, and disorders like pancreatic or biliary issues.

Describe the underlying nature of functional dyspepsia according to its definition.

<p>It's characterized as a disorder of gut-brain interaction (DGBI).</p> Signup and view all the answers

What is the primary requirement for diagnosing functional dyspepsia, according to the text?

<p>Exclusion of other organic, systemic, or metabolic diseases.</p> Signup and view all the answers

Name the two subtypes of functional dyspepsia recognized under the Rome IV criteria.

<p>Postprandial Distress Syndrome (PDS) and Epigastric Pain Syndrome (EPS).</p> Signup and view all the answers

What criteria must be consistently present for a diagnosis of Mixed PDS/EPS according to Rome IV criteria?

<p>Symptoms must be present consistently for 3 months, with symptom onset occurring at least 6 months prior to diagnosis.</p> Signup and view all the answers

List three alarm symptoms or signs that would necessitate urgent investigation when evaluating dyspepsia.

<p>Any sign of chronic gastrointestinal bleeding, progressive unintentional weight loss, or dysphagia.</p> Signup and view all the answers

Name three investigations used to exclude organic diseases in the workup of dyspepsia.

<p>Upper gastrointestinal endoscopy, ultrasound or CT scan of the abdomen, and <em>H. pylori</em> testing.</p> Signup and view all the answers

List three 'alarm features' to urgently assess in a patient presenting with dyspepsia.

<p>Complete blood counts, electrolytes, sugar and creatinine, or thyroid and liver function.</p> Signup and view all the answers

Describe two specific dietary recommendations for managing functional dyspepsia.

<p>Eating slowly and regularly and avoiding high-fat meals.</p> Signup and view all the answers

Besides diet, briefly explain the importance of the patient-physician relationship in managing functional dyspepsia.

<p>Establishing a strong relationship helps in obtaining psychosocial background information, which can influence management.</p> Signup and view all the answers

Give two examples of acid suppressants used in the management of dyspepsia.

<p>H2 receptor antagonists (H2RAs) or Proton pump inhibitors (PPIs).</p> Signup and view all the answers

Describe the role of prokinetics in the management of functional dyspepsia.

<p>They help improve gastric emptying and reduce symptoms like fullness and bloating.</p> Signup and view all the answers

Name one class of neuromodulator medications that may be used in the treatment of functional dyspepsia.

<p>Tricyclic antidepressants (TCAs).</p> Signup and view all the answers

Explain how testing for H. pylori informs the management of dyspepsia.

<p>If positive, curative therapy for H. pylori is indicated; if negative, other causes or functional dyspepsia should be considered.</p> Signup and view all the answers

Which diagnostic criteria from the text are used to diagnose functional dyspepsia?

<p>Rome IV criteria.</p> Signup and view all the answers

If a patient is not responding to first-line treatment, according to the flowchart, what is the next step in diagnosing their dyspepsia?

<p>Second-line treatment or Diagnostic imaging</p> Signup and view all the answers

What is the recommendation if the patient is showing signs of uninvestigated dyspepsia?

<p>Referral to organic pathology.</p> Signup and view all the answers

Briefly outline the initial treatment approach for functional dyspepsia, based on the provided case.

<p>Dietary advice (low fat, small regular meals) and a prokinetic agent were prescribed.</p> Signup and view all the answers

List four symptoms that may indicate pain or discomfort related to dyspepsia.

<p>Chronic or recurrent epigastric pain and/or burning, postprandial fullness or early satiety, symptoms of gastro-esophageal reflux, nausea, vomiting, and belching.</p> Signup and view all the answers

What is the primary difference between functional and organic dyspepsia in terms of structural abnormalities?

<p>Functional dyspepsia lacks structural abnormalities in the GIT, whereas organic dyspepsia involves structural abnormalities.</p> Signup and view all the answers

Describe the Rome IV criteria's diagnostic timeframe for functional dyspepsia.

