Functional Dyspepsia Review in NEJM 2015

imgresNEJM has a great article here – a summary of latest/greatest on Functional Dyspepsia. An often frustrating diagnosis.

Key Points: 1) Watch out for alarm symptoms, such as dysphagia that is progressive, melena, fam hx of esophageal cancer, iron deficiency anemia, weight loss, etc, but keep in mind that these are of very limited value. The sensitivity of alarm symptoms varied from 0% to 83% with considerable heterogeneity between studies. The specificity also varied significantly from 40% to 98%.

2) Classification may be useful, but probably isn’t – Postprandial distress syndrome versus Epigastric Pain syndrome.  Mainly here to highlight that some of these patients will have issues with gastric emptying.  86% of patients with gastroparesis will have dyspepsia.

3) Pathophysiology – no clear answer here, mostly magical thinking and theories. Probably a link between Brain-Stress-Epithelial Permeability- Eosinophils-Duodenum Sensitivity- etc. etc. etc.

4) Rate of response to placebo is ~40%.

5) The NNT for H.pylori eradication is 15. But only 5% of functional dyspepsia cases will be positive.

6) The NNT for acid suppression/PPI therapy is 10. But most trials with acid suppression happened before Rome III criteria were out, so maybe not.

7) Prokinetic agents are either dangerous, or do not work.

8) Complementary and Alternative Therapies are bogus.

9) Natural history is chronic and fluctuating.

10) Proposed Treatment Algorythm is acceptable.

Bottom Line: Article has great references. No new stuff, but good summary of what we know. File under teaching reference.