Gastroparesis and functional dyspepsia: excerpts from the AGA/ANMS meeting

BACKGROUND

Despite the relatively high prevalence of gastroparesis and functional dyspepsia, the aetiology and pathophysiology of these disorders remain incompletely understood. Similarly, the diagnostic and treatment options for these two disorders are relatively limited despite recent advances in our understanding of both disorders.

PURPOSE

This manuscript reviews the advances in the understanding of the epidemiology, pathophysiology, diagnosis, and treatment of gastroparesis and functional dyspepsia as discussed at a recent conference sponsored by the American Gastroenterological Association (AGA) and the American Neurogastroenterology and Motility Society (ANMS). Particular focus is placed on discussing unmet needs and areas for future research.

[Involutory maldigestion]

We described the indigestion caused by an involutive reduction in efficiency of intestinal digestion as a result of age-reduction enzymes of the pancreas, small intestine and stomach. Symptoms of involutive maldigestion eliminated fractional power, the use of pancreatic enzymes, pre- and probiotics.

Functional dyspepsia: a pragmatic approach

Functional dyspepsia includes one or more of four cardinal symptoms: postprandial fullness, early satiety, pain or burning in the epigastrum. According to the Rome III diagnostic criteria for functional dyspepsia, these symptoms must be present for the last 3 months with symptom onset at least 6 months prior to diagnosis. Functional dyspepsia is not the result of an underlying structural abnormality, but rather the consequence of multiple pathophysiological mechanisms such as abnormal gastric motility, gastric and duodenal hypersensitivity to acid, Helicobacter pylori infection. Dyspeptic patients over 50 or those with alarm symptoms should be investigated to detect any structural abnormality such as cancer, peptic ulcer or esophagitis. After structural abnormalities and gastroesophageal reflux disease are excluded the management of functional dyspepsia consists of either a test and treat approach (non invasive detection of Helicobacter pylori infection followed by eradication therapy) or empirical therapy. Although endoscopy was traditionally reserved for those patients without symptom relief after 6-8 weeks of therapy, the significant percentage of patients with functional dyspepsia with symptom breakthrough or relapse after antisecretory or prokinetic therapy discontinuation makes an initial endoscopic study a logical choice. Therapy with proton pump inhibitors yields results especially in those patients with regurgitation and epigastric burning sensation, while prokinetic agents with no extrapyramidal side effects (such as Domperidone and Itopride) alleviate satiation, bloating and nausea by accelerating gastric emptying. Second-line drugs with encouraging results in clinical trials which can be used in functional dyspepsia are low-dose tricyclic antidepressants as well as selective serotonine reuptake inhibitors.

["Influence of eradication of Helicobacter pylori in patients with non-ulcer dyspepsia in a hospital of Lima"]

OBJECTIVE

To determine whether erradication of Helicobacter pylori (HP) infection from gastric mucosae is associated with changes in symptoms severity and satisfaction degree in patients with non-ulcer dyspepsia (NUD).

METHODS

Prospective cohort study in patients with NUD and HP infection that were evaluated for six months following treatment, made up of 70 HP Negative patients in whom HP infection was erradicated, and 28 HP Positive patients in whom infection was not eradicated following treatment. Dyspeptic symptoms were assessed using SODA scale.

RESULTS

There was significant differences on decrease of pain (RR= 0.6, IC 90%: 0.47 -0.78) and non-pain symptoms intensity (RR= 0.5, IC 90%: 0.39 - 0.67), as well as on increase on degree of satisfaction (RR= 3.28, IC 90%: 2.86 - 3.75) among HP Negative patients group with regards to HP Positive patients at sixth month.

CONCLUSIONS

In patients with nonulcer dyspepsia, erradication of HP infection is associated with decrease in symptoms intensity and increase on degree of satisfaction six month after treatment.

Sulphate-bicarbonate mineral waters in the treatment of biliary and digestive tract diseases

The authors point out the therapeutic properties of sulphate-bicarbonate mineral waters. After summarizing the general mechanism of action of mineral waters, the main indications of such waters in thermal treatment are examined including: biliary sand, biliary dyskinesia, functional dyspepsia, irritable colon, chronic primitive constipation. The dysfunctions of biliary and digestive tracts are growing, mainly in the affluent world, because of the increase for stress, dietary habits, modern life style. Now they affect from 2,4% of general population to 7% of men and 20% of women, according to different studies. Mineral waters can improve symptoms and care some physiopathological underlying mechanisms. Authors stress the efficacy of sulphate-bicarbonate mineral waters in the therapy of biliary dyskinesias, namely gallbladder hypokinesia and Oddi's sphincter spasm, caused by their content in SO4 = anion and Mg++ cation and related effects on paracrine-endocrine gastrointestinal system. In addition, they report the effects of sulphate-bicarbonate mineral waters in the lithogenic bile (sand bile), because of their diluting and washing activity. Among the sulphate-bicarbonate mineral waters, the Authors outline the well-documented therapeutic activity of Acqua Santa and Fucoli of Chianciano Terme. Acqua Santa has stimulating effect on cholecystis's motility, as proved by controlled clinical trials. Finally, the therapeutic use of sulphate-bicarbonate mineral water is discussed in functional dyspepsia, chronic primitive constipation and irritable bowel syndrome.

