Diagnosis and treatment of functional (non-ulcer) dyspepsia

Psychotherapist

Krashkina

Irina Ivanovna

30 years of experience

Psychotherapist, Candidate of Medical Sciences, member of the Russian Professional Psychotherapeutic League

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Therapists are most often approached with complaints that are characteristic of disorders of the digestive system. Everyone should know what the symptoms of dyspepsia are in an adult. Diagnosis requires a serious differential approach, since this group includes all nonspecific signs of symptom complexes of the gastrointestinal tract. Treatment of dyspepsia directly depends on the causes of the disease, and in most cases this is a deficiency of digestive enzymes or poor nutrition.

Symptoms and signs of dyspepsia

Dyspepsia syndrome is a digestive disorder and symptoms that are characteristic of various diseases of the gastrointestinal tract and their borderline phases.

When digestion is disturbed, symptoms appear that are united by a common name - gastric dyspepsia, this includes:

• problems with swallowing;
• nausea and vomiting attacks;
• belching;
• pain in the stomach;
• heartburn;
• rumbling in the stomach;
• bloating;
• constipation, diarrhea.

Dyspepsia of the stomach and intestines causes pain in the epigastric region. They can be either quite intense or in the form of mild discomfort. There is a feeling of rapid satiety and fullness, and as a result, nausea, belching, and heartburn. Another alarming sign is loss of appetite, quickly and sharply. After this, the person begins to lose weight for no reason. Intestinal dyspepsia is accompanied by rumbling in the stomach, flatulence, diarrhea or constipation.

Disruption of the process of digesting food in the intestines may indicate pathologies such as dysbiosis, diverticulitis, enzymopathy, enteritis, colitis, tumors in the intestines, irritable bowel syndrome, pancreatic diseases, and metabolic pathologies. Also, intestinal dyspepsia may indicate that an infection is developing in it (dysentery, cholera, intestinal tuberculosis, salmonellosis, etc.).

There are 2 main groups of dyspeptic disorders - functional dyspepsia and organic. In the first case, only disturbances in the functioning of the organ are detected, that is, functional lesions, while in the second they are exclusively organic in nature. In the latter case, the symptoms will be more pronounced, and the disorders will continue for a long time.

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Diagnosis and treatment of functional (non-ulcer) dyspepsia

Cytokines (IL-1b, IL-6, IL-8) and tumor necrosis factor-alpha (TNF-alpha) are involved in the inhibitory effect of H. pylori on gastric motility. Taking this into account, anti-Helicobacter therapy can lead to normalization of gastric motility.

However, complete elimination of dyspeptic complaints is observed only in 20–25% of patients with FD. H. pylori eradication was found to have a beneficial effect on symptoms in patients with FD in only 8 of 16 studies. According to the conclusion of the US National Institutes of Health (1994), treatment of Helicobacter pylori infection in patients with FD is not required.

However, a number of studies have shown that the frequency of Helicobacter pylori infection among patients with non-ulcer dyspepsia is higher than in healthy individuals. In addition, H. pylori infection can cause dyspeptic symptoms.

Other authors have questioned the value of H. pylori eradication in the treatment of Helicobacter pylori-associated FD in order to eliminate symptoms. It was not possible to identify significant differences in the reduction in the frequency of dyspepsia symptoms, regardless of whether patients received anti-Helicobacter therapy or not. There is evidence that a year after treatment, symptoms of FD in patients with successful eradication of H. pylori are observed more often than in patients who were not previously treated with anti-Helicobacter therapy.

Among similar works, the study by J. Gillvary et al. stands out. (1997), because the classic “triple therapy” with colloidal bismuth subcitrate was used as an eradication scheme, and a good symptomatic response was obtained in patients. Since in some patients with FD, eradication of H. pylori leads to long-term improvement in well-being, the Maastricht Consensus II (2000) named FD as an indication for anti-Helicobacter therapy.

New facts served as the reason for holding the Third Council of Leading Scientists working on the problem of Helicobacter pylori infection in March 2005. As a result, the Third Maastricht Consensus was developed, which defines approaches to the diagnosis and eradication of H. pylori infection.

According to the new consensus, patients with untested FD are subject to mandatory testing for H. pylori infection and eradication therapy.

