Download Clinical Features of Functional Dyspepsia

© SUPPLEMENT TO JAPI • march 2012 • VOL. 60 21
Clinical Features of Functional Dyspepsia
BD Goswami*, Chiranjita Phukan**
F
unctional gastrointestinal disorders (FGID) comprises
of symptoms which arise mostly in the mid or lower
gastrointestinal tract that are not attributed to anatomic or
biochemical defects. 1,2 They are prevalent throughout the
world and often encountered by clinicians in their day to day
clinical practice. The three common Functional gastrointestinal
disorders (FGID) are Irritable Bowel Syndrome (IBS) Functional
Constipation and Functional Dyspepsia (FD).
In a retrospective analysis of symptoms and pathophysiological
abnormalities Kindl and his colleagues8 reported that epigastric
pain syndrome was in 53% of dyspeptic patients and post
prandial distress syndrome was in 84% of patients with an
overlap in 47%. Impaired accommodation was more prevalent
among patients with post prandial distress syndrome (38%)
than among patients with both epigatric pain syndrome or post
prandial distress syndrome.
Functional dyspepsia is an extremely common disorder
in an otherwise healthy population. On the basis of different
epidemiological studies, the prevalence of dyspepsia ranges
from 5% to 25%.3 Amongst individuals who experience dyspeptic
symptoms, approximately 25% seek treatment making the
condition responsible for 4% to 5% of all primary care physician
visits.4,5 Thus FD has gained acceptance as a major healthcare
concern which warrants a great deal of in-depth research
particularly on the management aspect.
Clinical Approach to Functional
Dyspepsia
Dyspepsia is often broadly defined as pain or discomfort
centered in the upper abdomen.4 It may include multiple and
varying symptoms such as epigastric pain, postprandial fullness,
early satiation (also called early satiety) anorexia, belching,
nausea and vomiting, upper abdominal bloating and even
heartburn and regurgitation.4 Symptoms of dyspepsia though
chronic are mostly intermittent even in the most symptomatic
episodes. Dyspepsia is usually polysymptomatic, with 99% of
patients reporting more than 2 symptoms, over 80% reporting
more than 5 symptoms, and less than 0.1% reporting 1 symptom.6
The definition of functional dyspepsia has evolved over the
years leading to several consensus definitions till date. However
the most recent consensus committee Rome III has defined
functional dyspepsia as the presence of symptoms considered
by the physician to originate from the gastro duodenal region
in the absence of organic, systemic or metabolic disease that
is likely to explain the symptoms.7 The diagnostic criteria7 for
functional dyspepsia are the occurrence of one or more of the
following symptoms at least for three months with onset at least
six months previously – bothersome post prandial fullness, early
satiation, epigastric pain and epigastric burning.
Postprandial fullness is an unpleasant sensation perceived as
the prolonged persistence of food in the stomach. Early satiation
is a feeling that the stomach is overfilled soon after starting to eat,
out of proportion to the size of the meal being eaten and such
that the meal cannot be finished. Epigastric refers to the region
between the umbilicus and the lower end of the stomach within
the midclavicular line and Epigastric Pain refers to a subjective
unpleasant sensation. Epigastric burning is referred to as an
unpleasant subjective sensation of heat.
The Rome III consensus committee 7 has proposed that
Functional dyspepsia should be subdivided into two groups on
the distinction of meal related and meal unrelated symptoms –
1. Post prandial distress syndrome- It is meal related
dyspeptic symptoms characterized by post prandial fullness
and early satiety.
2. Epigastric pain syndrome- It is meal unrelated dyspeptic
symptoms characterized by Epigastric pain and burning.
HOD, Gastroenterology, **Assistant Professor of Medicine, Gauhati
Medical College, Gauhati, Assam
*
While evaluating a patient with uninvestigated dyspepsia
proper attention should be given to the history and physical
examination. The nature of symptoms, their duration and
frequency particularly with regard to their relationship to the
duration of meals, the possible influence of dietary habits should
be ascertained.
Onset of symptoms can also occur after an attack of enteritis.
In a prospective cohort study, development of Functional
dyspepsia was increased five fold in patients one year after
acute salmonella gastroenteritis compared to subjects who did
not have gastroenteritis.9 In a cohort study10 of 2597 subjects
eligible, (64.9%) had reported acute gastroenteritis. Multivariate
odd ratios for dyspepsia at 8 years in exposed individuals
using a broad definition and the Rome II definition were 2.09
(95% confidence interval: 1.58–2.78) and 2.30 (95% confidence
interval: 1.63–3.26), respectively. Prevalence of dyspepsia was
higher in females; smokers; those with premorbid irritable bowel
syndrome, anxiety, or depression; and those reporting >7 days
of diarrhea or abdominal cramps during the acute illness.
Use of medication like NSAIDS and COX2 inhibitors has
been linked to dyspeptic symptoms of functional dyspepsia.11
Dietary habits linked to meals with high fat content, spicy food
containing capsaicin and other irritants coffee, alcohol and
smoking can cause and aggravate functional dyspepsia.
