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Grechenig M, Gruber R, Weitzendorfer M, von Rahden BHA, Widmann B, Emmanuel K, Koch O. [Reflux Symptoms - No Difference in Severity and Intensity in Patients with and without Functional Verified Gastroesophageal Reflux Disease]. Zentralbl Chir 2021; 146:170-175. [PMID: 33556980 DOI: 10.1055/a-1333-3910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Patients with gastroesophageal reflux disease (GERD) often suffer greatly from their symptoms. The aim of this study was to determine if there is a difference in quality of life and gastrointestinal symptom complexes between patients with purely functional complaints and patients with objective GERD. MATERIAL AND METHODS We included all patients with typical reflux symptoms, who had a GERD examination in 2017 at our department. All patients underwent high resolution manometry, 24-h-pH-metry impedance measurement and gastroscopy. Quality of life was assessed using the Gastrointestinal Quality of Life Index (GIQLI) and gastrointestinal symptoms were rated by a symptom checklist (SCL), assessing the severity and intensity of 14 different symptoms. Based on the results of the 24-h-pH-metry impedance measurement, patients were divided into 2 groups: patients with functional reflux symptoms and patients with true GERD. These two groups were compared. RESULTS Complete data were available in 162 patients, of whom 86 (52.2%) were objectively suffering from reflux (DeMeester score mean: 37.85; SD ± 29.11) and 76 (46.1%) had a normal DeMeester score (Mean: 7.01; SD ± 4.09). No significant difference in quality of life was found between the two groups (mean GIQLI of GERD patients: 94.81, SD ± 22.40, and mean GIQLI of patients with functional reflux symptoms: 95.26, SD ± 20.33, p = 0.988). Furthermore, no significant difference could be found in the evaluated symptoms (mean general SCL score of GERD patients: 46.97; SD ± 29.23; patients with functional reflux symptoms: 48.03; SD ± 29.17, p = 0.827). CONCLUSION Patients with functional complaints suffer just as much from their symptoms as patients with objectively diagnosed GERD. Differentiation between gastroesophageal reflux disease and functional reflux symptoms is only possible by means of functional diagnostic testing.
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Affiliation(s)
- Michael Grechenig
- Universitätsklinik für Chirurgie, Landeskrankenhaus Salzburg - Universitätsklinikum der Paracelsus Medizinischen Privatuniversität, Salzburg, Österreich
| | - Ricarda Gruber
- Universitätsklinik für Chirurgie, Landeskrankenhaus Salzburg - Universitätsklinikum der Paracelsus Medizinischen Privatuniversität, Salzburg, Österreich
| | - Michael Weitzendorfer
- Universitätsklinik für Chirurgie, Landeskrankenhaus Salzburg - Universitätsklinikum der Paracelsus Medizinischen Privatuniversität, Salzburg, Österreich
| | - Burkhard H A von Rahden
- Universitätsklinik für Chirurgie, Landeskrankenhaus Salzburg - Universitätsklinikum der Paracelsus Medizinischen Privatuniversität, Salzburg, Österreich
| | - Bernhard Widmann
- Universitätsklinik für Chirurgie, Landeskrankenhaus Salzburg - Universitätsklinikum der Paracelsus Medizinischen Privatuniversität, Salzburg, Österreich.,Abteilung für Chirurgie, Kantonsspital St Gallen, Schweiz
| | - Klaus Emmanuel
- Universitätsklinik für Chirurgie, Landeskrankenhaus Salzburg - Universitätsklinikum der Paracelsus Medizinischen Privatuniversität, Salzburg, Österreich
| | - Oliver Koch
- Universitätsklinik für Chirurgie, Landeskrankenhaus Salzburg - Universitätsklinikum der Paracelsus Medizinischen Privatuniversität, Salzburg, Österreich
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Jung SW, Joo MS, Choi HC, Jang SI, Woo YS, Kim JB, Park SH, Lee MS. Epigastric symptoms of gallbladder dyskinesia mistaken for functional dyspepsia: Retrospective observational study. Medicine (Baltimore) 2017; 96:e6702. [PMID: 28422887 PMCID: PMC5406103 DOI: 10.1097/md.0000000000006702] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 03/29/2017] [Accepted: 03/31/2017] [Indexed: 01/19/2023] Open
Abstract
Functional dyspepsia (FD) is a constellation of epigastric symptoms originating in the gastroduodenal region without organic and metabolic cause. However, similar confounding symptoms can also appear in patients with gallbladder (GB) dyskinesia. Therefore, symptoms of GB dyskinesia may be mistaken for FD. We aimed to identify GB dyskinesia as a cause of FD symptoms compatible with the Rome IV criteria and the need for an evaluation of GB function in patients with FD symptoms.We investigated information of patients with FD symptoms who underwent a quantitative Tc-diisoproyl iminodiacetic acid cholescintigraphy (DISIDA scan) through electronic medical records, and GB dyskinesia was judged to be the cause of the FD symptoms if the symptoms disappeared as GB function normalized on the follow-up DISIA scan in patient with decreased GB function on the initial DISIDA scan.A total of 275 patients underwent a DISIDA scan. Eighteen patients of them had FD symptoms compatible with the Rome IV criteria. Three were lost after undergoing a DISIDA scan. Eight had normal GB function, and the other 7 had decreased GB function on the initial DISIDA scan. In 4 of the 7 patients with GB dyskinesia, FD symptoms disappeared as GB function normalized. As a result, GB dyskinesia was the cause of the symptoms in 4 of 18 patients with FD symptoms compatible with the Rome IV criteria.It is necessary to evaluate GB function in patients with refractory FD symptoms because the symptoms can be caused by GB dyskinesia.
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Yu YH, Jo Y, Jung JY, Kim BK, Seok JW. Gastric emptying in migraine: a comparison with functional dyspepsia. J Neurogastroenterol Motil 2012; 18:412-8. [PMID: 23106002 PMCID: PMC3479255 DOI: 10.5056/jnm.2012.18.4.412] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Revised: 09/13/2012] [Accepted: 09/17/2012] [Indexed: 12/12/2022] Open
Abstract
Background/Aims Gastric stasis in migraineurs remains controversial. The aim of this study is to investigate gastric emptying (GE) time, and any associations between GE parameters and dyspeptic symptoms among patients with functional dyspepsia (FD) and migraine without any gastrointestinal symptoms during the interictal period. Methods We enrolled 27 migraine patients, 32 FD patients and 12 healthy people as controls, and performed GE scintigraphy as gastric function test. Gastrointestinal symptoms were evaluated in the FD and migraine. Results The age-adjusted mean gastric half-emptying time in FD (125.51 ± 52.55 minutes) patients was longer than in migraineurs (100.82 ± 23.94 minutes, P = 0.035) and controls (95.25 ± 23.29 minutes, P = 0.021). The percentage of gastric retention was higher in FD than in migraine. However, migraineurs did not show an obvious delayed gastric emptying or an increase of gastric retention when compared to the normal controls. The association between each dyspeptic symptom and GE parameters was not significant, but postprandial fullness and early satiety showed a tendency of delayed GE. In migraineurs, GE time did not show significant association with nausea and vomiting during interictal periods. Conclusions Delayed GE does not appear to be a mechanism that patients with FD and migraine have in common. Migraineurs without dyspepsia during interictal period had normal GE, and further study for association with FD should be investigated.
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Affiliation(s)
- Yeon Hwa Yu
- Department of Internal Medicine, Hanyang University College of Medicine, Guri, Gyeonggi-do, Korea
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Sun J, Yuan YZ, Holtmann G. Itopride in the treatment of functional dyspepsia in Chinese patients: a prospective, multicentre, post-marketing observational study. Clin Drug Investig 2012. [PMID: 22035464 DOI: 10.2165/11593290-000000000-00000] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Prokinetic agents are commonly used in the symptomatic treatment of functional dyspepsia (FD). Safety or efficacy issues associated with the use of available prokinetics, such as metoclopramide, domperidone, cisapride and mosapride, mean there is a need for an effective and well tolerated prokinetic agent. Itopride is a novel prokinetic agent with a dual mode of action, good safety profile and documented efficacy in placebo-controlled trials. OBJECTIVE The objective of this study was to assess the effectiveness and safety of itopride in the management of FD. METHODS This was a prospective, multicentre, post-marketing observational study carried out in private outpatient clinics throughout China. The study included patients with symptomatic FD aged ≥18 years. Patients were prescribed itopride 50 mg three times daily before meals for 4 weeks, after which there was a 2-week follow-up period during which they did not take itopride. Effectiveness and tolerability data obtained from patients who completed 4 weeks of therapy were analysed. The treatment response rate after 4 weeks was measured by patient global assessment; scores at the end of treatment were compared with baseline scores. Response rate based on symptom scoring was also measured after 4 weeks, with an effective treatment being defined as a symptom improvement of ≥50%. RESULTS In total, 587 patients with FD were enrolled. The mean ± SD difference in the total symptom score before and after the 4-week treatment period was -5.62 ± 3.27, corresponding to a 69.23 ± 26.53% reduction from baseline (p < 0.001). The treatment response rates in patients who fulfilled Rome I, II and III criteria for FD were 33.68%, 34.71% and 35.50%, respectively, after 1 week of treatment; 52.82%, 54.61% and 56.51%, respectively, after 2 weeks; 66.67%, 67.23% and 68.64%, respectively, after 3 weeks; and 72.82%, 73.54% and 75.15%, respectively, after 4 weeks. Response rates were significantly different at 1 week versus 4 weeks of treatment. Nine patients (1.54%) had adverse events: four were probably related to the study drug, three were possibly related and two were not related. Of the nine patients with adverse events, two discontinued the study drug, two suspended (i.e. temporarily discontinued the drug until the adverse event subsided) the study drug, and five continued the study drug. Seven of the nine patients with adverse events had adverse reactions (defined as adverse events considered causally related to the study drug): two improved, three recovered and two showed no change. No adverse reactions were serious enough to warrant discontinuation of therapy. CONCLUSION Itopride was an effective and well tolerated drug in the management of FD in this patient population.