<p>Symptoms must be present consistently for 3 months, with onset at least 6 months prior to diagnosis.</p> Signup and view all the answers

Name the two main subtypes of Functional Dyspepsia (FD) according to the Rome IV classification.

<p>Postprandial Distress Syndrome (PDS) and Epigastric Pain Syndrome (EPS).</p> Signup and view all the answers

List six alarm symptoms that would warrant urgent investigation of dyspepsia.

<p>Any sign of chronic gastrointestinal bleeding, progressive unintentional weight loss, dysphagia, persistent vomiting, iron-deficiency anemia and epigastric mass or lymphadenopathy.</p> Signup and view all the answers

What specific information should be obtained to establish a strong patient-physician relationship when managing functional dyspepsia?

<p>Obtaining psychosocial background information from the patient.</p> Signup and view all the answers

Name three dietary recommendations for managing functional dyspepsia.

<p>Eating slowly and regularly, eating smaller and more frequent meals, and avoiding high-fat meals.</p> Signup and view all the answers

Describe the initial step in managing a patient with dyspepsia, as outlined in the provided algorithm.

<p>Interview, blood tests, age, alarm signs, medication history, previous examinations, presence of H. pylori infection.</p> Signup and view all the answers

After endoscopy reveals no findings explaining symptoms of dyspepsia, what is the next step, according to the algorithm?

<p>Test for H. pylori.</p> Signup and view all the answers

If a patient's symptoms do not change after first-line treatment for dyspepsia, what step should be taken next according to the algorithm?

<p>Second-line treatment.</p> Signup and view all the answers

List three classes of medications used as neuromodulators in the management of functional dyspepsia.

<p>Tricyclic antidepressants (TCAs), antipsychotics, and gabapentinoids (pregabalin).</p> Signup and view all the answers

Name three exclusions for organic diseases when investigating dyspepsia.

<p>Upper gastrointestinal endoscopy, ultrasound or CT scan of the abdomen and H. Pylori testing.</p> Signup and view all the answers

According to the case study, what diagnosis was made for the 39-year-old female patient?

<p>Functional or non-ulcer dyspepsia (postprandial distress syndrome (PPD), based on the Rome IV criteria.</p> Signup and view all the answers

Outline the purpose of behavioral therapies in the treatment of refractory functional dyspepsia (FD).

<p>Behavioral therapies aim to address psychological factors influencing gut function, such as stress, anxiety, and maladaptive coping mechanisms.</p> Signup and view all the answers

Which method should be used to assess for H. pylori after endoscopy shows no abnormalities?

<p>Test for H. pylori</p> Signup and view all the answers

What is the significance of symptoms recurring after initial improvement in the diagnostic algorithm for functional dyspepsia?

<p>If symptoms recur, H. pylori-associated dyspepsia must be considered, and further diagnostic imaging should be performed to rule out other diseases.</p> Signup and view all the answers

Explain how altered gastric emptying contributes to the abnormal motor or sensory function seen in functional dyspepsia.

<p>Delayed gastric emptying may cause early satiety and postprandial fullness, while rapid emptying may trigger duodenal hypersensitivity and dyspeptic symptoms.</p> Signup and view all the answers

Describe the characteristic symptoms of postprandial distress syndrome (PDS), and indicate the minimum frequency with which these symptoms must occur to meet the Rome IV criteria.

<p>PDS is characterized by early satiation and/or postprandial fullness, occurring at least three times a week.</p> Signup and view all the answers

Why is it important to exclude any other organic, systemic, or metabolic diseases during the diagnosis of functional dyspepsia, as mentioned in the text?

<p>Exclusion ensures that the symptoms are not caused by an underlying condition that requires specific treatment, and helps prevent misdiagnosis.</p> Signup and view all the answers

If a patient has been confirmed free of H. pylori, explain the classification for symptom improvements over 6-12 month period.

<p>Those patients can be classified as &quot;H. pylori associated dyspepsia.&quot;</p> Signup and view all the answers

Flashcards

Dyspepsia

Difficult digestion, characterized by pain or discomfort in upper abdomen.

