Should we still subcategorize helicobacter pylori-associated dyspepsia as functional disease?

Abstract

Functional dyspepsia is a group of disorders featuring symptoms believed to be derived from the stomach and duodenum such as upper abdominal discomfort, pain, postprandial fullness and early satiety. A key diagnostic requisite is the absence of organic, metabolic, or systemic disorders to explain "dyspeptic symptoms." Therefore, when peptic ulcer diseases (including scars), erosive esophagitis and upper gastrointestinal malignancies are found at endoscopic examinations, the diagnosis of functional dyspepsia is excluded. One notable exception, however, is Helicobacter pylori infection. According to the Rome III definition, H. pylori infection is included in functional dyspepsia. This is an obvious deviation from the diagnostic principle of functional dyspepsia, since H. pylori infection is a definite cause of mucosal inflammation, which affects a number of important gastric physiologies such as acid secretion, gastric endocrine function and motility. The chronic persistent nature of infection also results in more dramatic mucosal changes such as atrophy or intestinal metaplasia, the presence of which in the esophagus (Barrett's esophagus) precludes the diagnosis of functional dyspepsia. Since careful endoscopic examination can diagnose reliably H. pylori infection not only in Japan but also in Western contries, it is now feasible and more logical to exclude patients with chronic gastritis caused by H. pylori infection as having dyspeptic symptoms. It is time to establish the Asian consensus to declare that H. pylori infection should be separated from functional dyspepsia.

Keywords: Dyspepsia; Functional dyspepsia; Gastric acid; Helicobacter pylori; Ulcer.

Figure 1

Endoscopic features of nodular gastritis. Note diffuse whitish elevations on the distal gastric mucosa (A, white light), which can be further enhanced by flexible spectral imaging color enhancement mode of observation (B).

Figure 2

Concept of coexistence of functional disorder with organic diseases. Dyspepstic subjects caused by specific organic causes are shown as graded dark area in the bar representing the population. Patients with severe symptoms are depicted darker in the right side of the bars. Unexplained persistent dyspeptic symptoms may be unraveled only after removal of the causative diseases or drugs. In peptic ulcer diseases (A), for example, a proportion of patients with dyspeptic symptoms may represnt the majority. In contrast, the proportion of symptomatic patients may be smaller in non-steroidal anti-inflammatory drug users (B) and in subjects with chronic gastritis (C). After curing the diseases or stopping the drugs responsible for the symptoms, some subjects may still continue to be symptomatic (indicated as a light grey part of the bars on the right side panels). This group of subjects may be considered as having functional dyspepsia. In this concept, organic diseases and functional diseases are not mutually exclusive and may coexist. PUD, peptic ulcer Diseases; NSAID, non-steroidal anti-inflammatory drug; HP, Helicobacter pylori.