Functional dyspepsiaK31.88

Irritable stomach syndrome, also called functional dyspepsia, is one of the most common functional gastrointestinal disorders. The term "dyspepsia" (from Greek: dys = bad, and pepsis = digestion) is used to summarize a spectrum of complaints that the patient localizes in the upper abdomen (between the umbilicus and the xiphoid process) and laterally. According to the Rome IV criteria (Talley NJ 2016), functional dyspepsia is defined by:

• persistent or recurrent dyspepsia for more than three months within the last six months.
• lack of evidence of an organic cause in the endoscopic clarification, which could explain the complaints
• lack of evidence that the dyspepsia is relieved solely by defecation or is associated with stool irregularity (this criterion was introduced to exclude a possible causative irritable bowel syndrome (IBS) for the complaints).

Functional dyspepsia comprises three subtypes with presumably different pathophysiology and etiology (Enck P et al.(2017):

• the postprandial distress syndrome (PDS)
• the epigastric pain syndrome (EPS)
• a subtype with overlapping PDS and EPS features.

Functional dyspepsia affects up to 16% of otherwise healthy individuals in the general population (Ford AC et al.2020). It causes significant direct and especially indirect costs. An average GP practice sees 6-10 RMS patients per week.

Functional dyspepsia is present if no causative structural and biochemically detectable abnormalities are detectable in routine diagnostics, including endoscopy. If the symptoms are refractory to therapy, screening for psychological disorders such as anxiety, depression and stress should also be performed. Caution: About 30 % of all patients with functional dyspepsia also suffer from irritable bowel syndrome (Enck P et al.2017).

Dyspeptic symptoms include (Madisch A et al. 2018):

• epigastric pain and burning sensation (60-70%).
• postprandial feeling of fullness (80 %)
• early satiety (60-70 %)
• feeling of bloating in the upper abdomen (80 %)
• nausea (60 %)
• vomiting (40 %).

Basically, dyspeptic complaints can occur acutely, for example in gastroenteritis, or chronically, whereby organic (e.g. ulcer, reflux disease, esoinophilic duodenitis, pancreatic disease, cardiac and muscular diseases) or functional causes can underlie.

Rational apparative exclusion diagnostics. Esophagogastroduodenoscopy including examination for Helicobacter pylori and ultrasound examination of the abdomen and, in case of additional irritable bowel symptoms, endoscopic clarification of the colon are considered sufficient.

However, the benefit of endoscopy in those patients with typical symptoms of functional dyspepsia is considered minimal. Its use should be limited to those aged 55 years and older or those with prominent features such as weight loss or vomiting (Ford AC et al 2020).

Patients with dyspepsia show causal diseases for the symptoms in 20-30 % of cases during diagnostic workup (Madisch A et al. 2018). Functional dyspepsia (irritable stomach syndrome) is present if no causative structural and biochemically detectable abnormalities are detectable in routine diagnostics including endoscopy. Findings such as gallstones, a hiatal hernia, erosions in the stomach or a "gastritis" do not necessarily explain the complaints and are not exclusion diagnoses (Ford AC et al.2020).

After a gastroscopy, treatment is purely symptomatic. It is important to observe and, if necessary, change eating habits and avoid stress. For example, eating many small meals can be helpful.

Helicobacter pylori therapy: In view of the lack of causal treatment options for functional dyspepsia, Helicobacter pylori therapy is an important, potentially curative treatment option for functional dyspepsia, as recommended by national and international guidelines.

Phytotherapeutics, see also below Phytotherapy internal: Preparations are usually fixed combinations of peppermint and caraway oil as well as mixtures of peasant mustard, wormwood, gentian and angelica root, usually in combination with spasmolytic and sedative extracts such as chamomile, peppermint, caraway, lemon balm and others (Madisch A et al. 2018). see also under Phytotherapy internal.

Antidepressants: Antidepressants are used in cases of treatment failure after the above-mentioned therapies. Tricyclic antidepressants have proven efficacy, whereas serotonin reuptake inhibitors do not.

Psychotherapy: There are also supporting data for psychotherapy, which should be considered in particular in cases of treatment resistance.

It is important to explain the nature of the disorder to the patient in simple and understandable terms, pointing out that functional dyspepsia is a benign but organic clinical picture, which may be based on various disorders.

Further general measures

• Conflict resolution in psychosocial areas
• Promotion of personal responsibility
• relaxation exercises
• therapeutic alliance for long-term care
• psychotherapeutic options

Phytotherapeutic preparations are mostly fixed combinations of peppermint and caraway oil and mixtures of farmer's mustard: Iberis amara totalis, wormwood: Absinthii herba, gentian: Gentianae radix and angelica root, mostly in combination with spasmolytic and sedative extracts such as chamomile: Matricariae flos, peppermint: Menthae piperitae folium, caraway: Carvi fructus, lemon balm: Melissae folium and others (Madisch A et al. 2018).

Success is reported from mallow leaves/flowers(Malvae folium/flos) (Schilcher H 2015) for which ESCOP,WHO recommendations are available. Dosage: 5g drug/day. Prepare crushed drug for infusions. Note: Collect mallow leaves collected by self, dry and use as mallow tea (infus).

Linseed (Lini semen) - indication in empirical medicine (Schilcher H 2015): Freshly ground linseed - soak 3 tablespoons / 500 ml of water overnight. Boil briefly, sieve the excess water in a close-meshed kitchen sieve or cloth made of linen. Press the solid component through the cloth or strainer and remove it from the outside with a spoon. Drink in sips. Effective even if resistant to PPI, some of which are controversial, no side effects.

Due to mutagenic and carcinogenic side effects not without reservation Calami rhizoma.

In empirical medicine - also comfrey root: Symphyti radix.

The most commonly prescribed drugs were:

• phytotherapeutics (88.2%)
• proton pump inhibitors (PPI, 73.6%)
• Prokinetics (61.5%).
• Antacids, digestive enzymes of the stomach and pancreas 10-20%.
• The treatment failure rate was estimated to be 21-40%.

1. Enck P et al.(2017) Functional dyspepsia. Nat Rev Dis Primers 3:17081.
2. Fan K et al.(2017) Functional dyspepsia and duodenal eosinophilia: A new model. J Dig Dis 18:667-677
3. Ford AC et al.(2020) Functional dyspepsia. Lancet 396:1689-1702.
4. Madisch A et al. (2018) Diagnosis and therapy of functional dyspepsia. Dtsch Arztebl Int 115:: 222-232.
5. Moayyedi P (2012). Dyspepsia. Curr Opin Gastroenterol 28:602-607.
6. Mounsey A et. al.(2020) Functional dyspepsia: evaluation and management. Am Fam Physician 101:84-88.
7. Schilcher H (2015) Plant profiles. In: guide to phytotherapy. Urban and Fischer Publishers Munich, p. 203
8. Talley NJ (2016) Functional dyspepsia. Curr Opin Gastroenterol 32:467-473.