WITHDRAWN: Initial management strategies for dyspepsia

BACKGROUND

This review considers management strategies (combinations of initial investigation and empirical treatments) for dyspeptic patients. Dyspepsia was defined to include both epigastric pain and heartburn.

OBJECTIVES

To determine the effectiveness, acceptability, and cost effectiveness of the following initial management strategies for patients presenting with dyspepsia (a) Initial pharmacological therapy (including endoscopy for treatment failures). (b) Early endoscopy. (c) Testing for Helicobacter pylori (H. pylori )and endoscope only those positive. (d) H. pylori eradication therapy with or without prior testing.

SEARCH STRATEGY

Trials were located through electronic searches and extensive contact with trialists.

SELECTION CRITERIA

All randomised controlled trials of dyspeptic patients presenting in primary care.

DATA COLLECTION AND ANALYSIS

Data were collected on dyspeptic symptoms, quality of life and use of resources. An individual patient data meta-analysis of health economic data was conducted

MAIN RESULTS

Twenty-five papers reporting 27 comparisons were found. Trials comparing proton pump inhibitors (PPI) with antacids (three trials) and histamine H2-receptor antagonists (H2RAs) (three trials), early endoscopy with initial acid suppression (five trials), H. pylori test and endoscope versus usual management (three trials), H. pylori test and treat versus endoscopy (six trials), and test and treat versus acid suppression alone in H. pylori positive patients (four trials), were pooled. PPIs were significantly more effective than both H2RAs and antacids. Relative risks (RR) and 95% confidence intervals (CI) were; for PPI compared with antacid 0.72 (95% CI 0.64 to 0.80), PPI compared with H2RA 0.63 (95% CI 0.47 to 0.85). Results for other drug comparisons were either absent or inconclusive. Initial endoscopy was associated with a small reduction in the risk of recurrent dyspeptic symptoms compared with H. pylori test and treat (OR 0.75, 95% CI 0.58 to 0.96), but was not cost effective (mean additional cost of endoscopy US$401 (95% CI $328 to 474). Test and treat may be more effective than acid suppression alone (RR 0.59 95% CI 0.42 to 0.83).

AUTHORS' CONCLUSIONS

Proton pump inhibitor drugs (PPIs) are effective in the treatment of dyspepsia in these trials which may not adequately exclude patients with gastro-oesophageal reflux disease (GORD). The relative efficacy of histamine H2-receptor antagonists (H2RAs) and PPIs is uncertain. Early investigation by endoscopy or H. pylori testing may benefit some patients with dyspepsia but is not cost effective as part of an overall management strategy.

Dyspepsia and gastroesophageal reflux disease (GERD): is there any correlation?

Dyspepsia is a syndrome characterized by symptoms and signs of upper gastrointestinal tract and the adjacent organs. It is estimated that 25% of the community have symptoms of dyspepsia syndrome. One-third of patients who visit general physician practices are patients with dyspepsia syndrome; and half of patients who visit gastroenterologists are also patients with dyspepsia syndrome. Dyspepsia syndrome and gastroesophageal reflux disease (GERD) are very prevalent in the community throughout the world.Gastroesophageal reflux disease (GERD) is more and more commonly found in daily medical practice. Until now,the natural history of disease on GERD and dyspepsia is hardly understood, even though many scientists studied both conditions and there are frequently overlapping. In an individual, GERD and dyspepsia may occur simultaneously and therefore they are hardly to be discriminated.The management of GERD is performed in keeping with Indonesia and Asia Pacific consensus, life-style modification and administering the acid suppression agents (Proton pump inhibitor (drug of choice), H2-receptor antagonist, etc),prokinetic agents (Cisapride, domperidone, etc). Life-style modification shall be performed as follows, i.e. sleep with 30-45 degree elevated head or upper chest, do not avoid sour beverages, chocolate, coffee or alcohol, avoid fat and various fried foods, sour food, less stress, stop smoking, small but frequent feeding, etc. There is a correlation between dyspepsia syndrome and gastroesophageal reflux disease(GERD), particularly between the functional dyspepsia and non-erosive gastroesophageal reflux (NERD). More appropriate definition is necessary to differentiate the dyspepsia syndrome and GERD. Further studies are needed to establish distinct definition and criteria between dyspepsia syndrome and GERD.

