Sunday, September 18, 2016

Functional Dyspepsia

Background :
Up to 40% of persons who have functional dyspepsia consult a physician, and the condition negatively affects attendance and productivity in the workplace.
Functional dyspepsia has substantial financial implications for patients, health care organizations, and society as a whole; costs associated with the condition in the United States in 2009 were in excess of $18 billion.

Definition :
Dyspepsia is a constellation of symptoms referable to the gastroduodenal region of the upper gastrointestinal tract.
Functional dyspepsia à a sensation of pain or burning in the epigastrium, early satiety (inability to finish a normal-sized meal), fullness during or after a meal, or a combination of these symptoms (Rome III Classification )
Rome III Classification : The criteria should be fulfilled for the last three months with symptom onset at least six months before diagnosis.

Dyspepsia : Organic vs Functional
Symptom alone cannot differentiate functional or organic causes
80% person with functional dyspepsia related with ingestion of meal
In most cases, the cause can be clarified by means of upper gastrointestinal endoscopy, a test that generally shows that less than 10% of patients with dyspepsia have a peptic ulcer, less than 1% have gastroesophageal cancer, and more than 70% have functional dyspepsia

H.Pylori associated Dyspepsia
Who do not alarm symptom à back ground H.pylori prevalence
Biopsy, HpSA, anti H.pylori IgG , Urea Breath Test
Recommended test if prevalence at that area > 10 %
Study 5 big centers in Indonesia (Jakarta, Surabaya, Jayapura, Makassar, Pontianak and Medan) 
Overall Indonesian prevalance  22.1 %

Confusional diagnosis based on symptom
GERD à retrosternal burning pain, regurgitation of acid into the mouth
Irritable Bowel Syndrome à lower abdominal discomfort or pain associated with a change in stool form or frequency

Dyspepsia symptoms overlapping with GI problems
Heart burn with Dyspepsia à related with failure of the gastric fundus to relax properly
Functional Dyspepsia with lower GI symptom such as diarrhea or constipation
Functional dyspepsia vs gastroparesis à proven by gastric scintigraphy

1. EPIGASTRIC PAIN SYNDROME : intermittent pain or burning in the epigastrium, occurring at least once per week
2. POSTPRANDIAL DISTRESS SYNDROME : occurrence at least several times per week of bothersome postprandial fullness occurring after normal-sized meals or by early satiety that prevents the person from finishing a regular meal

Patophysiological Features of Functional dyspepsia

  • Psychological distress, particularly anxiety
  • Genetic : weak connection
  • Slow gastric emptying
  • Fundic disaccommodation: Failure Gastric fundus to relax after a meal
  • Gastric acomodation failure: Transient relaxations of LES
  • Duodenal hypersensitivity / duodenal eosinophilia : smoking related
  • Infection : Salmonella, E. Coli, Giardia, Norovirus
  • Proximal small intestine inflamed (on the other hand distal small intestine  colon inflammation related with IBS)
  • High-fat meal
Treatment : H.Pylori therapy

Treatment : Acid suppressant therapy
PPI à effective for epigastric pain syndrome classification, but not for dysmotility type dyspepsia
In general, twice daily PPIs are no better than once daily PPIs for the treatment of functional dyspepsia and twice daily dosing should be discouraged
Histamine H2 antagonist à effect small compare PPI
Antacids, bismuth and sucralfate à not efficacious

Treatment : Prokinetic
Mostly for dyspepsia with related with abnormalities in gastric motility and fundal accomodation

  • Cisapride à Withdrawn (sudden death effect)
  • Domperidone ; Itopride
  • Metochlorpropamide  Not routinely used (irreversible tardive dyskinesia), less effective
  • Acotiamide : acetylcholinesterase accelerates gastric emptying and enhance gastric accomodations
  • Buspirone (if delayed fundus empyting)

Treatment : Antidepressant
Tricyclic antidepressants should be considered in patients with functional dyspepsia and persistent symptoms despite PPI therapy for eight weeks
Amitryptilline à tricyclic antidepressant à more preffered compare SSRI
Start with 10 to 25 mg at night time, continue to 8 to 12 weeks before stop it due to ineffective, but may continue about 6 months, before try to stop it
Other meds : Escitalopram, Setraline, Mirtazapine

Treatment : Alternative Psychological
10 weeks psychotherapy
Iberogast (STW5)

Management of Refractory Functional dyspepsia
Combination acid suppresion with prokinetic agent
Combination drug therapy and psychological treatment
Anti psychotic drug (levosulpride) , or add anxiolyitc (buspirone) with tricyclic anti depressant.

50 % resolved the problem
30 -35 % fluctuating symptom
15-20 % patient will have persistent syndrome

Saturday, May 12, 2012

Chronic hepatitis B EASLD

4 phases of natural history chronic hepatitis B
1. Immune tolerance
2. Immune clearance
3. Inactive carrier/ Immune control
4. Reactivation/ Immune escape

Candidate for treatment :
1. Immune clearance
2. Reactivation phase/ Immune escape

Clinical guideline for antiviral treatment EASL 2009:
1. Serum HBV DNA is above 2000 IU/ml, and/or
 2. Serum ALT levels are above the upper limit of normal , and
3. Liver biopsy shows moderate to severe active necroinflammation and/or fibrosis using a standardized scoring e.g > A2 and/or > F2 when using METAVIR score

For comparison form other guidelines:

Total of 6 drugs are available for treatment of hepatitis B :

Recommendation Asian Pacific consensus 2008 to stop treatment for anti viral are :
- In HBeAg-positive patients, treatment can be stopped if HBeAg seroconversion and undetectable HBV DNA
- In HBe-Ag negative, it is not clear how long this treatment should be continues, but the treatment can be considered to discontinue if undetectable HBV DNA has been documented on 3 occasions at least 6 months apart.

Once starting medication, the monitor should as follows :
1. Patient’s condition
2. ALT 3. If using Nucleoside analogue : only HBV DNA monitoring If using interferon(the expectation is seroconversion HBeAg) : HBV DNA + Quantitative HBs Ag on 12 weeks and 24 weeks after treatment

Friday, April 6, 2012

New Hope for GERD patient

The FDA has approved a single-use, surgically-installed device for the treatment of gastroesophageal reflux disease (GERD) for patients whose symptoms persist despite use of maximum lifestyle and medical therapy.

The LINX Reflux Management System is made up of a series of magnetic titanium beads connected with independent titanium wires in a ring shape. The device is implanted in the lower esophageal sphincter to prevent the backflow of stomach contents.

Magnets in the titanium beads help keep weak lower esophageal sphincters closed by overcoming pressure created by swallowing forces, while expanding to accommodate normal swallowing of food or drink, according to a statement from the FDA.

Manufacturer Torax Medical showed device efficacy in two studies totaling 144 patients with GERD and chronic GERD symptoms despite prior therapy. Results of the studies showed benefits of the implant outweighed risks, the FDA said.

Product approval also requires Torax to institute a training program for healthcare professionals in patient selection, device implantation, and post-procedural care for patients.

Adverse events with the device included difficulty swallowing, pain when swallowing food, chest pain, vomiting, and nausea.

Patients receiving the LINX implant cannot undergo MRI because the magnetic beads will cause interference, and there is a potential for damage to the device and the patient.

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