According to the 2nd and 3rd Maastricht consensuses, the “gold standard” for diagnosing Helicobacter pylori infection and confirming the success of eradication remains the breath test. But for bleeding ulcers, atrophic gastritis, MALT lymphomas, and after taking proton pump inhibitors (PPIs), this method is not recommended, since the likelihood of false results increases significantly. In these cases, the method of choice is to determine antibodies in the blood. When conducting epidemiological studies, preference is given to non-invasive methods for detecting H. pylori antigens in saliva and urine.

The new consensus provides for first-line treatment regimens and reserve eradication regimens, as well as “salvage therapy”, which is used in cases of failure of therapy with first-line drugs and reserve agents. Two well-proven triple regimens are offered as 1st-line therapy: PPI + clarithromycin + amoxicillin or metronidazole. In accordance with the Maastricht Consensus III, three-component anti-Helicobacter therapy lasting 14 days increases eradication efficiency by 12%. Moreover, it is undesirable to prescribe clarithromycin in the population if there is data on the resistance of H. pylori to this antibiotic over 30%. The same applies to metronidazole and amoxicillin, although resistance to the latter in H. pylori is much less common.

In the case of simultaneous resistance of H. pylori to two 1st-line drugs, it is recommended to immediately begin eradication with a reserve regimen, i.e., use the reserve treatment regimen as the first line.

Psychotropic drugs. Includes antidepressants, serotonin receptor and serotonin reuptake blockers, anxiolytics. Currently, there are no results from controlled studies on the use of these drugs in FD. It should be expected that the effect of such drugs is close to their beneficial effect on patients suffering from non-cardiac thoracalgia or irritable bowel syndrome.

Empirical therapy. If there are no signs of serious organic diseases or they were not detected during a standard diagnostic examination, the prescription of so-called empirical therapy is justified.

In young patients without signs of organic gastric diseases, a serological test for IgG antibodies to H. pylori or a urease breath test is used to detect Helicobacter pylori infection. Patients with positive test results should be given eradication therapy. If the dyspeptic symptoms disappear, no further examination is required.

In patients who do not have Helicobacter pylori infection or have it but have not responded to treatment with anti-Helicobacter pylori drugs, treatment with H2 blockers or proton pump inhibitors and prokinetics should be started. If there is no effect, endoscopy and other studies are indicated to select further treatment tactics.

Antacids. Studies on reducing gastric acidity in the treatment of FD have revealed the low effectiveness of antacids. Thus, 14 of 24 studies showed that these drugs in high doses caused an improvement in well-being in 35-80% of patients compared to 30-60% of people receiving placebo.

Antacids are well known to both patients and doctors, their use has been proven to be safe, so this group of drugs is used in FD.

The most commonly used (both on the recommendations of doctors and taken by patients on their own) are antacids such as Almagel Neo, Phosphalugel, Rutacid, Gelusil Lac, the main property of which is to neutralize the acid secreted by the parietal cells of the mucous membrane. This allows you to quickly reduce the intensity of pain in the epigastric region and heartburn, and in many patients - other dyspeptic disorders.

The drug "Almagel Neo" allows you not only to neutralize the acidic contents of the stomach, but also to eliminate symptoms of discomfort, prevent the occurrence of flatulence, and improve bowel movements. The effectiveness of Almagel Neo is due to the optimal content of aluminum hydroxide and magnesium hydroxide in its composition and the presence of the defoamer simethicone.

Acid suppressive drugs. This is a group of drugs that are often used to treat FD. Some authors believe that the positive results from histamine H2 receptor antagonists in a number of clinical trials were obtained due to the group of patients with GERD who were included in these trials due to imperfect selection criteria.

However, the meta-analysis by G. Dobrilla et al. (1989) showed that when using H2-blockers, the therapeutic effect was 20% greater than the placebo effect.

There is an opinion that a high dose of histamine H2 receptor antagonists is effective for FD, but serious research is needed to confirm this.

PPIs have so far been little used in FD. A recently completed study with high statistical significance showed a good effect of omeprazole in FD, and the best result was obtained in the group of patients with the ulcer-like variant compared to the dyskinetic one. In the OCAY study, omeprazole monotherapy was effective in relieving symptoms of dyspepsia, as was eradication therapy for H. pylori infection.