Managing dyspepsia in primary care

NICE recommends immediate referral for patients with dyspepsia and significant acute GI bleeding and urgent specialist referral for investigation if any of the following alarm symptoms are present: progressive difficulty swallowing; chronic GI bleeding; unintentional weight loss; persistent vomiting; abdominal mass; iron deficiency anaemia; suspicious findings on barium meal. Patients aged > 55 with unexplained and persistent dyspepsia, despite H. pylori testing and acid suppression therapy, should also be considered for endoscopy, as should those with previous gastric ulcer or surgery, continuing need for NSAIDs or raised risk of gastric cancer. Patients with uninvestigated dyspepsia should be managed by empirical treatment with a PPI or testing for and treating H. pylori if present. Testing by urea breath test, stool antigen test, or locally validated lab-based serology is suggested. H. pylori eradication is usually given as triple therapy, for seven days, involving a PPI, clarithromycin and either amoxicillin or metronidazole. It is important to take a thorough history and to enquire about any medication the patient is taking. Drugs that are common culprits for dyspepsia include: NSAIDs; calcium antagonists; bisphosphonates; steroids; theophyllines; nitrates. NSAIDs can also cause GI bleeding. Absence of dyspepsia in patients taking NSAIDs does not indicate a reduced risk of bleeding. Peptic ulcers fall into three categories: H. pylori associated ulcers; drug-induced ulcers (particularly NSAIDs); and ulcers in H. pylori-negative patients not taking causative medication. H. pylori is associated with both gastric and duodenal ulcer disease but it is in the duodenum where the closest relationship exists. In any 6-12 month period, 20-40% of healthy people, more commonly men, will experience symptoms of heartburn. Oesophageal reflux can progress to more serious disease such as erosive oesophagitis, stricture or Barrett's oesophagus.

[Gastroenterology and FSS]

Functional gastrointestinal disorders (FGIDs) such as functional dyspepsia (FD) and irritable bowel syndrome (IBS) are included in functional somatic syndromes (FSS), which are designated as medically unexplained physical symptoms. Pathopysiology of these diseases are characterized by multi-functional disorders of the gastrointestinal (GI) tract including psychosomatic sensation, brain-gut interaction, autonomic nervous systems, motility disorders, local inflammation, and visceral perception. However, the standard therapy for these diseases is not established, since predominant factors among them associated with respective patients are difficult to be identified in a clinical field. In this section, we are going to present the accumulating evidences for the pathophysiology and therapeutic strategy of FD and IBS.

The effect of Helicobacter pylori eradication on dyspeptic symptoms, acid reflux and quality of life in patients with functional dyspepsia

BACKGROUND

The aims of this study were to investigate the effect of Helicobacter pylori eradication on gastroesophageal reflux, gastrointestinal symptoms and quality of life in patients with functional dyspepsia.

METHODS

20 H. pylori positive patients diagnosed as having functional dyspepsia according to Roma-II criteria completed the study period. Esophageal motility testing and pH recordings were obtained from each patient before and at the end of the study period. Each patient's gastrointestinal symptoms were evaluated according to Glasgow dyspepsia score. 36-Item short-form health survey (SF-36) and EDQ5 health survey were obtained form each patient.

RESULTS

H. pylori eradication was accomplished in 13 patients (65%). Glasgow dyspepsia symptom score improved in H. pylori eradicated patients (10.3 vs 7.5, p<0.05) compared to baseline. Fasting lower esophageal sphincter pressures increased (21.6 vs 25.4 mmHg, p<0.05) after H. pylori eradication Neither the amplitude of peristaltic contractions in the esophageal body (59.4 vs 57.7 mmHg, p=ns) nor the velocity of peristaltic contractions changed before and after eradication. The percent time of esophageal pH<4 (0.7 vs 2.6, p<0.001), reflux events longer than 5 min (0 vs 0.7, p<0.005) and total reflux number (10.3 vs 19.3, p<0.005) significantly increased after eradication therapy. In the SF-36 health-related quality of life survey, general health score was 3.5 vs. 3.4, physical activity 25.2 vs. 26.4, physical role 5.9 vs. 6.3, emotional pain 4.6 vs. 4.5, social activity 2.0 vs. 1.9, physical pain 3.4 vs. 3.0, vitality 32.3 vs. 34.6, and mental health 11.9 vs. 11.5, before and at the end of treatment (p=ns), respectively.

CONCLUSIONS

H. pylori eradication did not influence quality of life in patients with functional dyspepsia. Majority of the patients experienced a significant change in esophageal acid exposure after H. pylori eradication. H. pylori eradication significantly decreases gastrointestinal symptoms, however has no effect on quality of life in patients with functional dyspepsia.

Should we step-up or step-down in the treatment of new-onset dyspepsia in primary care?

