Dyspepsia Dyspepsia (from the Greek - dys- and pepsis "digestion"), also known as upset stomach or indigestion, refers

s to a condition of impaired digestion. It is a medical condition characterized by chronic or recurrent pain in the upper abdomen, upper abdominal fullness and feeling full earlier than expected when eating. It can be accompanied by bloating, belching,nausea, or heartburn. Dyspepsia is a common problem, and is frequently due togastroesophageal reflux disease (GERD) or gastritis, but in a small minority may be the first symptom of peptic ulcer disease (an ulcer of the stomach or duodenum) and occasionallycancer. Hence, unexplained newlyonset dyspepsia in people over 55 or the presence of other alarming symptoms may require further investigations. Functional dyspepsia (previously called nonulcer dyspepsia) is dyspepsia "without evidence of an organic disease that is likely to explain the symptoms". Functional dyspepsia is estimated to affect about 15% of the general population in western countries.

Dyspepsia in most cases is not a serious condition but it may lead to much discomfort affecting general wellbeing. If it is chronic or persistent, one should seek consult to make sure there are no serious problems such as ulcer or cancer. Cancer of the stomach or esophagus is rare among patients with dyspepsia and few arises in patients less than 45 years old unless with risk factors namely:

Previous history of surgery in the stomach Family history of malignancy in the stomach or esophagus Patients with H. Pylori infection

Sings and Symptoms We usually think of symptoms of dyspepsia as originating from the upper gastrointestinal tract, primarily the stomach and first part of the small intestine. These symptoms include: Postprandial upper abdominal fullness, Burning pain, Nausea, Anorexia or loss of appetite, Heartburn (burning sensation felt in the chest), Regurgitation, Frequent burping (belching) or early satiety. o The symptoms most often are provoked by eating, which is a time when many different gastrointestinal functions are called upon to work in concert. This tendency to occur after meals is what gave rise to the notion that dyspepsia might be caused by an abnormality in the digestion of food.

Causes of Dyspepsia It can be caused by several factors such as food, medications or drugs, diseases of the GI tract such as peptic ulcer and gastroesophageal reflux disease (GERD). Some of the causes are listed below. Gastrointestinai Tract Food intolerance Peptic ulcer disease (PUD) Gastroesophageal reflux (GERD) Gastric or esophageal mass/cancer Gastroparesis (diabetes, postvagotomy, scleroderma, chronic intestinal pseudoobstruction, postviral, idiopathic) Infiltrative gastric disorders (Mntrier's disease, Crohn's disease, eosinophilic gastroenteritis, sarcoidosis, amyloidosis) Medications Ethanol /Alcoholic Beverage Aspirin, nsaids (including COX-2 selective agents) Theophylline Digitalis preparations Glucocorticoids, Steroids, Colchicine Iron, potassium chloride Niacin, gemfibrozil Pancreaticobiliary Disorders Chronic pancreatitis Pancreatic mass/cancer Gall stone Systemic Conditions Diabetes mellitus Thyroid disease, hyperparathyroidism Renal disease (Renal insufficiency) Myocardial ischemia, congestive heart failure Intra-abdominal malignancy Pregnancy Nsaids, nonsteroidal anti-inflammatory drugs; COX-2, cyclooxygenase-2. Gastric infections (cytomegalovirus, fungus, tuberculosis, syphilis) Parasites (Giardia lamblia, Strongyloides stercoralis) Chronic gastric volvulus Chronic gastric or intestinal ischemia Irritable bowel syndrome Functional dyspepsia

