Management of uninvestigated and functional dyspepsia: a Working Party report for the World Congresses of Gastroenterology 1998

Association between dental caries and Helicobacter pylori infection in Japanese adults: A cross-sectional study

Helicobacter pylori (H. pylori) is widely known as a cause of gastric disorders. Presence of H. pylori in dental pulp has been reported. Dental caries may influence the presence or absence of systemic H. pylori infection by serving as a source of H. pylori. In this cross-sectional study, we examined whether H. pylori infection in blood were associated with dental caries in Japanese adults. The participants were 752 individuals (513 males and 239 females, mean age 53.8 years) who underwent both H. pylori testing (H. pylori antibody test and pepsinogen test) and dental checkups at the Asahi University Hospital Human Health Center between April 2018 and March 2019. Those diagnosed as positive for H. pylori antibody test or positive for serum pepsinogen test as H. pylori test in the human health checkup were judged as those with H. pylori infection in the blood. In our study, 83 participants (11%) were determined to be infected with H. pylori in the blood. The proportion of those with decayed teeth was higher in participants with H. pylori infection in blood than in those without H. pylori infection in blood (p< 0.001). The logistic analysis showed that presence of H. pylori infection in blood was positively associated with those with decayed teeth (OR, 5.656; 95% CI, 3.374 to 9.479) after adjusting for age, gender, gastric disease, regular dental checkups, antibiotic medication history, and decayed teeth. Furthermore, the proportion of H. pylori infection in blood increased according to number of decayed teeth (p< 0.001). The results indicate that H. pylori infection in blood were associated with decayed teeth. Untreated dental caries may have an impact on systemic H. pylori infection.

Management of Helicobacter Pylori in the United States: Results from a national survey of gastroenterology physicians

BACKGROUND AND AIMS

We sought to determine current knowledge and practices among gastroenterology physicians and assess adherence to current guidelines for H. pylori management.

METHODS

Online surveys were distributed in 2014 to practicing gastroenterology physicians for information related to the diagnosis and treatment of H. pylori infection.

RESULTS

A total of 582 completed surveys were reviewed. The H. pylori screening test used "almost always" was gastric biopsy obtained during endoscopy (histology) (59%) followed by stool antigen test (20%). Standard triple therapy for 14days was commonly prescribed by 53% of respondents. The stool antigen test was most frequently chosen to confirm H. pylori eradication (51%), although only 58% of physicians checked for eradication in patients who underwent treatment.

CONCLUSIONS

Adherence to current American College of Gastroenterology guidelines is low. Although more physicians treat patients with a positive H. pylori test, only half ensure eradication after treatment. Improving knowledge of the resistance patterns of H. pylori may be critical to ensure successful eradication.

Physiologically-Based Pharmacokinetic and Pharmacodynamic Modeling for the Inhibition of Acetylcholinesterase by Acotiamide, A Novel Gastroprokinetic Agent for the Treatment of Functional Dyspepsia, in Rat Stomach

Purpose

Acotiamide, a gastroprokinetic agent used to treat functional dyspepsia, is transported to at least two compartments in rat stomach. However, the role of these stomach compartments in pharmacokinetics and pharmacodynamics of acotiamide remains unclear. Thus, the purpose of this study was to elucidate the relationship of the blood and stomach concentration of acotiamide with its inhibitory effect on acetylcholinesterase (AChE).

Methods

Concentration profiles of acotiamide and acetylcholine (ACh) were determined after intravenous administration to rats and analyzed by physiologically-based pharmacokinetic and pharmacodynamic (PBPK/PD) model containing vascular space, precursor pool and deep pool of stomach.

Results

Acotiamide was eliminated from the blood and stomach in a biexponential manner. Our PBPK/PD model estimated that acotiamide concentration in the precursor pool exceeded 2 μM at approximately 2 h after administration. Acotiamide inhibited AChE activity in vitro with a 50% inhibitory concentration of 1.79 μM. ACh reached the maximum concentration at 2 h after administration.

Conclusions

Our PBPK model well described the profile of acotiamide and ACh concentration in the stomach in the assumption that acotiamide was distributed by carrier mediated process and inhibited AChE in the precursor pool of stomach. Thus, Acotiamide in the precursor pool plays an important role for producing the pharmacological action.

Efficacy and safety of jollab to treat functional dyspepsia: a randomized placebo-controlled clinical trial

BACKGROUND

Functional dyspepsia (FD) is a common gastrointestinal disease that is highly prevalent worldwide. Because of its heterogeneous pathophysiology, treatment options for FD can be difficult to choose; in this context, complementary and alternative medicine modalities have been suggested as promising options.

AIM

To evaluate the efficacy of a traditional Persian medicine, jollab, in reducing patients' FD symptoms.

METHODS

In a double-blind randomized clinical trial, 160 patients with a diagnosis of FD were enrolled and treated with either jollab or placebo (15ml, t.i.d., four weeks, orally). The outcomes reported were changes in symptom frequency and severity as recorded in patients' diaries and evaluated with the Short Form of the Leeds Dyspepsia Questionnaire (SF-LDQ), and physical examination.

RESULTS

The response rate was higher in the treatment group (78%) than in the placebo group (31%) according to per-protocol sample analysis (P < .001). Symptoms of FD disappeared significantly more frequently, and the rate of concomitant synthetic drug consumption was significantly lower, in the jollab group compared to the placebo group at the end of the trial. Mean total symptom frequency and severity according to the SF-LDQ score was 1.55 ± 2.78 in the treatment group versus 5.61 ± 3.80 in the placebo group at the last follow-up time point (P < .001). A promising safety profile for jollab was observed throughout the trial.

