1. Functional Dyspepsia Norbert Welkovics Heine van der Walt

2. Definition • Characteristics: • Central abdomen • Pain or discomfort • Not associated with bowel movements • No structural or biochemical abnormalty • Part of Gastroduodenal disorders (Rome II)

3. Fx Gastro-intstinal disordersRome II (1999) A. Esophagial disordersE.Billiary disorders A1. GlobusE1. Gallbladder dysfunction A2. Rumination SyndromeE2. Sphincter of Odi dysfunction A3. Functional chest pain of presumed oesophageal origin A4. Functional heartburn A5. Functional dysphagia A6. Unspecified oesophageal disorder B.Gastroduodenal disordersF.Anorectal disorders B1. Functional dyspepsiaF1. Functional faecal incontinence B1a. Ulcer like dyspepsiaF2. Functional anorectal pain B1b. Dysmotility like dyspepsiaF2a. Levator ani syndrome B1c. Non-specific dyspepsia F2b. Proctalgia fugax B2. Aerophagia B3. Functional vomiting C.Bowel disorders C1. Irritable bowel syndrome C2. Functional abdominal bloating C3. Functional constipation C4. Functional diarrhoea C5. Unspecified functional bowel disorder D.Functional abdominal pain D1. Functional abdominal pain syndrome D2. Unspecified functional abdominal pain

4. Classification • Organic dyspepsia • PUD, GERD, Pancreatico-billiry disease • Functional dyspepsia • Ulcer-like dyspepsiea • Pain • Dysmotility-like dyspepsia • Discomort; nausea, vomiting, postprandial fullness and upper abdominal bloating • Reflux-like dyspepsia • Heartburn but not the predominant symptom

5. Epidemiology • Common complaint (15 – 25%) • On upper GIT endoscopy: • Peptic ulcer disease 22% • Esophagitis 10% • Cancer 1% • Functional dyspepsia 67% • Comparable to asymptomatics

6. Aetiology • Cause and effect difficult to establish 1. Symptoms experienced are intermittent and changing 2. High placebo response rate (30%) 3. No specific findings in all patients present 4. Findings present in asymptomatic patients as well 5. Symptoms and findings often do not correlate 6. There is no universal effective treatment 7. The response to treatment is difficult to predict

7. Ulcer-like Dyspepsia Helicobacter pylori Gastritis / Duodenitis Missed PUD Acid sensitivity Occult GERD Dysmotility-like Dyspepsia Gastroparesis Abnormal relaxation Visceral hypersensitivity Brain-gut disorder Psychological disorder Aetiology Postulates

8. Aetiology Helicobacter pylori • Controversial: • Background infection rates increase with age • H.pylori gastritis equal in asymptomatics • Possible CagA+ strain • For treatment • WHO declared HP carcinogen • Response to treatment 20% at 1 year

9. Aetiology Helicobacter pylori • Against treatment • Response to PPI not to antibiotics • Low background infection rate in 1st world countries • MAASTRICHT CONSENSUS • Test and treat approach in uninvestigated dyspepsia in • patients younger than 45 in the absence of: • Alarm symptoms • NSAID use • Predominant reflux symptoms • Family history of gastric carcinoma

10. Aetiology Gastritis • NSAID gastropathy and functional dyspepsia can occur simultaniously • Stop NSAID • If symptoms don’t improve, treat as functional dyspepsia

11. Aetiology Duodenitis • Presence of past PUD diagnosis • Manage as PUD even if endoscopy normal • Missed PUD? • Absence of past history • Treat as functional dyspepsia

12. Aetiology Acid sensitivity • Normal acid secretion • Acid sensitivity increased • 20% incidence in functional dyspepsia • Decreased acid clearance by duodenum • ? H2 treatment response • 20% above placebo rate

13. Aetiology Occult GERD • Reflux s a normal phenominon • High positive predictive value • If dominant symptom = GERD • Might form part of functional dyspepsia