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Affiliation(s)
- Jing Sun
- Department of Gastroenterology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, China
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Sun J, Yuan YZ, Holtmann G. Itopride in the Treatment of Functional Dyspepsia in Chinese Patients. Clin Drug Investig 2012; 31:865-75. [DOI: 10.1007/bf03256924] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Nassr AO, Gilani SNS, Atie M, Abdelhafiz T, Connolly V, Hickey N, Walsh TN. Does impaired gallbladder function contribute to the development of Barrett's esophagus and esophageal adenocarcinoma? J Gastrointest Surg 2011; 15:908-14. [PMID: 21484485 DOI: 10.1007/s11605-011-1520-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2010] [Accepted: 03/24/2011] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Esophageal adenocarcinoma is aetiologically associated with gastro-esophageal reflux, but the mechanisms responsible for the metaplasia-dysplasia sequence are unknown. Bile components are implicated. Impaired gallbladder function may contribute to duodenogastric reflux (DGR) and harmful GERD. AIMS This study aims to compare gallbladder function in patients with Barrett's esophagus, adenocarcinoma, and controls. METHODS Three groups of patients, all free of gallstone disease, were studied. Group 1: (n = 15) were normal controls. Group 2: (n = 15) were patients with >3-cm-long segment of Barrett's esophagus. Group 3: (n = 15) were patients with esophageal adenocarcinoma. Using real-time ultrasonography unit, gallbladder volume was measured in subjects following a 10-h fast. Ejection fraction was calculated before and after standard liquid meal and compared between the groups. RESULTS The mean percentage reduction in gallbladder volume was 50% at 40 min in the adenocarcinoma group compared with 72.4% in the control group (p < 0.001). At 60 min, gallbladder filling had recommenced in the control group to 64.1% of fasting volume while continuing to empty with further reduction to 63% in the Barrett's group and to 50.6% (p = 0.008) in the adenocarcinoma group. The mean gallbladder ejection fraction decreased progressively from controls to Barrett's to adenocarcinoma and was significantly lower in Barrett's group (60.9%; p = 0.019) and adenocarcinoma group (47.9%; p < 0.001) compared with normal controls (70.9%). CONCLUSION Gallbladder function is progressively impaired in Barrett's esophagus and adenocarcinoma. Gallbladder malfunction increases duodenogastric reflux, exposing the lower esophagus to an altered chemical milieu which, in turn, may have a role in promoting metaplasia-dysplasia-neoplasia sequence in the lower esophageal mucosa.
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Affiliation(s)
- Ayman O Nassr
- Department of Surgery, Academic Centre, Connolly Hospital, Blanchardstown, Dublin 15, Ireland
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Okumura T, Tanno S, Ohhira M, Tanno S. Prevalence of functional dyspepsia in an outpatient clinic with primary care physicians in Japan. J Gastroenterol 2010; 45:187-94. [PMID: 19997854 DOI: 10.1007/s00535-009-0168-x] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2009] [Accepted: 11/08/2009] [Indexed: 02/04/2023]
Abstract
BACKGROUND Since little is known about the prevalence of patients with functional gastrointestinal disorders (FGID), this study was performed to clarify the prevalence of FGID, especially functional dyspepsia (FD), in new patients of an outpatient clinic with primary care physicians in Japan. METHODS We analyzed consecutive outpatients (n = 5183) who first visited the Department of General Medicine, Asahikawa Medical College Hospital, between April 2004 and March 2009. RESULTS Out of 5813 patients, 818 (14.1%) visited because of abdominal symptoms. Final diagnoses of the 818 patients were FGID (n = 320, 39.1%), organic gastrointestinal diseases (n = 237, 28.9%), organic non-GI disease (n = 135, 16.5%), and others (n = 126, 15.4%). The 320 patients with FGID had FD (n = 170), irritable bowel syndrome (IBS) (n = 68), and other FGIDs (n = 88). The rate of FGID or FD in all patients was 5.5% or 2.9%, respectively. Among outpatients (n = 381) who complained of upper abdominal symptoms, approximately 45% had FD. There was no gender difference in the frequency of FGID, FD, or IBS in all ages of patients. A lower incidence of FD was shown in female patients over 70 years old and a higher incidence of IBS in male patients under 29 years old. DISCUSSION These results suggest that the prevalence of FGID, especially FD, is very high in an outpatient clinic with primary care physicians in Japan.
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Affiliation(s)
- Toshikatsu Okumura
- Department of General Medicine, Asahikawa Medical College, 2-1-1 Midorigaoka-Higashi, Asahikawa 078-8510, Japan.
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Tack J, Jones MP, Karamanolis G, Coulie B, Dubois D. Symptom pattern and pathophysiological correlates of weight loss in tertiary-referred functional dyspepsia. Neurogastroenterol Motil 2010; 22:29-e5. [PMID: 19210630 DOI: 10.1111/j.1365-2982.2008.01240.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
In patients with gastrointestinal symptoms, weight loss is an alarm symptom, indicative of organic disease. Recent studies reported weight loss in subsets of functional dyspepsia (FD) patients. The aim of this study was to analyse symptom patterns associated with weight loss in tertiary care FD. Six hundred and thirty-six FD patients (67% female, mean age 43 years) completed a dyspepsia questionnaire, and underwent gastric emptying and gastric barostat studies. After identifying independent symptom domains through orthogonal factor analysis, patients were clustered on the basis of symptom profile. Clusters were compared in terms of their association with weight loss and gastric emptying or sensorimotor function. Weight loss (4.2 kg on average) correlated most strongly with early satiety followed by nausea and vomiting (rho respectively 0.38, 0.28 and 0.23, all P < 0.0001). Factor analysis revealed three factors: Factor 1 characterized by nausea, vomiting and early satiety; factor 2 by early satiety, postprandial fullness and bloating; and factor 3 by pain, epigastric burning and belching. Subsequent cluster analysis revealed six patient clusters. The most severe cluster, which loaded high on all three factors, and a cluster dominated factor 2 were associated with the highest average weight loss (6.8 and 8.0 kg, respectively). The former cluster was also characterized by visceral hypersensitivity and delayed gastric emptying. The lowest weight loss occurred in the two clusters that had depressed scores for both early satiety associated factors (2.4 and 2.5 kg, respectively). In tertiary care FD, weight loss is strongly associated with two early satiety associated symptom clusters.
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Affiliation(s)
- J Tack
- Department of Pathophysiology, Catholic University Leuven, Leuven, Belgium.
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The response of Asian patients with functional dyspepsia to eradication of Helicobacter pylori infection. Eur J Gastroenterol Hepatol 2009; 21:417-24. [PMID: 19369829 DOI: 10.1097/meg.0b013e328317b89e] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES/BACKGROUND The role of Helicobacter pylori infection in functional dyspepsia (FD) remains controversial. Several randomized controlled trials involving populations in the West, observed no statistically significant advantage over placebo. However, none of these studies involved Asian populations which have high infection rates. METHODS A double blind, randomized, placebo-controlled trial of H. pylori eradication for FD was conducted in our Singapore-based Asian population. Forty-one patients received active treatment consisting of a 1-week course of omeprazole 20 mg once daily, clarithromycin 250 mg twice daily and tinidazole 500 mg twice daily whereas another 41 patients received matching placebo tablets. A dyspepsia score was derived by grading 5 dyspeptic symptoms on a Likert scale. Symptom assessment and urea breath test were repeated at 6 weeks, 6 and 12 months from the start of treatment. The primary end point was symptom resolution, defined as a dyspepsia score of 0 or 1 at the end of 12 months follow-up. RESULTS On intention-to-treat analyses, symptom resolution was observed in 24% of patients on active treatment and 7% on placebo; the difference in proportion of patients with symptom resolution was statistically significant (P=0.02, 95% confidence interval: 1.1-17.7). H. pylori eradication rates perprotocol and intention-to-treat were 80.0 and 68.3%, on active treatment and 5.6 and 4.9% on placebo (both P values<0.0001). Among patients with H. pylori eradicated on active treatment the symptom resolution rate was 39% (10 of 26), whereas it was 3% (one of 35) among patients in the placebo group who had persistent H. pylori infection. In multivariate analysis, posttreatment H. pylori status was the only predictor of symptom resolution. The majority of patients, 91.5%, had ulcer-like dyspepsia; heartburn and acid regurgitation were uncommon, and no increase was observed after treatment. CONCLUSION In contrast to Western populations, our results suggest that patients with FD in Asia would benefit from treatment for H. pylori infection with as much as a 13-fold increased chance of symptom resolution following its eradication.