Discussions continue regarding the selection of the optimal PPI. The Russian Gastroenterological Association recommends the use of rabeprazole. A sustainable effect from its use is noted from the 1st day. In addition, there is no need for a 2-3 day interval between the administration of rabeprazole and the antibacterial components of eradication therapy; they can be used in combination from the first days. Amoxicillin and clarithromycin exhibit an antibacterial effect against H. pylori only at a pH of 5.0 and above, therefore, the administration of other PPIs with a longer period of onset of effect simultaneously with these antibiotics leads to a decrease in the % eradication of H. pylori.

Most experts believe that there are no significant differences in the effectiveness of eradication therapy depending on which PPI is used. The summary of Maastricht III does not mention individual names of PPIs at all, which apparently reflects the absence of any disagreement among experts on this component of FD treatment.

All major PPIs are present on the domestic pharmaceutical market: omeprazole, lansoprazole, pantoprazole, rabeprazole and esomeprazole. Omeprazole is used more often than others in Russian practice, which is quite justified given the number of clinical studies on this drug. The domestic generic, which has undergone bioequivalence studies to the original drug, is Gastrozol.

We have experience with a course of monotherapy with the drug "Omez" at a dose of 20 mg 2 times a day for 4 weeks in 12 patients diagnosed with FD syndrome, 8 of whom had ulcerative type FD, 2 had dyskinetic type FD, 2 had nonspecific FD. . The age of the patients ranged from 22 to 35 years, among them there were 5 men and 7 women. In the control group (n = 10), comparable in gender and age to the main group, ranitidine was used at a dose of 150 mg 2 times a day.

During the treatment, it was found that in the group using Omez, the severity of clinical symptoms decreased significantly more quickly, the level of anxiety on the Taylor scale, depression on the Zung scale decreased, the Kerdo autonomic index normalized, the severity of pain on the visual analogue scale (VAS) decreased, and the quality of life increased (QoL) compared with the comparison group where ranitidine monotherapy was used.

Causes

There are several forms depending on the reasons that cause the development of the syndrome:

• simple dyspepsia. It is also called nutritional. Caused by nutritional problems. In turn, there is fatty (soapy), fermentative and putrefactive dyspepsia. In the latter case, it develops if the food is dominated by protein products or stale meat is used. Fermentation develops from excessive consumption of carbohydrates (bread, cabbage, legumes, sugar) and drinks that cause fermentation (beer and kvass). Fatty dyspepsia develops with excessive consumption of fatty foods, especially pork and lamb;
• dyspepsia associated with a deficiency of secreted enzymes for digesting food in the intestines and stomach. In turn, it can be gastrogenic (lack of enzymes in the stomach), pancreatogenic (deficiency of pancreatic substances), enterogenic (lack of intestinal juices), hepatogenic (insufficient secretion of bile from the liver);
• dyspepsia, which is associated with problems with the absorption of food in the intestines with malabsorption syndrome. As a result, nutritional components do not flow from the intestines into the blood;
• dyspepsia, which is associated with intestinal infections. In this case, it could be either dysentery or salmonellosis.
• intoxication. It manifests itself due to poisoning in various diseases, including influenza, acute surgical pathologies, and also when consuming poisons.

All of these factors can contribute to the onset of the disease. Symptoms and treatment of dyspepsia of the stomach and intestines directly depend on the causes.

Preventing indigestion

The normal functioning of the digestive system requires compliance with the following rules:

• healthy eating to prevent indigestion
  (refusal of strict diets, balanced composition of proteins, fats and carbohydrates, consumption of vegetables and fruits in sufficient quantities, exclusion of fast food, etc.);
• getting rid of bad habits
  (frequent drinking of alcohol, eating dry food, eating on the go, overeating at night, not having breakfast);
• developing an adequate response to stress
  (indigestion is often associated with negative emotions and nervous tension).

Measures to prevent dyspepsia also include proper rest, healthy sleep, and sufficient physical activity.

You can get tested for a tendency to gastrointestinal diseases, including indigestion, at the Medical Genetics Center.

Risk factors

These include:

• frequent and severe stress, emotional tension. In this case, the pathology will have a neurotic origin;
• some medication use. This applies to antibiotics, hormonal or antitumor and other agents;
• poor nutrition. Most often this concerns overeating;
• intoxication. In this case, there may be either a disease of viral or bacterial origin, or household poisoning;
• excessive release of hydrochloric acid;
• problems with gastrointestinal motility.

These are the main factors that contribute to the occurrence of dyspepsia.

