Am Fam Physician. 2009 Feb 1;79(3).
Case Study: Mrs. C. is experiencing symptoms of pressure and pain in her stomach. They are present every day and worsen after eating, leaving her feeling full and queasy. She complains of having the urge to vomit, but she does not. She no longer eats out with friends because she feels nausea and pain afterward. The pressure also limits her ability to exercise. Sometimes, Mrs. C. will eat certain foods that later make her feel sick; however, the next day she will eat the same foods and feel fine. The symptoms do not improve with heartburn medication or any of the other medications she is taking. Evaluation initially included a normal physical examination, with the exception of mild epigastric tenderness to palpation. Her laboratory tests were normal, except for Helicobacter pylori testing, for which she was treated. Despite treatment, Mrs. C's symptoms persisted. She ultimately had a normal endoscopy, and was diagnosed with functional dyspepsia.
Background: The estimated prevalence of functional dyspepsia is 15 to 30 percent in developed countries, although the incidence of functional dyspepsia is difficult to estimate. One study estimated an incidence of less than 1 percent over three months. The estimated evaluation and treatment costs of functional dyspepsia result in an economic burden of almost $1 billion per year, making it a significant public health concern.
Functional dyspepsia is a diagnosis of exclusion. Symptoms must be present for at least six months, and must include one of the following: early satiety, epigastric burning, and postprandial fullness. Two variants of functional dyspepsia are postprandial distress syndrome and epigastric pain syndrome. Functional dyspepsia does not affect mortality, but significantly reduces quality of life. Pathophysiologic mechanisms are believed to include motor function disturbances and heightened visceral sensation. There may be a genetic component contributing to functional dyspepsia, as well as an association with acute gastrointestinal infection and psychogenic factors.
Recommendations: The work-up of functional dyspepsia includes a complete blood count to rule out anemia. Other laboratory tests should be targeted to symptoms. H. pylori testing is recommended, whereas endoscopy should be reserved for patients older than 55 years with alarm symptoms (i.e., dysphagia, recurrent vomiting, unexplained weight loss, gastrointestinal bleeding, anemia, jaundice, palpable mass, and ascites), or those who fail medical therapy with H. pylori eradication or antisecretory agents.
Treatment of functional dyspepsia is nonpharmacologic and pharmacologic. Nonpharmacologic approaches include dietary modification, such as limiting dietary fat, avoiding meals too late in the day, and eating smaller meals. Patients should avoid specific foods if they correlate with symptoms. There are few trials on psychological treatment and hypnotherapy, but these can be recommended as adjuncts to conventional treatment.
Pharmacologic treatments may be beneficial. There may be a small positive impact on symptoms with H. pylori eradication (number needed to treat = 14), but this should be initiated only with proven infection. Although study results are inconsistent, proton pump inhibitors should be tried in patients not infected with H. pylori or in patients not responding to H. pylori eradication, especially those with reflux-predominant symptoms.
Prokinetic agents may be tried, but larger studies showed no benefit compared with placebo. The use of metoclopramide (Reglan) is questionable because it causes sedation, and domperidone (Motilium) is not available in the United States. Other mixed or partial 5-hydroxytryptamine 4 (5-HT4) agonists have been withdrawn from the U.S. market because of adverse cardiac effects.
Antidepressants were shown to be of benefit in one systematic review. Selective serotonin reuptake inhibitors have not been studied, but tricyclics are thought to have beneficial impact on symptoms through their anticholinergic effect. Doses required for functional dyspepsia are lower than those for depression. Symptom improvement was found at four and eight weeks with one herbal agent, Iberogast.
Lacy BE, Cash BD. A 32-year-old woman with chronic abdominal pain. JAMA. February 6, 2008;299(5):555-565.
Copyright © 2009 by the American Academy of Family Physicians.
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