Dyspepsia is common in the community, and the condition represents a considerable burden to the health service. Individuals over the age of 50 to 55 years consulting with new-onset dyspepsia and those with alarming features, such as dysphagia and weight loss, require urgent endoscopy to exclude gastro-esophageal malignancy. For younger individuals without alarm features prompt endoscopy and "test and scope" are not cost-effective initial management strategies. "Test and treat" or empirical acid suppression therapy should be preferred, depending on patient and physician choice, as well as local prevalence of Helicobacter pylori. If empirical acid suppression therapy is favored, a recent primary care-based trial from the Netherlands suggests the choice of initial acid suppressant (antacid or proton pump inhibitor [PPI]) has little effect on the likelihood of remaining symptomatic, and that stepping-up from antacid to PPI is more cost-effective than stepping-down from PPI, when current prices of branded drugs were considered.

[Clinical observation on transcutaneous electrical acupoint stimulation for treatment of functional dyspepsia]

OBJECTIVE

To compare the therapeutic effects of transcutaneous electrical point stimulation and medication on functional dyspepsia.

METHODS

Two hundred and fifty cases were randomly divided into an observation group and a control group, 125 cases in each group. The observation group was treated with transcutaneous electrical acupoint stimulation and oral administration of placebo, transcutaneous electrical stimulated at Zusanli (ST 36), Liangmen (ST 21), Taichong (LR 3) etc. The control group was treated with oral administration of Mosapride citrate dispersible tablets, Domperidone and Omeprazole and the placebo treatment of transcutaneous electrical acupoint stimulation, the stimulated position was 3-4 cm to the selected points of the observation group, the amount of the stimulation did not reach the treatment amount. The symptom score, the plasma motilin (MTL) concentration and the somatostatin (SS) concentration were observed before and after treatment of 3 courses.

RESULTS

All symptom scores after treatment were lower than that before treatment in the two groups, the scores of the upper abdominal pain, acid regurgitation, belching and abdominal distention in the observation group were significantly lower than that in the control group (P < 0.05, P < 0.01); the treatments of both two groups can increase the plasma MTL concentration and decrease the SS concentration (both P < 0.001), and the plasma MTL concentration in the observation group was significantly higher than that in the control group (P < 0.01), and the SS concentration was significantly lower than that in the control group (P < 0.05).

CONCLUSION

Transcutaneous electrical point stimulation can more reduce the symptoms of upper abdominal pain, acid regurgitation, belching and abdominal distention, etc. in the functional dyspepsia patients than medication treatment, and can increase the concentration of the plasma MTL and decrease the SS concentration, thus to improve the gastrointestinal motility.

Brain areas involved in acupuncture treatment on functional dyspepsia patients: a PET-CT study

Neuroimaging studies on brain responses to acupuncture stimulations have received considerable attention recently. The majority of these studies are centered on healthy controls (HC) and neuropathy, while little work has addressed other disorders. This study aimed to investigate the influence of acupuncture stimulations on brain activities in functional dyspepsia (FD) patients. Eight FD patients and eight healthy controls (HC) were involved in this study. Each HC received an 18F-FDG PET-CT scan at baseline, while each patient received scans at baseline and after acupuncture stimulations. Manual acupuncture stimulations were performed at ST34 (Liangqiu), ST36 (Zusanli), ST40 (Fenglong) and ST42 (Chongyang) in FD patients. The images were analyzed with the Statistical Parametric Mapping software 2.0. Compared to HC, the FD patients showed a lower glycometabolism in the right orbital gyrus, the left caudate tail and the cingulate gyrus, and a higher glycometabolism in the left inferior temporal gyrus (p<0.005). After acupuncture stimulations, the FD patients showed a glycometabolism decrease in the postcentral gyrus and the cerebella, and an increase in the visual-related cortices(p<0.005). The results suggest that the anterior cingulate cortex, the prefrontal cortices and the caudate tail involve in processing gastric perceptions in FD patients and that the deactivation of the primary somatosensory area and the cerebella is contributable to acupuncture stimulation, while activation of the visual-related cortex is a response to pain or acupoint actions.

Functional (non-ulcer) dyspepsia and gastroparesis--differentiating these conditions and practical management approaches

Because of the limited therapeutic options, management of patients with functional dyspepsia can be remarkably difficult. This review considers the current state of the art for patients who present with unexplained dyspepsia, and outlines a practical management approach for clinicians.

What is the evidence for the use of probiotics in functional disorders?

A rationale for the use of probiotics for a number of functional gastrointestinal symptoms and syndromes can be developed, and an experimental basis for their use continues to emerge, but data from well-conducted clinical trials of probiotics in this area remain scarce. Irritable bowel syndrome (IBS) has attracted the most attention; recent revelations regarding the potential pathogenic roles of the enteric flora and immune activation have led to reawakened interest in bacterio-therapy for this common and challenging disorder. Some recent randomized, controlled studies attest to the efficacy of some probiotics in alleviating individual IBS symptoms, and selected strains have a more global impact. Evidence for long-term efficacy is also beginning to emerge, though more studies are needed in this regard. In other functional syndromes, data are far from adequate to make recommendations, but there is evidence for efficacy of probiotics in treating individual symptoms such as diarrhea, constipation, and bloating. The interpretation of much of the literature in this area is complicated by lack of quality control, use of many different species and strains, and, above all, significant deficiencies in trial methodology.