Reasons for development

Most often, dyspepsia is considered as a psychosocial disease that develops with frequent exposure to a stress factor on the human body. First of all, under the influence of stress, the functional state of the stomach is disrupted, after which all structures of the gastrointestinal tract are involved in the process. In addition to the psycho-emotional factor, factors such as poor nutrition, a poor, monotonous diet, taking certain groups of medications (antibiotics, non-steroidal anti-inflammatory drugs), hypersecretion of gastric juice, enzymatic deficiency, as well as infection with the bacterium Helicobacter Pylori can lead to functional dyspepsia.

Other causes of dyspepsia include:

• cholelithiasis;
• gastritis and gastric ulcer;
• achlorhydria;
• pancreatitis;
• pyloric stenosis;
• benign and malignant neoplasms of the gastrointestinal tract;
• infectious lesion of the gastrointestinal tract;
• diaphragmatic hernia;
• cholecystitis, as well as previous surgery to remove the gallbladder.

Complications

Gastric dyspepsia occurs in diseases such as esophagitis, GERD, cancer, stenosis or ulcer of the esophagus, cancer or the presence of benign tumors, periesophagitis, scleroderma, diverticulum. Also, the presence of dyspepsia of the stomach and intestines may indicate diseases of the muscles, central and peripheral nervous systems, pathologies of internal organs, for example, narrowing of the esophagus can be caused by cysts and tumors that oppress it from the outside. This also applies to aortic aneurysm, vascular anomalies, and thyroid hyperplasia.

Complications of dyspepsia are most often associated with the underlying illness that causes the appearance of this syndrome. The patient may suddenly lose weight and lose appetite for a long time. One of the severe consequences is Mallory-Weiss syndrome. In this case, the mucous layers of the lower part of the esophagus, where it passes into the stomach, rupture. Because of this, gastric bleeding begins. It can be quite intense and even lead to death. Most often, the occurrence of Mallory-Weiss syndrome is associated with repeated bouts of vomiting.

When to see a doctor

For treatment of stomach or intestinal dyspepsia, you should contact a gastroenterologist. Don't delay going to the doctor. Particular attention should be paid to such symptoms as abdominal pain at night, sudden weight loss for no reason, nausea, vomiting, frequent belching, and heartburn attacks. Diagnostics can be carried out at JSC "Medicine" (clinic of Academician Roitberg), which is located in the center of Moscow.

Causes and forms of indigestion

Among the prerequisites for dyspepsia are such as hasty eating (food is poorly chewed, digestive juices do not have time to secrete in sufficient quantities), overeating, and consumption of certain foods and drinks (containing carbon dioxide, sugar, caffeine). Dyspepsia can be caused by stress and physical activity immediately after eating. Digestive problems can be caused by NSAIDs.

Indigestion can be caused by medical conditions. Half of the patients complaining of dyspepsia suffer from peptic ulcers or gastroesophageal reflux disease. Pancreatitis, cholecystitis, cholelithiasis, tumors of the stomach and pancreas also cause characteristic symptoms.

Organic dyspepsia (which is caused by certain diseases) differs from functional dyspepsia in the seasonal nature of pain, night pain (passing after eating), episodes of intense heartburn (at least twice a week), weight loss, etc.

Functional dyspepsia

is indigestion, which is accompanied by characteristic complaints against the background of a person’s general satisfactory condition and is characterized by a favorable course of the disease without progression. Such a disorder can occur due to psycho-emotional stress, irregular eating patterns, smoking, alcohol consumption, H. pylori infection, and the influence of unfavorable external factors.

Diagnosis of dyspepsia

If you complain of indigestion, you should contact a gastroenterologist or therapist.

In order to diagnose problems with digestion of food, the doctor gives a referral for examination:

• fibrogastroduodenoscopy;
• Ultrasound of the gastrointestinal tract;
• test for H. pylori;
• intragastric pH-metry;
• blood and stool tests;
• study of gastroduodenal motility.

Diagnosis of dyspepsia

Before starting treatment for dyspepsia, it is necessary to undergo an examination, which includes not only a description of complaints, an external examination, but also the following:

• laboratory tests - general and biochemical blood tests, examination of stool for the presence of blood, coprogram;
• instrumental studies - a test for gastric acid secretion, esophagogastroduodenoscopy, examination of gastric materials for the presence of Helicobacter pylori, ultrasound of the abdominal organs, colonoscopy, radiography, computed tomography, esophageal and antroduodenal manometry.