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Tack J, Talley NJ, Camilleri M, Holtmann G, Hu P, Malagelada JR, Stanghellini V. Functional gastroduodenal disorders. Gastroenterology 2006; 130:1466-79. [PMID: 16678560 DOI: 10.1053/j.gastro.2005.11.059] [Citation(s) in RCA: 1191] [Impact Index Per Article: 62.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2005] [Accepted: 11/03/2005] [Indexed: 02/07/2023]
Abstract
A numerically important group of patients with functional gastrointestinal disorders have chronic symptoms that can be attributed to the gastroduodenal region. Based on the consensus opinion of an international panel of clinical investigators who reviewed the available evidence, a classification of the functional gastroduodenal disorders is proposed. Four categories of functional gastroduodenal disorders are distinguished. The first category, functional dyspepsia, groups patients with symptoms thought to originate from the gastroduodenal region, specifically epigastric pain or burning, postprandial fullness, or early satiation. Based on recent evidence and clinical experience, a subgroup classification is proposed for postprandial distress syndrome (early satiation or postprandial fullness) and epigastric pain syndrome (pain or burning in the epigastrium). The second category, belching disorders, comprises aerophagia (troublesome repetitive belching with observed excessive air swallowing) and unspecified belching (no evidence of excessive air swallowing). The third category, nausea and vomiting disorders, comprises chronic idiopathic nausea (frequent bothersome nausea without vomiting), functional vomiting (recurrent vomiting in the absence of self-induced vomiting, or underlying eating disorders, metabolic disorders, drug intake, or psychiatric or central nervous system disorders), and cyclic vomiting syndrome (stereotypical episodes of vomiting with vomiting-free intervals). The rumination syndrome is a fourth category of functional gastroduodenal disorder characterized by effortless regurgitation of recently ingested food into the mouth followed by rechewing and reswallowing or expulsion. The proposed classification requires further research and careful validation but the criteria should be of value for clinical practice; for epidemiological, pathophysiological, and clinical management studies; and for drug development.
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Affiliation(s)
- Jan Tack
- Department of Gastroenterology, University Hospitals Leuven, Leuven, Belgium.
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Delgado-Aros S. [Gastric emptying and functional dyspepsia]. GASTROENTEROLOGIA Y HEPATOLOGIA 2006; 29:34-9. [PMID: 16393629 DOI: 10.1157/13083250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Dyspeptic syndrome includes symptoms such as upper abdominal pain, nausea and/or vomiting. These symptoms are common to highly diverse processes such as duodenal ulcer, pancreatitis and even intestinal ischemia, among many others. However, most patients who consult for this syndrome do not have any of these well known processes. New mechanisms have been proposed that could explain the symptoms presented by these patients. Among these mechanisms are those relating to an alteration of normal gastroduodenal motor function, such as alterations of gastric compliance, antral distension, gastric accommodation to anomalous ingestion, and alterations of gastric emptying. The present review evaluates the role of gastric emptying in producing dyspeptic symptoms according to the evidence available to date. We discuss gastric emptying in patients with functional or idiopathic dyspepsia compared with that in the healthy population, the correlation between gastric emptying and dyspeptic symptoms, and the response of dyspeptic symptoms to the prokinetic therapies carried out to date.
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Affiliation(s)
- S Delgado-Aros
- Fisiopatología Digestiva y Hepatología, Fundación Vall d'Hebron, Barcelona, Spain.
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Abstract
Functional dyspepsia (FD) is one of the most common gastrointestinal disorders. This review summarizes recent progress in our understanding of the pathogenesis and therapy for FD. Although distinction among FD, irritable bowel syndrome, and reflux disease is difficult in population-based studies, separate entities can be recognized in patients who seek medical attention. The pathogenesis of FD remains unclear, but recent studies have demonstrated a role for acute gastrointestinal infection in triggering FD and in genetic polymorphisms of G-proteins in predisposing to FD. The role of abnormalities in gastric motor function, visceral hypersensitivity, and psychosocial factors in the pathophysiology of dyspeptic symptoms has been the topic of multiple studies. Treatment options for FD remain limited. Recent studies have focused on acid-suppressive drugs and on novel prokinetics. Progress in our understanding of the pathogenesis and pathophysiology of FD may lead to new or improved treatment modalities. Areas of major advances are the role of infection and genetic predisposition and studies on the role of abnormalities in gastric motility and sensitivity.
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Affiliation(s)
- Jan Tack
- Department of Internal Medicine, Division of Gastroenterology, University Hospital Gasthuisberg, University of Leuven, Herestraat 49, B-3000 Leuven, Belgium.
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Abstract
Dyspepsia is a chronic or recurrent pain or discomfort centered in the upper abdomen; patients with predominant or frequent (more than once a week) heartburn or acid regurgitation, should be considered to have gastroesophageal reflux disease (GERD) until proven otherwise. Dyspeptic patients over 55 yr of age, or those with alarm features should undergo prompt esophagogastroduodenoscopy (EGD). In all other patients, there are two approximately equivalent options: (i) test and treat for Helicobacter pylori (H. pylori) using a validated noninvasive test and a trial of acid suppression if eradication is successful but symptoms do not resolve or (ii) an empiric trial of acid suppression with a proton pump inhibitor (PPI) for 4-8 wk. The test-and-treat option is preferable in populations with a moderate to high prevalence of H. pylori infection (> or =10%); empirical PPI is an initial option in low prevalence situations. If initial acid suppression fails after 2-4 wk, it is reasonable to consider changing drug class or dosing. If the patient fails to respond or relapses rapidly on stopping antisecretory therapy, then the test-and-treat strategy is best applied before consideration of referral for EGD. Prokinetics are not currently recommended as first-line therapy for uninvestigated dyspepsia. EGD is not mandatory in those who remain symptomatic as the yield is low; the decision to endoscope or not must be based on clinical judgement. In patients who do respond to initial therapy, stop treatment after 4-8 wk; if symptoms recur, another course of the same treatment is justified. The management of functional dyspepsia is challenging when initial antisecretory therapy and H. pylori eradication fails. There are very limited data to support the use of low-dose tricyclic antidepressants or psychological treatments in functional dyspepsia.
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Affiliation(s)
- Nicholas J Talley
- Division of Gastroenterology and Hepatology, Mayo Clinic, Clinical Enteric Neuroscience Translational and Epidemiological Research Program, Mayo Clinic, Rochester, Minnesota 55905, USA
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Chiocca JC, Olmos JA, Salis GB, Soifer LO, Higa R, Marcolongo M. Prevalence, clinical spectrum and atypical symptoms of gastro-oesophageal reflux in Argentina: a nationwide population-based study. Aliment Pharmacol Ther 2005; 22:331-42. [PMID: 16098000 DOI: 10.1111/j.1365-2036.2005.02565.x] [Citation(s) in RCA: 94] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Population-based data on gastro-oesophageal reflux in Latin America are lacking. AIM To assess gastro-oesophageal reflux symptom prevalence, clinical spectrum and association with the atypical symptoms in our country. METHODS Gastro-oesophageal reflux self-report questionnaires validated at Mayo Clinic, USA, were submitted to a sample of 1000 residents (aged 18-80 years) from 17 representative geographical areas of Argentina. The samples were selected and stratified according to age, gender, geographical areas and size of town of residence provided by the Argentine Bureau of Statistics and Census. RESULTS The overall prevalence of any typical gastro-oesophageal reflux symptom experienced in the previous year was 61.2% (95% CI, 57.9-64.6), the prevalence of frequent gastro-oesophageal reflux symptoms was 23.0% (95% CI, 20.1-25.9) and the prevalence of gastro-oesophageal reflux disease was 11.9% (95% CI, 9.6-14.1). Frequent gastro-oesophageal reflux symptoms were associated with dysphagia (OR 2.12, 95% CI, 1.27-3.54, P < 0.01), globus (OR 2.22, 95% CI, 1.35-3.66, P < 0.01) and non-cardiac chest pain (OR 1.55, 95% CI, 1.04-2.31, P < 0.05). CONCLUSIONS In Argentina, typical symptoms of gastro-oesophageal reflux are highly prevalent at the national level, and frequent gastro-oesophageal reflux symptoms are significantly associated with dysphagia, globus and non-cardiac chest pain.
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Affiliation(s)
- J C Chiocca
- Department of Gastroenterology, Hospital Nacional Prof. Dr Alejandro Posadas, El Palomar, Buenos Aires, Argentina.
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Jian R. [How to explore and treat a dyspeptic patient?]. GASTROENTEROLOGIE CLINIQUE ET BIOLOGIQUE 2005; 29:818-27. [PMID: 16294151 DOI: 10.1016/s0399-8320(05)86353-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Affiliation(s)
- Raymond Jian
- Hépato-Gastroentérologie, Hôpital Européen Georges Pompidou, 75908 Paris Cedex 15
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Abstract
Functional dyspepsia is far more common than dyspepsia due to organic disease, both in the community and general practice. Proposed aetiopathogenic factors include gastric acid, Helicobacter pylori infection, delayed emptying, hypersensitivity or impaired accommodation of the stomach, dysfunction of the duodenum or brain-gut axis, psychosocial morbidity and post-infective mucosal damage. More effective therapy will depend on the development of drugs targeted at these putative pathophysiological mechanisms. On current evidence tricyclic antidepressants appear to be more effective than either acid suppressants or H. pylori eradication.
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Heikkinen M, Räsänen H, Färkkilä M. Clinical value of ultrasound in the evaluation of dyspepsia in primary health care. Scand J Gastroenterol 2005; 40:980-4. [PMID: 16165712 DOI: 10.1080/00365520510015845] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE In general practice, upper abdominal ultrasound (US) is widely used in the evaluation of patients with dyspepsia. However, there is a dearth of published data on the role of US in the dyspepsia work-up. There are no data on the use of US as a follow-up study in functional dyspepsia. The aims of this study were to assess the role of US in evaluating dyspepsia, and to assess the long-term clinical relevance of minor findings revealed by US in patients with functional dyspepsia. MATERIAL AND METHODS Four hundred consecutive dyspeptic patients were recruited. At baseline, all patients underwent gastroscopy and US. Patients were divided into two groups: "endoscopy-negative patients" and "endoscopy-positive patients". "The endoscopy-negative" group included all cases in which the final diagnoses could not be settled after gastroscopy. US was repeated after 6-7 years in patients who had functional dyspepsia. RESULTS In the endoscopy-negative group, gallstones were detected in 21 patients, but this was considered to be a cause of symptoms in 9 patients. No malignant lesions were detected by US in the endoscopy-negative group. In the endoscopy-positive group, a malignant tumor in the kidney was suspected in 3 patients. Only one of these tumors turned out to be an incidental small carcinoma. Moreover, several minor findings were shown by US: usually these consisted of abnormal echogenicity of the liver. During the follow-up period, 6 patients developed gallstones. At the end of the follow-up period, two clinically significant findings were diagnosed: a small renal cancer and hydronephrosis. CONCLUSIONS This study shows that the wide, untargeted use of abdominal US in the evaluation of patients with dyspepsia following a gastroscopy is not necessary. Repeated US examination in cases of functional dyspepsia is not recommended, and rarely changes the diagnosis.
