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| | '''For patient information, click [[Dyspepsia (patient information)|here]]''' |
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| {{Editor Help}} | | {{Dyspepsia}} |
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| ==Overview==
| | {{CMG}} {{AE}} {{Ajay}} |
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| DiseasesDB = 30831 |
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| ICD10 = {{ICD10|K|30||k|20}} |
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| ICD9 = {{ICD9|536.8}} |
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| MeshName = Dyspepsia |
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| MeshNumber = C23.888.821.236 |
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| '''Dyspepsia''' (from the [[Greek language|Greek]] "δυς-" (Dys-), meaning hard or difficult, and "πέψη" (Pepse), meaning digestion) is chronic or recurrent pain or discomfort centered in the upper abdomen <ref>N. Talley, et al., "Guidelines for the management of dyspepsia", ''American Journal of Gastroenterology'' 100 (2005), pp. 2324-2337.</ref> Discomfort, in this context, includes mild pain, upper abdominal fullness and feeling full earlier than expected with eating. It can be accompanied by bloating, belching, [[nausea]] or heartburn. [[Heartburn]] is excluded from the definition of dyspesia in ICD 10, as it usually has a different cause and management pathway.
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| Many people get dyspepsia. It is often caused by lifestyle factors, such as smoking and diet, but there are some serious causes such as cancer of the stomach, peptic ulcer disease and some medications. When people have dyspepsia but no risk factors for any of the serious causes, it can be labeled undifferentiated dyspepsia and treated without further investigations. When people have been investigated for dyspepsia but no cause has been found it can be labeled as functional dyspepsia.
| | {{SK}} Functional dyspepsia; dyspepsia, functional; non-ulcer dyspepsia; nonulcer dyspepsia |
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| ==Investigation of dyspepsia== | | ==[[Dyspepsia overview|Overview]]== |
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| People without risk factors for serious causes of dyspepsia usually do not need investigation beyond an office based clinical examination. However, people over the age 55 years and those with alarm features are usually investigated by esophagogastroduodenoscopy (EGD or OGD in Britain). In this painless investigation the esophagus, stomach and duodenum are examined through an endoscope passed down through the mouth. This will rule out peptic ulcer disease, medication related ulceration, malignancy and other rarer causes.
| | ==[[Dyspepsia historical perspective|Historical Perspective]]== |
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| People under the age of 55 years with no alarm features do not need EGD but are considered for investigation for peptic ulcer disease caused by ''[[Helicobacter pylori]]'' [[infection]]. Investigation for ''H.pylori'' infection is usually performed when there is a moderate to high prevalence of this infection in the local community or the person with dyspepsia has other risk factors for ''H. pylori'' infection, related for example to ethnicity or immigration from a high-prevalence area. If infection is confirmed it can usually be eradicated by medication.
| | ==[[Dyspepsia classification|Classification]]== |
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| Medication related dyspepsia is usually related to [[non-steroidal anti-inflammatory drug|Non-Steroidal Anti-inflammatory Drugs (NSAIDs)]] and can be complicated by bleeding or ulceration with perforation of the stomach wall.
| | ==[[Dyspepsia pathophysiology|Pathophysiology]]== |
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| ==Treatment of Functional Dyspepsia and Undifferentiated Dyspepsia== | | ==[[Dyspepsia causes|Causes]]== |
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| Treatment safely and successfully prescribed by doctors in Pakistan is a 10 day course and includes the following:<br>
| | ==[[Dyspepsia differential diagnosis|Differentiating Dyspepsia from other Diseases]]== |
| (1)Risek 20mg capsules 1+1 for 10 days<br>
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| (2)Amoxil 500mg capsules 2+2 for 10 days<br>
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| (3)Claritek 500mg tablets 1+1 for 10 days<br>
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| (4)Ulsanic syrup 2+2+2 for 10 days<br>
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| Functional and undifferentiated dyspepsia have similar treatments. Decisions around the use of drug therapy are difficult because trials included heartburn in the definition of dyspepsia. This led to the results favoring [[proton pump inhibitors]] (PPIs), which are questionably effective for the treatment of heartburn.
