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Functional
Dyspepsia
Patient
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INTRODUCTION
Functional dyspepsia, sometimes referred
to as non-ulcer dyspepsia, is a common
functional disorder of the upper digestive
tract (stomach and upper small intestine).
Functional dyspepsia is characterised by
chronic or recurrent upper abdominal pain
or discomfort, often in conjunction with
feelings of early satiety (fullness), pressure in
the abdomen, burning, bloating, belching or
nausea. Symptoms may occur after eating a
meal, but can happen at any time. Similarly,
certain foods or drinks may worsen symptoms
for some people.
As with other functional disorders, there
is no evidence of organic disease or other
structural abnormality in the gut (such as
an ulcer or inflamed esophagus) that can
account for the symptoms that are present.
While the condition is uncomfortable and can
be distressing, especially if symptoms are
chronic, functional dyspepsia does not cause
other, more serious conditions. The symptoms
associated with functional dyspepsia can
be addressed, as outlined further in this
leaflet, and the prognosis for the condition is
generally quite good.
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CAUSES
The exact cause of functional dyspepsia is not known, however symptoms are
thought to be linked to an increased sensitivity in the esophagus and upper
gastrointestinal system, which can be triggered by a variety of factors.
These may include: impaired peristalsis (contraction and
relaxation of the intestinal muscles that move food
through the upper digestive tract), acid secretion, diet,
lifestyle, and psychological factors. Many people with
functional dyspepsia have an increased awareness of their
stomach and upper gut activity and can have impaired
digestion or be sensitive to food intake. Many people with
functional dyspepsia find that certain foods can make
symptoms worse, however, food is not the cause of
functional dyspepsia.
Functional Dyspepsia is one of several conditions known as
functional gastrointestinal disorders. The term ‘functional
disorder’ refers to the presence of symptoms with a normal
clinical examination and normal investigations. In other
words there is nothing visibly wrong with the body. In the
case of functional dyspepsia, the lining of the gut is not
inflamed and the amount of acid in the stomach is normal.
This can be very frustrating for patient and clinicians
especially when the symptoms are very severe. An ‘organic
disorder’ refers to conditions where symptoms are
associated with findings on clinical examination and/or
abnormal diagnostic tests which identify the source of
symptoms and direct future treatment.
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Contributory elements to the
development of functional dyspepsia
Biological factors
Functional dyspepsia can be caused by a failure of
the stomach or upper digestive system to move food
through the body in a normal way. Typically, the
body moves food through the digestive system by
rhythmically contracting and relaxing the muscles of
the digestive system. In this way, food moves from
the stomach through the intestinal tract. However, in
those with functional dyspepsia, this process is often
disturbed and the stomach or small intestine may not
relax, contract, or empty normally after a meal.
Issues relating to the brain-gut axis
The link between the brain and the gut has been
well established. Research using MRI scans showed
that certain areas in the gut and in the brain are more
active in functional dyspepsia than in non-functional
dyspepsia subjects. It is therefore believed that functional
dyspepsia is related to excessive nerve transmission
between the gut and the brain, which is mediated by
nerve chemicals (neurotransmitters). In other words, a
primary trigger driving functional dyspepsia symptoms
is that the gut is hypersensitive to stimuli and that food
does not pass through the digestive systems of people
with functional dyspepsia properly. This is because the
signals that travel back and forth from the brain to the
gut, controlling the nerves, are disrupted in some way.
Because of this, food, drinks, and emotions may trigger
pain. The sensitivity, as mentioned above, stems from
hypersensitive gut nerves that send excess signals to the
brain, particularly to the area that processes pain. The
brain then sends abnormal signals back to the gut to alter
its motility or relax muscles. This back and forth electrical
communication between the brain and gut is represented
by the brain-gut axis and understanding this interaction
forms the basis of current treatment approaches to
functional dyspepsia.
Emotional factors
It has recently become evident that stress and other
psychological factors, such as anxiety and depression,
can affect the gastrointestinal system. These
psychological factors can make functional dyspepsia
symptoms worse, and sufferers more sensitive and less
tolerant of food. Heightened emotional states can lead
to chemical changes in the body that can hinder the
process of digestion. This can be cyclical as well, as the
uncomfortable nature of functional dyspepsia can lead
to more stress, depression, anxiety or anger.