Patients with functional dyspepsia also suffer from psychiatric
co-morbidities, anxiety disorders, depressive disorders,
somatoform disorders and a recent or remote history of physical
or sexual abuse. 12 Geeraerts and colleagues 13 studied 162
patients with functional dyspepsia who completed a validated
questionnaire on abuse in addition to gastric barostat studies;
an association was reported between slow solid emptying and
a history of childhood abuse and also between psychological
abuse in adulthood and gastric hypersensitivity.
The American Gastroenterological Association4 recommends
for a careful history to be taken to exclude alternative conditions
(GERD, GB diseases, IBS etc) and to identify alarm features.
Alarm features or red flag sign in patients presenting with
dyspepsia include age older then 55 years, and for young people
with recurrent vomiting, weight loss, dysphagia, and evidence
of GI bleed or family history of cancer. Patients with these alarm
features are at high risk for underlying malignancies hence
prompt upper endoscopy is recommended.
In younger patients without the presence of these alarm signs,
Consensus guidelines14 recommend avoiding UGI endoscopy
and advocates presenting empiric therapy. In a meta analysis of
14 cohort studies15 that assessed alarm features and the results of
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endoscopy in a total of 17792 patients, only 1.4% had malignancy.
The sensitivity of alarm features ranged widely (0-100%) and
specificity was ranging from 21%-98%. Thus alarm features have
found to have a poor predictive value in identifying upper GI
malignancy as based on the meta analysis.
Weight loss if present is considered to be a symptom for alarm,
it being a harbinger towards serious organic diseases. However
patients with functional dyspepsia may also present unexplained
weight loss which has been documented in population based
studies. GERD and peptic ulcer causes symptoms which mimic
functional dyspepsia.16 Burning pain in the epigastrium is a
cardinal symptom of dyspepsia and should not be considered
to be heart burn unless the pain radiates retrosternally.7 A
word picture questionnaire may help the patient recognize the
typical symptom pattern. Presence of typical reflux symptom
requires management as a patient of GERD. However if patient’s
symptoms do not respond overlap with functional dyspepsia may
be considered.7 In a systematic review evaluating 11366 patients
the overall pooled diagnostic odds ratio (DOR) of identifying
functional from organic dyspepsia was only 3.99. (with 10 greater
being a clinically relevant number) The investigators concluded
that a clinical history remained inadequate for distinguishing an
organic from a functional cause of dyspepsia.17
Because many patients have overlapping symptoms of
IBS and dyspepsia, maintaining two separate diagnoses leads
to separate, but often parallel, processes of evaluation and
treatment. Unfortunately, this results in redundant laboratory
tests, duplication of diagnostic studies, frequent office visits, and
the use of multiple medications. Dyspeptic symptoms in a patient
with systemic diseases like Diabetes Mellitus, cardiac diseases,
thyroid disorders and of the patients family and personal history
needs to be evaluated for specific organic diseases. Presence of
physical findings such as an abdominal mass or organomegaly,
ascitis or fecal occult blood is a requisite for further evaluation.4
Functional dyspepsia is also associated with reduced quality
of life. This is most likely because of the symptom severity rather
than by another factor such as co morbid anxiety or depression
or delayed gastric emptying. In a study evaluating 864 patients
fulfilling Rome III criteria for functional dyspepsia symptom
severity score over a two year period was independently
associated with decreased quality of life scores and this was
significant after considering gastric emptying as well as age,
sex and body mass index.18 Kindt and colleagues8 evaluated
164 patients with functional dyspepsia, and evaluated qualityof-life parameters as measured by the validated PAGI-QOL
(Patient Assessment of Upper Gastrointestinal Quality of Life)
questionnaire. Both postprandial fullness and satiety, as well
as nausea and vomiting, appeared to be the major symptom
determinants of impaired quality of life in this cohort with
functional dyspepsia. However, since no control group was
assessed, these results must be viewed as preliminary. It is
evident from these studies that quality-of-life impairment is
not only real, but is also symptom driven. It is hence presumed
relief of symptoms would improve quality of life.
The role of Helicobacter pylori infection in the pathogenesis of
functional dyspepsia is debated. Though the role of Helicobacter
Pylori has often been implemented in the cause of functional
dyspepsia over the past decade, is has now been established
from various studies that this organism can also inhabit the
gastric mucosa without any ulceration. A Meta-Analysis of ten
randomized, Controlled Trials19 provides little support for the
use of H. pylori eradication therapy in patients with non ulcer
dyspepsia
© SUPPLEMENT TO JAPI • march 2012 • VOL. 60
Though managing patients with Functional Dyspepsia can
be a challenging and frustrating process for clinicians, but the
huge economic burden incurred indirectly from this condition
makes it imperative for the clinician to work towards a common
goal to diagnose and manage these conditions.
References
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American Gastroenterological Association. Medical position
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10. Prevalence of Uninvestigated Dyspepsia 8 Years After a Large
Waterborne Outbreak of Bacterial Dysentery: A Cohort Study.
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[Poster M1246]
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diagnosis of functional dyspepsia. Gastroenterology 2005;128(suppl
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