DYSPEPSIA

Ign. Sinta Murti

1
Case 1
Mr Thomson , 60 year old man presented with a 6 month
history of daily epigastric pain and discomfort relieved by eating.
He had not experienced this problem previously. There were no
aggravating factors.
He was otherwise healthy, had no other complaints, and had
not lost weight. He did not smoke. He took no drugs.

Physical examination and basic labotary tests (complete blood

count, basic metabolic panel, and urinalysis) were normal. The
stool guaiac was negative.

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What is the diagnose ?

A. GERD
B. Functional Dyspepsia
C. Uninvestigated Dyspepsia
D. Ulcer like Dyspepsia
Case 2
Mr. Ray, 30 year old man presented with years history of
recurrent epigastric pain, when the stomach empty and also
after eating. He also complain of nausea
He had not lost weight. He not smoke or drink alcohol. and
always try to eat regulary. He never took any medication
Physical examination and basic labotary tests (complete blood
count, basic metabolic panel, and urinalysis) were normal. The
stool guaiac was negative.

4
What is the diagnose ?

A. GERD
B. Functional Dyspepsia
C. Uninvestigated Dyspepsia
D. Ulcer like Dyspepsia
Case 3
A 42 year old man visits his primary care physician. He
complains of heartburn that frequently occurs in the middle of the
night. His discomfort often causes him to awaken in the night,
resulting in a restless night sleep. He rarely feel nausea nor
vomite.
He takes a daily aspirin for his heart disease. He is not
overweight and does not smoke. When asked about his drinking
habits, he admits that he has recently mildly increased his
alcohol consumption.

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What is the diagnose ?

A. GERD
B. Functional Dyspepsia
C. Uninvestigated Dyspepsia
D. Ulcer like Dyspepsia
 DEFINITION &
CLASIFICATION
Dyspepsia

▷ Any symptoms (abdominal discomfort)

referable to the upper gastrointestinal
tract : Epigastric pain, epigastric
burning, fullness, satiety, nausea,
vomiting, belching
▷ Timing : not mention, 4 weeks
Rome IV criteria

Any combination of 4 symptoms:

Postprandial fullness, Early satiety
Epigastric pain, Epigastric burning
Occur at least 3 days per week over the last
3 months with an onset of at least 6 months
in advance -- Functional dyspepsia
GERD

Symptoms or complications resulting

from the reflux of gastric contents into
the esophagus or beyond, into the oral
cavity (including larynx) or lung'. Typical
symptoms are heartburn and acid
regurgitation.
CLASIFICATION
- Uninvestigated dyspepsia
- Investigated dyspepsia
(Endoscopy, Radiologic, blood test)
- Organic dyspepsia
- Functional dyspepsia
- Ulcer like dyspepsia
- Dismotility like dyspepsia
- Reflux like dyspepsia

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Dyspepsia organic

The most organic causes of dyspepsia are peptic

ulcer & erosive esophagitis (GERD). Less prevalent
are gastric erosion, gastric/esophageal cancer,
pancreatitis, food intolerance, chron's

Dyspepsia functional
No structural lesion

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Lack of discriminant value of dyspepsia subgroups in
patients referred for upper endoscopy
Nicholas J. Talley, Amy L. Weafer, Dixie L. Tesmer, Alan R. Zinsmeister

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Regadless of dominant symptom sub group, the prevalence of gastric and
duodenal finding were similar. This indicates that upper gastrointestinal symptoms
are poor predictors of endoscopic findingsi ven that reflux oesophagitis was the
most common finding regardless of the presenting symptoms, empirical initial acid
suppressive therapy may be considered for these patients

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Case 1

What is the diagnose ?

A. GERD
B. Functional Dyspepsia
C. Uninvestigated Dyspepsia
D. Ulcer like Dyspepsia

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Case 2

What is the diagnose ?

A. GERD
B. Functional Dyspepsia
C. Uninvestigated Dyspepsia
D. Ulcer like Dyspepsia

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Case 3

What is the diagnose ?

A. GERD
B. Functional Dyspepsia
C. Uninvestigated Dyspepsia
D. Ulcer like Dyspepsia

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Highlight

DIAGNOSE DYSPEPSIA

Dyspepsia - discomfort feeling upper abdominal. epigastric pain, burning

early satiety, fullness, bloating.
Differentiate it with GERD - heart burn, regurgitation
Time course : Indonesia guideline doesn't mention (might follow Rome IV) .
Some : 4 weeks
Better use Uninvestigate - unless to guide treatment
Case 1

Should we proceed to Gastroscopy examination

for Mr Thomson ?
A. Yes because he has alarm symptom
B. Yes because of his age
C. No because he never took any medication

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Case 2

What should we do for Mr Ray ?

