KEYWORDS: < Differential diagnosis of Dyspepsia > Functional or nonulcer dyspepsia Up to 60% Dyspepsia caused Peptic ulcer disease : 15~25% by structural or Reflux esophagitis : 5~15% biochemical disease Gastric or esophageal cancer < 2% Rare cases : Biliary tract disease, Gastroparesis, Pancreatitis, Carbohydrate malabsorption (lactose, sorbitol, fructose, mannitol), Medication (Acarbose, Alcohol, Alendronate, Antibiotics-erythromycin, Codeine, Corticosteroids, Herbs-garlic, ginkgo, saw palmetto, feverfew, chaste tree berry, white willow, Iron, Metformin, Miglitol, NSAIDs including cyclooxygenase2 enzyme inhibitors, Orlistat, Potassium, Risedronate, Theophylline) Infiltrative diseases of the stomach (Crohn's disease, sarcoidosis), Metabolic disturbances (Hypercalcemia, hyperkalemia), Hepatoma, Ischemic bowel disease, Systemic disorders (DM, thyroid and parathyroid disorders, connective tissure disease), Intestinal parasites (Giardia species, Strongyloides species), Abdominal cancer, especially pancreatic cancer Rome II criteria of functional dyspepsia (nonulcer dyspepsia) ▶ more than 3 months, may not be consecutive within the preceding 12 months ..persistent or recurrent dyspepsia in the upper abdomen ..not organic disease ..not Irritable bowel syndrome ..우리나라에선 dysmotility-like dyspepsia (nausea, bloating, early satiety, anorexia)가 반 수 이상으로 가장 흔하며, 그 다음으로 ulcer-like dyspepsia (buring sensation, relief with antacids and histamine H2 blockers or PPI), non-specific dyspepsia 순이다. ..Randomized clinical trials을 통해 아직 검증되진 않았지만 motility dysfunction, H.pylori related infection같은 physiologic factors와 Anxiety, Depression같은 Psychologic factors를 동시에 고려해 치료하는 것이 최선이다. Dyspepsia 1. Endoscopy if having any of following ..Age > 45 years ..Alarm signs (anemia, bleeding, dysphagia, weight loss, protracted vomiting) ..Changing chronic symptoms ..Fear of GI cancer 2. Non-invasive H.pylori test (serology, urea breath test etc) if having any of following ..Age < 45 years ..No alarm signs ..Chronic, mild symptoms ..Prior full evaluation → If positive, eradication of H.pylori is recommended : Test and Treat strategy 145 The Root of ambulatory care Key tests Fig 1. Evaluation and management of nonulcer dyspepsia Patient with dyspepsia Endoscopy Specific diagnosis : treat patient according to the standard of care Diagnosis is nonulcer dyspepsia Trial of antisecretory therapy Evaluate patient for stress, anxiety, and depression ; based on evaluation, treat with medication or psychologic interventions Consider endoscopy or treatment of H.pylori infection (if present) Continue treatment and reevaluate patient periodically Exclude by history : Irritable bowel syndrome Biliary tract disease Gastroesophageal reflux disease Medication-induced dyspepsia Evaluate patient for serious risk factors : Age > 45years Alarm signs (anemia, bleeding, dysphagia, weight loss, protracted vomiting) Changing chronic symptoms Fear of GI cancer Risk factor (+) negative Risk factor (-) Key treatments Key treatments Dyspepsia - life style modification 1. 술, 담배 제한 2. 적절한 운동 3. 체중 조절 (비만이나 과체중 조절) 4. 식사 조절 (과식 제한, 탄산 음료 섭취 제한) (하부 위장관계 증상에서는 고지방, 커피, 콩류 등의 유발음식 제한) 5. 스트레스 조절 ..기능성 위장장애는 위약효과가 높은 질환으로 내시경 검사 등을 시행하여 정상소견을 확인한 환자들은 증상의 재발, 약제복용, 병원방문 횟수가 내시 경검사를 시행하지 않았던 환자에 비해 현저히 적었다는 보고가 있다. - pharmacologic 1. Antagonist of gastric juice ..Cimetidine.. 200mg 2T bid ..OMP.. 20mg 1T bid ..Curan.. 150mg 1T bid 2. Prokinetics ..Ganaton.. 50mg 1T tid 식전 ..Gasmotin.. 5mg 1T tid 식전 혹은 식후 3. Antispasmodics - 복통이 심한 경우 ..Tiropa.. 1T tid ..Algiron.. 1T tid 4. Minor Tranquilizer ..Amitriptyline.. 10mg 1T, 1T-5T pohs ..Buspar.. 5mg 1T, 1/2-1T tid ..Xanax.. 0.25mg 1T, 1/2-1T tid 5. Digestants( & Simethicone) ..Festal-gold.. 1T tid ..Phazyme.. 1T tid ..Bearse.. 1T tid 147 The Root of ambulatory care H.pylori eradication remedy ..OMP.. 20mg 1T bid ..Amoxapen.. 250mg 4C bid ..Klaricid.. 250mg 2T bid × 1week ( - 2weeks ) ..OMP.. - Omeprazole ..Curan.. - Ranitidine ..Gasmotin.. - Mosapride citrate ..Ganaton.. - Itopride hydrochloride ..Tiropa.. -Tiropamide ..Algiron.. - Cimetropium ..Buspar.. - Buspirone ..Xanax.. - Alprazolam ..최근 연구에 의하면 nonulcer dyspepsia 환자에서 PPI가 H2 receptor antagonist 보다 뛰어난 효과가 없다고 알려져 있으며, 비용-효과면에서 H2 receptor antagonist이 더 우수하다고 밝히고 있다. ..Minor tranquilizer 처방 시 addictive potential로 인해 가능하면 benzodiazepine계열은 처방하지 않는게 좋으며, SSRI나 other anxiolytic drugs(buspirone) 등이 좋다. 만일 benzodiazepine계열의 약물을 처방했다면 1개월 이 상 처방하지 않는게 좋으며 끊을 때는 tapering이 필요하다. 또한 SSRI계열이 나 buspirone을 처방 시 serotoninergic effect로 인해 gastrointestinal upset, 투 여초기에 소화불량이 심해지는 등의 부작용이 있을 수 있기에 주의를 요하 며, 낮은 용량부터 조금씩 증량해야 한다. ..Bloating Symptoms이 있는 환자에겐 특히 Simethicone 성분이 있는 소화제 처 방이 좋다. 참고 문헌 Lori M. Dickerson, Pharm. D., Dana E. King, M.D. : Evaluation and Management of Nonulcer Dyspepsia. A journal of the American Family Physicains 2004 ; 70 : 107-114 Alan M. Adelman, M.D., M.S.: Dyspepsia, in A Lange clinical manual Family Medicine Ambulatory Care & Prevention, 4th ed, Mark B. Mengel,M.D., L. Peter Schwiebert M.D.(ed).United States of America, The McGrwa-Hill Companies, Inc., 2005, P 112-116 Jae-Hyoung Cho, Ji-Hyeon Ju,Jeoung-Won Jang: Dyspepsia, in Clinical Road Map of Internal Medicine. Seoul, Panmun Book, 2005, P 71