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Affiliation(s)
- Markku Heikkinen
- Department of Medicine, Unit of Gastroenterology, Kuopio University Hospital, Finland.
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18
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Pallotta N, Pezzotti P, Calabrese E, Baccini F, Corazziari E. Relationship between gastrointestinal and extra-gastrointestinal symptoms and delayed gastric emptying in functional dyspeptic patients. World J Gastroenterol 2005; 11:4375-81. [PMID: 16038037 PMCID: PMC4434665 DOI: 10.3748/wjg.v11.i28.4375] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: Delayed gastric emptying and an enlarged fasting gastric antrum are common findings in functional dyspepsia but their relationship with gastrointestinal (GI), and the frequently associated extra-GI symptoms remains unclear. This study evaluated the relationship between GI and extra-GI symptoms, fasting antral volume and delayed gastric emptying in functional dyspepsia.
METHODS: In 108 functional dyspeptic patients antral volume and gastric emptying were assessed with ultraso-nography (US). Symptoms were assessed with standardized questionnaire. The association of symptoms and fasting antral volume with delayed gastric emptying was estimated with logistic regression analysis.
RESULTS: Delayed gastric emptying was detected in 39.8% of the patients. Postprandial drowsiness (AOR 11.25; 95%CI 2.75-45.93), nausea (AOR 3.51; 95%CI 1.19-10.32), fasting antral volume (AOR 1.93; 95%CI 1.22-3.05), were significantly associated with delayed gastric emptying. Symptoms, mainly the extra-GI ones as postprandial drowsiness and nausea, combined with fasting antral volume predicted the modality of gastric emptying with a sensitivity and specificity of 78%.
CONCLUSION: In functional dyspeptic patients, (1) an analysis of fasting antral volume and of symptoms can offer valuable indication on the modality of gastric emptying, and (2) it seems appropriate to inquire on postprandial drowsiness that showed the best correlation with delayed gastric emptying.
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Affiliation(s)
- N Pallotta
- Dpt di Scienze Cliniche, Universito La Sapienza, Policlinico Umberto I, V.le del Policlinico, Rome 00161, Italy
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19
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Seno H, Nakase H, Chiba T. Usefulness of famotidine in functional dyspepsia patient treatment: comparison among prokinetic, acid suppression and antianxiety therapies. Aliment Pharmacol Ther 2005; 21 Suppl 2:32-6. [PMID: 15943844 DOI: 10.1111/j.1365-2036.2005.02471.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The treatment of functional dyspepsia is controversial. AIM The purpose of this paper is to clarify the initial effect of prokinetic, acid suppression and antianxiety treatment for functional dyspepsia patients. PATIENTS AND METHODS Sixty-four functional dyspepsia patients without Helicobacter pylori infection were randomly assigned to 15 mg/day of mosapride, 40 mg/day of famotidine, or 30 mg/day of tandospirone during an 8-week treatment. Individual functional dyspepsia symptoms were evaluated with 4 cm visual analogue scale before and at 2, 4 and 8 weeks after treatment. RESULTS Among 64 enrolled patients, 62 completed the study. Within 2 weeks, visual analogue scale score in the mosapride-treated group decreased from 2.29 +/-0.14 to 1.57 +/- 0.20; in the famotidine from 2.04 +/- 0.16 to 1.09 +/- 0.12 (mean +/- S.E.). Therefore, there were significant improvements of functional dyspepsia symptoms in mosapride- and famotidine-treated patients (P <0.01). Furthermore, famotidine was significantly more effective than mosapride (P < 0.05). On the contrary, visual analogue scale score in the tandospirone therapy was 2.23 +/- 0.20 and 2.13 +/- 0.22 before and at 2 weeks, respectively, without any significant improvement. CONCLUSIONS A treatment regimen of famotidine at 40 mg/day had a significant favourable effect on the clinical outcome in functional dyspepsia patients.
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Affiliation(s)
- H Seno
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
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20
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Abstract
Functional dyspepsia is a highly prevalent symptom complex and a heterogenous disorder. Recent studies showed potential associations between specific pathophysiologic disturbances and dyspeptic symptoms. Delayed gastric emptying reported in about 30% of patients with functional dyspepsia is associated with the symptoms of postprandial fullness, nausea, and vomiting. Impaired gastric accommodation present in 40% of functional dyspepsia patients is found to be associated with early satiety. Hypersensitivity to gastric distension is observed in 37% of functional dyspepsia patients and associated with the symptoms of postprandial pain, belching, and weight loss. Psychosocial factors and altered response to duodenal lipids or acid have also been identified as pathophysiologic mechanisms. Therapeutic options are still limited but targeted therapy directed at the underlying pathophysiology seems desirable. Thus, efforts to further elucidate underlying pathophysiologic mechanisms and identify the appropriate patient population using some type of pathophysiologic testing will be required.
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Affiliation(s)
- Jan Tack
- Department of Internal Medicine, Division of Gastroenterology, University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium.
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21
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Affiliation(s)
- Jan Tack
- Division of Gastroenterology, Department of Internal Medicine, University Hospital Gasthuisberg, University of Leuven, Belgium.
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22
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Madsen LG, Wallin L, Bytzer P. Identifying response to acid suppressive therapy in functional dyspepsia using a random starting day trial--is gastro-oesophageal reflux important? Aliment Pharmacol Ther 2004; 20:423-30. [PMID: 15298636 DOI: 10.1111/j.1365-2036.2004.02084.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Single subject trials offer an alternative approach to identify and characterize responders to a specific treatment. AIM To test a new single subject trials design, called random starting day trial, to identify acid-related symptoms in dyspepsia. METHODS A total of 119 patients with functional dyspepsia entered a 12-day, double-blind random starting day trial. All patients started on placebo and switched to omeprazole 80 mg/day at a randomized and blinded day between day 5 and day 9, with active treatment continuing for the rest of the trial. Based on changes of a daily symptom score, response was defined as a sustained > or =50% reduction of symptoms within 3 days of active treatment. RESULTS Thirteen of 119 patients (11%) were classified as spontaneous responders because of complete symptom relief before switching to omeprazole. Of the remaining 106 patients, 15 (15.6%) were classified as responders. Five of six (83%) responders compared with 28 of 53 (53%) non-responders had pathological reflux. Multivariate testing identified symptoms suggestive of gastro-oesophageal reflux predictive of response. CONCLUSIONS The random starting day trial design could identify a subset of dyspeptic patients with a uniform symptomatic response to acid-suppressive therapy. Response seems to be associated with gastro-oesophageal reflux. The random starting day trial needs to be further validated to be considered as a reliable instrument in clinical research.
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Affiliation(s)
- L G Madsen
- Department of Medical Gastroenterology, Glostrup University Hospital, Glostrup, Denmark
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23
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Abstract
Functional dyspepsia is a highly prevalent symptom complex and a heterogeneous disorder. Recent studies showed potential associations between specific pathophysiologic disturbances and dyspeptic symptoms. Delayed gastric emptying reported in about 30% of patients with functional dyspepsia is associated with the symptoms of postprandial fullness, nausea, and vomiting. Impaired gastric accommodation present in 40% of functional dyspepsia patients is found to be associated with early satiety. Hypersensitivity to gastric distension is observed in 37% of functional dyspepsia patients and associated with the symptoms of postprandial pain, belching, and weight loss. Psychosocial factors and altered response to duodenal lipids or acid have also been identified as pathophysiologic mechanisms.
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Affiliation(s)
- Kwang-Jae Lee
- Department of Internal Medicine, Division of Gastroenterology, University Hospital Gasthuisberg, University of Leuven, Herestraat 49, B-3000 Leuven, Belgium
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24
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Heikkinen M, Vornanen M, Hollmén S, Färkkilä M. Prognostic significance of antrum-predominant gastritis in functional dyspepsia. Scand J Gastroenterol 2004; 39:227-31. [PMID: 15074391 DOI: 10.1080/00365520310008287] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The role of Helicobacter pylori infection in functional dyspepsia is still controversial, and subgroups of patients with functional dyspepsia who may benefit from H. pylori eradication should be identified. Patients with functional dyspepsia and antrum-predominant H. pylori-positive chronic gastritis, it has been argued, have fewer symptoms after eradication therapy. In the present study, we analysed the clinical significance of antrum-predominant gastritis on the long-term prognosis of functional dyspepsia. METHODS Consecutive unselected dyspeptic patients were investigated in primary care and the patients with functional dyspepsia were enrolled in this long-term follow-up study. Altogether 182 patients were recruited: 65 with normal histology of the stomach, 36 with antrum-predominant gastritis, 21 with corpus-predominant gastritis and 60 with pangastritis. Patients' medical histories were reviewed after 6 to 7 years, with total number and outcome of repeated investigations analysed. At the end of follow-up, all patients were invited for voluntary gastroscopy. RESULTS At the end of follow-up, the proportion of asymptomatic patients ranged from 21% (normal histology) to 26% (antrum-predominant gastritis). No statistically significant differences between groups appeared in regard to re-visits or to proportion of patients examined by sigmoideo- or colonoscopy during follow-up. Patients with antrum-predominant gastritis less often underwent upper endoscopy. Peptic ulcer was more frequent (P = 0.05) in patients with antrum gastritis than in other groups, but no other differences existed among any organic gastrointestinal findings. No significant differences between subgroups appeared among the 30% of patients using drugs for upper abdominal complaints during the previous year. CONCLUSIONS Functional dyspepsia has an excellent long-term prognosis. Antrum-predominant gastritis in functional dyspepsia seems to carry an increased risk for peptic ulcer, and for this group in particular, H. pylori eradication should be considered. This finding requires confirmation in future studies performed in primary care.