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symptoms
General Symptoms
The symptoms of functional dyspepsia vary between each individual, as does their
severity. At times, symptoms and signs can be mild, and at other times they can be
painful and debilitating. Symptoms are often worse after eating and tend to come and
go in bouts.
Core symptoms of functional dyspepsia often include
the following:
oo
Pain or discomfort in your upper abdomen or chest
oo
A feeling of fullness in your upper abdomen
oo
A burning feeling in your neck or esophagus (heartburn)
oo
Loss of appetite
oo
Belching
oo
Bloating
oo
Nausea
oo
Vomiting
Stress/depression/anxiety
Alarm symptoms
The symptoms of functional dyspepsia
can mostly be managed at home and do
not require urgent care. However, due to
the discomfort, pain and/or distress of
functional dyspepsia, the clinical picture
may well be accompanied by feelings of
depression, anxiety and/or stress. These
psychological factors should be related
to your doctor, who can help to manage
or treat them, along with your physical
symptoms.
It is important to see a doctor if you have:
oo
a noticeable change in any of the
general or associated symptoms of
functional dyspepsia
oo
difficulty swallowing
oo
difficulty breathing
oo
frequent vomiting or blood in
your vomit
oo
family history of stomach cancer
oo
family history of gastric cancer
oo
shortness of breath
oo
unintentional weight loss
oo
or if you are 55 or older
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DIAGNOSIS
Functional dyspepsia is a functional gastrointestinal
disorder, with no obvious physical abnormalities of the
digestive tract, and so there is no specific test that can
determine if it is present. Therefore, functional dyspepsia
is largely a diagnosis of exclusion. Your doctor will need
to ask you a series of health questions, take your medical
history, and complete a physical exam in order to rule out
other causes. A diagnosis is made based on the symptoms
you describe and the exclusion of other causes.
An international working group developed a list of
diagnostic criteria for functional dyspepsia. These criteria
were developed in Rome and are now at their third version
hence they are being referred to as the ‘Rome III criteria’.
In some cases, particularly if you have alarm symptoms
(see previous heading), your doctor may want to carry out
additional tests. This is to rule out the possibility of other,
more serious conditions, or infection or inflammation or
the upper GI tract.
Functional Dyspepsia Rome III
diagnostic criteria
Symptoms must include one or more of the following:
1
Bothersome postprandial fullness
2
Early satiation
3
Epigastric pain
4
Epigastric burning
and
5
No evidence of structural disease (including at upper endoscopy) that
is likely to explain symptoms
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These criteria need to be
fulfilled for the last three
months with symptom
onset at least six months
prior to diagnosis
In some cases, particularly if you have alarm symptoms (see previous heading), your
doctor may want to carry out additional tests. This is to rule out the possibility of
other, more serious conditions, or infection or inflammation or the upper GI tract.
Further Tests
If alarm symptoms are raised, further tests may be recommended in order to rule
out other conditions. Further investigations may include the following, depending on
your symptoms and concerns:
Endoscopy Computerised tomography (CT) scan This test is used to examine the oesophagus, stomach,
and duodenum by inserting a thin, flexible tube down the
oesophagus.
A CT scan may be used to scan the abdomen and pelvis,
producing cross-sectional images of the abdominal
organs, which can be used to help rule out other physical
causes for symptoms.
Helicobacter pylori test
A stool or breath test may be performed to rule out
the presence of h. pylori, which is a type of infection
sometimes associated with dyspeptic symptoms.
Blood tests
A blood sample may be required to rule out more serious
conditions.
Food allergy tests
If your doctor suspects your symptoms may be linked to
an intolerance of certain foods, he or she may order
a food allergy test or ask you to eliminate certain products
from your diet for a period of time.
Barium swallow and meal X-ray
This test involves ingesting a drink that contains barium
prior to having an abdominal X-ray. Barium is a substance
that can be seen on X-ray images, enabling your doctor to
more clearly see the inside of your gut
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TREATMENT
Once diagnosed with functional dyspepsia, there are a
number of treatment options that can help you alleviate
your symptoms. Sometimes, with mild to moderate cases
of functional dyspepsia, symptoms can be managed at
home by changing elements of your diet and lifestyle.
