functional gastrointestinal disorder : psychosomatic review
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Presentasi ini ditampilkan untuk kalangan dokter umum pada acara seminar medis untuk dokter di RS OMNI Alam SuteraTRANSCRIPT
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
4
Definition of FGID
• Chronic and recurrent symptoms of the gastrointestinal (GI) tract: oPain, nausea, vomiting, bloating,
diarrhea, constipation
• Without detectable structural or biochemical abnormalities
5
Classification : Rome Criteria
Rome Committees:
Multinational Working Teams
Symptom-based diagnostic criteria:
Rome I 1994
Rome II 1999
Rome III 2006
6
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
11
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
12
13
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
15
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
16
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