Quinidine Estrogens Levodopa Nitrates Sildenafil Orlistat Acarbose

Anatomy and Physiology of Digestive System The mouth, or oral cavity, is the first part of the digestive tract. It is adapted to receive food by ingestion, break it into small particles by mastication, and mix it with saliva. The lips, cheeks, and palate form the boundaries. The oral cavity contains the teeth and tongue and receives the secretions from the salivary glands. Lips and Cheeks The lips and cheeks help hold food in the mouth and keep it in place for chewing. They are also used in the formation of words for speech. The lips contain numerous sensory receptors that are useful for judging the temperature and texture of foods. Palate The palate is the roof of the oral cavity. It separates the oral cavity from the nasal cavity. The anterior portion, the hard palate, is supported by bone. The posterior portion, the soft palate, is skeletal muscle and connective tissue. Posteriorly, the soft palate ends in a projection called the uvula. During swallowing, the soft palate and uvula move upward to direct food away from the nasal cavity and into the oropharynx. Tongue The tongue manipulates food in the mouth and is used in speech. The surface is covered with papillae that provide friction and contain the taste buds. Teeth A complete set of deciduous (primary) teeth contains 20 teeth. There are 32 teeth in a complete permanent (secondary) set. The shape of each tooth type corresponds to the way it handles food. Pharynx The pharynx is a fibromuscular passageway that connects the nasal and oral cavities to the larynx and esophagus. It serves both the respiratory and digestive systems as a channel for air and food. The upper region, the nasopharynx, is posterior to the nasal cavity. It contains the pharyngeal tonsils, or adenoids, functions as a passageway for air, and has no function in the digestive system. The middle region posterior to the oral cavity is the oropharynx. This is the

first region food enters when it is swallowed. The opening from the oral cavity into the oropharynx is called the fauces. Masses of lymphoid tissue, the palatine tonsils, are near the fauces. The lower region, posterior to the larynx, is the laryngopharynx, or hypopharynx. The laryngopharynx opens into both the esophagus and the larynx. Esophagus The esophagus is a collapsible muscular tube that serves as a passageway between the pharynx and stomach. As it descends, it is posterior to the trachea and anterior to the vertebral column. It passes through an opening in the diaphragm, called the esophageal hiatus, and then empties into the stomach. The mucosa has glands that secrete mucus to keep the lining moist and well lubricated to ease the passage of food. Upper and lower esophageal sphincters control the movement of food into and out of the esophagus. The lower esophageal sphincter is sometimes called the cardiac sphincter and resides at the esophagogastric junction Stomach the stomach, which receives food from the esophagus, is located in the upper left quadrant of the abdomen. The stomach is divided into the fundic, cardiac, body, and pyloric regions. The lesser and greater curvatures are on the right and left sides, respectively, of the stomach. Small Intestine The small intestine extends from the pyloric sphincter to the ileocecal valve, where it empties into the large intestine. The small intestine finishes the process of digestion, absorbs the nutrients, and passes the residue on to the large intestine. The liver, gallbladder, and pancreas are accessory organs of the digestive system that are closely associated with the small intestine. The small intestine is divided into the duodenum, jejunum, and ileum. The small intestine follows the general structure of the digestive tract in that the wall has a mucosa with simple columnar epithelium, submucosa, smooth muscle with inner circular and outer longitudinal layers, and serosa. The absorptive surface area of the small intestine is increased by plicae circulares, villi, and microvilli. Exocrine cells in the mucosa of the small intestine secrete mucus, peptidase, sucrase, maltase, lactase, lipase, and enterokinase. Endocrine cells secrete cholecystokinin and secretin. The most important factor for regulating secretions in the small intestine is the presence of chyme. This is largely a local reflex action in response to chemical and mechanical irritation from the chyme and in response to distention of the intestinal wall. This is a direct reflex action, thus the greater the amount of chyme, the greater the secretion. Large Intestine The large intestine is larger in diameter than the small intestine. It begins at the ileocecal junction, where the ileum enters the large intestine, and ends at the anus. The large intestine consists of the colon, rectum, and anal canal. The wall of the large intestine has the same types of tissue that are found in other parts of the digestive tract but there are some distinguishing characteristics. The mucosa has a large number of goblet cells but does not have any villi. The longitudinal muscle layer, although present, is incomplete. The longitudinal muscle is limited to three distinct bands, called teniae coli, that run the entire length of the colon. Contraction of the teniae coli exerts pressure on the wall and creates a series of pouches, called haustra, along the colon. Epiploic appendages, pieces of fat-filled connective tissue, are attached to the outer surface of the colon. Unlike the small intestine, the large intestine produces no digestive enzymes. Chemical digestion is completed in the small intestine before the chyme reaches the large intestine. Functions of the large intestine include the absorption of water and electrolytes and the elimination of feces. Rectum and Anus The rectum continues from the signoid colon to the anal canal and has a thick muscular layer. It follows the curvature of the sacrum and is firmly attached to it by connective tissue. The rectum and ends about 5 cm below the tip of the coccyx, at the beginning of the anal canal. The last 2 to 3 cm of the digestive tract is the anal canal, which continues from the rectum and opens to the outside at the anus. The mucosa of the rectum is folded to form longitudinal anal columns. The smooth muscle layer is thick and forms the internal anal sphincter at the superior end of the anal canal. This sphincter is under involuntary control. There is an external anal sphincter at the inferior end of the anal canal. This sphincter is composed of skeletal muscle and is under voluntary control.