CONCLUSIONS

In patients with FD, jollab appeared to be more effective than the placebo. Complementary and alternative therapies such as the use of this traditional medicinal substance may be beneficial in relieving symptoms of dyspepsia [ACTRN12613000584730].

Evidence-based approach to dyspepsia: from Helicobacter pylori to functional disease

Patients with dyspepsia may present with associated complaints of abdominal pain, bloating, fullness, acid reflux, and epigastric tenderness on examination. The evaluation of patients with dyspepsia includes taking a comprehensive history and performing a physical examination. Although taking a patient history has its limitations in making an accurate diagnosis, it is useful in guiding the selection of subsequent diagnostic tests. Differential diagnoses of dyspepsia are best addressed using an anatomical approach. Patients with chronic dyspepsia lasting > 1 month should be evaluated for the presence of alarm features. Alarm features mandate an upper gastrointestinal endoscopy examination, as these may be suggestive of a malignancy. In patients without alarm features, a Helicobacter pylori test-and-treat strategy is cost-effective if the prevalence of H. pylori infection is high. Tests for H. pylori infection can be divided into non-invasive and minimally invasive tests. Many different antibiotic combination therapies (eg, triple therapy, quadruple therapy, levofloxacin-based therapy, sequential therapy, concomitant therapy, and probiotics with eradication therapy) are now available for the eradication of H. pylori infection. In patients who are symptomatic without an organic pathology, functional dyspepsia and other causes of abdominal pain need to be considered. Functional dyspepsia is best managed using a multifaceted approach by establishing a good physician-patient relationship, dietary and lifestyle interventions, medical therapy, psychotherapy, and the use of psychotropic medications. This review rationalizes the current-day recommendations for the evaluation and management of patients with dyspepsia in a clinical setting.

Proton pump inhibitors: the good, the bad, and the unwanted

Proton pump inhibitors (PPIs) are one of the most commonly prescribed classes of medications in the United States. By inhibiting gastric H/K adenosine triphosphatase via covalent binding to the cysteine residues of the proton pump, they provide the most potent acid suppression available. Long-term PPI use accounts for the majority of total PPI use. Absolute indications include peptic ulcer disease, chronic nonsteroidal anti-inflammatory drugs use, treatment of Helicobacter pylori, and erosive esophagitis. Although PPIs are generally considered safe, numerous adverse effects, particularly associated with long-term use have been reported. Many patients receiving chronic PPI therapy do not have clear indications for their use, prompting consideration for reduction or discontinuation of their use. This article reviews the indications for PPI use, the adverse effects/risks involved with their use, and conditions in which their use is controversial.

Investigating functional dyspepsia in Asia

The diagnosis of functional dyspepsia (FD) is challenging since it depends largely on symptoms which are often heterogeneous and overlapping. This is particularly so in Asia with many different cultures and languages. Symptom-based diagnosis of FD based on Rome III criteria has not been fully validated and it may not be suitable in some Asian populations. Clinicians often assume that investigations in FD are not rewarding and physiological tests are often not available unless in the research setting. Investigation of alarm features and role of Helicobacter pylori in FD remain controversial but experts agreed that both should be tested. Physiological tests including gastric accommodation and chemical hypersensitivity tests are underutilized in Asia and available studies were few. While experts do not recommend routine clinical use of gastric accommodation tests but they agree that these tests can be advocated if clinically indicated. Empiric therapeutic trial is not currently a diagnostic option. The pathogenesis of FD is still poorly understood and there is a substantial placebo response. As a conclusion, a diagnosis of FD is challenging especially so in the context of Asia and despite the limitations of available physiological tests experts agreed that these tests can be advocated if and when clinically indicated.

Helicobacter pylori related dyspepsia: prevalence and treatment outcomes at University Kebangsaan Malaysia-Primary Care Centre

BACKGROUND

Optimum management of dyspepsia in primary care is a debatable subject. Testing for Helicobacter pylori (HP) has been recommended in primary care as this strategy will cure most underlying peptic ulcer disease and prevent future gastro duodenal disease.

METHODS

A total of 98 patients completed Modified Glasgow Dyspepsia Severity Score Questionnaire (MGDSSQ) at initial presentation before undergoing the 13Carbon Urea Breath Test (UBT) for HP. Those with positive UBT received Eradication Therapy with oral Omeprazole 20 mg twice daily, Clarithromycin 500 mg daily and Amoxycillin 500 mg twice daily for one week followed by Omeprazole to be completed for another 4 to 6 weeks. Those with negative UBT received empirical treatment with oral Omeprazole 20 mg twice daily for 4 to 6 weeks. Patients were assessed again using the MGDSSQ at the completion of treatment and one month after stopping treatment.

RESULTS

The prevalence of dyspepsia at Universiti Kebangsaan Malaysia-Primary Care Centre was 1.12% (124/11037), out of which 23.5% (23/98) was due to HP. Post treatment assessment in both HP (95.7%, 22/23) and non HP-related dyspepsia (86.7%, 65/75) groups showed complete or almost complete resolution of dyspepsia. Only about 4.3% (1/23) in the HP related dyspepsia and 13.3% (10/75) in the non HP group required endoscopy.

CONCLUSION

The prevalence of dyspepsia due to HP in this primary care centre was 23.5%. Detection of HP related dyspepsia yielded good treatment outcomes (95.7%).

Changes in indications for upper gastrointestinal tract endoscopy and endoscopic findings during the last fifteen years in south-western Greece

BACKGROUND

During the past years, major advances in the management of upper gastrointestinal diseases have been achieved. The aim of this study was to determine if changes in indications for upper gastrointestinal endoscopy and endoscopic findings have occurred during the last 15 years in our area.

