CURICULUM VITAE

Nama : Titong Sugihartono, dr.,SpPD.,KGEH

Jabatan : Staf Divisi Gastroenterologi & Hepatologi
Departemen/SMF Ilmu Penyakit Dalam
FK Unair / RSU Dr. Soetomo Surabaya
TTL : Surabaya, 27 04 1963
Riwayat Pendidikan :
SD : SD Karanggayam II Surabaya (1977)
SMP : SMP Negeri I Surabaya (1979)
SMA : SMA Negeri 2 Surabaya (1982)
Dokter : Fakultas Kedokteran Unair (1988)
Spesialis : FK Unair RSUD Dr. Soetomo (2001)
Course : Digestive Disease Center
Showa University, Northern Yokohama Hospital
Konsultan : FK Unair RSUD Dr. Soetomo (2010)
DYSPEPSIA

Titong Sugihartono

SYMPOSIUM SWEIM 2017

Hotel Bumi Surabaya, 15 Oktober 2017
Overview
- Introduction
- Epidemiology
- Definition
- Differential diagnosis
- Management
- Diet Modification
- Possible complication
 DYSPEPSIA
Important problem

A common disorder with

a negative impact on patients quality of life

QUALITY OF LIFE WITH DYSPEPSIA
Personality profiles are similar to people with other pain syndrome,
both organic, and functional in nature
Higher score on measures of anxiety, neuroticisms, depression and
hypochondriasis compared with healthy controls.
Quality of life patients with GORD has been shown to be similar to
that of people with severe angina pectoris
Quality of life score improve with improvement of dyspepsia,
suggesting that anxiety and stress-related symptoms may be the
results of dyspepsia rather than it cause

Richter JE. Stress and psychologic and environmental factor in functional dyspepsia. Scand J gstroenterol 1991;26(supp 182):40-6
Talley NJ, Weaver AL, Zinsmeiser AR. Impact of functional dyspepsia on quality of life. Dig Dis Sci 1995; 40:584-9
Meineche-Schimdt V, et al. Impact functional dyspepsia on quality of life and health care consumption after cessation of antisecretory treatment.
Scand J gasatroenterol 1999;34:566-74
Kaplan-Machlis B. Health-related quality of life in primary care patients with gastroesophageal reflux disease. Ann Pharmacother
1999;33(10):1032-6
PGWB = psychological general well being index
Jones RH. Gut 2002;50:iv42-iv46
 EPIDEMIOLOGY
Prevalence : 25-40 % population
50% self medicate
25% consult their G.P.
5% of G.P. consultations are for dyspepsia
OTC indigestion remedies sold for $100M in 2002
 DEFINITION
Dyspepsia used to be broadly defined as
any upper abdominal symptoms
Use restricted to increase specificity
Dyspepsia is limited by Rome III to :
epigastric pain (or burning), or
meal-related symptoms

Tack J, Talley NJ. AM J Gastroenterol. 2010; 105:757-63

Lacy B eet al. Am J Gastroenterol. 2010;105:2525-9
 Dyspepsia

Not a diagnosis

Symptoms may be episodic, recurrent or chronic

It is a symptom complex associated with:

Upper gastrointestinal tract conditions (eg, peptic ulcer

or gastric cancer)

Upper abdominal pathology (eg, gallstones)

Disorders related to other system (eg, cardiovascular)

 Symptoms
The main symptoms:
Retrosternal or epigastric pain
Fullness
Bloating
Heartburn
Anorexia
Nausea and vomiting
Pain can vary from mild to severe, and may often resolve
itself without medication
DYSPEPSIA SUB-GROUPS
Reflux like Heartburn acid regurgitation
Ulcers like Upper abdominal pain predominant with three or more of :
Epigastric pain or discomfort

Pain relieved by food

Pain relieved by antacids or ulcer-reducing drugs

Pain occurring before meals or when hungry

Pain that at times wakens the person from sleep

Periodic pain with remission and relapse

Dysmotility like Upper abdominal discomfort characterized by three or more of:

