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In a recent study, patients with peptic ulcer disease were compared with patients with functional
dyspepsia in an age and sex-matched study. Although the functional dyspepsia group reported
more upper abdominal fullness, nausea, and overall greater distress and anxiety, almost all the
same symptoms were seen in both groups. Therefore, it is the clinicians challenging task to
separate patients who may have an organic disorder, and thus warrant further diagnostic testing,
from patients who have functional dyspepsia, who are given empiric symptomatic treatment.The
workup should be targeted to identify or rule out specific causes. Traditionally, people at high-risk
have been identified by alarm features. However, the utility of these features in identifying the
presence of upper cancer of the esophagus or stomach has been debated. A meta analysis
looking at the sensitivity and specificity of alarm features found a range of 080% and 4098%,
respectively. However, there was high heterogeneity between studies.[citation needed]
The physical examination may elicit abdominal tenderness, but this finding is nonspecific. A
positive Carnett sign, or focal tenderness that increases with abdominal wall contraction and
palpation, suggests an etiology involving the abdominal wall musculature. Cutaneous
dermatomal distribution of pain may suggest a thoracic polyradiculopathy. Thump tenderness
over the right upper quadrant may suggest chronic cholecystitis.[7]
Cause[edit]
Non-ulcer dyspepsia[edit]
In about 50-70% of patients with dyspepsia, no definite organic cause can be determined. In this
case, dyspepsia is referred to as non-ulcer dyspepsia and its diagnosis is established by the
presence of epigastralgia for at least 6 months, in the absence of any other cause explaining the
symptoms.
Post-infectious dyspepsia[edit]
Gastroenteritis increases the risk of developing chronic dyspepsia. Post infectious dyspepsia is
the term given when dyspepsia occurs after an acute gastroenteritis infection. It is believed that
the underlying causes of post-infectious IBS and post-infectious dyspepsia may be similar and
represent different aspects of the same pathophysiology.[8]
Functional Dyspepsia[edit]
This is the most common cause of chronic dyspepsia. Up to three-fourths of patients have no
obvious organic cause for their symptoms after evaluation. Symptoms may arise from a complex
interaction of increased visceral afferent sensitivity, gastric delayed emptying or impaired
accommodation to food, or psychosocial stressors. Although benign, these symptoms may be
chronic and difficult to treat.
Systemic diseases[edit]
There is a number of systemic diseases that may involve dyspepsia and include coronary
disease, congestive heart failure,diabetes mellitus, hyperparathyroidism, thyroid disease, chronic
renal disease and adrenal fatigue.[13]
Pathophysiology[edit]
Psychosomatic and cognitive factors are important in the evaluation of patients with chronic
dyspepsia. The psychiatric hypothesis holds that the symptoms of dyspepsia maybe due to
depression,increased anxiety,or a somatization disorder. Epidemiologic studies suggest there is
an association between functional dyspepsia and psychological disorders. Symptoms of
neurosis, anxiety, hypochondriasis, and depression are more common in patients being
evaluated for unexplained gastrointestinal complaints than in healthy controls.Comparisons of
functional and organic dyspepsia have demonstrated that patients with functional dyspepsia are
less likely to have decreased stress or anxiety at 1-year follow-up after being reassured of having
no serious disease. This suggests that functional dyspepsia symptoms are long-lasting,
compared with those of organic dyspepsia,and that the emotional ties are strong.[14]
Diagnosis[edit]
People under 55 years without alarm symptoms can be treated without investigation. People over
55 years with recent onset dyspepsia or those with alarm symptoms should be urgently
investigated by upper gastrointestinal endoscopy. This will rule out peptic ulcer disease,
medication-related ulceration, malignancy and other rarer causes.[4]
People under the age of 55 years with no alarm features do not need endoscopy 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.
Treatment[edit]
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 effective for the treatment of
heartburn.
Traditional therapies used for this diagnosis include lifestyle modification, antacids, H2-receptor
antagonists (H2-RAs),prokinetic agents, and antiflatulents. It 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.[15]
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.[15]
The CADET study was the first to compare a PPI (omeprazole 20 mg daily) to both an H2-RA
(ranitidine 150 mg BID) as well as a prokinetic agent (cisapride 20 mg BID) alongside
placebo.[25] 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 = .001) while it was just above the cutoff for being statistically significantly
better than ranitidine (21%) (p = .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 = .01 to .05).
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 < .001).[26][27]
Acotiamide is a new drug approved in Japan in March 2013 for the treatment of meal related
symptoms of functional dyspepsia. It is an acetylcholinesterase inhibitor