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 FUNCTIONAL DYSPEPSIA AND IT'S TREATMENT IN THE PEDIATRIC AGE GROUP 
KETEVAN GOGBERASHVILI, MD, PhD, Professor,
Department of Pediatrics, Tbilisi State Medical University

Functional dyspepsia is heterogeneous, high prevalence symptom-complex in practice of general physicians. It has high incidence in pediatric patients also.
 
In accordance with modern explanation, functional dyspepsia is complex of symptoms diagnosed in any age-group of pediatric patients and comprise pain and discomfort in epigastric area (associated or not associated with food intake). It is characterized by feeling of gastric fullness, puking, nausea, vomiting, fat and milk intolerance; lasting at least 12 weeks during 1 year period and having no organic pathology proven by laboratory and instrumental studies. Because of variable clinical expression new classification of the disease has been developed according to so called “Rome III” criteria. These clinical forms are:
 
- Ulcer like
- Reflux like
- Dyskinetic
- Not otherwise specified
 
In case of functional dyspepsia with ulcer-like symptoms, irritable gastric complaints are prominent: epigastric pain associated with food intake, sometimes with nocturnal pain.
 
In reflux type dyspepsia: burning sensation, mouthwash, vomiting, nausea, acid taste in mouth, bloating are prominent.
 
In case of dyskinetic clinical forms: epigastric heaviness, early satiety, nausea, vomiting, bloating, fat and milk intolerance are prominent.
 
In non-specific clinical form patients have mixed clinical manifestation and can’t be placed into specific group.
 
Among the reasons of dyspepsia; emotional exhaustion, psychological stresses, heavy physical strain, tobacco and alcohol intake are important. In children dyspepsia is often associated with certain medications and food allergy.
 
Deranged motility of upper gastro-intestinal tract is the main factor in the process of disease pathogenesis. In children gastro-duodenal reflux, sphincter insufficiency or laxity, hypo- or hyper dyskinetic derangements can be prominent. These manifestations are linked to deregulation of vegetative innervations and neuro-humoral regulation. Intensity of the disease manifestation depends on gastric acid formation. Helicobacter pylori infection is matter of debate in disease pathogenesis.
 
Irritable bowel syndrome is second trend of the disease development. In such cases: abdominal pain, episodic diarrhea/constipation , feeling of unsatisfactory empting during defecation and vegeto-vascular dystonia are main complaints.
 
During childhood periods, functional dyspepsia is mainly manifested by gastro-esophageal reflux, regurgitation, rumination, cyclic vomiting and aerophagy.
 
During reflux disease, retrograde gastro-intestinal content regurgitation can occur from stomach and/or gut back into esophagus. Reflux can also be physiologic. Pathologic reflux is linked to neuro-humoral deregulation or is manifestation of the organic pathology.
 
In the genesis of gastro-esophageal reflux, lower esophageal sphincter incompetence and increased intra-gastric pressure are main factors. Increased gastric acidity plays additional role and is the main cause of esophageal damage. Secondarily developed complications like esophagitis, gastric content aspiration and mouth mucosal lesions due to gastric acid indicates transformation of functional disorder into the organic one.
 
Among one of the most common pediatric functional dyspeptic disorders is regurgitation – return of food soon after intake. In the first months of life regurgitation is regarded as normal physiologic phenomenon, if it is seldom, not profuse and occurs in an hour after food intake. The reasons for regurgitation may be: anatomic and physiologic traits of neonatal gastrointestinal tract, immaturity of sphincter and gastric neuro-humoral activity. Often regurgitation is caused by overfeeding, abnormal diet, or central nervous system lesions.
 
Rumination - is contractive movement episode of abdominal , diaphragmatic and glossal muscles , that causes return of gastric content into mouth, the child swallows it after chewing again. Usually rumination appears from 3 to 8 months of age and is not associated with some kind of food. Signs of discomfort are not expressed.
 