Early satiety

Postprandial fullness

Nausea

Retching and/or vomiting

Bloating in upper abdomen not accompanied by visible distention

Upper abdominal discomfort often aggravated by food

Unspecified Dyspepsia that cannot be classified into the other groups

(non-specific)
Overlap of subgroup of dyspepsia
based on symptoms
Ulcer-like
1% Dysmotility-like

17%
9%
3%
18% 9%

27%
16%

Symptomatic gastro-esophageal Non-specific

reflux disease (reflux-like)

Talley NJ, Phung N, Kalantar JS. ABC of the upper gastrointestingal tract:
Indigestion: When is it functional? BMJ 323:2001; 1294-1297
 Classification

Functional dyspepsia (60%)

Secondary dyspepsia
 Rome Criteria
Rome III Criteria for Functional Bowel
Disorders Associated with Abdominal Pain
or Discomfort in Children and Adolescents
Functional Dyspepsia
Irritable Bowel Syndrome
Childhood Functional Abdominal Pain and
Syndrome
 Functional Dyspepsia
A. Persistent/recurrent pain centered in upper
abdomen, above umbilicus
B. Pain not relieved by defecation, or assoc. w.
onset of change in stool frequency or stool
form (i.e., NOT IBS).
C. No evidence of inflammatory, anatomic,
neoplastic process to explain symptoms
DIFFERENTIAL DIAGNOSIS
Upper Gastrointestinal Tract
Reflux oesophagitis 12%
Duodenal ulcer 10%
Gastric ulcer 6%
Gastric carcinoma 1%
Oesophageal carcinoma 0.5%

Non-erosive GORD
Functional (non-ulcer) dyspepsia
 Causes of Dyspepsia
Drugs
NSAIDs Corticosteroids
COX-2 selective inhibitors Niacin
Calcium channel blockers Gemfibrozil
Methylxanthines Narcotics
Alendronate Colchicine
Orlistat Quinidine
Potassium supplements Estrogens
Certain antibiotics including Levodopa
erythromycin Acarbose
 Causes of Dyspepsia
Others
Biliary pain Hepatoma
Chronic abdominal wall pain Ischemic bowel disease
Gastroparesis Systemic disorders
Pancreatitis Intestinal parasites
Carbohydrate malabsorption Abdominal cancer
Infiltrative diseases of the Celiac disease
stomach steatohepatitis
Metabolic disturbances
CLINICAL APROACH
 Initial Evaluation

History
Physical Examination
Laboratory Evaluation
 First Approach to Dyspepsia
Consider possible causes outside upper GI tract
- Heart, lung, liver, gall bladder, pancreas,
bowel

Consider drugs and stop if possible

- Aspirin / NSAIDs, calcium antagonists,
nitrates, theophyllines, biphosphonate,
steroids
Clinical Management Tool
5 key steps
Are symptoms Upper GI?
Alarm symptoms
On NSAIDs or aspirin
Dominant heartburn
Do non-invasive Hp-test

Can Med Assoc J 2000; 162(S12)53-23

 Alarm Symptoms
GI bleeding (same day referral)
Persistent vomiting
Weight loss (progressive unintentional)
Dysphagia
Epigastric mass
Anaemia due to possible GI blood loss
Thus all patients with new-onset dyspepsia should
have abdominal examination and FBC
Features increase the likehood significant
organic disese:
Family history of gastric cancer (onset age < 50 yaers)
Severe or persistent dyspeptic symptoms
Previous peptic ulcer disease, particularly if complicated
Ingestion of NSAIDs, particularly in those at risk
Unexplained weight loss
GI bleeding
Anemia
Dysphagia
Coughing spell or nocturnal aspiration
Protracted vomiting
Palpable abdominal mass
 Initial Management
Dyspeptic
symptoms

Heartburn and/or NSAID/ Cox-2 Dyspepsia without obvious

regurgitation are presenting inhibitor use GERD or NSAID use
complaint, predominant or
frequent

Manage as GERD Consider discontinuing See Figure

(acid suppression) NSAID, switching to another later
agent or adding PPI
Management of dyspepsia based
on age and alarms features

Dyspepsia without GERD

or NSAIDs

Age > 55 or Age < 55 or

Alarm symptoms present No alarm symptoms

Esophago- Test for H pylori

gastro-
duodenoscopy
 Clinical evaluation:
Determine reason for presentation
History and physical examination