When symptoms are more severe, or if your functional
dyspepsia has become chronic, medication and
psychological treatments can also be useful. The different
psychological treatments for functional dyspepsia are
cognitive behavioural therapy (CBT), psychodynamic
psychotherapy and hypnotherapy.
Eat regularly
Discussing these treatment options with your doctor, while
considering your symptoms and how functional dyspepsia
is affecting your daily life, can help identify the most
appropriate treatment options.
Smoking is known to greatly exacerbate the symptoms
of functional dyspepsia. If you smoke, it is recommended
that you quit.
Diet, Lifestyle, and Exercise
If a dietary or lifestyle cause is suspected, it may be
helpful to change your diet or exercise regime. Your GP
may also refer you to a dietician or recommend some of
the following dietary changes to see if they help reduce
your symptoms.
Diet
Identify problem foods
In many cases, certain foods and drinks can exacerbate
the symptoms of functional dyspepsia. Foods with a
high fat or sugar content, for example, can slow down
the passage of food through the gut and break down
producing gas and liquid, which may make dyspeptic
symptoms worse. While these foods are not the cause
of functional dyspepsia, your gut may not tolerate them
well. Identifying and limiting your intake of certain types
of foods, in conjunction with a healthy, balanced diet, may
improve your symptoms.
Consider the following list of foods and drinks that are
sometimes associated with functional dyspepsia and
consider limiting your intake if you are finding any of these
make your symptoms worse:
oo
fatty foods (such as fried food, higher fat meats, cheese,
nuts, etc)
oo
acidic foods (such as citrus fruits/juice or tomatoes and
tomato-based products)
oo
spicy foods
oo
alcohol
oo
caffeinated beverages (such as coffee, tea or soda)
oo
carbonated beverages
oo
lactose
oo
chocolate
Irregular eating patterns have been proven to exacerbate
the symptoms of functional dyspepsia. Try to eat meals
at regular intervals and avoiding skipping meals or going
a long time without eating, which can make symptoms
worse. Eating small to moderate portions and eating
slowly have also been known to decrease symptoms of
functional dyspepsia.
Lifestyle
Smoking
Caffeine and alcohol
Caffeine and alcohol are known to worsen the symptoms
of functional dyspepsia. If you consume caffeinated or
alcoholic beverages, it is recommended that you reduce
your intake of these, or exclude them altogether.
Weight Management
If you are overweight, your doctor may recommend losing
weight or seeing a nutritionist who can help you identify
and address your diet. Being overweight can contribute to
the symptoms of functional dyspepsia and losing weight
may help improve or alleviate your symptoms.
Exercise
Your doctor will likely recommend that you exercise
regularly. Many people find a light to moderate exercise
regime helps alleviate symptoms of functional dyspepsia
and reduces stress. Talk to your GP about finding the type
of exercise programme that would be most suitable and
enjoyable for you. Try to exercise three times per week, for
a minimum of 30 minutes, doing something that increases
your heart rate and breathing, such as brisk walking,
swimming, cycling or using a cardiovascular machine.
Therapeutic Interventions
If more conservative treatment, such as changes to diet
and exercise routines do not help relieve your symptoms,
or if functional dyspepsia is having a significant impact on
your daily activities and quality of life, a talking therapy
or counseling can often be helpful. This is particularly true
for those who experience high levels of stress, or who
feel stress worsens their symptoms. Reducing the amount
of tension you experience or learning tools to manage
stress and anxiety can often reduce the severity and
frequency of functional dyspepsia symptoms and improve
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your overall quality of life. It can also be helpful to talk to
someone who understands how difficult such conditions
can be, and to discuss the correlation functional dyspepsia
may have to your mood, troubling thoughts, or negative
feelings. There are a range of therapeutic treatment
options available which your doctor may recommend
and that can help alleviate stress or manage feelings of
depression. The main therapeutic approaches available for
functional dyspepsia are cognitive behavioural therapy,
psychodynamic psychotherapy and hypnotherapy
Cognitive behavioural therapy (CBT)
CBT is a psychotherapeutic approach based on cognitive
and behavioural principles that aims to identify and
understand negative thoughts, beliefs and patterns
of behaviour. Once these emotions and patterns are
recognized, you can then better understand and change
them based on a series of action oriented and problem
solving strategies. Many studies show that if you can
train yourself to react differently to stress, anxiety and
depression (i.e. to think more positively or incorporate
relaxation techniques), your physical symptoms of pain
and discomfort can be alleviated. Thus, the task in CBT is
to break the chain in terms of how you may be responding
to anxiety.
