Functional Dyspepsia; Chronic and persistent upper abdominal pain that's often related to eating

Functional Dyspepsia
You're having trouble with your stomach. You feel uncomfortable. It's not heartburn, but it may be related to eating. You feel bloated and full. You complain of nausea or sometimes you even vomit. You think you might be having “indigestion.”

It's called dyspepsia — literally, “bad digestion.” It 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 chronic and persistent upper abdominal pain that's often related to eating, and for which there is no clearly identifiable cause such as peptic ulcer disease. Because peptic ulcer disease produces similar symptoms, functional dyspepsia is sometimes called non-ulcer 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 sure-fire cure.

Is it an ulcer?
The first question on most people's minds is, “Do I have an ulcer?” It's a reasonable question, considering that 10% of Americans develop a peptic ulcer at some time in their lives.
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 (see Figure 5). 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.

Diagnosing peptic ulcers A peptic ulcer is a raw, crater-like break in the lining of the stomach or duodenum. To diagnose this condition, physicians often first prescribe medication. If the pain persists, a physician can use a tube with a lighted scope at the end known as an endoscope to view the lining of the stomach and confirm the presence of an ulcer.

In the early 1980s, researchers made a major discovery. They identified Helicobacter pylori (see Figure 6), 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. At least 90% of people with duodenal ulcers and 75%–85% of those with gastric ulcers are infected with this organism.

Bacteria in the gutHelicobacter pylori is a bacteria that thrives in the stomach because it can produce large quantities of urease, an enzyme that generates ammonia which neutralizes the acid and quickly kills other bacteria. The corkscrew-shaped H. pylori attaches to the surface of stomach cells, after twisting through the mucus that protects the lining from corrosive gastric juices. Scientists believe that H. pylori contributes to ulcers in several ways including thinning the protective mucous layer, poisoning nearby cells with ammonia or other toxins, or even increasing acid production.

Certain medications can add to the irritation. Talk to your doctor to see if any of the medications you are taking may be causing your symptoms. 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.

Symptoms of functional dyspepsia Persistent upper abdominal pain that occurs during or after eating Bloated, full feeling Symptoms come and go over days or months

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 may respond to treatment with a placebo pill (one that contains no active ingredient). In both conditions, pressing on the patient’s abdomen may produce tenderness.
Typically, the first step is to confirm or exclude the possibility of a peptic ulcer. Pain is the most common symptom of an ulcer. Usually, it is a dull, gnawing ache that comes and goes. It occurs two to three hours after a meal, or in the middle of the night, and is relieved by food.
Your medical history and details about the frequency of the pain (how long it's persisted, and when it's most severe) are important in making this diagnosis. Discomfort that feels worse on an empty stomach and is relieved by eating suggests a duodenal ulcer, although it isn't definitive. Ulcer pain often awakens a person during the night. If this pain is relieved by medications that typically help GERD symptoms, it may indicate an ulcer. Other health habits are also relevant, such as whether you smoke or drink alcoholic beverages, and whether other family members have ever been diagnosed with a peptic ulcer.

Symptoms of an ulcer Aside from dyspepsia, other symptoms that may point to an ulcer, rather than to FD, include: Evidence of bleeding, such as vomiting blood or material that resembles coffee grounds, or passing black stools. 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.

To confirm the presence of an ulcer, the doctor may order an endoscopy or upper GI series. At the same time, some physicians may be hesitant to order these tests because in most instances of dyspepsia, results are negative and are unlikely to influence initial treatment strategies. Still, most patients take comfort in learning that he or she doesn't have an ulcer.
Diagnosing FD is further complicated by the disorder's resemblance to other illnesses. Gastritis, gastroesophageal reflux, irritable bowel syndrome, chronic pancreatitis (inflammation of the pancreas), stomach cancer, and hepatobiliary pain (pain originating from the liver or gallbladder) all can cause symptoms much like those of FD (see “Functional dyspepsia: What else could it be?”).

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 hardly ever the case, especially when symptoms persist for months or years without worsening. Fortunately, more serious ailments have characteristics that set them apart from FD. 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. If a stone is stuck for several hours, inflammation can result, and the patient may experience extreme tenderness if a hand is pressed below the ribs on the right side. He or she may develop fever and an elevated white blood cell count. Jaundice (a yellowing of the skin and the whites of the eyes), dark urine, and pale stools occur when a gallstone slips out of the gallbladder and obstructs the duct that drains bile from the liver into the duodenum. 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.

