2 English reference functional dyspepsia [National Guidelines for Clinical Application of Essential Drugs: 20 12 Edition]. Chemicals and biological products]
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Overview Functional dyspepsia (FD) refers to a group of persistent or recurrent dyspeptic symptoms centered on the upper abdomen, including upper abdominal discomfort, pain, fullness, early satiety, loss of appetite, organic diseases [1] (such as gastrointestinal tract, hepatobiliary tract, pancreas, etc.). ) can cause corresponding symptoms, through laboratory examination and imaging examination. 59860.6886868866 1
Functional dyspepsia can be divided into two types: ① postprandial discomfort syndrome; ② Upper abdominal pain syndrome [1].
Symptoms of functional dyspepsia can persist or recur, and the onset time of symptoms exceeds 1 month every year.
4 disease name functional dyspepsia
5 English name functional dyspepsia
6 functional dyspepsia alias functional dyspepsia
7 disease classification > gastroenterology; Gastroduodenal diseases >: other diseases of the stomach
8 ICD number K3 1.8
9 Epidemiological data of functional dyspepsia Functional dyspepsia is the most common functional gastrointestinal disease in clinic. Epidemiological surveys in Europe and America show that the general population has dyspeptic symptoms accounting for 19% ~ 4 1%, and the incidence rate in China is 20% ~ 30%.
Etiology of functional dyspepsia 10 Functional dyspepsia may be related to gastric motility and sensory disturbance, abnormal gastric acid secretion, Helicobacter pylori infection and duodenitis, mental stress and environmental factors. Healthy people show characteristic migrating complex motion waves (MMC) during the interdigestive period, in which MMC ⅲ plays an important role as a scavenger. After a meal, the proximal stomach relaxes adaptively to accommodate food, while the distal stomach contracts and squirms, digesting food and turning it into fine particles. The coordinated movement of gastric antrum, pylorus and duodenum plays an important role in the process of emptying. Dyskinesia of gastric antrum, pylorus and duodenum in FD patients exists not only in digestive period, but also in interdigestive period. The latter includes decreased frequency of MMC ⅲ, decreased motility of MMC ⅱ, duodenogastric reflux and so on. Therefore, patients have symptoms on an empty stomach, which do not relieve or even worsen after meals.
Pathogenesis of functional dyspepsia 1 1 The etiology and pathogenesis of functional dyspepsia are not completely clear, which may be related to many factors. At present, it is considered that upper gastrointestinal motility disorder is the main pathophysiological basis, and mental factors and stress factors have always been considered to be closely related to its pathogenesis. FD patients have abnormal personality, and the scores of anxiety and depression are significantly higher than those of normal people and duodenal ulcer group.
12 Clinical manifestations of functional dyspepsia 12. 1 Symptoms of functional dyspepsia include upper abdominal pain, upper abdominal distension, early satiety, belching, loss of appetite, nausea and vomiting. Most of them are symptoms of a certain 1 group or a certain 1 group, lasting or accumulating for at least 4 weeks/year. The onset is slow, and the course of disease often lasts for several years, showing persistent or repeated attacks. Many patients are induced by factors such as diet and spirit. Some patients are accompanied by insomnia, anxiety, depression, headache, inattention and other mental symptoms, and there are no wasting diseases such as anemia and emaciation. FD is clinically divided into three types: ulcer type (mainly upper abdominal pain and acid regurgitation), dyskinesia type (mainly early satiety, loss of appetite and abdominal distension) and atypical type.
12.2 signs The signs of functional dyspepsia are mostly nonspecific, and most patients have tenderness or discomfort in the upper abdomen.
Complications of functional dyspepsia 13 If the clinical symptoms of functional dyspepsia (early satiety, loss of appetite, nausea, vomiting, etc. ) can not be alleviated, vitamin deficiency and hypoproteinemia may occur.
14 Diagnostic criteria for functional dyspepsia 14. 1 Diagnostic criteria for functional dyspepsia must include the following two items [1]:
(1) The patient has one or more of the following four symptoms [1]:
1) fullness and discomfort after meals;
2) early satiety;
3) stomachache;
4) There is a burning sensation in the upper abdomen.
(2) There is no evidence of structural diseases to explain the above symptoms [1]. The diagnosis can only be made if the medical history is at least 6 months and nearly 3 months [1].
1) Endoscopic examination showed that there were no ulcer, erosion and tumor lesions in esophagus, stomach and duodenum, and there was no such history.
2)B-ultrasound, X-ray, CT, MRI and related laboratory tests ruled out hepatobiliary and pancreatic diseases.