METHODS

Indications for upper gastrointestinal tract endoscopy and endoscopy findings of patients who underwent upper endoscopy in years 1990, 1995, 2000, and 2005 in our department were compared.

RESULTS

Over the 15-year period, the number of diagnostic endoscopies performed in our department in years 1990, 1995, 2000, and 2005 increased (953, 1245, 2350, and 2528, respectively). Acute upper gastrointestinal bleeding had become less frequent (40%, 42.8%, 19.7%, 14.3%, P<0.001), but dyspepsia (24.4%, 33.6%, 54.3%, 51.3%, P=0.002) and reflux (1.8%, 1.3%, 5.1%, 10.8%, P=0.005) more frequent indications for upper endoscopy. The endoscopic findings of duodenal ulcer (39.1%, 22.5%, 20.5%, 9.3%, P<0.001), gastric ulcer (15.9%, 8.3%, 5.7%, 4.6%, P=0.036) as well as erosive gastroduodenitis (35.6%, 22.2%, 15.3%, 4.7%, P<0.001) decreased, whereas that of reflux esophagitis (3.1%, 10.1%, 12%, 16%, P=0.034) increased. Moreover, the percentage of patients with negative endoscopy or minimal endoscopic findings (eg, nonerosive gastritis) increased (12.8%, 33.7%, 54.1%, 64.4%, P<0.001).

CONCLUSIONS

In south-western Greece, dyspepsia and reflux as an indication for upper endoscopy have been increasing, whereas acute upper gastrointestinal bleeding has been decreasing. The finding of peptic ulcers at the upper gastrointestinal tract endoscopy has become significantly less frequent, while the percentage of patients with negative results of endoscopy seems to have been increasing rapidly.

Clinical trial: a randomized controlled cross-over study of flupenthixol + melitracen in functional dyspepsia

BACKGROUND

Functional dyspepsia is a prevalent condition associated with diminished quality of life (QoL) and high economic burden.

AIM

To study the efficacy of a combination of flupenthixol and melitracen (F + M) with anxiolytic and antidepressant properties in functional dyspepsia using a randomized controlled cross-over design.

METHODS

Patients met the Rome III criteria for functional dyspepsia and a validated questionnaire was used to exclude those with anxiety or depression. Moreover, patients had to have failed a trial of acid-suppressive therapy and Helicobacter pylori eradication when positive. End points included subjective global symptom relief and QoL assessed by the Nepean Dyspepsia Index (NDI).

RESULTS

Twenty-five patients (14 females, 11 males; mean age = 34.3 +/- 9.9 years) were enrolled and 24 completed the 8-week study. There was a significant improvement in subjective global symptom relief with F + M vs. placebo (ITT: 73.9% vs. 26.1%, P = 0.001) and a significant drop in the NDI score vs. placebo (ITT: -9.0 +/- 11.9 vs. -2.4 +/- 8.9, P = 0.03). No difference was noted whether the initial treatment was F + M or placebo. No significant side effects were noted.

CONCLUSIONS

A combination of F and M is safe and effective in the short-term treatment of functional dyspepsia. F + M is associated with significant improvement in QoL independent of the presence of anxiety or depression.

Flexible coping psychotherapy for functional dyspeptic patients: a randomized, controlled trial

OBJECTIVE

This study tested the efficacy of a new psychotherapy, flexible coping psychotherapy (FCP), specifically designed for enhancing coping flexibility of patients with functional dyspepsia (FD). The design of this psychotherapy is based on the general cognitive-behavioral model and previous findings on FD.

METHODS

We adopted a randomized, controlled design to examine the differences between the target (FCP) and control (supportive psychotherapy [SPP]) conditions. Coping flexibility and outcome measures reported by 75 Chinese FD patients (18-65 years; 35% men) were assessed before and 12 months after treatment.

RESULTS

Results revealed that participants who received the FCP reported an increase in coping flexibility as well as reductions in self-rated dyspeptic symptom severity (SDSS), gastroenterologist-rated dyspeptic symptom severity, and anxiety levels (p values <.01). Participants who received the SPP reported reductions in SDSS and anxiety levels (p values <.0001). Although both groups reported a decrease in SDSS, only the SDSS level of the FCP group was comparable to that of a healthy community sample (p = .28).

CONCLUSIONS

These findings suggest that FCP is a potentially effective intervention for treating FD symptoms. Its effectiveness may be attributable to the specific components of FCP rather than common psychotherapeutic factors such as emotional support and empathy per se.

Economic evaluation of empirical antisecretory therapy versus Helicobacter pylori test for management of dyspepsia: a randomized trial in primary care

OBJECTIVES

An economic evaluation was performed of empirical antisecretory therapy versus test for Helicobacter pylori in the management of dyspepsia patients presenting in primary care.

METHODS

A randomized trial in 106 general practices in the County of Funen, Denmark, was designed to include prospective collection of clinical outcome measures and resource utilization data. Dyspepsia patients (n = 722) presenting in general practice with more than 2 weeks of epigastric pain or discomfort were managed according to one of three initial management strategies: (i) empirical antisecretory therapy, (ii) testing for Helicobacter pylori, or (iii) empirical antisecretory therapy, followed by Helicobacter pylori testing if symptoms improved. Cost-effectiveness and incremental cost-effectiveness ratios of the strategies were determined.