Diagnosis To diagnose indigestion, the doctor asks about the person's current symptoms and medical history and performs a physical examination. The doctor may order x rays of the stomach and small intestine. The doctor may perform blood, breath, or stool tests if the type of bacteria that causes peptic ulcer disease is suspected as the cause of indigestion. The doctor may perform an upper endoscopy. After giving a sedative to help the person become drowsy, the doctor passes an endoscopea long, thin tube that has a light and small camera on the endthrough the mouth and gently guides it down the esophagus into the stomach. The doctor can look at the esophagus and stomach with the endoscope to check for any abnormalities. The doctor may perform biopsiesremoving small pieces of tissue for examination with a microscopeto look for possible damage from GERD or an infection. Because indigestion can be a sign of a more serious condition, people should see a doctor right away if they experience:

Frequent vomiting Blood in vomit Weight loss or loss of appetite Black tarry stools Difficult or painful swallowing Abdominal pain in a nonepigastric area Indigestion accompanied by shortness of breath, sweating, or pain that radiates to the jaw, neck, or arm Symptoms that persist for more than 2 weeks

Diagnostic Procedures Endoscopy (pronounced /ndskpi/) means looking inside and typically refers to looking inside
the body for medical reasons using an endoscope (pronounced /ndskop/), an instrument used to examine the interior of a hollow organ or cavity of the body. Unlike most other medical imaging devices, endoscopes are inserted directly into the organ. Endoscopy can also refer to using a borescope in technical situations where direct line of-sight observation is not feasible. Abdominal x-ray is an x-ray of the abdomen. The abdominal x-ray is a test that can be carried out quickly and easily in an emergency department. The test can help diagnose some abdominal conditions. It is not a useful investigation for most abdominal conditions. Small and large bowel obstructions, volvulus and malrotations can be diagnosed by AXR. Renal, urethral and bladder stones can sometimes be identified on plain x-ray, although it is usual now to use CT as a first line investigation to confirm clinical suspicion. Gallstones are sometimes noted on x-ray, although ultrasound is the more usual imaging modality used when clinically suspected. Plain abdominal radiography is not usually helpful in diagnosis of appendicitis. Abdominal ultrasonography (also called abdominal ultrasound imaging or abdominal sonography) is a form of medical ultrasonography (medical application of ultrasoundtechnology) to visualise abdominal anatomical structures. It uses transmission and reflection of ultrasound waves to visualise internal organs through the abdominal wall (with the help of gel which helps transmission of the sound waves). For this reason, the procedure is also called atransabdominal ultrasound, in contrast with endoscopic ultrasound, the latter combining ultrasound with endoscopy through visualize internal structures from within hollow organs.