3) No psychosis, connective tissue diseases, endocrine and metabolic diseases and kidney diseases.
4) No history of abdominal surgery.
Subtype diagnostic criteria are [1]:
(1) Postprandial discomfort syndrome
Either of the following two items must be included [1]:
1) occurs several times a week after eating a normal meal [1];
2) Early satiety makes patients unable to finish their usual meals, which occurs several times a week. Other symptoms may include bloating of the upper abdomen, nausea and excessive burping. [ 1]
(2) Upper abdominal pain syndrome
All the following conditions must be included [1]:
1) At least moderate upper abdominal pain or burning sensation, at least once a week [1];
2) The pain is intermittent [1];
3) Do not spread or appear in other areas of abdomen and chest [1];
4) Not relieved after defecation or exhaust [1];
5) It does not meet the diagnostic criteria of gallbladder or Oddi sphincter dysfunction [1].
14.2 Laboratory examination 14.2. 1 Determination of fat in feces Quantitative analysis of fat is a simple and reliable test for the diagnosis of steatorrhea. Normal people excrete less than 6 g of fat in feces within 24 hours, or the fat absorption coefficient is greater than 94%; In the absorption test of 14C triolein, normal people exhaled more than 3.5% of the given quantitative marker every hour.
Abnormal absorption of vitamin B 14.2.2 Schilling test often indicates terminal ileal lesions, and patients with pancreatic exocrine dysfunction are often accompanied by vitamin B 12 absorption disorders. Schilling test is also helpful to diagnose bacterial overgrowth in small intestine, especially blindness syndrome, scleroderma and multiple small intestinal diverticula. For example, the 1 and 2 parts of Schilling test are abnormal in blind ring syndrome. After proper antibiotic treatment, Schilling test can return to normal.
14.3 auxiliary examination 14.3. 1 imaging examination b-ultrasound, endoscopy and other imaging examinations (including x-ray, CT, MRI, etc. ), its significance lies in excluding organic diseases, which is beneficial to distinguish from organic diseases such as gastric and duodenal ulcers, esophagitis, hepatobiliary and pancreatic diseases, tumors and so on. X-ray and MRI imaging techniques can also reflect the gastric emptying rate at different times to some extent.
14.3.2 radionuclide scanning is considered as the gold standard for determining gastric emptying, and 25% ~ 50% of patients have prolonged gastric emptying time, mainly solid food.
15 When diagnosing patients with functional dyspepsia from diseases that need to be differentiated from functional dyspepsia, organic dyspepsia must be ruled out, and the latter can show related causes through relevant examinations, such as peptic ulcer, erosive gastritis, esophagitis and malignant diseases. FD should be differentiated from the following diseases.
15. 1 Chronic gastritis Symptoms and signs of chronic gastritis are difficult to distinguish from FD. Gastroscopy found that the gastric mucosa was obviously congested, eroded or bleeding, and even atrophic changes, which often suggested chronic gastritis.
15.2 Periodic and rhythmic pain of peptic ulcer can also be seen in FD patients. The diagnosis of peptic ulcer can be confirmed by X-ray barium meal and gastroscopy.
Chronic cholecystitis 15.3 chronic cholecystitis often coexists with gallstones, and may also have indigestion symptoms such as fullness, nausea and belching in the upper abdomen. Abdominal ultrasound, oral cholecystography, CT and other imaging examinations can often find signs of gallstones and cholecystitis, which can be distinguished from FD.
15.4 Other functional dyspepsia needs to be differentiated from other secondary gastric motility disorders, such as diabetic gastroparesis and gastrointestinal neuromuscular diseases, which can generally be differentiated by their characteristic clinical manifestations and signs.
16 the treatment of functional dyspepsia is mainly symptomatic treatment, and the principles of comprehensive treatment and individualized treatment should be followed.
Patients with alarm symptoms, such as progressive dysphagia, persistent vomiting, weight loss, unexplained anemia, jaundice, etc. It should be suggested to go to a tertiary general hospital or a specialized hospital for diagnosis and treatment, and improve the gastroscopy [1]. The pathogenesis of functional dyspepsia is not clear, but psychological factors and visceral hypersensitivity play a role in the pathogenesis. In the process of treatment, patients should be guided to manage themselves and adjust their emotions [1].
16. 1 the principle of treatment is mainly symptomatic treatment, and the principles of comprehensive treatment and individualized treatment should be followed.