A. Treat him with anti secretory drugs
B. Do H. pylori test (test and treat approach)
C. Do prompt gastroscopy

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 APPROACH FOR
DYSPEPSIA DIAGNOSIS
 Approach to Dyspepsia : life style
modification

• Advice for healthy eating

• smoking, alcohol, coffee, chocolate, fatty
foods and being overweight.
• Avoid precipitant drugs (NSAID, steroid)

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Approach to Dyspepsia : Empiric Anti
secretory agent

▷ PPI or H2 receptor blocker 2-4 weeks

▷ Cost effective for place with low H.pylori

prevalence (below 10%)

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Approach to Dyspepsia : Test and
treat approach
▷ Cost effective for place with high H.pylori
prevalence

▷ Do H. pylori diagnostic test without empiric therapy

before - treat if the test is positive

▷ Indonesia doesn’t follow this approach - test if no

response to empiric treatment

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Approach to Dyspepsia : Endoscopy

Early endoscopy is indicated in several

condition :
1. Present of alarm symptom
2. Onset age : 50, 55, 60 (depend on gastric
cancer case)

Late endoscopy is indicated for :

1. No response to empiric therapy

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Alarm symptom
▷ Penurunan berat badan (unintended)
▷ Disfagia progresif
▷ Muntah rekuren atau persisten
▷ Pendarahan saluran cerna
▷ Anemia
▷ Massa daerah abdomen bagian atas
▷ Riwayat keluarga kanker lambung
▷ Dispepsia awitan baru pada pasien di atas 45 tahun

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Case 1

Should we proceed to Gastroscopy examination

for Mr Thomson ?
A. Yes because he has alarm symptom
B. Yes because of his age
C. No because he never took any medication

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Case 1
Mr Thomson , 60 year old man presented with a 6 month
history of daily epigastric pain and discomfort relieved by eating.
He had not experienced this problem previously. There were no
aggravating factors.
He was otherwise healthy, had no other complaints, and had
not lost weight. He did not smoke. He took no drugs.

Physical examination and basic labotary tests (complete blood

count, basic metabolic panel, and urinalysis) were normal. The
stool guaiac was negative.

29
Case 2

What should we do for Mr Ray ?

A. Treat him with anti secretory drugs
B. Do H. pylori test (test and treat approach)
C. Do prompt gastroscopy

30
Case 2

Mr. Ray, 30 year old man presented with years history of

recurrent epigastric pain, when the stomach empty and
also after eating. He also complain of nausea
He had not lost weight. He not smoke or drink alcohol.
and always try to eat regulary. He never took any
medication
Physical examination and basic labotary tests (complete
blood count, basic metabolic panel, and urinalysis) were
normal. The stool guaiac was negative.

31
Highlight

DYSPEPSIA APPROACH
Algoritme Tata Laksana Dispepsia di Berbagai Tingkat
Layanan Kesehatan

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CASE 1
Mr Thomson underwent upper gastrointestinal
endoscopy which showed 1.5 cm benign appearing
gastric ulcer 1 cm proximal to the angularis incisura.
Biopsies are taken from of the ulcer edge and base.

Histological interpretation was:

- Mild intestinal metaplasia (atrophhy +--)
- Inflammatory infiltrate
- With H. Pylori are present (++-)

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35
What kind of H. pylori test that Mr Thomson
had ?

A. Non invasive H. pylori antigen stool test

B. Invasive biopsy

C. Invasive rapid urease test

D. Non invasive H. pylori serology test

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CASE 2

Mr Ray underwent a urea breath test which was

positive in result. Mr Ray lives in part of Malaysia that
has less than 20% case of Claritromycine resistance

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Which statement is false ?

A. IgG serology test can be used only in country with

high prevalence of H.pylori infection

B. Stool Antigen and urea breath test can detect

present infection of H pylori

C. IgG serology is recomended for confirmation test

after H. pylori eradication

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What is the H.pylori treatment choice for Mr Ray ?

A. PPI + Amoxicillin 2x1000mg + Claritromicyn 2x500mg

B. PPI + Amoxicillin 2x1000mg + Claritromicyn 2x250mg
C. PPI + Bismut subsalisilate + Metronidazol 2x500mg +
Tetracycline
D. PPI + Amoxicillin 2x1000mg + Claritromicyn 2x500mg +
Metronodazole 3x500mg

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DYSPEPSIA AND H
PYLORI INFECTION
Pathogenesis H pylory infection

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▷ Colonization with H. pylori virtually always leads to infiltration of
the gastric mucosa in both antrum and corpus with neutrophilic
and mononuclear cells

▷ Acute gastritis : acute phase of colonization with H. pylori may be

associated with transient dyspeptic symptoms, such as fullness,
nausea, and vomiting, and with considerable inflammation of
both the proximal and distal stomach mucosa, or pangastritis.
This phase is often associated with hypochlorhydria

▷ Chronic gastritis : intact acid secretion (antrum predominant

gastritis) vs impaired acid secretion (pangastritis)

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H pylori test

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H pylori eradication

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What kind of H. pylori test that Mr Thomson
had ?

