Dyspepsia

Agung F. Sumantri, dr, SpPD Departemen Penyakit Dalam FK UNISBA

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Key words Functional dyspepsia Rome III Criteria proton pump inhibitors prokinetics, endoscopy antidepressants.
Dyspepsia is a nonspecific term used to describe upper abdominal discomfort caused by disorders of the upper digestive tract.

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Rome III
They consist of one or more of the following symptoms : a. Bothersome postprandial fullness b. Early satiation c. Epigastric pain d. Epigastric burning

AND
No evidence of structural disease (including at upper endoscopy) that is likely to explain the symptoms. Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis

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dyspepsia
structural abnormality (40%) : - peptic ulcer (25%) - reflux esophagitis - gastric cancer - biliary and pancreatic disorders
Functional (60%)
- POSTPRANDIAL DISTRESS SYNDROME - EPIGASTRIC PAIN SYNDROME

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Patients in whom heartburn is the main symptom are not considered to have functional dyspepsia since in all likelihood their diagnosis is gastroesophageal reflux disease.

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

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following possible mechanisms :

Helicobacter pylori epigastric pain Postprandial fullness, nausea, vomiting delayed gastric emptying Early satiety, weight loss impaired accommodation Bloating, absence of nausea unsuppressed phasic contractility Nausea duodenal acid and lipid hypersensitivity

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Alarm symptoms : Age > 50 yrs Family history of digestive malignancy Involuntary weight loss Gastrointestinal bleeding of feriprive anemia Progressive dysphagia Odinophagia Recurrent vomiting Palpable tumor or adenopathy Icterus

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GERD
(Gastro-Esophageal Reflux Disease)

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Definition : Symptoms or mucosal damage produced by the abnormal reflux of gastric contents into the esophagus
Cardinal symptoms : Heartburn & regurgitation& dysphagia AS : chest pain, water brash (Hypersalivation), globus sensation, odynophagia (Esophageal ulcer), nausea
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Diferential diagnosis Another esophagitis (Inf, eosinophilic) Peptic ulcer CAD Esophageal motor disorder

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Who gets reflux disease?

*Inherited and acquired factors both contribute to the development of GERD. *The prevalence of reflux symptoms is high in the parents of affected people, and in identical twin pairs than it is in non-identical twin pairs. *Genetic factors contribute 18-31% to the cause of GERD. *Lifestyle factors. Smokers are more likely to have reflux symptoms. *Obesity is also associated with GERD; Moreover obese people tend to eat larger meals and choose rich, energy dense foods , dietary factors that increase the risk of reflux.
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In contrast, although patients often think that coffee, chocolate, and alcohol can trigger symptoms, firm evidence linking specific foods with GERD is lacking.
*Advice on lifestyle, such as stopping smoking, losing weight, and avoiding large, late meals can reduce the frequency and severity of reflux symptoms, although it is rare for these measures to remove the need for acid suppression.

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Why does reflux occur?

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Why does reflux occur?

*Everybody experiences gastro-oesophageal reflux at some time. *In health, reflux of air (belching) occurs during transient relaxations of the lower oesophageal sphincter triggered by gastric distension (bloating). Small volumes of ingested food and gastric acid may pass into the oesophagus during such episodes. *But GERD is present only when the reflux of gastric contents causes frequent, severe symptoms or mucosal damage

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Dignostic tools Esophagoscopy Ambulatory esophageal PH monitoring Esophageal manometry Bernstein test Hystology Radiography vs endoscopy

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Endoscopic findings in GERD

NERD. 65%

ERD 25%

Barrett's Esoph. 10%

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Classification Savary-Miller classification Grade I exhibits one or more supravestibular, non-confluent reddish spots, with or without exudate Grade II demonstrates erosive and exudative lesions in the distal esophagus that may be confluent, but not circumferential Grade III is characterized by circumferential erosions in the distal esophagus, covered by hemorrhagic and pseudomembranous exudate Grade IV is defined by the presence of chronic complications such as deep ulcers, stenosis, or scarring with Barrett's metaplasia

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Los Angeles classification Grade A one or more mucosal breaks each 5 mm in length Grade B at least one mucosal break >5 mm long, but not continuous between the tops of adjacent mucosal folds Grade C at least one mucosal break that is continuous between the tops of adjacent mucosal folds, but which is not circumferential Grade D mucosal break that involves at least three-fourths of the luminal circumference

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Extraesophageal disorders in GERD