[Major gastrointestinal syndromes (2): dyspepsia or syndrome of the upper digestive system related with food (2)]

We expose, this time, our ideas and findings on the etiopathogenesis, diagnosis and treatment of the dyspeptic syndrome.

[Integrative therapy of a patient with complex psychosomatic complaints]

We present the case of a 76-year-old female patient with complex psychosomatic complaints. The patient suffered from depression, panic attacks, chronic pain and dyspepsia with nausea and loss of appetite. In addition to the conventional psychosomatic care, the patient received individual homeopathic treatment for her dyspepsia, resulting in complete remission. The therapeutic value of homeopathy in the present case is discussed in the context of recent findings from placebo research.

Herbal remedies for dyspepsia: peppermint seems effective

(1) Functional dyspepsia is extremely common, yet few if any treatments have been shown to be effective. This review examines the potential benefits and risks of using herbal products in treating symptoms of dyspepsia. (2) About forty plants have been approved in France in the composition of products traditionally used for dyspepsia. (3) The clinical efficacy of most of these plants has not been assessed. Some essential oils can cause severe adverse effects, including seizures. Herbal teas appear to be safe when used appropriately. (4) A few randomised controlled clinical trials suggest that peppermint essential oil is effective in reducing abdominal pain, flatulence and diarrhea in patients with "irritable bowel syndrome". Peppermint tea, containing essential oil, has no known adverse effects. (5) There is no sound reason to discourage patients from using herbal teas made from plants such as lemon balm, German chamomile or star anise.

Gastritis, dyspepsia and peptic ulcer disease

Peptic ulcer disease remains a common problem and it most frequently due to the presence of an Helicobacter pylori infection or use of non-steroidal anti-inflammatory drugs (NSAIDs). Dyspepsia is neither sensitive or specific for diagnosing peptic ulcer disease. The approach to patients with dyspepsia is to arrive at a definitive diagnosis without unnecessary exposure to invasive or costly diagnostic procedures. Non-invasive testing is preferred with endoscopy being reserved for those with alarm markers or above a specified age (e.g., 55 years in Western countries). Patients negative for H. pylori infection should receive an empiric trial of acid suppression for 4 to 8 weeks and if beneficial it can be continued.

[Dysbiotic manifestations during eradication therapy of Helicobacter pylori and their corrections]

Forty-eight patients with duodenal peptic ulcer disease infected with Helicobacter pylori were examined. All patients undergo conventional 1-week eradication therapy. After its ending the patients were randomized to two groups: those who will be treated by synbiotics or control group. Normoflorin B and Normoflorin L, which contain bifidobacteria or lactobacilli in complex with different microelements, vitamins, aminoacids, organic acids, and antioxidants, were used as synbiotics. Morphologic study of biopsy samples of small intestine mucosa were performed in patients from both groups. It was determined that eradication therapy worsened existing symptoms of dyspepsia in 80.9% of cases or lead to their emergence, connected with dysbiotic manifestations, in 55.5% of patients. Inclusion of synbiotics in complex therapy resulted in rapid and effective elimination of dyspeptic symptoms, promoted recovery of affected morphologic and functional states of small intestine mucosal epithelium, and optimized metabolic processes important for the digestion.

A 32-year-old woman with chronic abdominal pain

Functional dyspepsia is a highly prevalent disorder that accounts for 5% of visits to primary care clinicians. It frequently coexists with other gastrointestinal tract disorders, including irritable bowel syndrome and gastroesophageal reflux disease. Symptoms of functional dyspepsia, including epigastric pain, early satiety, and postprandial nausea, are nonspecific, making its diagnosis difficult. Functional dyspepsia is a heterogeneous disorder involving a number of different pathophysiologic processes, culminating in both gastrointestinal sensory and motor dysfunction. Although functional dyspepsia does not impart any increased risks to long-term health, it significantly affects both individuals and society. The economic burden of evaluating and treating functional dyspepsia is estimated to be at least $1 billion per year, and patients with functional dyspepsia experience a markedly reduced quality of life. Using the case of Ms C, we apply an evidence-based approach to highlight current knowledge in the diagnosis, evaluation, and treatment of functional dyspepsia.