Symptoms of Dyspepsia

Chronic or recurrent epigastric pain and or epigastric burning are symptoms. Postprandial fullness or early satiety is also a symptom. Classical symptoms of gastro-esophageal reflux can also classify as dyspepsia, as so can nausea, vomiting and belching

Functional Dyspepsia Definition

Disorder of gut-brain interaction

Postprandial Distress Syndrome (PDS)

Characterized by early satiation and/or postprandial fullness. Occurring at least 3 times a week. It represents 67% of FD.

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Epigastric Pain Syndrome (EPS)

Characterized by epigastric pain and/or burning. Occurring at least once a week. It represents 28% of FD.

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Alarm Symptoms of Dyspepsia

Any sign of chronic gastrointestinal bleeding. Progressive unintentional weight loss. Dysphagia. Persistent vomiting. Iron-deficiency anemia. An epigastric mass or lymphadenopathy.

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Dietary Management for Dyspepsia

Eating slowly and regularly; Eating smaller, more frequent meals; Avoiding high-fat meals, & ↓ intake of ultra-processed foods; Avoiding Fatty and spicy foods, carbonated drinks, alcoholic beverages, and food with high citric acid; Avoiding foods and beverages containing caffeine.

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Acid Suppressants Used For Dyspepsia

H2 receptor antagonists(H2RAs) e.g., Famotidine. Proton pump inhibitors (PPIs) e.g., Pantoprazole. Potassium-competitive acid blockers (P CABs) e.g., Vonoprazan

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Organic Dyspepsia

Structural abnormalities in the GIT (gastrointestinal tract).

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Functional Dyspepsia

No structural abnormalities in the GIT (gastrointestinal tract).

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Diagnosing Functional Dyspepsia

Diagnosis of FD requires excluding other organic, systemic, or metabolic diseases through investigations like endoscopy.

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Functional Dyspepsia Prevalence

10-40% in Western countries and 5-30% in Asia.

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Clidinium/chlordiazepoxide

Combination of antispasmodic and anxiolytic drugs with PPI for Refractory FD.

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Behavioural Therapies

Psychodynamic interpersonal, cognitive behavioral, stress management, and hypnotherapy.

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Exclusion of Organic Diseases

Upper gastrointestinal endoscopy, Ultrasound or CT scan of the abdomen, and H. Pylori testing.

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Study Notes

  • Dyspepsia is difficult digestion marked by pain or discomfort in the upper abdomen
  • Pain or discomfort includes one or more of the following:
  • Chronic or recurrent epigastric pain and/or burning
  • Postprandial fullness or early satiety that inhibits finishing a normal sized meal
  • Classical symptoms of gastro-esophageal reflux like heartburn or acid regurgitation
  • Nausea, vomiting and belching
  • Dyspepsia prevalence ranges from 20% to 25% in the western world

Functional Dyspepsia (FD)

  • There are no structural abnormalities in the GIT.
  • It is a disorder of gut-brain interaction (DGBI).
  • Prevalence is 10–40% in Western countries and 5–30% in Asia.
  • Diagnosis of FD necessitates excluding any other organic, systemic, or metabolic diseases through investigations, including endoscopy.
  • Includes:
  • Unidentified pathophysiological or microbiological abnormality
  • Abnormal motor or sensory functions
  • Altered gastric emptying
  • Fundic dysaccommodation
  • Gastroduodenal hypersensitivity

Organic Dyspepsia

  • There are structural abnormalities in the GIT
  • Includes:
  • Peptic ulcer
  • Gastro-esophageal reflux disease (GERD)
  • Gastric or esophageal cancer
  • Pancreatic or biliary disorders
  • Intolerance to food or drugs
  • H. pylori and other infectious or systemic diseases

Types of FD (Rome IV Classification)