| | ==[[Dyspepsia epidemiology and demographics|Epidemiology and Demographics]]== |
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| Traditional therapies used for this diagnosis include lifestyle modification, antacids, [[h2-receptor antagonist|H2-receptor antagonists (H2-RAs)]], [[prokinetic]] agents, and [[antiflatulent]]s. It is has been noted that one of the most frustrating aspects of treating functional dyspepsia is that these traditional agents have been shown to have little or no efficacy<ref name="Monkemuller">Monkemuller K, Malfertheiner P. Drug treatment of functional dyspepsia. World J Gastroenterol. 2006 May 7;12(17):2694-700.</ref>.
| | ==[[Dyspepsia risk factors|Risk Factors]]== |
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| Antacids and sucralfate were found to be no better than placebo in a literature review. H2-RAs have been shown to have marked benefit in poor quality trials (30% relative risk reduction), but only a marginal benefit in good quality trials<ref name="Monkemuller"/>. Prokinetic agents would empirically seem to work well since delayed gastric emptying is considered a major pathophysiological mechanism in functional dyspepsia<ref name="Monkemuller"/>. They have been shown in a meta-analysis to produce a relative risk reduction of up to 50%, but the studies evaluated to come to this conclusion used the drug cisapride which has since been removed from the market (now only available as an investigational agent<ref>Anonymous. Information regarding withdrawal of Propulsid (cisapride) by Janssen Pharmaceutica. From FDA website (http://www.fda.gov/medwatch/safety/2000/safety00.htm#propul).</ref>) due to serious adverse events such as torsades¬, and publication bias has been cited as a potential partial explanation for such a high benefit. Modern prokinetic agents such as metoclopramide, erythromycin and tegaserod have little or no established efficacy and often result in substantial side effects. Simethicone has been found to be of some value, as one trial suggests potential benefit over placebo and another shows equivalence with cisapride. So, with the somewhat recent advent of the proton pump inhibitor (PPI) class of medications, the question of whether these new agents are superior to traditional therapy has arisen.
| | ==[[Dyspepsia screening|Screening]]== |
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| A 2004 meta-analysis pooling data from three double-blind placebo-controlled studies found the multiple herbal extract Iberogast to be significantly more effective than placebo (p value = 0.001) at treating patients with functional dyspepsia through the targeting of multiple dyspeptic pathologies<ref name="Melzer2004"> {{cite journal|title=Meta-analysis: phytotherapy of functional dyspepsia with the herbal drug preparation STW-5 (Iberogast)|year=2004|author=Melzer J, Rosch W, Reichling J, Brignoli R, Saller R|journal=Aliment Pharmacol Ther|volume=20|pages=1279–87}}</ref>. This German-made phytopharmaceutical was found to be equivalent to cisapride and significantly superior to metochlopramide at reducing the symptoms of functional dyspepsia over a four week period.<ref name="Rosch2002">{{cite journal|journal=Z Gastroenterol|title=A randomised clinical trial comparing the efficacy of a herbal preparation STW 5 with the prokinetic drug cisapride in patients with dysmotility type of functional dyspepsia|author=Rosch w, Vinson B, Sassin, I|year=2002|volume=40|pages=401–8}}</ref><ref name="Hanisch2005">{{cite journal|journal=Med Klinik|title=The efficacy and safety of STW 5 versus Metochlopramide oral for functional dyspepsia under practice conditions (in German)|author=Hanisch J, Bock P, Vinson B|year=2005|volume=100|pages107}}</ref> Retrospective surveillance of 40,961 children (12 years and under) found no serious side-effects<ref name="Leichtle1999">{{cite journal|journal=Forschungsbericht Steigerwald Arzneimittelwerk|title=Experience reports on the use of Iberogast in children (in German)|author=Liechtle K|year=1999|volume=GmbH}}</ref>.
| | ==[[Dyspepsia natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
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| Currently, PPIs are, depending on the specific drug, FDA indicated for erosive esophagitis, gastroesophageal reflux disease (GERD), Zollinger-Ellison syndrome, eradication of H. pylori, duodenal and gastric ulcers, and NSAID-induced ulcer healing and prevention, but not functional dyspepsia. There are, however, evidence-based guidelines and literature that evaluate the use of PPIs for this indication. A helpful chart summarizing the major trials is available from the functional dyspepsia guidelines published in the World Journal of Gastroenterology in 2006<ref name="Monkemuller"/>.