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Affiliation(s)
- M Heikkinen
- Dept. of Medicine, Unit of Gastroenterology, Kuopio University Hospital, Finland.
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25
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Berman DA, Porter RS, Graber M. The GI Cocktail is no more effective than plain liquid antacid: a randomized, double blind clinical trial. J Emerg Med 2003; 25:239-44. [PMID: 14585449 DOI: 10.1016/s0736-4679(03)00196-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The "GI Cocktail" is a mixture of medications often given in the Emergency Department (ED) for dyspepsia symptoms. Several combinations are used, but the most effective has not yet been determined. This study compared three combinations commonly given for dyspepsia. The study was a prospective, randomized, double-blinded trial comparing antacid (group 1); antacid + Donnatal (group 2); antacid + Donnatal + viscous lidocaine (group 3) for acute treatment of dyspepsia in the ED. Patients were randomly assigned to receive one of the three medication combinations. Patients rated their discomfort on a Visual Analog Scale (VAS) immediately before receiving the medication and 30 min later. Change in VAS was the primary study endpoint. A 13-mm difference in VAS was considered clinically significant. VAS change in the three groups was compared using multivariable regression, controlling for pretreatment VAS, study drug, previous antacid use, and gastrointestinal (GI) history. One hundred twenty patients were enrolled between July and December 2000. One hundred thirteen subjects (113) completed the protocol: Group 1 (N = 38); Group 2 (N = 37); Group 3 (N = 38). There was no statistically significant difference between the groups in terms of age, gender, GI history, previous antacid use, or initial degree of pain. Group 1 had a 25 +/- 27 mm mean (+/- SD), decrease in pain; Group 2, 23 +/- 22 mm decrease; and Group 3, 24 +/- 26 mm decrease. There was no statistically significant difference in pain relief between the three groups on univariate analysis or multivariable regression. In conclusion, the addition of Donnatal or Donnatal + lidocaine to an antacid did not relieve dyspepsia better than plain antacid. The "GI Cocktail" concoction may not be necessary.
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Affiliation(s)
- Dean A Berman
- Department of Emergency Medicine, Albert Einstein Medical Center, Philadelphia, Pennsylvania, USA
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26
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Abstract
BACKGROUND Functional dyspepsia is often a long-lasting disorder that accounts for substantial healthcare costs. It has been classified into subgroups assuming that it can guide management of dyspepsia. AIM To evaluate the clinical significance of subgrouping functional dyspepsia in a long-term perspective study. METHODS Consecutive patients with dyspepsia identified by general practitioners were investigated. Those patients with functional dyspepsia (n=201) were enrolled in this study. Initially, patients were divided into five subgroups (ulcer-like, dysmotility-like, reflux-like, unspecified, and irritable bowel syndrome-like). Patients' medical histories were reviewed after 6-7 years, and the number and outcome of repeated investigations were analysed. At the end of follow-up, patients filled in a questionnaire similar to that at baseline, and were invited for gastroscopy. RESULTS Only 2% of patients developed peptic ulcer during follow-up, none of them were in the ulcer-like subgroup. When referrals to hospital and examinations during follow-up were registered, no statistically significant differences existed between subgroups. Patients with reflux-like dyspepsia made fewer revisits than others (P=0.02), but had used antidyspepsia drugs during the previous year more often (P=0.036). Stability of the subgroups over time was poor. CONCLUSIONS Functional dyspepsia is a long-lasting disorder with a very good prognosis. Subgroups of functional dyspepsia play only a minor role in prediction of the long-term outcome, and their usefulness in clinical practice is also hampered by subgroup instability over time.
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Affiliation(s)
- M Heikkinen
- Department of Medicine, Unit of Gastroenterology, Kuopio University Hospital, Finland.
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27
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Varadarajulu S, Hawes RH. Is EUS the answer for dyspepsia? Am J Gastroenterol 2003; 98:1650-2. [PMID: 12873596 DOI: 10.1111/j.1572-0241.2003.07555.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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28
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Abstract
Functional dyspepsia is one of the most common disorders seen in general practice and by gastroenterologists. New concepts regarding the pathophysiology and its role for the symptom pattern have emerged during the last few years. This is of importance for development of new treatment alternatives in the near future. At the moment, however, empirical treatment with acid-suppressive agents and prokinetics is the recommended therapeutic approach in the management of these patients, despite limited efficacy. Identification and treatment of H pylori infection has been recommended for uninvestigated dyspepsia, because it may cure underlying peptic ulcer disease, but is unlikely to provide symptomatic benefit to patients with functional dyspepsia. Refractory patients may respond to antidepressants or to psychologic treatments, but proof of efficacy is limited. New and more effective approaches are badly needed for functional dyspepsia.
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Affiliation(s)
- Magnus Simrén
- Department of Internal Medicine, Division of Gastroenterology, University Hospital Gasthuisberg, University of Leuven, Herestraat 49, B-3000, Leuven, Belgium
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29
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Stanghellini V, Tosetti C, De Giorgio R, Barbara G, Corinaldesi R. Dyspepsia and dyspepsia subgroups. Not all roads lead to Rome. Dig Liver Dis 2002; 34:316-318. [PMID: 12118946 DOI: 10.1016/s1590-8658(02)80122-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- V Stanghellini
- Department of Internal Medicine & Gastroenterology, University of Bologna S Orsola-Malpighi Hospital, Italy.
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30
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Abstract
Although up to 50% of patients diagnosed with nonulcer dyspepsia (NUD) have Helicobacter pylori infection and underlying chronic gastritis, it remains controversial whether any causal relationship exists. The results of worldwide epidemiological studies have been unconvincing. No clear-cut link has been documented between H. pylori and any specific symptom profile or pathophysiological mechanism in NUD. In the randomized controlled trials, methodological weaknesses may explain in part the conflicting results, but even in the well-conducted trials controversy persists. Although meta-analyses have attempted to resolve the issue, inherent methodological difficulties with meta-analysis remain a problem. Moreover, even the methodologically sound meta-analyses have reported conflicting results. In addition, predictors of treatment response remain obscure, and there continue to be theoretical concerns about the treatment of H. pylori infection in all patients with NUD. Hence, the management of these patients is challenging, but eradication of H. pylori infection may be beneficial in a small subgroup of cases with NUD that cannot be identified before treatment.
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Affiliation(s)
- N J Talley
- University of Sydney, Nepean Hospital, Penrith, Australia.
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31
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Chou LT, Wu CY, Chen HP, Chang CS, Wong PG, Ko CW, Chen GH. The correlation of depression and gastric dysrhythmia in functional dyspepsia. J Clin Gastroenterol 2001; 33:127-31. [PMID: 11468439 DOI: 10.1097/00004836-200108000-00007] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Psychologic factors in functional dyspepsia have been discussed in many previous articles. However, the relationship between depression and functional dyspepsia is still obscure. We investigated the impact of depression on clinical symptoms and gastric dysrhythmia in functional dyspepsia. Thirty-nine patients with functional dyspepsia and 18 healthy subjects were included. Patients were investigated with clinical symptoms assessment, Zung's self-rating depression scale, and electrogastrography. Patients with functional dyspepsia were divided into two groups: 21 patients with depression and 18 patients without depression. The depressed patients had similar total gastrointestinal symptom severity scores compared with the nondepressed patients, but with higher total symptom frequency scores (p < 0.05). With regards to symptoms, the depressed patients had higher abdominal fullness severity and frequency scores and nausea frequency scores. The patients with functional dyspepsia had a lower percentage of normal slow wave in both the fasting and fed states and a higher percentage of bradygastria in the fasting state and tachygastria in the postprandial state (p < 0.05). There was no significant difference in the percentage of bradygastria or tachygastria between the depressed and nondepressed patients. There was no correlation between the specific type of electrogastrographic abnormality and the presence or absence of depression in functional dyspepsia patients.
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Affiliation(s)
- L T Chou
- Division of Gastroenterology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
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32
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Azuma T, Ito Y, Suto H, Ohtani M, Dojo M, Muramatsu A, Kuriyama M, Kato T. The effect of Helicobacter pylori eradication therapy on dyspepsia symptoms in industrial workers in Japan. Aliment Pharmacol Ther 2001; 15:805-11. [PMID: 11380318 DOI: 10.1046/j.1365-2036.2001.00987.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The relationship between Helicobacter pylori infection and non-ulcer dyspepsia is still controversial. The potential benefits and risks of the treatment could depend on local conditions, such as the prevalence of the infection and the local rates of gastric cancer. AIM To evaluate the effects of H. pylori eradication therapy on non-ulcer dyspepsia symptoms in industrial workers in Japan. METHODS A total of 615 employees of an industrial corporation were examined for H. pylori infection and symptom scores; 215 H. pylori-positive non-ulcer dyspepsia cases underwent eradication therapy. Symptom scores were also analysed 12 months after the eradication therapy. Serum pepsinogen A and pepsinogen C levels were analysed and chronic atrophic gastritis was serologically diagnosed on the basis of the criteria of a pepsinogen A < 70 ng/mL and pepsinogen A : pepsinogen C ratio < 3.0. RESULTS The symptom score improved significantly in the cured cases, but not in the non-cured cases. The effect of the cure of H. pylori infection on symptoms was analysed according to the serological diagnosis of chronic atrophic gastritis. In both groups, cases with atrophic gastritis and cases with chronic gastritis only, the cure of infection was effective in improving symptoms. CONCLUSION The cure of H. pylori infection was effective in reducing non-ulcer dyspepsia symptoms in industrial workers in Japan.