RESULTS

The mean proportion of days without dyspeptic symptoms during the 1-year follow-up was 0.59 in the group treated with empirical antisecretory therapy, 0.57 in the H. pylori test-and-eradicate group, and 0.53 in the combination group. After 1 year, 23 percent, 26 percent, and 22 percent, respectively, were symptom-free. Applying the proportion of days without dyspeptic symptoms, the cost-effectiveness for empirical treatment, H. pylori test and the combination were 12,131 Danish kroner (DKK), 9,576 DKK, and 7,301 DKK, respectively. The incremental cost-effectiveness going from the combination strategy to empirical antisecretory treatment or H. pylori test alone was 54,783 DKK and 39,700 DKK per additional proportion of days without dyspeptic symptoms.

CONCLUSIONS

Empirical antisecretory therapy confers a small insignificant benefit but costs more than strategies based on test for H. pylori and is probably not a cost-effective strategy for the management of dyspepsia in primary care.

Effect of acupuncture on proximal gastric motility in patients with functional dyspepsia

AIM: To investigate the effect of acupuncture on the proximal gastric motility in patients with functional dyspepsia (FD) induced by mechanical gastric distention.

METHODS: Sixty patients were divided into group A and B. Isovolumetric gastric distention was performed on all the subjects. The patients in group A were given acupuncture with electrical stimulation of pulse train, while those served as the controlled group. The minimal distension pressure (MDP), initial and maximal tolerable volume, pressure and compliance (the ratio of volume to pressure) were recorded in the two groups.

RESULTS: MDP had no significant difference between group A and B (P > 0.05). In group A, the initial volume and pressure (560.9 ± 119.5 mL vs 352.0 ± 139.3 mL; 8.06 ± 2.95 mmHg vs 5.40 ± 2.41 mmHg), the maximal tolerable volume and pressure (810.7 ± 119.62 mL vs 504.1 ± 159.6 mL; 13.25 ± 2.23 mmHg vs 9.82 ± 1.9 mmHg) and the compliance (61.2 ± 18.6 mL/mmHg vs 51.4 ± 17.8 mL/mmHg) were significantly higher than those in group B (P < 0.05).

CONCLUSION: Acupuncture can improve proximal gastric motility and reduce visceral sensitivity in patients with FD.

Management of the dyspeptic patient: anything goes?

Guidelines on the initial management of dyspeptic patients are remarkably conflicting or ambiguous and recommend a variety of initial approaches and no single strategy has been successfully implemented in primary care. In this issue of the American Journal of Gastroenterology, Jarbol and colleagues report the results of a large Danish trial comparing a test-and-treat strategy, an empiric PPI strategy, and a combined strategy with Helicobacter testing if symptoms improved after the PPI. Patient-related outcomes at 1 yr did not differ, but the use of endoscopy was highest in the PPI strategy. From the patient's perspective it seems that anything goes as long as the clinician sticks to a well-defined and proven strategy. Helicobacter pylori testing is still recommendable owing to the long-term benefits, but the rapidly decreasing Helicobacter prevalence will soon make the test-and-treat strategy cost-ineffective as the initial step.

Proton pump inhibitor or testing for Helicobacter pylori as the first step for patients presenting with dyspepsia? A cluster-randomized trial

OBJECTIVES

The optimal approach for management of patients with dyspepsia has not been determined. The aim of this study was to compare the efficacy of three strategies for management of dyspepsia: empirical antisecretory therapy, testing for Helicobacter pylori (H. pylori), or a combination of the two.

METHODS

Cluster-randomized trial in general practices. Initial treatment with proton pump inhibitor (PPI) was performed in 222 patients, H. pylori test-and-eradicate in 250 patients, and PPI followed by H. pylori-testing if symptoms improved in 250 patients. Symptoms, quality of life, patient satisfaction, and use of resources were recorded during a 1-yr follow-up.

RESULTS

The prevalence of H. pylori infection was 24%. We found no difference among the three strategies (p=0.16) in terms of the proportion of days without dyspeptic symptoms. After 1 yr gastrointestinal symptom scores and quality-of-life scores had improved significantly and equally in the three groups (p<0.001), but no statistically significant differences were found among the groups. The mean use of endoscopies per patient after 1 yr was higher in the PPI group (0.36 [95% CI 0.30-0.43]) than in the test-and-eradicate group (0.28 [95% CI 0.23-0.34]) and the combination group (0.22 [95% CI 0.17-0.27]), p=0.02. H. pylori-positive patients given eradication therapy had more days without dyspeptic symptoms (p<0.001), used less antisecretory therapy (p<0.01), and were more satisfied (p<0.001) than H. pylori-negative patients.

CONCLUSION

The strategies based on H. pylori test enjoyed similar symptom resolution, but reduced endoscopic workload and lower 1-yr total costs compared with empirical antisecretory therapy.

Drug treatment of functional dyspepsia

Symptomatic improvement of patients with functional dyspepsia after drug therapy is often incomplete and obtained in not more than 60% of patients. This is likely because functional dyspepsia is a heterogeneous disease. Although great advance has been achieved with the consensus definitions of the Rome I and II criteria, there are still some aspects about the definition of functional dyspepsia that require clarification. The Rome criteria explicitly recognise that epigastric pain or discomfort must be the predominant complaint in patients labelled as suffering from functional dyspepsia. However, this strict definition can create problems in the daily primary care clinical practice, where the patient with functional dyspepsia presents with multiple symptoms. Before starting drug therapy it is recommended to provide the patient with an explanation of the disease process and reassurance. A thorough physical examination and judicious use of laboratory data and endoscopy are also indicated. In general, the approach to treat patients with functional dyspepsia based on their main symptom is practical and effective. Generally, patients should be treated with acid suppressive therapy using proton-pump inhibitors if the predominant symptoms are epigastric pain or gastroesophageal reflux symptoms. Although the role of Helicobacter pylori (H pylori) in functional dyspepsia continues to be a matter of debate, recent data indicate that there is modest but clear benefit of eradication of H pylori in patients with functional dyspepsia. In addition, H pylori is a gastric carcinogen and if found it should be eliminated. Although there are no specific diets for patients with FD, it may be helpful to guide the patients on healthy exercise and eating habits.

