Functional dyspepsia
| January 1, 2008
Functional dyspepsia
You're having trouble with your stomach. You feel uncomfortable. It's not heartburn, but it seems to be related to eating. You feel bloated and full or have a burning pain. You complain of nausea, or sometimes you even vomit. You think you might be having "indigestion."
Doctors call it dyspepsia — literally, "bad digestion." The word is derived from the Greek dys, which means bad, and peptein, which means "to cook" or "to digest."
The term functional dyspepsia (FD) is used to describe persistent upper abdominal pain or discomfort that's often related to eating, and for which there is no identifiable cause such as peptic ulcer disease. Because peptic ulcer disease produces similar symptoms, functional dyspepsia is sometimes called nonulcer dyspepsia.
In most cases, the uncomfortable upper abdominal symptoms appear after eating, but there's no difficulty in swallowing. Sometimes the discomfort begins during the meal, sometimes about half an hour later. It tends to come and go in spurts over a period of about three months.
This condition affects about a quarter of the population — twice as many as have peptic ulcer disease — and it hits men and women equally. It's responsible for a significant percentage of visits to primary care doctors. Many people suspect they're suffering from ulcers, but are found not to be. The cause of FD is unknown. Even more frustrating, there's no surefire cure.
The first question on most people's minds is "Do I have an ulcer?" It's not an unreasonable question, considering that 10% of Americans develop a peptic ulcer at some time in their lives. And it's important to answer it quickly. Ulcers can have serious complications, while FD generally does not. Ulcers can be treated with medications, while in most cases medications don't do much to remedy FD.
Peptic ulcers are raw, crater-like breaks in the mucosal lining of the digestive tract. They occur in the stomach and duodenum and are linked to the erosive action of gastric acid and sometimes to a reduction in protective mucus. In essence, the stomach, which is designed to digest foods, is digesting a part of its own lining. These localized, generally circular craters are rarely more than an inch in diameter.
In the early 1980s, researchers made a major discovery. They identified Helicobacter pylori, a spiral bacterium with an affinity for the stomach, as a major culprit in ulcer disease. H. pylori is the cause of many peptic ulcers (see Figure 8). At least 90% of people with duodenal ulcers and 75% to 85% of those with gastric (stomach) ulcers are infected with this organism.
Figure 8: How an ulcer starts
The corkscrew-shaped bacterium Helicobacter pylori attaches to the surface of the stomach by twisting through the mucus that protects the stomach lining from corrosive gastric juices. |
The percentage of ulcers that are not caused by H. pylori has increased; researchers are not yet sure why. Other causes of ulcers include irritating substances such as aspirin, ibuprofen, and other NSAIDs. Cigarette smoking impairs the healing of ulcers, and stress appears to aggravate ulcer symptoms. Studies show there's also a genetic component, as peptic ulcers sometimes run in families. They occur more often in people with type O blood than in those with other blood types. Sometimes there is no known cause.
Is it an ulcer?Aside from dyspepsia, other symptoms that may point to an ulcer, rather than to FD, include: evidence of bleeding, such as passing black stools or vomiting blood or material that resembles coffee grounds repeatedly vomiting large amounts of sour juice and food, which can signal an obstructing ulcer sudden, overwhelming pain — a rare but frightening signal that the ulcer has perforated the stomach or duodenal wall. |
Diagnosing FD
People with functional dyspepsia have the symptoms of an ulcer without the ulcer itself. Both conditions seem to be stress-related and affect people of all ages. In many cases, the symptoms of both respond to treatment with a placebo pill (which contains no active ingredient). In both conditions, pressing on the patient's abdomen may produce tenderness.
