Dyspepsia and functional dyspepsia

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Chapter 4 DYSPEPSIA AND FUNCTIONAL DYSPEPSIA

KEY POINTS

• Dyspepsia is defined as pain or discomfort located in the central upper abdomen.
• Dyspepsia may coexist with and be difficult to differentiate from gastro-oesophageal reflux disease.
• The most common cause of organic dyspepsia is reflux oesophagitis, followed by peptic ulcer disease.
• Functional dyspepsia accounts for over 60% of all dyspepsia.
• If identified, all cases of Helicobacter pylori in patients with dyspepsia should be treated.

DEFINITIONS

The definition of dyspepsia is controversial, with some authorities including reflux symptoms whereas others do not. An international committee of clinical investigators that meets in Rome have routinely excluded reflux symptoms.

Dyspepsia has historically been defined as pain or discomfort located in the upper abdomen (mainly in or around the midline as opposed to the right or left hypochondrium). Discomfort may include bloating, fullness, early satiety, postprandial fullness or nausea. Dyspepsia may be either organic, implying an organic, systemic or metabolic disease has been identified as the cause, or functional, where there is no identifiable explanation for the symptoms. Functional dyspepsia is also known as idiopathic or non-ulcer dyspepsia.

The Rome III committee has redefined functional dyspepsia and limited the term to refer to the four following symptoms: bothersome post-prandial fullness, early satiation, epigastric pain, or epigastric burning. The remaining symptoms of discomfort listed above have been allocated clinical entities of their own, and together they comprise the functional gastroduodenal disorders (Table 4.1). In addition, as shown in Table 4.2, there are two new diagnostic categories within functional dyspepsia; namely postprandial distress syndrome (PDS) and epigastric pain syndrome (EPS).

TABLE 4.1 Functional gastroduodenal disorders

• Functional dyspepsia

– Postprandial distress syndrome
– Epigastric pain syndrome

• Belching disorders

– Aerophagia
– Unspecified excessive belching

• Nausea and vomiting disorders

– Chronic idiopathic nausea
– Functional vomiting
– Cyclic vomiting syndrome

• Rumination syndrome in adults

TABLE 4.2 Subtypes of functional dyspepsia

Diagnostic criteria*for postprandial distress syndrome
Must include one or both of the following:
1. Bothersome postprandial fullness, occurring after ordinary sized meals, at least several times per week
2. Early satiation that prevents finishing a regular meal, at least several times per week
Supportive criteria
1. Upper abdominal bloating or postprandial nausea or excessive belching can be present
2. Epigastric pain syndrome may coexist
Diagnostic criteria*for epigastric pain syndrome
Must include all of the following:
1. Pain or burning localised to the epigastrium of at least moderate severity at least once per week
2. The pain is intermittent
3. Not generalised or localised to other abdominal or chest regions
4. Not relieved by defecation or passage of flatus
5. Not fulfilling criteria for gall bladder and sphincter of Oddi disorders
Supportive criteria
1. The pain may be of a burning quality but without a retrosternal component
2. The pain is commonly induced or relieved by ingestion of a meal but may occur while fasting
3. Postprandial distress syndrome may coexist

* Criteria fulfilled for the last 3 months with symptom onset at least 6 months before diagnosis

There is some overlap between symptoms of gastro-oesophageal reflux disease (GORD) and dyspepsia. Heartburn is traditionally excluded from the Rome II and III criteria for dyspepsia, although in Rome III a burning sensation confined to the epigastrium is not considered to be heartburn unless it also radiates retrosternally. Despite the exclusion of heartburn, reflux oesophagitis is the most common structural finding when patients with dyspepsia are evaluated by upper endoscopy in Western nations. Heartburn more than twice weekly strongly suggests GORD in favour of dyspepsia.

Uninvestigated dyspepsia refers to new onset or recurrent dyspepsia for which no diagnostic investigations have yet been performed and subsequently a specific diagnosis has not been reached. This has implications for both diagnostic and management pathways.

EPIDEMIOLOGY

The prevalence of dyspepsia in the Western society is approximately 25%, although the true prevalence depends on the population being studied. The annual incidence is cited between 1% and 10%. As similar numbers of patients experience resolution of their symptoms, fairly constant prevalence rates occur. Women suffer marginally more than men and symptoms tend to improve slightly with age.

CAUSES

Organic

Organic causes of dyspepsia are many and varied as outlined in Table 4.3, but the majority of cases are due to peptic ulcer disease, gastro-oesophageal reflux and malignancy.

TABLE 4.3

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