Functional dyspepsia--a multicausal disease and its therapy

Functional dyspepsia is a common chronic disorder with non-specific upper abdominal symptoms which can not be explained by organic or biochemical abnormalities. The dyspeptic symptoms are very compromising and bothersome and result in a substantial reduction of quality of life. The substantial direct and indirect medical and economical costs induce a high socioeconomic interest in the pathogenesis and the treatment options of this disease. Over the past 30 years several theories about the etiology of the symptoms in functional dyspepsia patients have been put forward. These include disorders of gastrointestinal motility, acid secretion, visceral hypersensitivity, adaptation and accommodation, Hp-infection, mucosal inflammation and finally genetic predisposition. There is increasing evidence that functional dyspepsia is a multi-causal disorder, which leads to altered processing of afferent information from the gastrointestinal tract to the CNS. Autonomic hypersensitivity and altered central processing could be a common phenomenon whereas motility changes, inflammation or altered secretion could increase neural afferent inputs. Treatment of this complex disorder could and should involve these different levels of symptom generation. Thus different approaches with anti-secretory, spasmolytic, prokinetic and anti-inflammatory effects and most preferably reduction of visceral hypersensitivity seem logical. This could explain the variety of drugs which show a positive symptomatic response. This could also offer the conclusion, whether a combination of these drugs could be clinically superior which remains to be proven. And this could offer a logical approach for the use of substances with a multi-target action, e.g. STW 5.

Guidelines for the management of dyspepsia

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.

Missing gastric cancer in dyspepsia

BACKGROUND

Dyspepsia is common in gastric cancer, but also in many benign conditions. European Helicobacter pylori Study Group and American Gastroenterological Association guidelines recommend endoscopy in dyspepsia for patients with alarm symptoms or at age >45 years. However, recommendations are controversial.

AIM

To investigate whether criteria for endoscopy in patients with dyspepsia are adequate to detect gastric cancer.

METHODS

In 215 patients at initial diagnosis of gastric adenocarcinoma, symptoms were classified as alarm and non-alarm. Cases were staged according to the TNM system. Stages T(1)-T(3)N(x)M(0) were defined as potentially curable.

RESULTS

Dyspepsia was present in 128 patients. Among patients with dyspepsia, 15 were < or =45 years and 41 denied alarm symptoms. The combination of both criteria excluded only three (2.3%) patients from endoscopy, but increasing the threshold to >50 and >55 years would have raised the rate of excluded patients to seven (5.5%) and 11 (8.6%). Only 53 potentially curable stages and 18 early gastric cancers occurred, but the tumour stage was not associated with dyspepsia duration, age threshold of 45 years, or alarm symptoms.

CONCLUSIONS

Our results support current European Helicobacter Study Group and American Gastroenterological Association criteria for endoscopy in patients with dyspepsia to detect gastric cancer. Regardless, most cancers are advanced at detection.

Serum leptin level in patients with functional dyspepsia

BACKGROUND/GOAL: Previous studies have shown that leptin plays a major role in the amount of food consumption. Recently, leptin and its receptors have been found in the human gastric mucosa. The aim of this study was to seek any possible correlation between serum leptin level and subtypes and pathological findings in functional dyspepsia.

MATERIALS AND METHODS

In a prospective study, we randomly select 44 patients as dysmotility-like and ulcer-like dyspepsia (according to ROME II criteria) in two equivalent groups and compared them with 22 healthy volunteers control group who matched the patients in relation to age, sex and body mass index. From each patient, a fasting blood sample for leptin level and two antral biopsies for evaluating the intensity of gastritis and Helicobacter pylori infection were provided and compared with the control group.

RESULTS

Compared to the control group, serum leptin level was significantly higher in patients with dysmotility-like dyspepsia (P < 0.05). Leptin level were also significantly correlated with the presence of gastritis and H. pylori infection (P < 0.05).

CONCLUSION

Leptin may have a role in the pathogenesis of the dysmotility variety of non-ulcer dyspepsia through mechanisms other than H. pylori infection. Further studies based on gastric leptin immunohistochemistry may need correlation between symptoms of functional dyspepsia and gastric leptin expression.

Endoscopic evaluation of patients with dyspepsia: results from the national endoscopic data repository

BACKGROUND & AIMS

Endoscopy is commonly performed to evaluate symptoms of dyspepsia. The aim of this study was to characterize patients who receive endoscopy for dyspepsia and measure predictors of primary endoscopic outcomes, utilizing a large national endoscopic database.

METHODS

The Clinical Outcomes Research Initiative (CORI) receives endoscopy reports from a network of 74 sites in the United States. Sixty-one percent of reports come from private practice settings. Patients with reflux dyspepsia and nonreflux dyspepsia were identified from January 2000 to June 2002. Patients with dysphagia and known Barrett's esophagus were excluded. Primary endoscopic outcomes included esophageal inflammation and stricture, gastric ulcer, duodenal ulcer, suspected Barrett's esophagus (> or =2 cm), and suspected esophageal and gastric malignancy. The presence or absence of alarm symptoms (vomiting, weight loss, and evidence of GI blood loss) was determined. Adjusted relative risk (RR) for predicting serious outcomes was calculated in a multivariate model.