Psychodynamic psychotherapy
Psychodynamic psychotherapy is a more explorative
therapy, which focuses on gaining an understanding
of unconscious processes that lie behind current
presentations. These processes often relate to the past
and so the objective is to gain insight into how our
past affects and influences our current feelings and
behaviour. Psychodynamic psychotherapists can help you
to explore your feelings of stress and discomfort around
functional dyspepsia, how this might relate to other parts
of your life, and how you might go about addressing
these in a psychologically healthy way. Psychodynamic
psychotherapy, therefore, involves bringing less conscious
psychological dynamics into awareness, finding words to
describe such feelings, and working through them in a
safe and confidential setting.
Medication
If other more conservative treatments do not have an
effect on your functional dyspepsia, medication can
sometimes be prescribed to reduce the severity of
symptoms. For further more specialised medications
consult your gastroenterologist.
Acid-suppressing medications
There are a range of over-the-counter medications from
your pharmacist that may help reduce the amount of acid
in the stomach. If your stomach is sensitive to acid, these
antacid medications may reduce dyspeptic symptoms,
such as bloating or upper abdominal discomfort. Acidsuppressing medications are not a long-term solution
however, and should only be used as needed and in the
short-term.
Prescription-only medications
If other means of controlling symptoms do not work,
your GP or gastroenterologist may try another type of
prescription medication, such as a prokinetic drug, to
address your symptoms.
Anti-depressant medications
If you are experiencing high levels of stress and/
or depression, your doctor may recommend an
antidepressant medication in addition to diet and exercise,
or in conjunction with psychotherapy treatment. These
medications can help with symptoms of depression and
via the brain-gut axis can inhibit the activity of neurons
that control the intestines. Sometimes antidepressant
medications are prescribed at a very low dose in the
absence of depression as these have been shown to
reduce the pain signals that eminate from the gut in
functional bowel disorders.
Hypnotherapy
Hypnotherapy has been shown to help some people with
functional disorders reduce their symptoms of pain and
discomfort. Hypnosis is used to change your unconscious
mind’s attitude towards your symptoms. You can have
hypnotherapy as an outpatient, or you can learn selfhypnosis techniques to practice at home.
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COMPLICATIONS
While functional dyspepsia is not linked to any life-threatening
condition or illness, there can often be an impact on day-to-day
activities and quality of life. For some people, the difficulties of coping
with the symptoms of functional dyspepsia (ie frequently belching
or experiencing discomfort in the abdomen) may limit their ability or
desire to make plans, maintain social commitments and recreational
activities. The pain and discomfort of functional dyspepsia, combined
with the effect it can have on one’s social, work, or personal
activities can be very taxing. Over time, this may lead to feelings of
discouragement, stress, depression, and anxiety.
If you are experiencing any of these symptoms, or if you feel
functional dyspepsia is limiting your activities or negatively affecting
your quality of life, it is recommended that you visit your GP, who
will be able to help identify an appropriate and effective treatment
for you.
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SUPPORT AND
FURTHER RESOURCES
Living with functional dyspepsia can be uncomfortable
and challenging and it can be difficult to know where
to turn for help. While your first point of contact should
always be your GP or gastroenterologist, educational
and community resources may help you to cope more
effectively with functional dyspepsia and improve your
quality of life.
The Core Charity (www.corecharity.org.uk) is such a
non-profit organisation that raises awareness and funds
research on gut and liver disease, promotes education
on gut function, and provides contacts for patient
organisations and support groups.
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