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Functional Gastroduodenal Disorders (Rome III Diagnostic Criteria)

Discuss the diagnosis of Functional dyspepsia?

1. Functional dyspepsia (FD)

Diagnostic criteria* must include:  One or more of the following:

  • Bothersome postprandial fullness
  • Early satiation
  • Epigastric pain
  • Epigastric burning

AND

No evidence of structural disease (including at upper endoscopy) that is likely to explain the symptoms
* Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis

PS- A gastric-emptying study (e.g., scintigraphy) is not currently recommended as a routine clinical test because the results uncommonly alter management. Recent studies have shown that less than 25% of patients with FD have delayed gastric emptying.

Postprandial distress syndrome and Epigastric pain syndrome are sub classified under functional dyspepsia

1a. Postprandial Distress Syndrome

Diagnostic criteria* must include one or both of the following:

  • Bothersome postprandial fullness, occurring after ordinary-sized meals, at least several times per week
  • Early satiation that prevents finishing a regular meal, at least several times per week

* Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis

Supportive criteria

  • Upper abdominal bloating or postprandial nausea or excessive belching can be present
  • Epigastric pain syndrome may coexist


1b. Epigastric Pain Syndrome

Diagnostic criteria* must include all of the following:
Pain or burning localized to the epigastrium of at least moderate severity, at least once per week

  • The pain is intermittent
  • Not generalized or localized to other abdominal or chest regions
  • Not relieved by defecation or passage of flatus
  • Not fulfilling criteria for gallbladder and sphincter of Oddi disorders

* Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis

Supportive criteria

  • The pain may be of a burning quality, but without a retrosternal component
  • The pain is commonly induced or relieved by ingestion of a meal, but may occur while fasting
  • Postprandial distress syndrome may coexist

Discuss the treatment of FD disorders?

  • Stopping smoking and ceasing consumption of coffee, alcohol, or NSAIDs is commonly recommended, but there is no convincing evidence of efficacy.
  • Although it seems plausible to recommend taking several small low-fat meals per day, this has not been formally investigated.
  • H. Pylori eradication may be helpful
  • Acid suppression is safe and remains first-line therapy in the absence of H. pylori infection; an adequate trial of therapy should be given and stepped up if unsuccessful initially.
  • Prokinetic drugs like metoclopramide and domperidone appear efficacious in functional dyspepsia compared with placebo but have been poorly studied.
  • The value of antidepressants in FD is not established. In 1 crossover trial of 7 patients, amitryptiline in low doses improved symptoms but not visceral hypersensitivity or sleep.

Discuss the diagnosis of functional belching disorders?

1a. Aerophagia
Diagnostic criteria* must include all of the following:

  • Troublesome repetitive belching at least several times a week
  • Air swallowing that is objectively observed or measured

* Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis

1b. Unspecified Excessive Belching
Diagnostic criteria* must include all of the following:

  • Troublesome repetitive belching at least several times a week
  • No evidence that excessive air swallowing underlies the symptom

* Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis

Discuss the treatment of belching disorders?

Dietary modification (avoiding sucking candies or chewing gum, eating slowly and encouraging small swallows, and avoiding carbonated beverages) is often recommended but has not been rigorously tested.
Behavioural therapy seems helpful in some cases, but clinical trials are lacking.

Discuss the diagnosis of functional nausea and vomiting disorders?

1a. Chronic Idiopathic Nausea

Diagnostic criteria* must include all of the following:

  • Bothersome nausea occurring at least several times per week
  • Not usually associated with vomiting
  • Absence of abnormalities at upper endoscopy or metabolic disease that explains the nausea

* Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis

1b. Functional Vomiting

Diagnostic criteria* must include all of the following:

  • On average one or more episodes of vomiting per week
  • Absence of criteria for an eating disorder, rumination, or major psychiatric disease according to DSM-IV
  • Absence of self-induced vomiting and chronic cannabinoid use and absence of abnormalities in the central nervous system or metabolic diseases to explain the recurrent vomiting

* Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis

1c. Cyclic Vomiting Syndrome
Diagnostic criteria must include all of the following:

  • Stereotypical episodes of vomiting regarding onset (acute) and duration (less than one week)
  • Three or more discrete episodes in the prior year
  • Absence of nausea and vomiting between episodes

Supportive criterion
History or family history of migraine headaches

Although it is rare, adults may develop cyclical vomiting in middle age, and both men and women are affected. Only 1 in 4 adults had a history of migraine headaches. Adults have a mean of 4 cycles of vomiting per year, with a mean duration of 6 days (range, 1–21) and an average symptom-free interval of 3 months (range, 0.5–6). The mechanisms underlying functional and cyclic vomiting remain unknown.

The treatment of chronic idiopathic nausea is not defined. Anti nausea drugs provide limited benefit empirically. Low-dose tricyclic antidepressant therapy may be helpful anecdotally.

Discuss the diagnosis of rumination syndrome in Adults?

Diagnostic criteria must include both of the following:

  • Persistent or recurrent regurgitation of recently ingested food into the mouth with subsequent spitting or remastication and swallowing
  • Regurgitation is not preceded by retching

Supportive criteria

  • Regurgitation events are usually not preceded by nausea
  • Cessation of the process when the regurgitated material becomes acidic
  • Regurgitant contains recognizable food with a pleasant taste

Discuss rumination syndrome?
Although initially described in infants and the developmentally disabled, it is now widely recognized that rumination syndrome occurs in males and females of all ages and cognitive abilities. In general, rumination is more common in females than males.
Rumination syndrome is a probably underappreciated condition in adults who are often misdiagnosed as having vomiting secondary to gastroparesis or gastroesophageal
reflux or anorexia or bulimia nervosa.
Typical clinical features include the following:

  • Repetitive regurgitation of gastric contents beginning within minutes of the start of a meal; this is to be contrasted with the typical history of vomiting in the later postprandial period in patients with gastroparesis.
  • Episodes often last 1–2 hours.
  • The regurgitant consists of partially recognizable food, which often has a pleasant taste according to the patients.
  • The regurgitation is effortless or preceded by a sensation of belching immediately before the regurgitation or arrival of food in the pharynx.
  • Regurgitation may be preceded by brisk voluntary contraction of the abdominis rectus.
  • There is usually lack of retching or nausea preceding the regurgitation.
  • Patients make a conscious decision regarding the regurgitant once it is present in the oropharynx. The choice may depend on the social situation at the time. Rumination is typically“meal-in, meal-out, day-in, day-out” behaviour.

Pathophysiological mechanisms involved in rumination syndrome remain somewhat unclear, although all observations suggest some adaptation of the belch reflex that overcomes the resistance to retrograde flow provided by the lower oesophageal sphincter.

Reassurance, explanation, and behavioural therapy are currently the mainstays of treatment in adolescents and adults of normal intelligence with rumination syndrome. The preferred behavioural treatment for rumination syndrome consists of habit reversal by using diaphragmatic breathing techniques to compete with the urge to regurgitate.

Ref

  1. http://www.romecriteria.org/criteria/
  2. Drossman DA. The functional gastrointestinal disorders and the Rome III process. Gastroenterology 2006: 130(5):1377-90



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