RESULTS

We received 117,497 endoscopic reports, representing 99,558 unique patients. Dyspepsia, with and without reflux symptoms, accounted for 43% of upper endoscopies. Among dyspeptic patients, 36.5% were younger than 50 years of age without alarm symptoms. Esophageal or gastric malignancy in patients with dyspepsia was associated with increasing age, male sex, Asian race, Native American race, and symptoms of weight loss and vomiting. Suspected Barrett's esophagus (> or =2 cm) was associated with reflux symptoms, male sex, age, and white race. Ulcers were associated with evidence of bleeding, vomiting, male sex, black race, and Hispanic ethnicity.

CONCLUSIONS

These practice-based data reveal important practice behaviors and outcomes.

Long-term follow-up of empirical treatment or prompt endoscopy for patients with persistent dyspeptic symptoms?

BACKGROUND

There are concerns about the safety and possible high costs of ongoing proton pump inhibitor therapy of empirical management strategies for patients with persistent dyspeptic symptoms.

AIM

To compare the long-term results of two treatment strategies: empirical treatment followed by the Helicobacter pylori test and treat strategy (treat and test group) and prompt upper gastrointestinal endoscopy followed by directed medical treatment (endoscopy group).

METHODS

In this study we describe the long-term follow-up data from a previously published randomized clinical trial. At least 6 years after randomization all participating general practitioners and patients were asked to give information about medication use, diagnostic testing, symptoms and quality of life by questionnaire.

RESULTS

Information about a total of 77 out of the 80 patients initially included (96%) was retrieved. Overall, 16 patients from the treat and test group (41%) underwent 18 diagnostic investigations. The 34 patients (100%) from the endoscopy group underwent 38 investigations (P < 0.01). The number of patients of the treat and test group and endoscopy group using acid inhibition therapy was 15 (38%) and 19 (56%), respectively (P = 0.14). There were also no differences in symptom prevalence and quality of life between the groups.

CONCLUSIONS

Treat and test management for patients with dyspeptic symptoms is safe and does not lead to additional diagnostic testing or use of medication when compared to prompt endoscopy.

Diagnostic approach to dyspepsia

The optimal diagnostic approach to the dyspeptic patient in primary care is still debated. Early endoscopy continues to be the diagnostic gold standard but competing non-invasive strategies challenge this. The most important approaches are empiric antisecretory treatment reserving endoscopy for unresponsive patients and patients with an early symptomatic relapse and helicobacter-based strategies reserving endoscopy for infected patients (test-and-scope) or for failures after eradication therapy (test-and-treat). Early endoscopy is recommended in patients with alarm features and should be considered in patients with new onset dyspepsia after age 50. In the remaining patients, early investigation can only be recommended in areas providing endoscopy at a low cost and with a short waiting list. The test-and-scope strategy may lead to a rise in the referral rates for endoscopy and cannot be recommended. The test-and-treat strategy is well documented in clinical trials as a safe and cost-effective approach. Helicobacter-based strategies are challenged by a decreasing prevalence of peptic ulcer disease and of the infection. In the near future, the empirical acid inhibition strategy will probably be cost-effective as gastro-oesophageal reflux becomes the predominant disorder in dyspeptic patients.

What the physician needs to know for correct management of gastro-oesophageal reflux disease and dyspepsia

Upper gastrointestinal symptoms are highly prevalent; usually those consulting have multiple symptoms, confounding management. Here, common clinically relevant management issues are considered based on the best available evidence. Regardless of the presenting symptoms, determine if there are any alarm features; these have a low positive predictive value for malignancy but all patients with them should be referred for prompt upper gastrointestinal endoscopy. Ask about medications; of most importance are the non-steroidal anti-inflammatory drugs (NSAIDs), both non-selective and COX-2 selective. Try to ascertain if the symptom pattern suggests gastro-oesophageal reflux disease (GERD) or not. Dominant heartburn, however, may be of limited value; if the background prevalence of GERD is 25% and the patient complains of dominant heartburn, then the likelihood that such a patient has GERD as identified by 24-h oesophageal pH testing is only just over 50%. If reflux disease is strongly suspected and there are no alarm features, give an empirical trial of a proton pump inhibitor (PPI). Symptoms cannot separate adequately functional from organic dyspepsia. Endoscopy in dyspepsia with no alarm features is more costly than an empirical management approach. H. pylori testing and treatment remains in most settings the preferable initial choice for managing dyspepsia without obvious GERD. However, a PPI trial may offer a similar outcome and may be preferable in low H. pylori prevalence areas; head-to-head management trials in primary care are lacking.

Predominant symptom behavior in patients with persistent dyspepsia during treatment

BACKGROUND

Grouping of patients based on a predominant dyspeptic symptom is frequently employed in management strategies for dyspepsia. Such subdivision, however, suggests that dyspeptic symptom patterns are constant over time.

OBJECTIVE

To investigate the behavior of symptoms over time and to study the effects of diagnostic procedures and treatment on the pattern and severity of dyspeptic symptoms.

METHODS

Patients with persistent dyspeptic symptoms completed a validated questionnaire at regular time intervals as part of a clinical trial in primary care. Based on predominant symptoms, patients were classified into ulcer-like dyspepsia, reflux-like dyspepsia, dysmotility-like dyspepsia, and unspecific dyspepsia according to the Rome II criteria.

RESULTS

Questionnaires were returned at baseline, 1, 3, and 6 months by 185, 172, 169, and 170 patients, respectively. At baseline, 35% of patients reported predominantly reflux-like dyspepsia, 34% had ulcer-like dyspepsia, 16% had dysmotility-like dyspepsia, and in 15% symptoms were not specific. During the 6-month follow-up period, only 35% of patients kept the same predominant symptom. Symptom (in)stability was not dependent on diagnostic procedures or on therapy with proton pump inhibitors, H2-receptor antagonists, prokinetics, or antacids.

