Special reports and reviewsPathophysiology and treatment of functional dyspepsia
Section snippets
The dyspepsia symptom complex
The symptom complex includes epigastric pain, bloating, early satiety, fullness, epigastric burning, belching, nausea, and vomiting. Although often chronic, the symptoms in functional dyspepsia are frequently intermittent, even during a period with marked symptoms. 6 In patients with functional dyspepsia seen at a tertiary referral center, the most prevalent symptoms were postprandial fullness and bloating, followed by epigastric pain, early satiety, nausea, and belching. 7, 8, 9, 10, 11
Pathophysiologic mechanisms and their relation to symptom pattern
Several pathophysiologic mechanisms have been suggested to underlie dyspeptic symptoms. These include delayed gastric emptying, impaired gastric accommodation to a meal, hypersensitivity to gastric distention, H. pylori infection, altered response to duodenal lipids or acid, abnormal duodenojejunal motility, or central nervous system dysfunction (Figure 2). At present, the pathophysiology of functional dyspepsia is only partially elucidated. However, there is growing evidence that functional
Relevance of putative pathophysiologic mechanisms to symptom generation
Although several pathophysiologic abnormalities are related to the dyspepsia symptom pattern and severity, as summarized in the previous section, this does not establish causality. It is conceivable that both simply coexist or that both depend on a presently unspecified causal mechanism. A close correlation between presence and severity of a certain pathophysiologic abnormality and presence and severity of certain symptoms adds strength to the association between both. A very strong case is
Pathogenesis
The pathogenesis of functional dyspepsia is obscure, but a postinfectious or inflammatory origin has been suggested for irritable bowel syndrome.103 Moreover, gastroparesis has been reported after a viral infection.104 Using a questionnaire in 400 consecutive patients with functional dyspepsia, we found that 17% had a history with acute onset, suggestive of a postinfectious origin.10 These patients had a particularly high prevalence of impaired accommodation. Because the proximal stomach in
Clinical presentation and diagnosis
Patients with predominant heartburn or acid regurgitation should, according to the Rome II criteria, not be included in the dyspeptic spectrum but should be referred to as having gastroesophageal reflux disease because the management differs substantially.5 It has been proposed that a substantial number of patients with predominant discomfort or pain centered in the upper abdomen actually have atypical reflux disease.109 However, by using a simple questionnaire to screen for reflux symptoms,110
General measures
Reassurance and education is of primary importance in patients with functional dyspepsia. It has been shown in irritable bowel syndrome that a positive physician-patient interaction can reduce health care seeking, and these findings are probably also valid for functional dyspepsia.121 Lifestyle and dietary measures are usually prescribed, although they have not been systematically studied. It seems logical to have patients eat more frequent, smaller meals and desirable to avoid food that
Conclusions
Functional dyspepsia is one of the most common disorders seen in general practice and by gastroenterologists. Functional dyspepsia seems to be a heterogenous disorder in which different pathophysiologic disturbances are associated with different symptom profiles. The available options for the treatment of functional dyspepsia are of limited efficacy, which probably reflects the incomplete understanding of the nature of this disorder. Current knowledge is in support of empirical treatment with
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