You can undergo diagnostics at JSC "Medicine" (clinic of Academician Roitberg), which is located in the central district of Moscow, near the Tverskaya, Novoslobodskaya, Belorusskaya, Chekhovskaya metro stations. If you have a disease, you may need to consult not only a gastroenterologist, but also other specialists: a psychiatrist, neurologist, cardiologist, endocrinologist.

Treatment of dyspepsia in children

Mild forms of nutritional dyspepsia in children are treated on an outpatient basis. The main component of the treatment of simple dyspepsia in children is the abolition of the product that led to indigestion, adherence to a diet and diet in accordance with the age of the child.

It is recommended for infants to replace 1-2 feedings per day with a water-tea break and reduce the volume of other feedings. The child is given glucose-saline solutions, carrot-rice broth, and weak tea to drink.

To improve digestion for dyspepsia in children, enzymes (pancreatin) are prescribed; for removing toxins - sorbents; to relieve pain - antispasmodics.

Since 75% of cases of dyspepsia syndrome in children are based on impaired gastric motility, it is advisable to prescribe prokinetics (motility regulators).

To restore the intestinal flora after dyspepsia, children can be given drugs with live cultures of bifidobacteria and lactobacilli.

Moderate and severe forms of dyspepsia in children must be treated in a hospital setting. Toxic dyspepsia in children requires the use of antibacterial drugs. A child suffering from dyspepsia needs careful care: maintaining an appropriate temperature, a calm environment, and maintaining hygiene. It is necessary to carefully monitor the dynamics of the child’s condition, examine the nature of vomit and bowel movements, and prevent aspiration of vomit into the respiratory tract.

Treatment

To treat dyspepsia, drug therapy is necessary. Separately, you need to get rid of diarrhea or constipation, and for this purpose special means are prescribed. Other drugs are also prescribed to treat dyspepsia and alleviate the patient’s condition:

• painkillers (antispasmodics);
• drugs that reduce the level of acidity in the stomach;
• enzyme agents to improve digestion processes.

Treatment must be comprehensive and systemic. It is necessary to treat the disease that caused dyspepsia, that is, gastritis, duodenitis, GERD, cholecystitis, gastric or intestinal ulcers, pancreatic diseases.

Treatment of indigestion

For patients with dyspepsia, an individual dietary regimen is recommended. It is necessary to exclude or reduce individually intolerant foods in the diet. If you have indigestion, it is recommended to stop smoking and drinking alcohol.

For dyspepsia, the following drugs are prescribed:

• prokinetics
  (means to normalize the motor function of the gastrointestinal tract);
• antibiotics
  (eradication therapy is carried out to combat H. pylori);
• antacids
  (neutralize the increased secretion of hydrochloric acid in the stomach).

To alleviate the patient’s condition with dyspepsia, the following measures are also recommended:

• diet correction
  (in the acute phase of indigestion, fasting for 1–2 days is indicated, then you must follow a therapeutic diet);
• taking medications with enzymes
  (pepsin, pancreatin, etc.);
• therapeutic exercises
  to improve gastrointestinal motility, abdominal massage.

Myths and dangerous misconceptions in the treatment of dyspepsia

Main misconceptions:

• nausea, heaviness and bloating will go away on their own. They are temporary, so you don't have to go to the hospital;
• antispasmodics or enzyme agents remove heaviness in the stomach and discomfort in the intestines;
• If you eat something sour or spicy, the discomfort will disappear.

All of the above opinions are completely wrong. You should not rely on myths that were previously believed. If alarming symptoms appear, you should consult a specialist.

Functional dyspepsia in children

Indigestion or simple dyspepsia is more common in children in the first years of life. It can develop acutely or against the background of precursors: anxiety, loss of appetite, regurgitation, increased bowel movements. After 3-4 days, the frequency of stool reaches 5-7 times a day, it becomes liquid, heterogeneous in color, resembling the appearance of a chopped egg with lumps of white, yellow and greenish color, mixed with mucus. With dyspepsia, children experience bloating, frequent passing of gas, regurgitation, and vomiting. The child is bothered by intestinal colic: before defecation, he twists his legs and cries. Appetite decreases to the point of refusing to eat, which leads to a halt in weight gain. Simple dyspepsia in children lasts 2-7 days. Against the background of dyspepsia, children may develop thrush, stomatitis, and diaper rash.