CONCLUSION

In the majority of dyspeptic patients, symptoms change continuously as time goes on. Symptom instability is not influenced by diagnostic procedures or therapy. Thus, there is little sense in symptom-based management of dyspepsia in primary care.

Review article: uninvestigated dyspepsia and non-ulcer dyspepsia-the use of endoscopy and the roles of Helicobacter pylori eradication and antisecretory therapy

Due to its prevalence, impact on quality-of-life and the associated significant health resource utilization, dyspepsia is a major healthcare concern. The available management strategies for uninvestigated dyspepsia include prompt endoscopy, the 'test-and-treat' strategy for Helicobacter pylori, and empiric antisecretory therapy. There is consensus that endoscopy should be reserved for patients with alarm features (e.g. symptom onset after 45 years of age, recurrent vomiting, weight loss, dysphagia, evidence of bleeding, anaemia), H. pylori-positive individuals who fail test-and-treat, and those with an inadequate response to empiric antisecretory therapy. Factors influencing the decision between test-and-treat and empiric antisecretory therapy in uninvestigated dyspepsia include the local prevalence of H. pylori and peptic ulcer disease and the proportion of ulcers attributable to H. pylori. For uninvestigated dyspepsia in patients without alarm features, test-and-treat is the preferred initial management method in Europe based on the relatively high prevalence of H. pylori/peptic ulcer disease whereas empiric antisecretory therapy is preferred in many parts of the United States, where the prevalence of H. pylori/peptic ulcer disease is relatively low. In patients with non-ulcer dyspepsia, H. pylori eradication and empiric antisecretory therapy result in comparable and small, but statistically significant, improvements in dyspepsia. Empiric antisecretory therapy is the preferred initial method of managing non-ulcer dyspepsia in Europe and the US. The test-and-treat approach would receive increased enthusiasm if H. pylori cure is shown to prevent development of gastric cancer in non-ulcer dyspepsia patients in a large Western trial.

"Alarm symptoms" in dyspepsia. How does the general practitioner investigate?

OBJECTIVE

Alarm symptoms are present in 10% of patients consulting a general practitioner (GP) because of dyspepsia. The options for the GP are: perform "own" investigation, refer to a specialist or secondary care, or maintain watchful waiting.

DESIGN

Postal questionnaire to GPs obtaining information from the records of patients who had consulted earlier owing to dyspepsia and reported one or more alarm symptoms at the consultation.

SETTING

92 general practices throughout Denmark.

SUBJECTS

In 7240 consecutive consultations in 1991-1992 a total of 749 patients reported 881 alarm symptoms. Follow-up data 3 years later were obtained from 81%.

MAIN OUTCOME MEASURES

The management of alarm symptoms by GPs: "own" investigation, referral to specialist, or expectance; procedures used in "own" investigations, patient characteristics related to such decisions, and gastrointestinal diseases diagnosed by this management.

RESULTS

67% of the patients with alarm symptoms were investigated promptly (8% by referral to specialists) and 33% were left uninvestigated, with great variations between alarm symptoms. The single most preferred GP investigation was endoscopy. A gastrointestinal diagnosis was obtained in 35% of the patients; 3% of these were malignancies while 9% were peptic ulcers.

CONCLUSION

The decision on whether and how to investigate alarm symptoms is complex and relates to specific symptom, type of dyspepsia, age, gender and dwelling of the patient.

The management of peptic ulcer disease

PURPOSE OF REVIEW

The period under review has seen little evolution in our understanding of the empiric management of dyspepsia. The role of Helicobacter pylori in this setting remains controversial, and a policy of risk stratification with the prudent use of test and treat and symptomatic therapy, with endoscopy for nonresponsive cases, seems to have some support from the literature in this period.

RECENT FINDINGS

The management of nonsteroidal antiinflammatory drug-associated and aspirin-associated complications has received a lot of attention in the period under review. The COX-2 selective agents have maintained their reputation as safer (but not "safe") options, although some of the original work with one of these agents has been rigorously interrogated and found wanting. Studies in the review period have focused our attention on the less than satisfactory protection of proton pump inhibitor cotherapy, the site-specific nature of ulcer recurrences (which may have therapeutic implications), lower gastroenterology complications associated with NSAID use, and the beneficial effect of proton pump inhibitor cotherapy for patients receiving low-dose aspirin. One should also expect a lot more information in the future with regard to the use of the nitric oxide donating class of nonsteroidal antiinflammatory drugs and aspirin.

SUMMARY

Findings are presented that suggest that the H.pylori stool antigen test is not as reliable as the urea breath test, while the most promising "new therapy" for H. pylori is not new, but rather an amalgam of some older drugs combined in a new "quadruple" therapy strategy, which shows some promise.

Gastric mucosal fibrosis: a novel explanation for dyspepsia

The etiology of functional dyspepsia has not been discerned yet which has led to inadequate treatment of this disease. It remains a common disorder with expensive and yet often ineffective therapy. We propose that the pathogenesis of this disease lies in the histological and ultrastructural changes inflicted on the gastric mucosa in chronic gastritis and fibrosis. This hypothesis, if substantiated will provide for therapy which will be based on the pathogenesis of the disease and which will be cheaper and easily available to most. It will also add impetus to the early eradication of Helicobacter pylori, which would prevent chronic gastritis and hence gastric fibrosis.