Treatment Some people may experience relief from symptoms of indigestion by

Eating several small, low-fat meals throughout the day at a slow pace Refraining from smoking Abstaining from consuming coffee, carbonated beverages, and alcohol Stopping use of medications that may irritate the stomach liningsuch as aspirin or antiinflammatory drugs Getting enough rest Finding ways to decrease emotional and physical stress, such as relaxation therapy or yoga

The doctor may recommend over-the-counter antacids or medications that reduce acid production or help the stomach move food more quickly into the small intestine. Many of these medications can be purchased without a prescription. Nonprescription medications should only be used at the dose and for the length of time recommended on the label unless advised differently by a doctor. Informing the doctor when starting a new medication is important. Antacids, such as Alka-Seltzer, Maalox, Mylanta, Rolaids, and Riopan, are usually the first drugs recommended to relieve symptoms of indigestion. Many brands on the market use different combinations of three basic saltsmagnesium, calcium, and aluminumwith hydroxide or bicarbonate ions to neutralize the acid in the stomach. Antacids, however, can have side effects. Magnesium salt can lead to diarrhea, and aluminum salt may cause constipation. Aluminum and magnesium salts are often combined in a single product to balance these effects. Calcium carbonate antacids, such as Tums, Titralac, and Alka-2, can also be a supplemental source of calcium, though they may cause constipation. H2 receptor antagonists (h2ras) include ranitidine (Zantac), cimetidine (Tagamet), famotidine (Pepcid), and nizatidine (Axid) and are available both by prescription and over-the-counter. H2ras treat symptoms of indigestion by reducing stomach acid. They work longer than but not as quickly as antacids. Side effects of h2ras may include headache, nausea, vomiting, constipation, diarrhea, and unusual bleeding or bruising. Proton pump inhibitors (ppis) include omeprazole (Prilosec, Zegerid), lansoprazole (Prevacid), pantoprazole (Protonix), rabeprazole (Aciphex), and esomeprazole (Nexium) and are available by prescription. Prilosec is also available in over-the-counter strength. Ppis, which are stronger than h2ras, also treat indigestion symptoms by reducing stomach acid. Ppis are most effective in treating symptoms of indigestion in people who also have GERD. Side effects of ppis may include back pain, aching, cough, headache, dizziness, abdominal pain, gas, nausea, vomiting, constipation, and diarrhea. Prokinetics such as metoclopramide (Reglan) may be helpful for people who have a problem with the stomach emptying too slowly. Metoclopramide also improves muscle action in the digestive tract. Prokinetics have frequent side effects that limit their usefulness, including fatigue, sleepiness, depression, anxiety, and involuntary muscle spasms or movements. If testing shows the type of bacteria that causes peptic ulcer disease, the doctor may prescribe antibiotics to treat the condition.

Scientific Updates
Update on management of functional dyspepsia and psychosomatic disorders
The current understanding of functional dyspepsia and the role of the enteric nervous system in psychosomatic disorders were discussed at a recent Update on Management of Functional Dyspepsia and Psychosomatic Disorders CME symposium held at the Mira Hotel on 19 May, 2011, by Prof. Benjamin WONG, Specialist in Gastroenterology and Hepatology, and President of The Hong Kong Society of Gastroenterology (HKSGE), and Prof. Siu Wa TANG, Emeritus Professor of Psychiatry at the University of California, Irvine, USA, and President of the Hong Kong Society of Biological Psychiatry (HKSBP). Sponsored by Lundbeck Hong Kong, the symposium was co-organized by HKSBP and HKSGE. Prof. Justin WU from the Institute of Digestive Disease, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, and Prof. Jean WOO, Head of the Division of Geriatrics, Department of Medicine and Therapeutics, The Chinese University of Hong Kong chaired the meeting.

Prof. Benjamin WONG

Specialist in Gastroenterology and Hepatology Honorary Clinical Professor Department of Medicine, University of Hong Kong President, The Hong Kong Society of Gastroenterology

Functional dyspepsia (FD) is characterized by chronic or recurrent pain or discomfort centred in the upper abdomen lacking evidence of structural disease likely to explain symptoms. Patients with FD may experience a variety of psychological comorbidities, primarily generalized anxiety disorder (GAD) and major depressive disorder (MDD). While 25% of the general Western population is estimated to suffer from dyspepsia, FD may account for as much as 60% of patients presenting with dyspepsia [1].

