Der Internist

, Volume 47, Issue 6, pp 568–577 | Cite as

Funktionelle Dyspepsie – eine Verlegenheitsdiagnose?

Schwerpunkt: Dyspepsie, Gastritis, Ulkusleiden

Zusammenfassung

Der Begriff Dyspepsie umfasst ein breites Spektrum von v. a. im Oberbauch lokalisierter Beschwerden wie Schmerz, Völlegefühl, Übelkeit, vorzeitiges Sättigungsgefühl und Meteorismus. Wenn mit den in der klinischen Praxis verfügbaren Untersuchungsverfahren keine Ursache nachweisbar ist, ist die Diagnose einer funktionellen Dyspepsie gerechtfertigt. Dies trifft bei weitaus mehr als 50% aller Patienten mit derartigen Symptomen zu. Der Ausschluss einer lebensbedrohlichen Erkrankung, die Vermittlung der Diagnose und eines Krankheitskonzepts, das vom Patienten verstanden wird, sind eine wichtige und oft ausreichende Behandlung. Diätetische Empfehlungen können hilfreich sein. Angesichts der ausgeprägten psychiatrischen Komorbidität ist eine begleitende psychosomatische Behandlung oft wichtiger Bestandteil der Therapie. Zur medikamentösen Therapie der funktionellen Dyspepsie werden verschiedene Substanzklassen, für die aufgrund kontrollierter Studien eine Wirksamkeit angenommen wird, eingesetzt. Dazu zählen Protonenpumpeninhibitoren, Prokinetika, oberflächenaktive Substanzen wie Simethicon, trizyklische Antidepressiva sowie bestimmte Phytopharmaka. Mit den genannten Pharmaka kann bei bis zu 80% der Patienten eine Linderung der Symptome erreicht werden. Der Stellenwert der H. pylori-Eradikation wird in der Therapie der funktionellen Dyspepsie allgemein überschätzt und bislang gibt es keine Therapie, die zu einer dauerhaften Heilung führt. Linderung der Symptome ist Ziel der Behandlung.

Schlüsselwörter

Funktionelle Dyspepsie H. pylori Medikamentöse Therapie Psychotherapie Plazebo 

Functional dyspepsia – diagnosis of desperation?

Abstract

Dyspepsia comprises a broad spectrum of predominantly upper abdominal symptoms, such as pain, indigestion, nausea, early satiety and bloating. While these symptoms are highly prevalent, in less than 50% of patients presenting with dyspepsia, structural lesions or biochemical abnormalities are found that explain the symptoms when routine clinical tests are used. In patients without structural lesions the diagnosis of functional dyspepsia is justified. Exclusion of life-threatening disorders as the cause of symptoms and reassurance of the patient as well as proper explanation of the diagnosis and its underlying disease mechanisms (i.e. symptoms are due to a sensitive gut) is crucial and can be considered as an essential element of treatment. Since there is a remarkable comorbidity of anxiety and depression, psychosomatic interventions might be necessary in selected patients. Based on controlled clinical trials few drugs, such as proton pump inhibitors, prokinetics, tricyclic antidepressants, simethicone and selected herbal preparations have been found to be effective for treatment of functional dyspepsia. Effects of H. pylori eradication, even though strongly advocated, are most likely due to undiagnosed peptic ulcer disease in a very small group of patients. While there is currently no therapy that cures functional dyspepsia, the therapeutic target is to control symptoms.