16.2 establish good living habits in general treatment, avoid smoking, drinking and taking non-steroidal anti-inflammatory drugs, and avoid food that can induce symptoms in personal life experience; Pay attention to psychotherapy according to the different characteristics of patients to eliminate their fears and doubts about the disease; Patients with insomnia and anxiety can take appropriate sedative and hypnotic drugs orally before going to bed.
16.3 there is no specific medicine for functional dyspepsia, but mainly empirical symptomatic treatment.
16.3. 1 gastric acid secretion inhibitor is suitable for patients with abdominal pain with acid reflux as the main symptom. Basic antacids or acid secretion inhibitors can be selected, such as H2 receptor antagonists such as cimetidine or proton pump inhibitors such as omeprazole.
16.3.2 gastrointestinal motility promoting drugs are suitable for patients with abdominal distension, early satiety and belching as the main symptoms. Domperidone is a peripheral dopamine receptor blocker. The usual dosage is 10mg, taken three times a day before meals 15min. Cisapride is a 5- hydroxytryptamine receptor agonist, with a dose of 5 ~ 10 mg, taken three times a day before meals 15 ~ 30 min, and the course of treatment is 2 ~ 8 weeks. However, cisapride can cause abdominal sounds, loose stool or diarrhea, abdominal pain, prolonged QT interval of myocardium and other side effects, so it is rarely used now, so patients with heart disease should use it with caution. Metoclopramide is a central and peripheral dopamine receptor blocker. Because long-term use of extrapyramidal drugs has great side effects, it has been rarely used or not used. In recent years, new gastrointestinal motility enhancers, such as mosapride and etobili, can also be selected. The usual dosage of mosapride is 5mg each time, 3 times a day, before meals 1/2 hours. For those with poor curative effect, gastric acid secretion inhibitor and gastrointestinal motility promoter can be used alternately or in combination.
16.3.3 Anti-Helicobacter pylori treatment FD patients with a small amount of Helicobacter pylori infection should use drugs to kill Helicobacter pylori, generally using two or three drugs.
16.3.4 antidepressants. Those with poor curative effect and obvious symptoms such as anxiety, tension and depression can try antidepressants, but the effect is slow. Commonly used drugs are bicyclic antidepressants, such as amitriptyline 25mg, 2 ~ 3 times a day; Antidepressants with anti-serotonin effect, such as fluoxetine 20mg, 1 time /d, should start with a small dose, and pay attention to the side effects of the drugs.
16.3.5 Other available mucosal protective agents, such as aluminum hydroxide gel, bismuth agent, sucralfate, Maizilin S, etc.
16.3.6 regimen 16.3.6. 1 domperidone can be taken orally at the onset of symptoms, 10mg, three times a day [1]. Take15 [1] 30 minutes before meals. Domperidone can promote gastric peristalsis, but it is forbidden for patients with upper gastrointestinal bleeding and intestinal obstruction [1].
Or oral metoclopramide, 5 ~ 10 mg, three times a day. At the same time, oral lactase 0.3~0.9g, three times a day, before meals, can be taken for a long time [1]. The serious side effects caused by metoclopramide include drowsiness, restlessness, fatigue and weakness, so metoclopramide should be stopped immediately and gastric lavage can be carried out within 6 hours [1]. Atropine 1 ~ 2 mg was given to the severely ill patients, and intravenous fluid infusion promoted excretion [1]. People with mild symptoms can drink more warm water [1]. This product is easy to cause nervous system symptoms when used with phenothiazine or butylbenzene, and should be avoided [1].
16.3.6.2 patients with epigastric pain can take compound aluminum hydroxide, 2 ~ 4 tablets, three times a day, and chew it half an hour before meals or after the onset of stomachache [1]. Continuous use shall not exceed 7 days [1]. Taking a large amount of aluminum hydroxide for a long time can cause severe constipation, and fecal caking can cause intestinal obstruction [1]. Stop taking medicine, and in severe cases, relieve constipation and clear intestines to treat intestinal obstruction [1]. Appendicitis, acute abdomen and those allergic to this drug are prohibited [1].
Ranitidine can also be taken orally, 150mg, twice a day; Or 300mg, take 1 time before going to bed [1]. Or famotidine orally, 20mg for adults, no more than twice a day [1].
Other commonly used drugs in clinic: omeprazole [1] is optional.
17 The prognosis of functional dyspepsia is treated by internal medicine, and most patients with functional dyspepsia have a good prognosis.
18 related drugs glycerin, vitamin B 12, cimetidine, omeprazole, domperidone, dopamine, cisapride, oxygen, metoclopramide, mosapride, amitriptyline, fluoxetine, aluminum hydroxide, sucralfate.
19 correlation test