functional gastrointestinal disorder : psychosomatic review

Functional Gastrointestinal Disorder : Psychosomatic Overview

Andri Psychosomatic Clinic Omni Hospital

Faculty of Medicine UKRIDA

Academy of Psychosomatic Medicine

American Psychosomatic Society

@mbahndi

Outline • Terminology

• Classification

• Pathophysiology

• Psychosomatic approach

• Treatment

A. Terminology • Functional Versus Organic

• Advantages : o Research of psychological factor of Functional Gastrointestinal

Disorder (FGID)

o Multidiscipline and Liaison : psychiatrist and gastroenterologist

o Biopsychosocial model of gastroenterology

• Disadvantages : o Separation of Mind and Body

o Interest of psychological aspect of disease waned

o Miss-perception : functional = psychiatric problem

o Ignore psychiatric disorder in organic disease vice versa

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Definition of FGID

• Chronic and recurrent symptoms of the gastrointestinal (GI) tract: oPain, nausea, vomiting, bloating,

diarrhea, constipation

• Without detectable structural or biochemical abnormalities

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Classification : Rome Criteria

Rome Committees:

Multinational Working Teams

Symptom-based diagnostic criteria:

Rome I 1994

Rome II 1999

Rome III 2006

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Classification FGIDs ( classified by anatomic region)

(A) Esophageal

(B) Gastroduodenal (B1: FD)

(C) Bowel (C1: IBS)

(D) Functional abdominal pain

(E) Biliary

(F) Anorectal.

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FGID—biopsychosocial model

Stres Psikis

Sistem Saraf Otonom

HPA Aksis Monoamine System

Simpatis Parasimpatis Kortisol •Serotonin

•Dopamin

•Norepineprin

HIPOTALAMUS

Stres Fisik

(Radang,tumor,infeksi,trauma)

Distress Eustress

GABA System

Skema 1. Menjelaskan tentang efek stres terhadap tubuh dan otak. Disarikan dari berbagai sumber oleh dr Andri,SpKJ tahun 2012

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0

10

20

30

40

50

60

Williams 1988 Stanghellini 1996 Heikkinen 1996

(n=1386) (n=1057) (n=766)

Major Causes of Dyspepsia %

of P

atie

nts

with

Dia

gn

osis

Gastric Cancer Peptic Ulcer Esophagitis/ Functional

GERD Dyspepsia

Ilustrasi Kasus • Perempuan usia 35 tahun sudah sekitar 1

tahun belakangan ini mengeluh nyeri perut atas disertai rasa seperti ingin muntah. Pemeriksaan obyektif tidak menemukan adanya kelainan. Oleh dokternya diresepkan racikan : o Librax ½ tablet

o Dogmatil 25mg

o Alprazolam 0.15mg

o Sertraline 15mg

o Serenace 0.5mg

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Diagnostic process FD remains a diagnosis of exclusion:

• Careful history and physical examination

• Upper endoscopy is necessary

• The others: exclusion of

chronic peptic ulcer disease,

gastroesophageal reflux disease,

esophagitis,

pancreatico-biliary disease

malignancy

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Differential Diagnosis

• GERD:

Heartburn is the predominant symptom

Upper endoscopy

Prolonged esophageal pH monitoring

Twenty-four hour esophageal pH monitoring

• IBS: overlap symptom

- Bloating or frequent defecation

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Treatment • The goal is to accept, diminish, and cope

with symptoms rather than eliminate them.

• The most important aspects

oexplanation that the symptoms are not imaginary

oevaluation of relevant psychosocial factors,

odietary advice

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Pharmacological therapies • H. pylori therapy ? controversial

• Acid suppression and prokinetic agents (digestive agents) ? may help

• Gut analgesics ? Relaxants of the

nervous system of the gut may be

beneficial, but do not use

Benzodiazepine

• Antidepressant? SNRI, TCA May help

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Management of Ulcer-like

Functional Dyspepsia Ulcer-like Symptoms Dominant

Education/lifestyle

modification

Test Hp

+ -

Eradicate Hp

Success Failure

Trial of acid suppression

Investigate Trial of prokinetic

Reassess

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Management of Dysmotility-like Functional Dyspepsia

Dysmotility-like Symptoms Dominant

Educate/lifestyle modification

Test H. pylori

+ -

Continue with

cyclic therapy

Success Failure

Investigate

Trial of prokinetic

medication

Eradicate

Gastroscopy or UGI

Success Failure

Consider H2

antagonists, tricyclics

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Role of psychosocial factors

1)Psychological stress exacerbates GI symptoms.

2)Psychological disturbances modify the

experience of illness and illness behaviors such

as health care seeking.

3) Psychosocial factors affect health status and

clinical outcome.

Take Home Message • Dyspepsia : Organic and Functional

• Clinical Practice : Functional > 50%

• Pay attention of Psychosocial aspect of functional gastrointestinal disorder

• Rationale use of drug, do not use benzodiazepine to eliminate symptoms

• Coping with the symptoms and a good diet are always be recommendation