Cyclic (functional) vomiting - is attack of protracted vomiting lasting few hours to several days with the periods of remission. It occurs in children older 3 years and is associated with severe central nervous system damage.
 
Aerophagy- swallowing of air, that causes repeated belching and bloating. Mild aerophagy is considered normal in the first months of life due to immaturity of swallowing process regulation. It is common in immature and preterm infants. After age of 1 presence of aerophagy should prompt nervous system evaluation. Aerophagy can also be caused by talking during food intake and by having fizzy drinks.
 
Cardial insufficiency is relatively common pathology, characterized by lower esophageal sphincter incompetence. Neonates have no marked anatomic sphincter at the junction of esophagus and cardiac portion of the stomach. Cardial closure is done by Gubarev’s equipment, where angle of Hiss plays crucial role. In healthy breast- feeding infants this angle is <900 degrees, increase in this angle leads to failure of cardial closure and lower esophageal sphincter insufficiency.
 
Correct diagnosing of functional disorder is crucial. All possible laboratory and instrumental studies should be done to exclude organic pathologies like, pyloric stenosis, gastric and duodenal ulcers, chronic gastritis and gastro-duodenitis, reflux-esophagitis, biliary stones, chronic pancreatitis, liver diseases and others.
 
Diagnosis is based on the following data:
-   Clinical history, revealing disease predisposing factors, genetic predisposition, social and economic environment of the patient.
-   Abdominal ultrasound
-   Coproscopy
-   Stool analysis for occult blood
-   Complete blood count
-   Pancreatic enzyme analysis in blood and urine
-   Biochemical tests
-   Serologic studies for antibodies
 
After diagnosis, regarding etiopathogenetic factors, treatment of functional dyspepsia is based on the following principles:
- Correction of psycho-neurology status, removal of inducing factors, treatment of co-morbidities
- Correction of motor dysfunction
- Correction of disorders caused by aberrant motor function
 
As mentioned above, correction of motor function is main component of treatment process. Correction of motor function includes: strict regimen, diet modification and medical therapy with prokinetic ( Domperidone) and antisecretory ( H2 receptor blockers and proton pump inhibitors) drugs.
 
Among prokinetic medications Doprokin (domperidone) “World Medicine”, England, is indicated in pediatric patients. This medication is Dopamine (D2) receptor antagonist. In contrast with Cerukal, Doprokin doesn’t cross blood-brain barrier and therefore has few side effects than central acting anti-dopaminergic drugs.
 
In newborns Doprokin should be used cautiously with appropriate doses, because immaturity of blood-brain barrier in infants.
 
Doprokin increases lower esophageal sphincter tone, increase gastric empting, improves antro-duodenal coordination. Doprokin is widely used in pediatry.
 
Dosing: 2,5 mg (1/4 tablet)/10kg body weight 3 times a day for 1-2 months.
Side effects: headache, adynamy and sleepiness in only 1,5-1,8 % of patients.
Contraindications: increased sensitivity, GI bleeding, mechanical bowel obstruction, perforation, Prolactin producing pituitary tumor.
 
In case of “ulcer like” dyspepsia; antisecretory medications ( for example, Ulsepan) and antacids (for example, Simalgel) are used.
 
In case of dyspepsia not otherwise specified: symptomatic treatment against main complaints is the main management. Considering prokinetik, antisecretory, enzyme replacement and antacid medications.
 
Long-term complex treatment, resort and physiotherapy are crucial.
 
Treating cardial chalasy with medications is directed at increasing lower esophageal sphincter tone: Cholinomimetics –Betacholine 0,2 mg/kg 3 times daily and –Dopamine receptor blocking drugs-Domperidone (Doprokin) 1 mg/kg 3 times a day, 0,5 hours before the meal-time.
 
Despite the prognosis of functional dyspepsia is benign, without timely and adequate treatment transformation of functional disorder into organic one is possible.
 

Literature:
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