Functional Dyspepsia, 2016

Nicholas J. Talley; Marjorie M. Walker; Gerald Holtmann

Disclosures

Curr Opin Gastroenterol. 2016;32(6):467-473. 

In This Article

Infection and Immune Dysregulation

It is now established that the incidence of either upper, lower, or both upper and lower functional gastrointestinal disorders (FGIDs) is increased following an infection. Gutiérrez et al.[17] recently reported, in a retrospective cohort study of the United States military post Clostridium difficile infection, that there was a significant three-fold risk of incident functional dyspepsia symptoms as well as an increased risk of new onset GERD (three-fold) and IBS (six-fold). These data support the concept that functional dyspepsia, GERD, and IBS all form part of the postinfection spectrum and can overlap.

Although most of the postinfection studies have focussed on bacterial infections in the gut, Wensaas et al.[18] report that 3 years following an outbreak of giardiasis, the risk of both functional dyspepsia and IBS was increased (respectively, four-fold and three-fold). Giardiasis is generally a proximal gut infestation. Spiller[19] has speculated that postinfection, the extent of the acute inflammatory process may be key to the symptom outcome; if only the stomach or proximal small intestine is affected, dyspepsia may develop in those genetically predisposed, whilst if the distal small intestine or colon is involved, IBS may develop; the more extensive the inflammation, the higher the risk of developing both functional dyspepsia and IBS. This hypothesis is testable and remains attractive.

H. pylori is a cause of functional dyspepsia, but the decision to treat must be individualized, as Du et al.[20] point out in a meta-analysis that summarizes the literature to include 5555 patients and 25 trials. The meta-analysis confirms that there are a minority who respond to eradication therapy long term (a year or longer), although quality of life appears not to significantly improve. A further benefit of eradication therapy in functional dyspepsia is the prevention of peptic ulceration in a significant number of cases, but those given eradication therapy also have more treatment-related side-effects. Overall, the data support offering eradication therapy to infected functional dyspepsia cases, but patients need to be informed about the risk benefit and understand that only a minority will obtain symptom relief.

The Kyoto H. pylori[21] global consensus report recommended that H. pylori-associated dyspepsia (defined as the subset of patients who have functional dyspepsia-like symptoms and H. pylori, and 1 year after successful H. pylori eradication have symptom resolution) should be classified separately from those with 'true functional dyspepsia' who are infected but fail to respond to therapy despite bacterial eradication. This conclusion was adopted by the Rome IV Working Team and is described as H. pylori dyspepsia (HpD).[4]

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