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Affiliation(s)
- T Azuma
- Second Department of Internal Medicine, Fukui Medical University, Fukui, Japan.
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Werdmuller BF, van der Putten TB, Balk TG, Lamers CB, Loffeld RJ. Clinical presentation of Helicobacter pylori-positive and -negative functional dyspepsia. J Gastroenterol Hepatol 2000; 15:498-502. [PMID: 10847435 DOI: 10.1046/j.1440-1746.2000.02080.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND A questionnaire was used to record the clinical presentation of functional dyspepsia in relation to Helicobacter pylori infection in a consecutive series of patients sent for upper gastrointestinal endoscopy. Only patients without macroscopic abnormalities in their oesophagus, stomach and duodenum were included. METHODS The study questionnaire included two questions related to daily life, and the calculation of a symptom score. Biopsy specimens were taken from all patients for histological and microbiological examination, and immunoglobulin G antibodies were also determined. RESULTS Two hundred and twenty-two patients were H. pylori positive and 182 patients were H. pylori negative. Loss of weight was significantly more common in the H. pylori positive group (P<0.001). Patients with H. pylori infection had a significantly higher overall symptom score compared with H. pylori-negative subjects (P<0.05). In addition, the severity of epigastric and nocturnal pain, heartburn, retrosternal heartburn, and vomiting was significantly higher in H. pylori-positive functional dyspeptic patients, and the influence on daily life and activities was significantly worse. CONCLUSIONS The combination of retrosternal pain, weight loss, food intolerance and the absence of halitosis signified a 64% accuracy in predicting H. pylori infection. It is not possible to differentiate between H. pylori-positive and H. pylori-negative functional dyspeptics on the basis of clinical presentation and the number of complaints. However, overall symptom score and severity of several symptoms was significantly higher in the H. pylori-positive group.
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Affiliation(s)
- B F Werdmuller
- Department of Internal Medicine, Ziekenhuis De Heel Zaandam, The Netherlands
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34
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Hession PT, Malagelada J. Review article: the initial management of uninvestigated dyspepsia in younger patients-the value of symptom-guided strategies should be reconsidered. Aliment Pharmacol Ther 2000; 14:379-88. [PMID: 10759616 DOI: 10.1046/j.1365-2036.2000.00727.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Several major management guidelines on dyspepsia (upper abdominal pain or discomfort) recommend an initial 'test-and-treat' policy (non-invasive Helicobacter pylori testing with eradication therapy if positive) in uninvestigated patients less than about 45 years old. However, the evidence that this is the optimal strategy is limited. Data from the few available randomized controlled trials provide evidence that this policy improves symptomatology more than a 'test-and-endoscope' approach (in which only H. pylori-positive patients undergo early endoscopy) in those with upper abdominal pain. The balance of cost-effectiveness data from clinical studies and decision analyses indicates that both 'test-and-treat' and empirical anti-secretory therapy approaches are more cost-effective than the 'test-and-endoscope' strategy. Therefore, given concerns about the safety of widespread H. pylori eradication, initial empirical anti-secretory therapy may be a cost-effective alternative to the 'test-and-treat' policy in some younger dyspeptic patients. The effectiveness of such an empirical approach might well be improved by symptom-guided therapy and there is growing evidence that the predominant dyspeptic symptom may provide this guide. The diagnostic, therapeutic and economic utility of this approach merits further clinical investigation.
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Affiliation(s)
- P T Hession
- Mediplex Medical Communications Consultancy, Wokingham, UK
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35
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Molinder H, Wallander MA, Hallberg M, Bodemar G. Dyspepsia--acid or stress? A study of controversy. Abandoned by experts, finalized in clinical practice? Scand J Gastroenterol 1999; 34:1057-64. [PMID: 10582753 DOI: 10.1080/003655299750024823] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- H Molinder
- Dept. of Public Health and Caring Sciences, Uppsala Science Park, Sweden
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36
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Talley NJ, Vakil N, Ballard ED, Fennerty MB. Absence of benefit of eradicating Helicobacter pylori in patients with nonulcer dyspepsia. N Engl J Med 1999; 341:1106-11. [PMID: 10511608 DOI: 10.1056/nejm199910073411502] [Citation(s) in RCA: 208] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The relation between Helicobacter pylori infection and nonulcer dyspepsia is uncertain. We tested the hypothesis that curing the infection will relieve symptoms of dyspepsia. METHODS We randomly assigned 170 H. pylori-infected patients with nonulcer dyspepsia to receive twice-daily treatment with 20 mg of omeprazole, 1000 mg of amoxicillin, and 500 mg of clarithromycin for 14 days and 167 such patients to receive identical-appearing placebos; all patients were then followed through regular visits for 12 months. Symptoms were scored on diary cards for seven days before each visit. A carbon-13 urea breath test was performed at base line and repeated at 1 and 12 months, and endoscopic biopsy was performed at 12 months to determine H. pylori status. Treatment was considered successful if the patient had only mild pain or discomfort or none at all. RESULTS The rate of eradication of H. pylori infection was 90 percent in the active-treatment group and 2 percent in the placebo group at four to six weeks (P<0.001). At 12 months, there was no significant difference between groups in the rate of successful treatment (46 percent in the active-treatment group and 50 percent in the placebo group; relative likelihood of success with active treatment, 0.93; 95 percent confidence interval, 0.73 to 1.18; P=0.56). There was also no significant difference in the rate of successful treatment at 12 months between patients who were H. pylori-negative and those who were H. pylori-positive (48 percent vs. 49 percent). The rates of successful treatment were also similar when patients were analyzed according to the type of dyspepsia (ulcer-like, reflux-like, or dysmotility-like) and changes in the quality of life. There was no significant association between treatment success and histologic improvement in chronic gastritis at 12 months (P=0.68). CONCLUSIONS We found no evidence that curing H. pylori infection in patients with nonulcer dyspepsia leads to relief of symptoms.
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Affiliation(s)
- N J Talley
- Department of Medicine, University of Sydney, Nepean Hospital, Penrith, NSW, Australia.
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Talley NJ, Axon A, Bytzer P, Holtmann G, Lam SK, Van Zanten S. Management of uninvestigated and functional dyspepsia: a Working Party report for the World Congresses of Gastroenterology 1998. Aliment Pharmacol Ther 1999; 13:1135-48. [PMID: 10468695 DOI: 10.1046/j.1365-2036.1999.00584.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND The management of dyspepsia is controversial. METHODS An international Working Party was convened in 1998 to review management strategies for dyspepsia and functional dyspepsia, based on a review of the literature and best clinical practice. RESULTS Dyspepsia, defined as pain or discomfort centred in the upper abdomen, can be managed with reassurance and over-the-counter therapy if its duration is less than 4 weeks on initial presentation. For patients with chronic symptoms, clinical evaluation depends on alarm features including patient age. The age cut off selected should depend on the age specific incidence when gastric cancer begins to increase, but in Western nations 50 years is generally an acceptable age threshold. In younger patients without alarm features, Helicobacter pylori test and treatment is the approach recommended because of its value in eliminating the peptic ulcer disease diathesis. If, after eradication of H. pylori, symptoms either are not relieved or rapidly recur, then an empirical trial of therapy is recommended. Similarly, in H. pylori-negative patients without alarm features, an empirical trial (with antisecretory or prokinetic therapy depending on the predominant symptom) for up to 8 weeks is recommended. If drugs fail, endoscopy should be considered because of its reassurance value although the yield will be low. In older patients or those with alarm features, prompt endoscopy is recommended. If endoscopy is non-diagnostic, gastric biopsies are recommended to document H. pylori status unless already known. While treatment of H. pylori is unlikely to relieve the symptoms of functional dyspepsia, the long-term benefits probably outweigh the risks and treatment can be considered on a case-by-case basis. In H. pylori-negative patients with documented functional dyspepsia, antisecretory or prokinetic therapy, depending on the predominant symptom, is reasonable, assuming reassurance and explanation are insufficient, unless patients have already failed this approach. Other treatment options include antidepressants, antispasmodics, visceral analgesics such as serotonin type 3 receptor antagonists, and behavioural or psychotherapy although these are all of uncertain efficacy. Long-term drug treatment in functional dyspepsia should be avoided; intermittent short courses of treatment as needed is preferred. CONCLUSION The management of dyspepsia recommended is based on current best evidence but must be tailored to local factors such as practice setting, the background prevalence of H. pylori and structural disease, and costs.
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Affiliation(s)
- N J Talley
- Department of Medicine, University of Sydney, Nepean Hospital, Sydney, Australia
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Abstract
Dyspepsia and heartburn are the two cardinal symptoms of foregut dysfunction. When confronting such a problem, that physician must first learn to discern between the two, because treatment can be quite different for the conditions presenting with these symptoms. This article details the approach to work-up and treatment of patients presenting with dyspepsia or heartburn.