Tests
As a first step toward both diagnosis and treatment, your doctor may try you on one or more drugs to see if the dyspepsia clears. He or she may also order a blood test to detect the presence of H. pylori bacteria. If the blood test is positive, treatment can eradicate the bacteria. If symptoms have not improved after a few weeks, the next step will probably be endoscopy to check for ulcers.
People over age 45 with a new onset of dyspepsia, and those with a family history of gastrointestinal cancers, should see their doctors promptly — as should patients whose dyspepsia is associated with additional worrisome symptoms, such as weight loss, dysphagia (difficulty swallowing), gastrointestinal bleeding, or anemia (low blood count).

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 of 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 mucosa, which has been altered in some way.

Some other ideas:

Visceral hypersensitivity. Many experts believe that patients with FD are more sensitive to gastrointestinal stimuli 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, the spontaneous movement of the digestive tract. Some patients' stomachs empty more slowly than normal, so food is retained longer. The patient feels as though food is not leaving the stomach; he or she fills up quickly during a meal and may belch or burp. The problem may be a mechanical failure of gastric contractions to empty the stomach. In addition, some FD patients have relatively stiff stomach walls, so that little distention can occur after a meal.

H. pylori infection. While the role of H. pylori infection as a cause of ulcers and gastritis is 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 doesn't significantly improve FD symptoms.

Duodenitis. Another condition that might produce symptoms of FD is duodenitis, a chronic inflammation of the lining of the duodenum. However, less than 20% of people with FD have this condition. Some physicians regard duodenitis as a precursor to peptic ulcer disease and may treat it as they would an ulcer.

Psychological factors. Although scientific data are scarce, psychological stress may be important in the development of some cases of dyspepsia.

Diet. Certain fatty foods and fatty acids are often blamed for dyspepsia. This connection makes sense because fat ingestion not only delays gastric emptying but also increases distention of the stomach. However, in one study, when people with a professed sensitivity to fats ate high-fat foods that were disguised, they didn't experience dyspepsia. Substances like alcohol and coffee may also aggravate symptoms.

Drugs. Certain medications can cause dyspepsia, ulcers, and gastritis. It's important to check with your doctor to see if anything you are taking could be contributing to functional dyspepsia.

Managing FD
No truly effective medication exists to treat FD. Still, for some, the knowledge that the condition isn't something more serious may cause the symptoms to disappear or at least become less troublesome. For others, however, the symptoms continue. There's no scientific basis for choosing a specific medication in a person with FD because the stomach and duodenal lining are intact and no pathological problem has been identified. Normally, there's no excess gastric acid production, or demonstrated motility problem, so medications to correct those conditions make no sense.

Lifestyle modifications for FD
The following lifestyle modifications may prove helpful.

Eating strategies

• Avoid foods that trigger symptoms (see “Foods that may aggravate functional dyspepsia”).
• Eat small portions, and avoid overeating.
• Eat smaller, more frequent meals.
• Chew your food slowly and completely.
• Don't drink during meals.
• Avoid activities that result in swallowing excess air, such as smoking, eating quickly, chewing gum, sipping through straws, and drinking carbonated beverages.
• Don't lie down within two hours of eating.
• Keep your weight under control.
 

Foods that may aggravate functional dyspepsia Alcohol Beans Caffeinated tea Coffee Colas Dairy products Fried foods Orange juice Peanuts Peppers Radishes Spicy sauces Tobacco Tomato juice

Stress reduction
Use stress reduction techniques, including relaxation therapies, biofeedback, cognitive-behavioral therapy, exercise, or listening to soothing music.

Reduce fatigue

• Get enough rest.
• Adopt a bedtime routine. Go to bed, and get up at the same time each day.
• Avoid caffeine after noon.
• Don't get too much sleep.


• Exercise

• Perform aerobic exercise three to five times a week for 20–40 minutes per session. Seek your doctor's permission before starting any new workout routine.
• Don't exercise immediately after eating.

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