  • Postprandial Distress Syndrome (PDS):
  • Characterized by early satiation and/or postprandial fullness
  • Occurs at least 3 times a week
  • Represents 67% of FD
  • Epigastric Pain Syndrome (EPS):
  • Characterized by epigastric pain and/or burning
  • Occurs at least once a week
  • Represents 28% of FD
  • Mixed PDS/EPS:
  • 12% of FD
  • Diagnosed if symptoms are present consistently for 3 months, with onset at least 6 months prior to diagnosis

Alarm Symptoms Requiring Urgent Investigation

  • Any sign of chronic gastrointestinal bleeding
  • Progressive unintentional weight loss
  • Dysphagia
  • Persistent vomiting
  • Iron-deficiency anemia
  • Epigastric mass or lymphadenopathy

Exclusion of Organic Diseases

  • Upper gastrointestinal endoscopy
  • Ultrasound or CT scan of the abdomen
  • H. Pylori testing

Alarm Features

  • Complete blood counts
  • Electrolytes, sugar and creatinine
  • Thyroid and liver function
  • Fecal blood testing and stool for parasites
  • Colonoscopy
  • Ultrasound or CT scan of the abdomen

Management of Functional Dyspepsia

  • Diet:
  • Eating slowly and regularly is important
  • Eating smaller, more frequent meals
  • Avoid high-fat meals, and decrease intake of ultra-processed foods
  • Avoid fatty and spicy foods, carbonated drinks, alcoholic beverages, and food with high citric acid
  • Avoid foods and beverages containing caffeine
  • Establish a strong patient-physician relationship to obtain psychosocial background information from the patient
  • Acid suppressants:
  • H2 receptor antagonists (H2RAs) e.g., Famotidine
  • Proton pump inhibitors (PPIs) e.g., Pantoprazole
  • Potassium-competitive acid blockers (P CABs) e.g., Vonoprazan
  • Prokinetics:
  • Acotiamide: acetylcholine-esterase inhibitor
  • Itopride: dopamine 2 receptor antagonist and cholinesterase inhibitor
  • Neuromodulators:
  • Tricyclic antidepressants (TCAs) such as amitriptyline, imipramine, and nortriptyline at low doses
  • Antipsychotics, such as sulpiride or levosulpiride, a 5-HT-1A agonist, tandospirone
  • Gabapentinoid, pregabalin
  • Mirtazapine might be effective in FD patients with weight loss

Treatment of Refractory FD

  • Clidinium/chlordiazepoxide: Combination of antispasmodic and anxiolytic drugs, in combination with PPIs.
  • Combination of the anxiolytic flupenthixol and antidepressant melitracen
  • Gabapentin, a neuropathic analgesic in combination with PPIs
  • Duodenal-release combination of caraway oil and L-menthol in combination with PPI
  • Behavioral Therapies:
  • Psychodynamic interpersonal therapy
  • Cognitive behavioral therapy
  • Stress management approaches
  • Hypnotherapy

Case Study

  • A 39-year-old female psychologist reports indigestion for the past year.
  • After eating a meal she feels very uncomfortable and full, causing interference with her life and bloating, making her unable to finish normal-sized meals.
  • She has these symptoms after most meals with occasional heartburn.
  • She never experiences acid regurgitation or dysphagia.
  • She has occasional nausea, but no vomiting.
  • Her bowel habits and weight are stable.
  • Her mother had indigestion problems for years.
  • She is not taking NASIDS.
  • An upper endoscopy by a gastroenterologist was normal and a 2 month trial of PPIs did not help.
  • The physical exam unremarkable and the Helicobacter pylori stool antigen test came back negative.
  • She received a diagnosis of functional or non-ulcer dyspepsia (postprandial distress syndrome (PPD), based on the Rome IV criteria.
  • She was provided dietary advice (low fat and small regular meals), and prescribed a prokinetic agent (domperidone, 10 mg before meals).
  • After one month, the patient had a good response and provider reassures her the condition is benign, but will have fluctuating symptoms.

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