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Affiliation(s)
- N A Ahmad
- Division of Gastroenterology, University of Pennsylvania School of Medicine, Philadelphia, USA
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Lind T, Havelund T, Lundell L, Glise H, Lauritsen K, Pedersen SA, Anker-Hansen O, Stubberöd A, Eriksson G, Carlsson R, Junghard O. On demand therapy with omeprazole for the long-term management of patients with heartburn without oesophagitis--a placebo-controlled randomized trial. Aliment Pharmacol Ther 1999; 13:907-14. [PMID: 10383525 DOI: 10.1046/j.1365-2036.1999.00564.x] [Citation(s) in RCA: 137] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
AIM To observe the natural course of gastro-oesophageal reflux disease (GERD) in patients without oesophagitis following effective symptom relief, and to determine the place of acid pump inhibitor therapy in the long-term management of these patients. METHODS We investigated the efficacy of on-demand therapy with omeprazole 20 mg or 10 mg, or placebo in a double-blind, randomized multicentre trial. It involved 424 patients with troublesome heartburn without endoscopic evidence of oesophagitis in whom heartburn had been resolved with short-term treatment. Patients were told to take study medication on demand once daily on recurrence of symptoms until symptoms resolved over a 6-month period. They also had access to antacids. The primary efficacy variable was time to discontinuation of treatment, due to unwillingness to continue. RESULTS According to life-table analysis, after 6 months the remission rates were 83% (95% CI: 77-89%) with omeprazole 20 mg, 69% (61-77%) with omeprazole 10 mg, and 56% (46-64%) with placebo (P < 0.01 for all intergroup differences). The mean (s.d.) number of study medications used per day in these groups was 0.43 (0.27), 0.41 (0.27) and 0.47 (0.27), respectively. The use of antacids was highest in the placebo group and lowest in the omeprazole 20 mg group. Treatment failure was associated with more than a doubling of antacid use, and a deterioration in patient quality of life. CONCLUSIONS Approximately 50% of patients with heartburn who do not have oesophagitis need acid inhibitory therapy in addition to antacid medication to maintain a normal quality of life. On-demand therapy with omeprazole 20 mg, is an effective treatment strategy in these patients.
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Affiliation(s)
- T Lind
- Department of Surgery, Kärnsjukhuset, Skövde, Sweden
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Janssen HA, Muris JW, Knottnerus JA. The clinical course and prognostic determinants of non-ulcer dyspepsia: a literature review. Scand J Gastroenterol 1999; 34:546-50. [PMID: 10440602 DOI: 10.1080/003655299750025985] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- H A Janssen
- Dept. of General Practice, Maastricht University, The Netherlands
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Meineche-Schmidt V, Krag E. Dyspepsia in general practice in Denmark. A 1-year analysis of consulters in general practice. Scand J Prim Health Care 1998; 16:216-21. [PMID: 9932314 DOI: 10.1080/028134398750002981] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
OBJECTIVE To estimate the incidence rate of patients with dyspepsia in general practice, related to age, gender and dwelling and to classify the patients into dyspepsia subgroups. DESIGN In a background population of 123,610 persons under the National Health Insurance System a systematic, prospective registration of dyspepsia patients consulting in general practice was done. Each patient was subject to a structured interview covering 18 dyspepsia symptoms and six alarm symptoms. A diagnostic chart was used to classify the patients into subgroups. SETTING General practice: 93 general practitioners in 63 centres in Denmark. PATIENTS Patients consulting the general practitioner with dyspepsia as their main complaint. RESULTS 4215 dyspepsia patients were registered within 1 year. The annual incidence rate of dyspepsia was 3.4%. Alarm symptoms were present in 11.7% of the patients. The highest incidence rates were related to middle age, female gender and rural dwelling. Of these 34% had dysmotility-like, 30% had reflux-like, 17% ulcer-like and 3% uncharacteristic dyspepsia, while 16% were classified into two or more groups. Dysmotility-like dyspepsia was predominant in women and reflux-like dyspepsia was predominant in men. CONCLUSIONS Within 1 year 34 patients out of 1000 will seek medical advise in general practice with a new episode of dyspepsia. Based on the registration of symptoms 28 of 34 can be classified into a single subgroup of dyspepsia; 4 of 34 patients will present with one or more alarm symptom.
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Affiliation(s)
- V Meineche-Schmidt
- Department of General Practice, Panum Institute, University of Copenhagen, Denmark
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Shaw M, Talley NJ, Adlis S, Beebe T, Tomshine P, Healey M. Development of a digestive health status instrument: tests of scaling assumptions, structure and reliability in a primary care population. Aliment Pharmacol Ther 1998; 12:1067-78. [PMID: 9845396 DOI: 10.1046/j.1365-2036.1998.00399.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND The absence of valid and reliable health status measures for functional gastrointestinal illness has limited research and patient care for this common group of disorders. A self-report survey has been developed. METHODS Initial development focused on extensive pre-testing of patients, primary care physicians and gastroenterologists. The disease-specific portion included the Rome criteria for dyspepsia subgroups and the Manning and Rome criteria for irritable bowel syndrome. The Short Form-36 was added. Psychometric analyses included techniques of multitrait scaling, scale internal consistency and criterion validation. RESULTS Six hundred and ninety patients presenting to their primary care physician for treatment of heartburn, abdominal pain or discomfort completed the 98 question survey. The disease-specific portion revealed five components including reflux, dysmotility, a two-domain bowel dysfunction complex, and a pain index. Internal consistency measures demonstrated good to excellent reliability. Scaling successes were observed on multitrait scaling. The disease-specific portion was reduced to 34 questions. Criterion validity was demonstrated with the correlation of the disease-specific questions to the SF-36. CONCLUSIONS The psychometric analyses lend credence to the concept of stomach and bowel symptom subgrouping as proposed by expert consensus. The psychometric properties of the five summated disease-specific scales compare favourably with standardized health status measures.
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Affiliation(s)
- M Shaw
- Health Research Center, Park Nicollet Clinic, Institute for Research and Education, HealthSystem, Minneapolis, Minnesota 55416, USA
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Soykan I, Sivri B, Sarosiek I, Kiernan B, McCallum RW. Demography, clinical characteristics, psychological and abuse profiles, treatment, and long-term follow-up of patients with gastroparesis. Dig Dis Sci 1998; 43:2398-404. [PMID: 9824125 DOI: 10.1023/a:1026665728213] [Citation(s) in RCA: 378] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Patients with gastroparesis frequently present challenging clinical, diagnostic, and therapeutic problems. Data from 146 gastroparesis patients seen over six years were analyzed. Patients were evaluated at the time of initial diagnosis and at the most recent follow-up in terms of gastric emptying and gastrointestinal symptomatology. The psychological status and physical and sexual abuse history in female idiopathic gastroparesis patients were ascertained and an association between those factors and gastrointestinal symptomatology was sought. Eighty-two percent of patients were females (mean age: 45 years old). The mean age for onset of gastroparesis was 33.7 years. The etiologies in 146 patients are: 36% idiopathic, 29% diabetic, 13% postgastric surgery, 7.5% Parkinson's disease, 4.8% collagen vascular disorders, 4.1% intestinal pseudoobstruction, and 6% miscellaneous causes. Subgroups were identified within the idiopathic group: 12 patients (23%) had a presentation consistent with a viral etiology, 48% had very prominent abdominal pain. Other subgroups were gastroesophageal reflux disease and nonulcer dyspepsia (19%), depression (23%), and onset of symptoms immediately after cholecystectomy (8%). Sixty-two percent of women with idiopathic gastroparesis reported a history of physical or sexual abuse, and physical abuse was significantly associated with abdominal pain, somatization, depression, and lifetime surgeries. At the end of the follow-up period, 74% required continuous prokinetic therapy, 22% were able to stop prokinetics, 5% had undergone gastrectomy, 6.2% went onto gastric electrical stimulation (pacing), and 7% had died. At some point 21% had required nutrition support with a feeding jejunostomy tube or periods of parenteral nutrition. A good response to pharmacological agents can be expected in the viral and dyspeptic subgroups of idiopathics, Parkinson's disease, and the majority of diabetics, whereas a poorer outcome to prokinetics can be expected in postgastrectomy patients, those with connective tissue disease, a subgroup of diabetics, and the subset of idiopathic gastroparesis dominated by abdominal pain and history of physical and sexual abuse. Appreciation of the different etiologies and psychological status of the patients may help predict response to prokinetic therapy.