A. on invasive H. pylori antigen stool test

B. Invasive biopsy

C. Invasive rapid urease test

D. Non invasive H. pylori serology test

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Which statement is false ?
A. IgG serology test can be used only in country
with high prevalence of H.pylori infection
B. Stool Antigen and urea breath test can detect
present infection of H pylori
C. IgG serology is recomended for confirmation test
after H. pylori eradication

4
What is the first line H.pylori treatment for Mr Ray ?

A. PPI + Amoxicillin 2x1000mg + Claritromicyn

2x500mg
B. PPI + Amoxicillin 2x1000mg + Claritromicyn
2x250mg
C. PPI + Bismut subsalisilate 2X2tab + Metronidazol
3x500mg + Tetracycline 4x250mg
D. PPI + Amoxicillin 2x1000mg + Claritromicyn
2x500mg + Metronodazole 3x500mg

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What test is recommended to confirm
eradication after H pylori treatment ?

A. Rapid urease test

B. IgG serology

C. Urea breath test and stool antigen

D. Histology

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Should we do endoscopy examination to Mr
Ray after his treatment finish ?
A. Yes

B. No

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Should we do endoscopy examination to Mr
Thomson after his treatment finish ?

A. Yes

B. No

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▷ It is estimated that H. pylori-positive patients
have a 10 to 20% lifetime risk of developing
ulcer disease and a 1 to 2% risk of developing
distal gastric cancer

▷ It was standard of care to follow-up all gastric

ulcer to confirm healing and more importantly
to reconfirm that the ulcer was not actualy a
gastric cancers. Endoscopic follow-up of
duodenal ulcers is unnecessary.

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Should we do endoscopy examination to Mr
Ray after his treatment finish ?

A. Yes

B. No

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Should we do endoscopy examination to Mr
Thomson after his treatment finish ?

A. Yes

B. No

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 HIGHLIGHT

DYSPEPSIA AND H
PYLORI INFECTION

To those wh are not a candidate promp endoscopy, Offer H pylori test to patient.
Can be preceded by empiric treatment, can be not, depend on guideline local or
H pylori prevalence.
Treat H pylori - Do test after treatment. For gastric ulcer , the need of endoscopic
evaluation stil debated
Algoritme Tatalaksana Eradikasi Infeksi H Pylori

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CASE 2
Mr Ray underwent a urea breath test post treatment
which was negative in result. But Mr Ray still complain
abdominal discomfort eventhough not every week.
What is our next step ?

A. On deman therapy
B. Endoscopy examination

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 ALGORITM FOR DIFFICULT CASE

• People who not response to empiric treatment, but

H pylori test negative
• People who still have complain after successful H
pylori treatment

Endoscopy need to be done ?

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CASE 2
Mr Ray underwent a urea breath test post treatment
which was negative in result. But Mr Ray still complain
abdominal discomfort eventhough not every week.
What is our next step ?

A. On deman therapy
B. Endoscopy examination

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 CASE 4

• 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.

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 CASE 4

• 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,

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CASE 4

What is the diagnose ?

A. Dyspepsia functional Postprandial distress

syndrome type
B. Dyspepsia functional Epigastric pain syndrome
type

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CASE 4

What is the diagnose ?

A. Dyspepsia functional Postprandial distress

syndrome type
B. Dyspepsia functional Epigastric pain syndrome
type

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CASE 4

What is the treatment of choice ?

A. Prokinetik
B. low dose PPI, sitoprotector
C. antidepresan
D. Physicological treatment

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CASE 4

What is the treatment of choice ?

A. Prokinetik
B. low dose PPI, sitoprotector
C. antidepresan
D. Physicological treatment

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 DYSPEPSIA FUNCTIONAL (Rome IV)

• Postprandial distress syndrome (meal-related

dyspeptic symptoms, characterized by postprandial
fullness and early satiation)

• Epigastric pain syndrome (meal-unrelated

dyspeptic symptoms, characterized by epigastric
pain and epigastric burning)

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ALGORITHM FUNCTIONAL DYSPEPSIA

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 CASE

Mr A 51 years old, came with a complain of epigastric pain, his

notice that his mal portion become fewer in last 2 months and
that make his body weight decrease. He took PPI all this time but
not so help
He dont have any other complain, and still work as usual as
headfield in mining company
His physical examination is normal. Haemoglobin normal. but he
didn't do fecal occult blood test. Anyway his ultrasound shows
gastric dilatation.

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▷ Rapid urease test was positif
▷ Histology finding : Adenocarcinoma
▷ Patient was planed to do partial
gastrectomy duodenectomy

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THANK YOU

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▷ In subjects with intact acid secretion, H. pylori in
▷ particular colonizes the gastric antrum, where few acid-secretory
▷ parietal cells are present. This colonization pattern is
▷ associated with an antrum-predominant gastritis. Histological
▷ evaluation of gastric corpus specimens in these cases reveals
▷ limited chronic inactive inflammation and low numbers of superficially
▷ colonizing H. pylori bacteria. Subjects in whom acid
▷ secretion is impaired, due to whatever mechanism, have a
▷ more even distribution of bacteria in antrum and corpus, and
▷ bacteria in the corpus are in closer contact with the mucosa,
▷ leading to a corpus-predominant pangastritis (339). The reduction
▷ in acid secretion can be due to a loss of parietal cells as a
▷ result of atrophic gastritis, but it can also occur when acidsecretory
▷ capacity is intact but parietal cell function is inhibited
▷ by vagotomy or acid-suppressive drugs, in particular, proton
▷ pump inhibitors (PPIs) (339). The

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