| | ==Diagnosis== |
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| | [[Dyspepsia history and symptoms|History and Symptoms]] | [[Dyspepsia physical examination|Physical Examination]] | [[Dyspepsia laboratory findings|Laboratory Findings]] | [[Dyspepsia x ray|X Ray]] | [[Dyspepsia CT|CT]] | [[Dyspepsia MRI|MRI]] | [[Dyspepsia ultrasound|Ultrasound]] | [[Dyspepsia other imaging findings|Other Imaging Findings]] | [[Dyspepsia other diagnostic studies|Other Diagnostic Studies]] |
| The CADET study was the first to compare a PPI (omeprazole 20mg daily) to both an H2-RA (ranitidine 150mg BID) as well as a prokinetic agent (cisapride 20mg BID) alongside placebo<ref>Veldhuyzen van Zanten SJ, Chiba N, Armstrong D, Barkun A, Thomson A, Smyth S, Escobedo S, Lee J, Sinclair P. A randomized trial comparing omeprazole, ranitidine, cisapride, or placebo in ''Helicobacter pylori'' negative, primary care patients with dyspepsia: the CADET-HN Study. Am J Gastroenterol. 2005 Jul;100(7):1477-88.</ref>. The study evaluated these agents in patients at 4 weeks and 6 months and noted that omeprazole had a significantly better response at 6 months (31%) than cisapride (13%) or placebo (14%) (p = 0.001) while it was just above the cutoff for being statistically significantly better than ranitidine (21%) (p = 0.053). Omeprazole also showed a significant increase in quality of life scores over the other agents and placebo in all but one category measured (p = 0.01 to 0.05).
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| The ENCORE study, which was a follow-up of patients from the OPERA study, showed responders to omeprazole therapy had fewer clinic visits than non-responders (1.5 vs 2.0) over a three month period (p < 0.001)<ref>Talley NJ, Meineche-Schmidt V, Pare P, Duckworth M, Raisanen P, Pap A, Kordecki H, Schmid V. Efficacy of omeprazole in functional dyspepsia: double-blind, randomized, placebo-controlled trials (the Bond and Opera studies). Aliment Pharmacol Ther. 1998 Nov;12(11):1055-65.</ref><ref>Meineche-Schmidt V, Talley NJ, Pap A, Kordecki H, Schmid V, Ohlsson L, Wahlqvist P, Wiklund I, Bolling-Sternevald E. Impact of functional dyspepsia on quality of life and health care consumption after cessation of antisecretory treatment. A multicentre 3-month follow-up study. Scand J Gastroenterol. 1999 Jun;34(6):566-74.</ref>.
| | ==Treatment== |
| | [[Dyspepsia medical therapy|Medical Therapy]] | [[Dyspepsia surgery|Surgery]] | [[Dyspepsia primary prevention|Primary Prevention]] | [[Dyspepsia secondary prevention|Secondary Prevention]] | [[Dyspepsia cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Dyspepsia future or investigational therapies|Future or Investigational Therapies]] |
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| == References == | | ==Case Studies== |
| <references/>
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| == See also == | | [[Dyspepsia case study one|Case #1]] |
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| | == Related Chapters == |
| * [[Gastritis]] | | * [[Gastritis]] |
| * [[Stomach ache]] | | * [[Stomach ache]] |
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| * [[Functional bowel disorder]] | | * [[Functional bowel disorder]] |
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| == External links ==
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| * [http://www.al-hikmah.org/dyspepsia.asp Dyspepsia]
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| * [http://www.gastroview.com Dyspepsia Test]
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| {{SIB}}
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| {{Gastroenterology}} | | {{Gastroenterology}} |
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| [[Category:Gastroenterology]]
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| [[Category:Digestive disease symptoms]]
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| [[Category:Symptoms]]
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| [[Category:Needs patient information]]
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| [[Category:Signs and symptoms]]
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| [[de:Verdauungsstörung]] | | [[de:Verdauungsstörung]] |
| [[es:Dispepsia]] | | [[es:Dispepsia]] |
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| | [[Category:Gastroenterology]] |