Failed therapy and directions for the future in dyspepsia

Functional gastrointestinal disorders including functional dyspepsia are highly prevalent. Their clinical course is benign without disease-associated mortality. On the other hand, the impact can be substantial for the affected patients with regard to the decrease of quality of life, and for society with regard to the economical implications. Functional dyspepsia is a clinical syndrome with various underlying pathophysiologies. Thus, it is understandable that there is no single cure available. Reassurance by ruling out relevant differential diagnoses, explanation, and general advice with regard to the underlying causes and dietary and life-style measures are important components of the management of these patients. Well established medical treatments include Helicobacter pylori eradication, acid inhibitory agents and prokinetics. The overall gain over placebo ranges from less than 5% for H. pylori eradication to 15% for antisecretory agents and prokinetics. Thus, even considering a substantial proportion of patients with spontaneous remissions (usually addressed as placebo response in clinical trials), there are 20 to 40% of patients who do not respond properly to these measures. In these patients, other treatment modalities need to be considered. These second- or third-line measures include herbal medicines and psychotropic agents. Some of the herbal preparations have been well studied in controlled clinical trials with sufficient scientific evidence to assume efficacy. Psychotropic drugs on the other hand have, as yet, not been specifically tested in functional dyspepsia. Medications such as clonidine, buspirone or octreotide can be helpful in few selected patients. However, a very careful assessment of potential risks and benefits needs to be undertaken on a case-by-case basis. Other evidence-based measures include psychological interventions such as psychotherapy and hypnotherapy.

[Epidemiology, classification and management of functional dyspepsia]

Functional dyspepsia belongs to functional disorders of the gastrointestinal tract. Its prevalence is estimated up to 25% of adult population of Western countries. On the contrary to irritable bowel syndrome, functional dyspepsia is slightly more frequent in men. The recent classification of functional dyspepsia includes its two subcategories: postprandial distress syndrome (DS, B1a) and epigastric pain syndrome (EPS, B1b). In the management of functional dyspepsia three strategies are taken into the consideration: 1. early gastroscopy performed in people over 45 years of age and independent of age in case of alarm symptoms. 2. Therapy based on noninvasive H. pylori testing: in young adults with dyspeptic symptoms, without alarm symptoms and not treated with nonsteroid antiphlogistic medications. 3. Empiric treatment: considered as an initial therapy in patients not diagnosed with dyspepsia, without alarm symptoms and in dyspeptic patients despite H. pylori eradication. In the treatment of functional dyspepsia the following treatments are applied: dietary treatment, farmacotherapy with antisecretory drugs, prokinetics, H. pylori eradication, antidepressants and psychotherapy. Directions of the further investigation in functional dyspepsia include: improvement of endoscopic methods, and searching for new groups of medications according to the new Rome III classification of functional dyspepsia, based on its pathophysiology.

Dyspepsia in childhood and adolescence: insights and treatment considerations

Functional dyspepsia (FD) is common in children, with as many as 80% of those being evaluated for chronic abdominal pain reporting symptoms of epigastric discomfort, nausea, or fullness. It is known that patients with persistent complaints have increased comorbidities such as depression and anxiety. The interaction with psychopathologic variables has been found to mediate the association between upper abdominal pain and gastric hypersensitivity. These observations suggest that abnormal central nervous system processing of gastric stimuli may be a relevant pathophysiologic mechanism in FD. Despite increased understanding, no specific therapy has emerged; however, recent nonpharmacological-based options such as hypnosis may be effective. Novel approaches, including dietary manipulation and use of nutraceuticals such as ginger and Iberogast (Medical Futures Inc., Ontario, Canada), may also be considered.

[Psychotherapy in somatic diseases--for example gastrointestinal disorders]

The functional gastrointestinal disorders (FGID) are the most frequent clinical conditions seen in practice. Up to 60% of these patients is also suffering from psychosocial problems. Therefore it is important to define the patient's complaints in terms of a biopsychosocial disorder, to acknowledge the relevance of the psychosocial aspects and to provide an integrated psychosomatic treatment or a psychotherapy if indicated. Most of the research on psychotherapy in FGID to date has focused on the irritable bowel syndrome and different methods of treatments were studied (e.g., cognitive-behavioral therapy, dynamic psychotherapy, hypnotherapy, and relaxation). Randomised controlled studies have shown that psychotherapy is superior to conventional medical therapy. Hypnotherapy is successful not only for irritable bowel syndrome but also for functional dyspepsia. Predictors of a positive response to psychological treatment generally are: (1) awareness that stress exacerbates their bowel symptoms, (2) at least mild anxiety or depression, (3) the predominant bowel symptom is abdominal pain or diarrhea and not constipation, (4) the abdominal pain waxes and wanes in response to eating, defecation, or stress rather than being constant pain, and 5) the symptoms are of relatively short duration. Benefits persist over years, and in the long run, clinic visits and health care costs can be reduced.