FD aetiology remains complex, unclear

FD involves a large web of interacting factors affecting gastrointestinal motility and sensitivity. Reflected in studies showing greater prevalence of anxiety disorders and depression among FD patients than patients with organic dyspepsia [2,3], FD involves a stronger psychosocial component than organic dyspepsia. As a result, patients with FD experience a wide range of psychosomatic manifestations, including panic attacks, sweating, shaking, and restlessness. These symptoms often exacerbate the symptoms of FD, increasing suffering and presenting challenges for treatment. Recent studies have posited disruptions in the signalling of the brain - gut axis hormones ghrelin and orexin as the basis for the gastrointestinal disturbances associated with FD [4,5].

Treatment strategies
While many treatment options exist for FD, pharmacotherapy only benefits some patients. When determining treatment regimens, it is useful to classify a patients FD based on their most predominant symptoms as dysmotility-like, ulcer-like, reflux-like, or non-specific FD. Selecting treatments based on the patients type of FD should result in the greatest chance at symptom relief. For example, a patient with reflux-like or ulcer-like FD will be most likely to respond to treatment with proton-pump inhibitors (PPIs). Classification of FD is supported by recent research underscoring the effectiveness of PPIs in certain subgroups of FD patients (Table) [6]. PPIs still offer marginal benefit over placebo in symptom control for unspecified FD [6]. While patients with organic dyspepsia have a higher prevalence of Helicobacter pylori infection, FD patients do not have a higher prevalence compared to the general population [7], indicating that H. pylori infection does not play a significant role in FD. Despite this, because H. pylori-positive (Hp+) patients are at increased risk of developing gastric cancer, this subgroup of FD patients should be treated for infection. A review of meta-analyses lends some support to the idea that Hp+ FD patients may actually experience some symptom relief when treated for infection [8]. Although studies remain inconclusive, antidepressants may eventually prove useful in reducing the symptoms of GAD and MDD that exacerbate FD symptoms. One meta-analysis showed a relative risk reduction of 0.55 in symptoms among FD patients [9], and a double-blind, randomized, controlled study comparing amitriptyline, escitalopram (Lexapro), and placebo for the treatment of FD is ongoing [10].

Conclusions
The diagnosis, classification, and treatment of FD remains challenging. In addition to gastrointestinal motility disruption and hypersensitivity, patients often suffer from a myriad of psychosomatic manifestations. While current treatment strategies rely heavily on PPIs and H. pylori eradication, antidepressants might also be useful for symptom control.

What is in the future for dyspepsia (indigestion)?

The future of dyspepsia will depend on our increasing knowledge of the processes (mechanisms) that cause dyspepsia. Acquiring this knowledge, in turn, depends on research funding. Because of the difficulties in conducting research in dyspepsia, this knowledge will not come quickly. Until we have an understanding of the mechanisms of dyspepsia, newer treatments will be based on our developing a better understanding of the normal control of gastrointestinal function, which is proceeding more rapidly. Specifically, there is intense interest in intestinal neurotransmitters, which are chemicals that the nerves of the intestine use to communicate with each other. The interactions of these neurotransmitters are responsible for adjusting (modulating) the functions of the intestines, such as contraction of muscles and secretion of fluid and mucus. 5-hydroxytriptamine (5-HT or serotonin) is a neurotransmitter that stimulates several different receptors on nerves in the intestine. Examples of experimental drugs that affect intestinal neurotransmission are sumatriptan(Imitrex) and buspirone (Buspar). These drugs are believed to reduce the responsiveness (sensitivity) of the sensory nerves to what's happening in the intestine by attaching to a particular 5-HT receptor, the 5-HT1 receptor. The 5-HT1 receptor drugs, however, have received only minimal study so far and their role in the treatment of dyspepsia, if any, is unknown

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