Your doctor's goal will be to confirm or exclude the possibility of an ulcer. During a medical exam, your clinician will ask questions about your medical history and about the frequency of the pain, how long it's persisted, and when it's most severe. Discomfort that feels worse on an empty stomach and is relieved by eating suggests a duodenal ulcer, although the diagnosis isn't definitive. Ulcer pain often awakens a person during the night. If this pain is relieved by antacids, H2 blockers, or proton pump inhibitors taken at bedtime, it may indicate an ulcer. Your physician will also address other health habits, such as whether you smoke or drink alcoholic beverages, and will want to know if other family members have ever been diagnosed with an ulcer.
To confirm the presence of an ulcer, the doctor may order an endoscopy or upper GI series. However, some physicians are hesitant to order these tests because in most instances of dyspepsia, results are negative and are unlikely to influence initial treatment strategies. Still, a patient will no doubt take comfort in learning that he or she doesn't have an ulcer.
Do you have functional dyspepsia?The Rome III criteria state that functional dyspepsia must include one or more of the following for the past three months, with symptoms beginning at least six months before diagnosis: bothersome feeling of fullness after eating early feeling of fullness pain in the upper abdomen burning in the upper abdomen and: no evidence of structural disease (including at upper endoscopy) that is likely to explain the symptoms. |
Tests and medication
As a first step toward both diagnosis and treatment, your doctor will probably prescribe one or more drugs that curtail acid secretion (see Table 2) to see if the dyspepsia clears. The doctor may also order a fecal, blood, or breath test to detect the presence of H. pylori bacteria. If the test is positive, the doctor will prescribe antibiotics to eradicate the bacteria. If symptoms have not improved after a few weeks, the next step will probably be endoscopy to check for ulcers (see Figure 9).
People over age 55 (some experts say over age 45) with a new onset of dyspepsia and those with a family history of gastrointestinal cancers should be promptly evaluated for underlying cancer. Prompt evaluation is also needed for patients whose dyspepsia is accompanied by additional worrisome symptoms, such as weight loss, dysphagia (difficulty swallowing), gastrointestinal bleeding, or anemia (low blood count). Only after tests and drug trials fail to pinpoint another cause can the condition be labeled FD.
Figure 9: Upper GI endoscopy
Depending on your symptoms, your doctor may want to look at your esophagus and stomach with an endoscope, a flexible tube with a light and camera at the end. With local anesthesia, you will be asked to lie on your side as the doctor gently slides the scope through your mouth and down your esophagus into the stomach, while watching for lesions on a video monitor. |
Causes of FD
Although there are several theories, no one really knows what causes FD. Many experts don't think that excess gastric acid is to blame. Studies have found no irregularities in acid secretion in dyspeptic patients and no correlation between symptoms and increased acid production. But the theory remains under consideration, as does the possibility that the abdominal pain associated with FD results from acid leaking through the gastric or duodenal mucosa, which has been altered in some way. Some other ideas include:
Visceral hypersensitivity. Many experts believe that patients with FD are more sensitive to pain than people without FD, and that they may have a lower threshold for pain than their healthy counterparts.
Abnormal motility or sensation. The symptoms of FD may reflect abnormal motility — that is, a problem with the movement of the digestive tract.
Stress, anxiety, or other psychological factors. Although scientific data are scarce, psychological stress may be important in the development of some cases.
H. pylori infection. While the role of H. pylori infection as a cause of ulcers and gastritis is well established, its involvement in FD is unclear. H. pylori infection is only slightly more common in people with FD than in the general population. Although the organism may contribute to FD symptoms in some cases, there's currently no way to distinguish these people from those in whom H. pylori does not cause FD. In most cases, eradicating H. pylori with antibiotics doesn't significantly improve FD symptoms.
Duodenitis. Another condition that might produce symptoms of FD is duodenitis, a long-term inflammation of the lining of the duodenum. However, less than 20% of people with FD have this condition.
Diet. Certain fatty foods are often blamed for dyspepsia. This connection makes sense because fat ingestion not only delays gastric emptying but also increases distension of the stomach. Substances like alcohol and coffee may also aggravate symptoms.
Drugs. Nonsteroidal anti-inflammatory drugs (NSAIDs), especially aspirin, can cause dyspepsia, ulcers, and gastritis. Other drugs, such as opiates, iron preparations, and digitalis, may also cause dyspepsia.
