Functional dyspepsia: Causes, treatments, and new directions – Harvard Health Blog

Functional dyspepsia (FD) is a common condition, defined by some doctors as a stomach ache with no clear cause. More specifically, it is characterized by a feeling of satiety during or after a meal, or a burning sensation in the middle-upper abdomen, just below the rib cage (not necessarily associated with meals). Symptoms can be severe enough to interfere with meals or participation in regular daily activities.

Those with FD often go through several tests like upper endoscopy, computed tomography and the study of gastric emptying. But despite often severe symptoms, no clear cause (such as cancer, ulcer disease or other inflammation) is identified.

Acid reflux, stomach and small intestine

Because there is no clear cause for the symptoms, treating FD is also difficult. The first step in treatment is usually to look for bacteria called H. pylori which can cause inflammation of the stomach and small intestine. Yes H. pylori is present, the person is treated with a course of antibiotics.

For those without H. pylori infection or with symptoms that persist despite the elimination of this bacteria, the next step is usually a test for a proton pump inhibitor (PPI). PPIs, which include omeprazole (Prilosec), esomeprazole (Nexium) and lansoprazole (Prevacid), suppress the production of stomach acid. PPIs can help patients whose FD symptoms are due in part to acid reflux disease. PPIs can also reduce the concentration of certain inflammatory cells in the duodenum (the first part of the small intestine), which can also play an important role in functional dyspepsia.

The brain-gut connection

Another class of drugs that are often used to treat FD are tricyclic antidepressants (TCA). In some people, FD is thought to be due to an abnormal brain-gut interaction. Specifically, these people may have hyperactive sensory nerves fueling the gastrointestinal tract or abnormal pain treatment by the brain. TCAs such as amitriptyline (Elavil), desipramine (Norpramin) and imipramine (Tofranil) are thought to modulate this abnormal brain-gut connection. When used for FD, TCAs are usually prescribed in low doses, where they have no significant antidepressant effect.

However, a large proportion of people with FD also suffer from anxiety, depression or other mental health issues. Treating these conditions, often with the help of a qualified psychiatrist or psychologist, can also improve symptoms of FD. Psychological therapy has not been as widely studied as medication for FD. But a small number of studies have suggested that psychological interventions like cognitive behavioral therapy may be even more effective than drugs; these interventions have been shown to resolve symptoms of FD in one in three correctly selected patients. In comparison, even the most effective medical treatments cause symptom relief in about one in six people treated.

Stomach accommodation

When you eat, the upper part of your stomach relaxes, increasing the volume of your stomach to accommodate your meal. Many FD patients have an impaired accommodation reflex, which can contribute to the post-meal discomfort experienced by many people with FD.

Unfortunately, no medication exists specifically to improve the accommodation of the stomach. However, buspirone (Buspar), a medication normally used for anxiety, would also improve gastric accommodation, and it has been shown in a few studies to be effective in treating FD. Medications that make an empty stomach quicker can also be tried for FD. However, many prokinetic drugs are associated with significant side effects, and only one that has been studied for FD, metoclopramide (Reglan), is available for clinical use in the United States.

Recent research has also suggested that altering the activity of the vagus nerve (the largest nerve carrying signals between the brain and the stomach), via electrical stimulation of the skin of the ear, could improve accommodation. gastric. However, research on this treatment is in its infancy and its effectiveness in relieving symptoms has not yet been studied in large groups of patients.

Limitations of Current Treatments Open the Door to New Treatments

While studies have shown that the treatments mentioned above work better than placebo, many patients do not show significant improvement in symptoms with them. Indeed, even the most effective FD drugs only resolve symptoms in one in six patients. Because of this limited effectiveness, recent studies have examined remedies that are not traditionally used in Western medicine.

For example, a recent Chinese study published in the Annals of internal medicine, has shown that a four-week course of acupuncture treatments eliminated symptoms in a greater percentage of people in distress after meals than a similar group receiving simulated acupuncture treatments. Although more studies are needed to confirm these results, this study suggests that acupuncture may be an option for those with symptoms of difficult-to-manage FD.

Understandable frustration, justifiable hope

FD remains an important challenge for patients and doctors. Some may be reassured that FD is not a dangerous condition in terms of the increased risk of death for patients. (A study of more than 8,000 patients followed for 10 years showed no increased risk of mortality in people with FD compared to those without FD).

However, the annoying and frequent symptoms remain a source of frustration for many. However, there is hope for those who suffer from the condition, both from the judicious use of existing and evidence-based treatments, and from the potential emergence of new treatments in the future.

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Jothi Venkat

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