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Affiliation(s)
- I Soykan
- Division of Gastroenterology, University of Kansas Medical Center, Kansas City 66160-7350, USA
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Perri F, Clemente R, Festa V, Annese V, Quitadamo M, Rutgeerts P, Andriulli A. Patterns of symptoms in functional dyspepsia: role of Helicobacter pylori infection and delayed gastric emptying. Am J Gastroenterol 1998; 93:2082-2088. [PMID: 9820377 DOI: 10.1111/j.1572-0241.1998.00597.x] [Citation(s) in RCA: 92] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Functional dyspepsia (FD) is a syndrome in which several causes are probably involved. Our aim was to investigate the association between specific dyspeptic symptoms and Helicobacter pylori infection or delayed gastric emptying. METHODS Nine hundred thirty-five consecutive outpatients with unexplained dyspepsia were studied. After appropriate investigation, 304 patients were diagnosed as affected by chronic FD and were tested for H. pylori infection and gastric emptying of solids by means of 13C-urea and 13C-octanoic acid breath tests. Four dyspeptic symptoms (epigastric pain or burning, postprandial fullness, nausea, and vomiting) were scored as absent, mild, moderate, or severe (0-3) according to their influence on the patients' activities. Symptoms of irritable bowel syndrome and gastroesophageal reflux disease were also assessed. On the basis of symptom scores, three groups were identified: "prevalent pain" (10.5%), "prevalent discomfort" (32.6 %), and "unclassifiable" dyspepsia (56.9%). RESULTS Of the 304 patients with FD, 208 (68.4 %) were H. pylori-positive on urea breath test. Gastric emptying was delayed in 99 subjects (32.6%). Patients with "prevalent pain" were infected significantly more often (81.2% vs 59.6%; p = 0.026) and less frequently had delayed gastric emptying (6.2% vs 40.4%; p = 0.0001) than those with "prevalent discomfort." H. pylori infection was independently associated with age > or =40 yr and epigastric pain or burning > or =2 (odds ratio [OR] and 95% confidence interval [CI] 4.09 [2.39-7.00] and 1.70 [1.04-2.77], respectively). Delayed gastric emptying was independently associated with a cumulative score > or =6 for postprandial fullness, nausea, and vomiting (OR [95% CI]: 3.13 [1.06-9.18]). H. pylori status had no influence on gastric emptying. Logistic regression analysis showed that delayed gastric emptying, female sex, and concomitant symptoms of inflammatory bowel syndrome were independently associated with a cumulative score > or =6 for postprandial fullness, nausea, and vomiting (p = 0.0281, p = 0.0387, and p = 0.0316, respectively). Moreover, concomitant symptoms of gastroesophageal reflux disease, female sex, and H. pylori infection were independently associated with epigastric pain or burning > or =2 (p = 0.002, p = 0.0001, and p = 0.0875, respectively). CONCLUSIONS Two subsets of FD patients have been identified on the basis of symptoms. One subgroup is mainly characterized by "prevalent pain," H. pylori infection, and normal gastric emptying; the other one demonstrates "prevalent discomfort" and delayed gastric emptying. These findings shed some light on possible etiopathogenetic mechanisms of FD.
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Affiliation(s)
- F Perri
- Division of Gastroenterology, Casa Sollievo della Sofferenza Hospital, I.R.C.C.S., San Giovanni Rotondo, Italy
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Carlsson R, Dent J, Bolling-Sternevald E, Johnsson F, Junghard O, Lauritsen K, Riley S, Lundell L. The usefulness of a structured questionnaire in the assessment of symptomatic gastroesophageal reflux disease. Scand J Gastroenterol 1998; 33:1023-9. [PMID: 9829354 DOI: 10.1080/003655298750026697] [Citation(s) in RCA: 309] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The diagnosis of gastroesophageal reflux disease (GERD) rests primarily on recognition of symptom patterns that are classical for reflux disease, but little attention has been paid to the use of a formal questionnaire for identifying such symptom patterns. METHODS A self-administered questionnaire was developed which has seven items that focus on the nature of the symptoms and the precipitating, exacerbating, and relieving factors. The diagnostic validity of the questionnaire was tested against endoscopy and 24-h pH monitoring. A further evaluation was undertaken in patients with symptoms suggestive of GERD and in patients with non-ulcer dyspepsia, to identify factors that might predict symptom relief during treatment with omeprazole. RESULTS When endoscopic esophageal mucosal breaks and 24-h pH data were used as criteria for the diagnosis of GERD, the questionnaire had a sensitivity of 92% but a very low specificity of 19%. Symptom relief during treatment with omeprazole was predicted by the presence of heartburn, described as 'a burning feeling rising from the stomach or lower chest up towards the neck' (P = 0.004), and 'relief from antacids' (P = 0.02). In non-ulcer dyspepsia a positive response to omeprazole was confined to the subgroup of patients who identified their main discomfort as heartburn as described above. CONCLUSION The present questionnaire using descriptive language usefully identified heartburn in patients presenting with upper abdominal symptoms, and this symptom predicted symptom resolution during treatment with omeprazole.
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Affiliation(s)
- R Carlsson
- Dept. of Surgery, Sahlgren's University Hospital, Göteborg, Sweden
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Rothenbacher D, Peter R, Bode G, Adler G, Brenner H. Dyspepsia in relation to Helicobacter pylori infection and psychosocial work stress in white collar employees. Am J Gastroenterol 1998; 93:1443-9. [PMID: 9732922 DOI: 10.1111/j.1572-0241.1998.00460.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE We undertook an investigation of the relationship between psychosocial work stress and Helicobacter pylori (H. pylori) infection with dyspepsia. METHODS We conducted a cross-sectional study among 189 employees of a health insurance company in the city of Ulm, Germany. RESULTS A clear association between work-related psychosocial factors and the occurrence of dyspeptic symptoms during the past 3 months was evident. Persons who were considered to have a critical style of coping with work demands suffered more often from dyspeptic symptoms. Current infection with H. pylori was not associated with prevalence of dyspeptic symptoms. These results were also confirmed by adjustment for age, gender, smoking status, education, and use of antiinflammatory drugs within the past 3 months, by means of multivariate analysis. The odds ratio (OR) for having a dyspepsia symptom score in the upper tertile versus the 1st or 2nd was 3.22 (95% confidence interval [CI], 1.56-6.65), given that the employee was considered to have a critical style of coping with work demands. The OR for having a dyspepsia symptom score in the upper tertile given H. pylori infection was 1.23 (95% CI, 0.44-3.46), indicating no association of current H. pylori infection with dyspeptic symptoms. CONCLUSIONS A critical style of coping with work demands may be an important determinant for dyspepsia-like symptoms. Therefore, in the absence of an underlying disease, specific intervention programs should be targeted at the behavior of the affected individual (e.g., stress-reduction programs) rather than on the treatment of specific symptoms or infection with H. pylori.
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Locke GR. Prevalence, incidence and natural history of dyspepsia and functional dyspepsia. BAILLIERE'S CLINICAL GASTROENTEROLOGY 1998; 12:435-42. [PMID: 9890080 DOI: 10.1016/s0950-3528(98)90016-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Estimates of the prevalence of dyspepsia in the community have varied between studies. This is, in large part, because of differences in the definitions used. Roughly speaking, 15-20% of the general population will report recurrent upper abdominal pain over the course of a year. Most of these people do not have endoscopic abnormalities and thus meet the criteria for functional dyspepsia. These symptoms appear to come and go, which makes determination of the incidence of dyspepsia quite difficult. Most studies have not distinguished whether the onset of symptoms represents recurrence or de novo symptoms. Approximately 5-10% of the population will develop symptoms of dyspepsia in a given year, and 50% of people with dyspepsia will lose their symptoms the following year. Regardless of the exact figures, all studies have demonstrated dyspepsia to be exceedingly common in the community.
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Affiliation(s)
- G R Locke
- Division in Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, USA
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48
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Bytzer P. How should new-onset dyspepsia be managed in general and specialist practice? BAILLIERE'S CLINICAL GASTROENTEROLOGY 1998; 12:587-99. [PMID: 9890090 DOI: 10.1016/s0950-3528(98)90026-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Managing patients with new-onset dyspeptic symptoms represents a real challenge in clinical decision-making. The major controversy has been over the optimal management strategy of patients with new-onset dyspeptic symptoms who do not present with alarm symptoms. Since unaided clinical diagnosis is unreliable, proposed management strategies have included empirical treatment algorithms, computer-assisted predictive score models and Helicobacter pylori-based strategies such as test-and-scope or test-and-treat algorithms. Endoscopy remains the diagnostic 'gold standard', and the management should ideally be based on endoscopic diagnosis. Because of economic constraints and increasing waiting lists, this is not possible. When precise and comprehensive guidelines have been formulated, future patients will probably be managed in primary care by a Helicobacter test-and-treat policy, leaving only empirical treatment failures for specialist evaluation.
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Affiliation(s)
- P Bytzer
- Department of Medical Gastroenterology F, Glostrup University Hospital, Ndr. Ringvej, Denmark
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Pantoflickova D, Blum AL, Koelz HR. Helicobacter pylori and functional dyspepsia: a real causal link? BAILLIERE'S CLINICAL GASTROENTEROLOGY 1998; 12:503-32. [PMID: 9890085 DOI: 10.1016/s0950-3528(98)90021-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
This chapter reviews the evidence for a link between functional dyspepsia and Helicobacter pylori infection from three angles. In the section on pathophysiology, we evaluate how H. pylori could theoretically produce dyspeptic symptoms: many mechanisms can be proposed. In the discussion on epidemiology, we evaluate possible associations between the occurrence of symptoms and infection. Here, many studies claiming a coincidence or chronological sequence of infection and symptoms are criticized because of their poor design. In the section on the improvement of functional dyspepsia by the treatment of H. pylori infection, the conclusion is reached that if such an effect occurs at all--which is unlikely--it is very weak. The controversy on the link between H. pylori infection and functional dyspepsia is presently ongoing. Some authors are still trying to save an elegant concept that once looked so plausible but now has the facts against it.
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Affiliation(s)
- D Pantoflickova
- Department of Medicine, University Hospital, CHUV, Lausanne, Switzerland
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50
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Veldhuyzen van Zanten SJ. Treatment of functional dyspepsia. BAILLIERE'S CLINICAL GASTROENTEROLOGY 1998; 12:573-86. [PMID: 9890089 DOI: 10.1016/s0950-3528(98)90025-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Many functional dyspepsia treatment trials have until recently suffered from important weaknesses in study design. A major problem has been the low number of studies that have used validated outcome measures. Fortunately, progress has been made in this area. The evidence for the efficacy of antacids, H2-receptor antagonists, omeprazole, domperidone, cisapride and anti-Helicobacter therapy is reviewed. Although several of these have shown benefit, it is unclear whether this may be a result of the inclusion of patients with unrecognized gastro-oesophageal reflux disease. The data on anti-Helicobacter therapy are conflicting.
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Affiliation(s)
- S J Veldhuyzen van Zanten
- Department of Medicine, Dalhousie University, QEII, Victoria General Hospital Site, Dr. R. C. Dickson Centre, Halifax, N.S., Canada
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