If patients has:
Consider: If patient has:
Age > 45 - 55 years
Dietary indiscretion Age < 45 55 years
Alarm features:
Medical induced and
Unexplained weight loss No alarm features
Cardiac disease
Bleeding/ anemia or
Condition associate with
Dysphagia Chronic, mild symptoms
gastroparesis
Protracted vomiting or
Hepatobilliary disoders
Change in character of chronic symptoms Prior full evaluation
Other systemic disease
Fear of cancer or organic disease

Endoscopy with biopsy for

Helicobacter pylori

Functional Organic disease:

dyspepsia PUD, GERD, cancer Treat as indicated

Reassurance
Life style changes
Treat H.pylori, if present
Trial of PPI for 4-8 weeks,
especially if heartburn
Consider IBS (altered bowel habits,
abdominal pain)
Symptoms persist
Reconsider: is diagnosis correct ?
Consider: gastroparesis
Consider: depression, psychosocial issue
Trial of antidepressants
Trial of prokinetics
Refractory disabling symptoms:
Consider high-dose PPI trial
Psychological therapies
Hypnotherapy
Referral to functional
disorder program
 Dyspepsia in patients
< 45 55 years

Alarm features: YES

Family history or ethnic
risk of GI cancer
Excessive worry
Empirical therapy NO
Non-invasive Hp test
UBT
Fecal antigen test
Serology

H.pylori negative:
H.pylori positive: Reassurance
Eradication therapy Lifestyle changes

Symptoms persist:
PPI trial for 4-8 weeks
Improvement No Improvement
Stop PPI EGD with biopsy
for H.pylori
If symptoms relapse Organic disease
Intermittent or Functional dyspepsia GERD
continuous PPI if Hp test still (+), PUD
Consider EGD treat with 2nd line regimen Cancer
 Refer if dyspepsia in 55+* year old

Alarm symptoms/signs (2 week referral)

Unexplained and persistent recent-onset

dyspepsia without alarm symptoms
Unexplained means no cause known
Persistent implies present for a length of time (NICE
suggest 4-6 weeks)
Recent-onset implies new-not a recurrent episode
 Flowchart of referral criteria:
Immediate referral is indicated for significant acute gastrointestinal
bleeding- same day.

Urgent endoscopic investigation: (Red Flags) within 2 weeks :

chronic gastrointestinal bleeding, progressive unintentional weight
loss, progressive difficulty swallowing, persistent vomiting, iron
deficiency anemia, epigastric mass or suspicious barium meal

Routine endoscopic investigation (up to 2 month) of patients of

any age, presenting with dyspepsia and without alarm signs, is not
necessary.

Urgent referral for endoscopy should be made in patients aged 55

years and older with unexplained and persistent recent-onset
dyspepsia alone
MANAGEMENT
 Management of simple dyspepsia
in those aged < 55 years
Stress benign nature of dyspepsia

Lifestyle advice
Healthy eating
Weight reduction
Stop smoking
Use of antacids
 Diet Modifications
Consume smaller meals with reduced fat contents
(Clinical Gastroenterology and Hepatology 2009;7:317-322)

Eating speed affects dyspepsia (Gut and Liver 2010; 4(2):173-78)

Some foods, especially spicy, pickled, and high-fat foods,
strongly induced dyspepsia and aggravated the symptoms in
dyspeptic patients (Middle East Journal of Digestive Disease 2015;7(1): 19-24)
GERD and functional dyspepsia : may be associated with
the consumption of canned food, fast food, and alcoholic
beverages (Turk J Gastroenterol 2016; 27: 73-80)
 SUMMARY
Dyspepsia is a common symptom complex, defined as pain or
discomfort in the upper abdomen
Symptoms may be episodic, recurrent or chronic
Dyspepsia is not a diagnosis.
Symptoms can associate with upper gastrointestinal (GI) tract
conditions, other upper abdominal pathology, or disorders related to
other system
Management depend on functional or secondary dyspepsia
Functional dyspepsia : healthy life style, positive diagnosis, reassure,
manage stress, pharmacotheraphy, psychological treatment