Click here to view next page of this article Heartburn and DyspepsiaDyspepsia is abdominal pain in the upper gut not explained by a structural abnormality. Dyspepsia is terribly common, affecting about 15% of the population. So we will walk out of here - 10% have IBS, 15% have dyspepsia. Unfortunately many have both. We know that most people with dyspepsia in the community actually don’t have peptic ulcer disease or esophagitis. When they come to investigation, about 2/3 of them have functional dyspepsia and this is true in the community as well. If you actually do endoscopy on people with dyspepsia in the community, maybe 12% have esophagitis, 8% have peptic ulcer disease. The rest don’t have either. The vast majority of dyspepsia out in the community is functional dyspepsia. Now the pathophysiology and functional dyspepsia is very similar to the pathophysiology of irritable bowel and we are looking at - is it a motor problem, a sensory problem, a psychological problem. There are a couple nuances to dyspepsia - this whole issue of H-pylori and occult gastroesophageal reflux. At the present time, how are we approaching our patients with dyspepsia? Now the key here is providing reassurance. In these people, many are afraid that they have cancer or something sinister, and doing an investigation which usually involves either an upper GI or endoscopy to relieve them from that fear. Most of these people have already been on some trial of acid inhibition, that is just the standard approach in the United States, and so these people have already been through that. So we want to look at is H-P eradication useful, proton pump inhibitor for occult reflux, prokinetic, or trial of low-dose antidepressants. These are the paths that we have been taking most recently. Is H-P eradication helpful in NUD? The controversy persists, and if you saw the New England Journal articles in December, we did not resolve this controversy. At the same time, we had another study, large scale clinical trial omeprazole antibiotics versus placebo and here 23% responded in the treatment group, 22% in the placebo group, and this of course is not clinically significant and it got buried in a session on DDW. The issue here though, really comes out to placebo response rates and this is always a problem in dyspepsia research. The placebo response rates vary between trials. Is it worth eradicating H-pylori in dyspepsia. Well I have to confess that I fell, if you have gone this far it is worth trying. You can almost justify H-P eradication on the basis of cancer prevention and so although we do not have great data, we have data as good for H-pylori as we do for many of the things we are doing for dyspepsia. We really should also remember using prokinetics in clinical trials. They frequently have been used in Europe, at least 14 trials with cisapride, and the efficacy is usually greater than that of placebo, but again you can see the tremendous difference in the placebo response rates against studies. We do not have Domperidone in the United States but it is in many ways similar in its efficacy to that of cisapride. Now what has been the big issue in the past year has been the reported toxicity of cisapride. So, in the future we will be looking at other therapies, improving a combination reducing sensation. We focus a lot in dyspepsia on the systolic function of the stomach. What we hope to look for in the next five years is increasing attention on the diastolic dysfunction, if you would, of the stomach, and looking at some new agents or even old agents. |