Functional dyspepsia: What else could it be?At least some of the distress associated with FD is due to the nagging fear that a more serious condition may be going undetected. This is rarely the case, especially when symptoms persist for months or years without worsening. Fortunately, more serious ailments have characteristics that set them apart from FD (see Figure 10). Gallstones. Stones can dwell silently in the gallbladder or can produce painful attacks, typically after a large, high-fat meal, if the gallbladder contracts and a stone lodges in its neck. The pain is usually located just under the right rib cage and may radiate to the right shoulder or back. Stomach cancer. Malignancies of the stomach generally occur later in life, after age 50. Tumors that burrow into the stomach wall often produce symptoms that resemble those associated with ulcers. Eating a full meal can become impossible if growths extrude into the hollow of the organ or spread through the stomach wall, making it too stiff to expand. Warning signs include bleeding, persistent vomiting, a constant sense of nausea or fullness that interferes with normal eating, and weight loss. Stomach cancer usually requires the surgical removal of all or part of the stomach. Figure 10: Other causes of pain
Other conditions that have symptoms similar to functional dyspepsia include gallstones, which can block the neck of the gallbladder, causing painful inflammation, or cancer of the lining of the stomach, which can create a sensation of painful bloating. |
Treating FD
No truly effective drug exists to treat FD. Many patients respond no better to drugs than to placebo. It is noteworthy, however, that in almost all clinical trials, 25% to 60% of patients respond to medications, and therefore doctors often recommend them, including over-the-counter antacids and Prilosec.
Herbal remedies may also be worth a try. In several clinical trials, a combination of enteric-coated peppermint oil and caraway oil successfully reduced fullness, bloating, and gastrointestinal spasms in patients with functional dyspepsia. Enteric-coated means that the preparation is able to pass through the stomach and won't dissolve until it reaches the small intestine.) Be aware, however, that peppermint oil may trigger reflux in people who are predisposed to it.
Doctors may recommend other medications. Anticholinergic medications that decrease contractions in the GI tract, such as hyoscyamine (Levsin), may be used for up to four to six weeks. Simethicone, which rids the gut of gas bubbles, is safe and may help if you have both dyspepsia and flatulence. Finally, the doctor may prescribe a low dose of a tricyclic antidepressant such as amitriptyline (Elavil, Endep). Some studies have founds that tricyclics improve symptoms.
Emerging treatments. Itopride, a dopamine D2 antagonist that is widely prescribed in Japan for patients with functional dyspepsia, is a prokinetic drug that stimulates gastric motility and may also affect gastric accommodation and hypersensitivity. In a 2006 study in The New England Journal of Medicine, itopride significantly improved FD symptoms.
Drug developers are also looking into medications that can help the stomach distend normally during a meal, so that more food can be ingested before a feeling of uncomfortable fullness sets in. One area of interest is a class of drugs that includes sumatriptan (Imitrex), a drug marketed for migraine headaches, and buspirone (Buspar), a drug used for anxiety.
In addition, studies looking at the effects of selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) on functional dyspepsia are under way.
Lifestyle modifications for FDBody position, diet, exercise habits, and more can help. Make good eating choices Avoid foods that trigger symptoms. Eat small portions and avoid overeating. Eat smaller, more frequent meals. Chew your food slowly and completely. Avoid activities that result in swallowing excess air, such as smoking, eating quickly, chewing gum, and drinking carbonated beverages. Don't lie down within two hours of eating. Keep your weight under control. Reduce stress Use stress reduction techniques, including relaxation therapies, cognitive behavioral therapy, or exercise. Reduce fatigue Get enough rest. Go to bed and get up at the same times each day. Avoid caffeine after noon. Exercise Perform aerobic exercise three to five times a week for 20 to 40 minutes per session. Don't exercise immediately after eating. |
Review Date: 2008-01-01
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