Keywords

Functional dyspepsia H. pylori Pharmacotherapy Psychotherapy Placebo 

Literatur

  1. 1.
    Allescher HD, Bockenhoff A, Knapp G et al. (2001) Treatment of non-ulcer dyspepsia: a meta-analysis of placebo-controlled prospective studies. Scand J Gastroenterol 36: 934–941CrossRefPubMedGoogle Scholar
  2. 2.
    Breslin NP, Thomson AB, Bailey RJ et al. (2000) Gastric cancer and other endoscopic diagnoses in patients with benign dyspepsia. Gut 46: 93–97CrossRefPubMedGoogle Scholar
  3. 3.
    Dobrilla G, Comberlato M, Steele A et al. (1989) Drug treatment of functional dyspepsia. A meta-analysis of randomized controlled clinical trials. J Clin Gastroenterol 11: 169–177PubMedGoogle Scholar
  4. 4.
    Drossman DA, Li Z, Andruzzi E et al. (1993) U.S. householder survey of functional gastrointestinal disorders. Prevalence, sociodemography, and health impact. Dig Dis Sci 38: 1569–1580CrossRefPubMedGoogle Scholar
  5. 5.
    Gillen D, McColl KE (1999) Does concern about missing malignancy justify endoscopy in uncomplicated dyspepsia in patients aged less than 55? Am J Gastroenterol 94: 2329–2330CrossRefGoogle Scholar
  6. 6.
    Gudjonsson H, Oddsson E, Bjornsson S et al. (1993) Efficacy of sucralfate in treatment of non-ulcer dyspepsia. A double-blind placebo-controlled study. Scand J Gastroenterol 28: 969–972PubMedGoogle Scholar
  7. 7.
    Hausken T, Stene-Larsen G, Lange O et al. (1990) Misoprostol treatment exacerbates abdominal discomfort in patients with non-ulcer dyspepsia and erosive prepyloric changes. A double-blind, placebo-controlled, multicentre study. Scand J Gastroenterol 25: 1028–1033PubMedGoogle Scholar
  8. 8.
    Holtmann G, Adam B, Haag S et al. (2003) Efficacy of artichoke leaf extract in the treatment of patients with functional dyspepsia: a six-week placebo-controlled, double-blind, multicentre trial. Aliment Pharmacol Ther 18: 1099–1105CrossRefPubMedGoogle Scholar
  9. 9.
    Holtmann G, Goebell H, Jockenhoevel F (1998) Altered vagal and intestinal mechanosensory function in chronic unexplained dyspepsia. Gut 42: 501–506PubMedGoogle Scholar
  10. 10.
    Holtmann G, Goebell H, Talley NJ (1996) Impaired small intestinal peristaltic reflexes and sensory thresholds are independent functional disturbances in patients with chronic unexplained dyspepsia. Am J Gastroenterol 91: 485–491PubMedGoogle Scholar
  11. 11.
    Holtmann G, Gschossmann J, Karaus M (1999) Randomised double-blind comparison of simethicone with cisapride in functional dyspepsia. Aliment Pharmacol Ther 13: 1459–1465CrossRefPubMedGoogle Scholar
  12. 12.
    Holtmann G, Gschossmann J, Mayr P et al. (2002) A randomized placebo-controlled trial of simethicone and cisapride for the treatment of patients with functional dyspepsia. Aliment Pharmacol Ther 16: 1641–1648CrossRefPubMedGoogle Scholar
  13. 13.
    Holtmann G, Gschossmann J, Neufang-Huber J et al. (2000) Differences in gastric mechanosensory function after repeated ramp distensions in non-consulters with dyspepsia and healthy controls. Gut 47: 332–336CrossRefPubMedGoogle Scholar
  14. 14.
    Holtmann G, Gschossmann JM, Buenger L et al. (2002) Do changes in visceral sensory function determine the development of dyspepsia during treatment with aspirin? Gastroenterology 123: 1451–1458CrossRefPubMedGoogle Scholar
  15. 15.
    Holtmann G, Haag S, Adam B et al. (2003) Effects of a fixed combination of peppermint oil and caraway oil on symptoms and quality of life in patients suffering from functional dyspepsia. Phytomedicine 10 [Suppl 4]: 56–57PubMedGoogle Scholar
  16. 16.
    Holtmann G, Kutscher SU, Haag S et al. (2004) Clinical presentation and personality factors are predictors of the response to treatment in patients with functional dyspepsia; a randomized, double-blind placebo-controlled crossover study. Dig Dis Sci 49: 672–679CrossRefPubMedGoogle Scholar
  17. 17.
    Holtmann G, Siffert W, Haag S et al. (2004) G-protein beta 3 subunit 825 CC genotype is associated with unexplained (functional) dyspepsia. Gastroenterology 126: 971–979CrossRefPubMedGoogle Scholar
  18. 18.
    Holtmann G, Talley NJ, Liebregts T et al. (2006) A placebo-controlled trial of itopride in functional dyspepsia. N Engl J Med 354: 832–840CrossRefPubMedGoogle Scholar
  19. 19.
    Jones RH, Baxter G (1997) Lansoprazole 30 mg daily versus ranitidine 150 mg b.d. in the treatment of acid-related dyspepsia in general practice. Aliment Pharmacol Ther 11: 541–546CrossRefPubMedGoogle Scholar
  20. 20.
    Kairaluoma MI, Hentilae R, Alavaikko M et al. (1987) Sucralfate versus placebo in treatment of non-ulcer dyspepsia. Am J Med 83: 51–55CrossRefPubMedGoogle Scholar
  21. 21.