Extraesophageal manifestations of gastroesophageal reflux disorder (GERD) are frequent, and consist broadly of
Noncardiac chest pain pulmonary diseases
Asthma chronic cough recurrent bronchitis sleep apnea pulmonary fibrosis Laryngitis subglottic stenosis laryngeal cancer Sinusitis Otitis media Pharyngitis dental erosion

laryngeal diseases

other ENT (ear, nose, throat) disorders

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Noncardiac chest pain is associated with GERD

Among patients with angina-like chest pain

30% will have normal coronary arteries; of these, 40% to 50% have objective evidence of GERD by endoscopy or ambulatory pH monitoring

Prevalence of GERD symptoms is 23% to 100% Esophagitis is seen in 0% to 47% Abnormal ambulatory pH recordings noted in 20% to 63% Empiric trial of PPI
78% sensitivity and 86% specificity , for diagnosing GERD association with noncardiac chest pain.

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Diagnosis
The majority of patients with extraesophageal manifestations of GERD do not have the classic symptoms of heartburn or regurgitation less than 30% have endoscopic evidence of reflux esophagitis Twenty-four-hour pH monitoring has been commonly used to look for evidence of acid reflux into the lower esophagus, upper esophagus, and pharynx. However, this test is not comfortable for most patients

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Mempertahankan pH >4 adalah penting untuk penatalaksanaan GERD

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pH > 4 memegang peranan penting dalam aktivitas pepsin

Aktivitas maksimum pepsin (%)

100 80 60 40 20 0 1 2 3 4 pH asam lambung Page 32

Berstad A. Scand J Gastroenterol 1970;5:343-8

Lama mempertahankan pH >4 berbanding lurus dengan angka kesembuhan pasien GERD
Pasien sembuh setelah 8 minggu (%)
100

80

60

40

20

0 10 12 14 16 18 Lama pH lambung >4 ( jam) Joelson & Johnson. GUT 1989; 30:1523-1525 Bell et al. Digestion 1992;51 Suppl1:59-67 2 4 6 8 20 22

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Efikasi pengontrolan asam lambung pada pH > 4

antar PPI berbeda
Data hari ke-5, penelitian five-way crossover pada pasien GERD

esomeprazole 40 mg sekali sehari rabeprazole 20 mg sekali sehari omeprazole 20 mg sekali sehari 13,3

15,3 ** *

12,9

n=34 *** p=0,0004 vs rabeprazole; p<0,0001 vs lansoprazole, omeprazole dan pantoprazole

lansoprazole 30 mg sekali sehari

pantoprazole 40 mg sekali sehari 0 5 10

12,7

11,2 15 20

Lama pH lambung >4 (jam) Miner P et al. Am J Gastroenterol 2006;101:404406

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Esomeprazole mengatasi gejala lebih cepat dibandingkan PPI oral lainnya

Kahrilas et al.1 n=1304

5 hari

p < 0,05

9 hari

Esomeprazole 40 mg sekali sehari omeprazole 20 mg sekali sehari

Castell et al.2 n=5241

7 hari

p 0,01

8 hari

lansoprazole 30 mg sekali sehari pantoprazole 40 mg sekali sehari

Labenz et al.3 n=3151

6 hari

p < 0,001

8 hari
0 1 2 3 4 5 6 7 8 9 Lama pasien mengalami sustained symptom resolution* hari

*Sustained

symptom resolution: Pasien bebas heartburn selama 7 hari berturut-turut

Kahrilas PJ, et al. Aliment Pharmacol Ther 2000;14:12491258, 2 Castell, et al. Am J Gastroenterol 2002;97(2):575 583, 3 Labenz, et al. Aliment Pharmacol Ther 2005;21:739746
1

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Coclusions
Gastroesophageal reflux is extremely common and may manifest with typical and atypical symptoms. At present it is extremely difficult to establish a definite diagnosis of extraesophageal GERD. Typical esophageal symptoms (heartburn, regurgitation) may be absent in a large number of patients.

Neither the type of ENT symptoms nor the ENT findings are of predictive value in determining underlying GERD.

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Conclusions
Although interesting new modalities for reflux testing are available (capsule pH monitoring, impedance testing) it remains to be seen whether these modalities improve diagnostic accuracy Currently, the most cost-effective approach for most patients with suspected reflux-related symptoms is a trial of a high-dose protonpump inhibitor for 3 months. pH testing reserved to confirm adequate acid suppression in those with refractory symptoms. Although improvement in cough symptoms may be evident within 2 weeks of treatment, improvement in other ENT disorders may require 3 or more months of therapy.

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