Clinical trial: effects of tegaserod on gastric motor and sensory function in patients with functional dyspepsia

BACKGROUND Tegaserod, a serotonin receptor type-4 partial agonist, stimulates gastrointestinal motility and has been shown to increase gastric volumes before and after a meal in healthy volunteers. Its effect on gastric motor and sensory function in patients with functional dyspepsia is unclear. AIM To evaluate the effects of tegaserod on gastric compliance, accommodation and gastric sensory function in patients with functional dyspepsia and healthy volunteers. METHODS Sixteen patients with functional dyspepsia and 12 healthy volunteers were studied on two occasions, each after a 7-day treatment with either placebo or tegaserod 6 mg b.d. using a double-blind, randomized, crossover design. After each treatment period a gastric barostat study was performed fasting and during intraduodenal lipid infusion. RESULTS Tegaserod increased postprandial gastric compliance in functional dyspepsia patients (P = 0.04). Healthy volunteers showed enhanced postprandial gastric compliance after placebo (P = 0.03). Between-treatment analysis of gastric accommodation revealed a significant increase in intrabag volumes after tegaserod in healthy volunteer (P = 0.04); no difference could be seen in functional dyspepsia patients. Tegaserod had no effect on gastric sensation. CONCLUSIONS Tegaserod enhances postprandial gastric compliance in functional dyspepsia patients and gastric accommodation in healthy volunteers. The improvement of proximal gastric motor function suggests a beneficial role of tegaserod in patients with functional dyspepsia.

[Cognitive behavioural therapy of functional recurrent abdominal pain in children]

Recurrent abdominal pain affects 10-20% of schoolchildren and is responsible for 2-4% of all pediatric office visits. In about 90% of cases the pain is termed functional as it cannot be explained by structural or biochemical abnormalities and medical treatment has only modest efficacy. Cognitive behavioural therapy of functional abdominal pain in children is a more recent treatment. A systematic literature review identifies only 5 randomised, controlled trials. The results from these studies indicate that the treatment reduces pain intensity and the frequency of pain episodes.

Breathing exercises with vagal biofeedback may benefit patients with functional dyspepsia

OBJECTIVE

Many patients with functional dyspepsia (FD) have postprandial symptoms, impaired gastric accommodation and low vagal tone. The aim of this study was to improve vagal tone, and thereby also drinking capacity, intragastric volume and quality of life, using breathing exercises with vagal biofeedback.

MATERIAL AND METHODS

Forty FD patients were randomized to either a biofeedback group or a control group. The patients received similar information and care. Patients in the biofeedback group were trained in breathing exercises, 6 breaths/min, 5 min each day for 4 weeks, using specially designed software for vagal biofeedback. Effect variables included maximal drinking capacity using a drink test (Toro clear meat soup 100 ml/min), intragastric volume at maximal drinking capacity, respiratory sinus arrhythmia (RSA), skin conductance (SC) and dyspepsia-related quality of life scores.

RESULTS

Drinking capacity and quality of life improved significantly more in the biofeedback group than in the control group (p=0.02 and p=0.01) without any significant change in baseline autonomic activity (RSA and SC) or intragastric volume. After the treatment period, RSA during breathing exercises was significantly correlated to drinking capacity (r=0.6, p=0.008).

CONCLUSIONS

Breathing exercises with vagal biofeedback increased drinking capacity and improved quality of life in FD patients, but did not improve baseline vagal tone.

[Diagnostic and therapeutic algorithm in functional dyspepsia]

INTRODUCTION

Dyspepsia is a word that means bad digestion. In the conviction of which it is a question of an entity that it includes different disciplines, we realize a meeting consensus to discuss and to resolve a diagnostic and therapeutic algorithm of national order.

OBJECTIVE

To agree on a national algorithm applicable to the functional dyspepsia.

MATERIAL AND METHODS

In June 2005 a multidisciplinary group met to design and to propose a diagnostic and therapeutic algorithm for the functional dyspepsia.

RESULTS

Priority gives to the medical-patient relationship and to the reinsurance. Then we divide the patients if they have signs of alarm. If they are present we studied them, if not we divide them, in accordance to the principal symptoms, in pain or epigastric discomfort. If they have pain we realized an endoscopy and a abdominal ultrasound scan. If they are positive, treatment of the disease. If the studies are negative or it has epigastric discomfort we propose a therapeutic test. Pain: H2 bloquers, wait 4 to 6 weeks, if it not response we propose a PPI, wait for 4 to 6 weeks, if there is no response psychiatric or psychological consultation. Discomfort: proquinetics, wait for 4 to 6 weeks if there are no answers, antidepressants in low doses, wait for 4 to 6 weeks if there are no answers, ca. bloquers, sumatriptan or trimebutina. In all cases we can add tranquillizers in anxious personality.

CONCLUSIONS

A multidisciplinary dignostic and therapeutic consensus of national order for the patients with functional dyspepsia was obtained.

Functional dyspepsia and nonerosive reflux disease: clinical interactions and their implications

Functional dyspepsia or nonulcer dyspepsia, and nonerosive reflux disease (NERD) or endoscopy-negative reflux disease, are common reasons for referral to a gastroenterologist. Although there is much confusion with regard to definition, recent research would suggest that these 2 conditions are linked and may represent components in the spectrum of the same disease entity, in terms of both symptoms and pathophysiology. Several theories have been proposed regarding the etiology of these disorders, including acid exposure, visceral hypersensitivity, impaired fundal accommodation, delayed gastric emptying, and Helicobacter pylori infection.