    Kamerling IM, Van Haarst AD, Burggraaf J et al. (2003) Motilin effects on the proximal stomach in patients with functional dyspepsia and healthy volunteers. Am J Physiol Gastrointest Liver Physiol 284: G776-G781PubMedGoogle Scholar
  22. 22.
    Liebregts T, Adam B, Holtmann G (2005) Susceptibility genes and functional gastrointestinal disorders. J Gastroenterol Hepatol 20: 1792–1793CrossRefPubMedGoogle Scholar
  23. 23.
    Malfertheiner P, Holtmann G, Peitz U (2001) Guidelines of the German Society of Digestive and Metabolic Diseases for treatment of dyspepsia. Z Gastroenterol 39: 937–956CrossRefPubMedGoogle Scholar
  24. 24.
    May B, Kuntz HD, Kieser M et al. (1996) Efficacy of a fixed peppermint oil/caraway oil combination in non-ulcer dyspepsia. Arzneimittelforschung 46: 1149–1153PubMedGoogle Scholar
  25. 25.
    McColl K, Murray L, el Omar E (1998) Symptomatic benefit from eradicating Helicobacter pylori infection in patients with nonulcer dyspepsia. N Engl J Med 339: 1869–1874CrossRefPubMedGoogle Scholar
  26. 26.
    McColl KE, El Nujumi A, Murray L et al. (1997) The Helicobacter pylori breath test: a surrogate marker for peptic ulcer disease in dyspeptic patients. Gut 40: 302–306PubMedGoogle Scholar
  27. 27.
    Mearin F, Balboa A, Zarate N et al. (1999) Placebo in functional dyspepsia: symptomatic, gastrointestinal motor, and gastric sensorial responses. Am J Gastroenterol 94:116–125CrossRefPubMedGoogle Scholar
  28. 28.
    Melzer J, Rosch W, Reichling J (2004) Meta-analysis: phytotherapy of functional dyspepsia with the herbal drug preparation STW 5 (Iberogast). Aliment Pharmacol Ther 20: 1279–1287CrossRefPubMedGoogle Scholar
  29. 29.
    Mertz H, Fass R, Kodner A et al. (1998) Effect of amitriptyline on symptoms, sleep, and visceral perception in patients with functional dyspepsia. Am J Gastroenterol 93: 160–165CrossRefPubMedGoogle Scholar
  30. 30.
    Moayyedi P, Feltbower R, Brown J et al. (2000) Effect of population screening and treatment for Helicobacter pylori on dyspepsia and quality of life in the community: a randomised controlled trial. Leeds HELP Study Group. Lancet 355: 1665–1669CrossRefPubMedGoogle Scholar
  31. 31.
    Moayyedi P, Soo S, Deeks J et al. (2004) Pharmacological interventions for non-ulcer dyspepsia. Cochrane Database Syst Rev CD001960Google Scholar
  32. 32.
    Nyren O, Adami HO, Bates S et al. (1986) Absence of therapeutic benefit from antacids or cimetidine in non-ulcer dyspepsia. N Engl J Med 314 339–343Google Scholar
  33. 33.
    Pazzi P, Gamberini S, Scagliarini R et al. (1994) Misoprostol for the treatment of chronic erosive gastritis: a double-blind placebo-controlled trial. Am J Gastroenterol 89: 1007–1013PubMedGoogle Scholar
  34. 34.
    Silverstein MD, Petterson T, Talley NJ (1996) Initial endoscopy or empirical therapy with or without testing for Helicobacter pylori for dyspepsia: a decision analysis. Gastroenterology 110: 72–83CrossRefPubMedGoogle Scholar
  35. 35.
    Soo S, Moayyedi P, Deeks J et al. (2001) Psychological interventions for non-ulcer dyspepsia. Cochrane Database Syst Rev CD002301Google Scholar
  36. 36.
    Talley NJ, Verlinden M, Snape W et al. (2000) Failure of a motilin receptor agonist (ABT-229) to relieve the symptoms of functional dyspepsia in patients with and without delayed gastric emptying: a randomized double-blind placebo-controlled trial. Aliment Pharmacol Ther 14: 1653–1661CrossRefPubMedGoogle Scholar
  37. 37.
    Talley NJ, Zinsmeister AR, Schleck CD et al. (1992) Dyspepsia and dyspepsia subgroups: a population-based study. Gastroenterology 102: 1259–1268PubMedGoogle Scholar
  38. 38.
    Tanum L, Malt UF (1996) A new pharmacologic treatment of functional gastrointestinal disorder. A double-blind placebo-controlled study with mianserin. Scand J Gastroenterol 31: 318–325PubMedGoogle Scholar
  39. 39.
    Thomson AB, Barkun AN, Armstrong D et al. (2003) The prevalence of clinically significant endoscopic findings in primary care patients with uninvestigated dyspepsia: the Canadian Adult Dyspepsia Empiric Treatment – Prompt Endoscopy (CADET-PE) study. Aliment Pharmacol Ther 17: 1481–1491CrossRefPubMedGoogle Scholar
  40. 40.
    Wu CY, Chou LT, Chen HP et al. (2003) Effect of fluoxetine on symptoms and gastric dysrhythmia in patients with functional dyspepsia. Hepatogastroenterology 50: 278–283PubMedGoogle Scholar

Copyright information

© Springer Medizin Verlag 2006

Authors and Affiliations

  1. 1.Department of Gastroenterology, Hepatology and General MedicineRoyal Adelaide Hospital, University of Adelaide, North TerraceAdelaideAustralia

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