Cost-effectiveness analysis of two management strategies for dyspepsia

OBJECTIVES

To compare the cost-effectiveness of endoscopy and empirical proton pump inhibition (PPI) therapy for management of dyspepsia in primary care.

METHODS

A randomized controlled trial, including prospective collection of economic resource data, was conducted in general practice from June 2000 to August 2002, Aarhus County, Denmark. We randomly assigned 368 dyspeptic patients from thirty-two general practices to treatment with omeprazol 40 mg for 2 weeks (n=184) or endoscopy (n=184). The study adopted a societal perspective, and the year of costing was 2006.

OUTCOME MEASURES

days free of dyspeptic symptoms and proportion of patients with dyspepsia after 1 year based on patients' and general practitioners' (GPs) assessment. Costs were estimated from patient and GP questionnaires and from medical records.

RESULTS

The incremental cost-effectiveness (CE) ratio for 1 day free of dyspeptic symptoms using the endoscopy strategy was euro/day 154 compared with the PPI strategy. The incremental CE ratio for one person free of dyspeptic symptoms after 1 year using the endoscopy strategy was euro13,905 based on the patients' evaluation, and the incremental CE ratio for one person free of predominant symptoms after 1 year was euro5,990 according to the GPs' evaluation. The PPI strategy was both cheaper and more effective than the endoscopy strategy when reflux was the predominant symptom.

CONCLUSIONS

A strategy using empirical antisecretory PPI therapy should be recommended if the alternative is an endoscopy strategy for managing dyspeptic patients in general practice, especially if reflux was the predominant symptom.

Is there a benefit from intensified medical and psychological interventions in patients with functional dyspepsia not responding to conventional therapy?

AIM

In a prospective randomized, controlled trial, to compare the long-term outcome of intensive medical therapy (with or without cognitive-behavioural or muscle relaxation therapy) vs. standard medical therapy in patients with refractory functional dyspepsia (FD), referred to a tertiary referral medical center.

METHODS

A total of 100 consecutive FD patients were allocated to a standardized symptom-oriented 4 month therapy (SMT, n = 24), intensive medical therapy (IMT, medical therapy with testing-for and targeting-of abnormalities of motor-and-sensory function, n = 28) or IMT plus psychological interventions (either progressive-muscle relaxation (IMT-MR, n = 20) or cognitive-behavioural therapy (IMT-CBT, n = 28). The symptom intensity (SI) and health-related quality-of-life (HRQoL) after 12 months were prespecified primary outcome parameters.

RESULTS

After 12 months, significantly greater improvement of SI occurred in patients with IMT-all (with or without psychological interventions) compared with SMT (P < 0.025 vs. IMT-all). IMT, IMT-MR and IMT-CBT alone also resulted in significantly better improvement of the primary outcome parameters (P all < 0.025 vs. SMT). HRQoL significantly improved in all groups with intensive medical therapy but not standard medical therapy. Differences between intensive medical therapy-all and standard medical therapy were not significant. Concomitant anxiety and depression was improved significantly by IMT-CBT (vs. SMT) but not other treatments.

CONCLUSIONS

In FD patients with refractory symptoms, intensified medical management involving function testing and psychological intervention yields superior long-term-outcomes. Additional CBT may be effective for the control of concomitant anxiety and depression.

[Study on effects of low frequency pulse plus auricular point magnetic therapy on electrogastrogram and clinical therapeutic effect in the patient of functional dyspepsia]

OBJECTIVE

To compare therapeutic effects of low frequency pulse plus auricular point magnetic therapy and prepulsid on functional dyspepsia (FD).

METHODS

Fifty cases of FD were randomly divided into a treatment group and a control group. The treatment group were treated with low frequency pulse stimulation on Zhongwan (CV 12), Weishu (BL 21), Neiguan (PC 6), Zusanli (ST 36), with Fenglong (ST 40) and Sanyinjiao (SP 6) selected according to syndrome differentiation, once a day, 30 min each session. The control group were treated with oral administration of prepulsid. Five days constituted one course. The scores of symptoms and parameters of electrogastrogram (EGG) before and after treatment and the therapeutic effect were investigated.

RESULTS

After treatment, the symptom scores significantly decreased (P < 0.01), with a significant difference in the decrease of symptom scores between the two groups (P < 0.05); and EGG parameters were improved (P < 0.05). The total effective rate of 93.3% in the treatment group was better than 75.0% in the control group with a significant difference between the two groups (P < 0.05).

CONCLUSION

Low frequency pulse plus auricular point magnetic therapy can significantly improve the clinical symptoms and gastric activities in the patient of FD, with a better therapeutic effect than prepulsid.