Gastric mucosal mast cells are increased in Helicobacter pylori-negative functional dyspepsia

BACKGROUND & AIMS

Mast cells might be involved in pathogenesis of functional dyspepsia because they can release a wide range of potent mediators, capable of altering gastric nerve and muscle function. This study aimed to determine whether mast cell numbers were increased in the gastric mucosa of patients with functional dyspepsia compared to control subjects.

METHODS

Biopsy samples were taken from the antrum and corpus of 111 patients: 20 asymptomatic control subjects, 62 patients with Rome criteria functional dyspepsia (33 Helicobacter pylori positive, 29 H. pylori negative), and 29 inflammatory control subjects (H. pylori positive). Mast cells were detected immunohistochemically by using a mouse monoclonal antibody specific for tryptase. Quantification was performed with light microscopy, and results were expressed as mast cells/mm(2) +/- standard error of mean.

RESULTS

Mast cells were significantly increased in H. pylori negative functional dyspepsia samples compared to normal control samples in the antrum (230.1 +/- 11.3 vs. 94.8 +/- 8.4, P < 0.001) and corpus (264.1 +/- 27.1 vs. 123.9 +/- 11.5, P = 0.001). Mast cells were also significantly increased in the antrum of patients with H. pylori positive functional dyspepsia compared to asymptomatic control subjects (166.5 +/- 17.0 vs. 94.8 +/- 8.4, P < 0.03). However, there was no significant difference between mast cell numbers in patients with H. pylori positive functional dyspepsia compared to inflammatory control subjects.

CONCLUSIONS

Mast cells are increased in functional dyspepsia, independently of inflammation. This might contribute to the pathogenesis of functional dyspepsia by altering signaling in the brain-gut axis.

Cost-effectiveness of routine endoscopic biopsies for Helicobacter pylori detection in patients with non-ulcer dyspepsia

BACKGROUND

The role of endoscopic biopsies in the detection of Helicobacter pylori in patients with nonulcer dyspepsia is poorly defined. This study assesses the cost-effectiveness of performing routine biopsies for the detection of H pylori at upper endoscopy in these patients.

METHODS

Clinical decision-making was modeled based on outcomes data from published articles and expert opinion. The target group was adults, less than 45 years of age, with nonulcer dyspepsia as defined by a normal endoscopy. Costs, expressed in Canadian dollars, were tabulated over a 1-year time horizon. The main outcome was relief of symptoms, defined as the absence of symptom persistence or recurrence over the 12 months. A strategy of performing a biopsy for the detection of H pylori with a rapid urease test during gastroscopy was compared with that of not performing a biopsy. In addition, as a secondary analysis, the cost-effectiveness of obtaining a biopsy specimen for histopathologic evaluation in patients after a negative rapid urease test was evaluated.

RESULTS

A strategy of endoscopy with biopsy and rapid urease testing costs 3940 dollars per additional symptom-free patient as compared with endoscopy without biopsy. This result was sensitive to the difference in symptomatic recurrence rate at 1 year between patients in whom H pylori was successfully and unsuccessfully eradicated, which in this analysis, was set at 9.9%. Only when the difference in symptomatic recurrence in patients with successful versus unsuccessful eradication fell to less than 4% was endoscopy with biopsy over 10,000 dollars per cured patient greater than endoscopy without biopsy. The conclusions were otherwise robust when varying the values of other variables across clinically relevant ranges. There was little additional benefit associated with histopathologic assessment of biopsy specimens in patients with a negative rapid urease test and the cost per additional cure was 25,529 dollars.

CONCLUSIONS

In adults with nonulcer dyspepsia under age 45 years undergoing endoscopy, routine procurement of a biopsy specimen for detection of H pylori was more costly yet more effective compared with not obtaining a specimen. The cost-effectiveness of a biopsy is dependent on the benefits of H pylori eradication in this patient population. The less likely a patient with nonulcer dyspepsia is to become asymptomatic after successful H pylori eradication, the more costly a strategy of routinely obtaining a specimen at endoscopy. The additional cost of sending a specimen for histopathologic analysis if the rapid urease test is negative does not appear warranted based on cost-effectiveness considerations.

Is it possible to predict treatment response to a proton pump inhibitor in functional dyspepsia?

BACKGROUND

The efficacy of proton pump inhibitors in functional dyspepsia is modest and the prognostic factors are almost unknown.

METHODS

Data were pooled on patients (n = 826) with a diagnosis of functional dyspepsia from two placebo-controlled trials who were treated with omeprazole, 10 or 20 mg once daily, for 4 weeks. Self-administered questionnaires for the assessment of symptoms and health-related quality of life were completed before entry, and epigastric pain/discomfort was recorded on diary cards. Treatment success was defined as the complete absence of epigastric pain/discomfort on each of the last 3 days of week 4. Prognostic factors were identified by multiple logistic regression analysis.

RESULTS

The most discriminating predictor of treatment success (P < 0.0001) was the number of days with epigastric pain/discomfort during the first week of treatment. Fewer days with symptoms during the first week led to higher response rates at 4 weeks. In addition, age > 40 years, bothersome heartburn, low scores for bloating, epigastric pain and diarrhoea, history of symptoms for < 3 months and low impairment of vitality at baseline were identified as positive predictors of outcome.

CONCLUSIONS

Early response to treatment with a proton pump inhibitor, during the first week, seems to predict the outcome after 4 weeks in patients with functional dyspepsia.

The prevalence of clinically significant endoscopic findings in primary care patients with uninvestigated dyspepsia: the Canadian Adult Dyspepsia Empiric Treatment - Prompt Endoscopy (CADET-PE) study

BACKGROUND

Uninvestigated dyspepsia is common in family practice. The prevalence of clinically significant upper gastrointestinal findings (CSFs) in adult uninvestigated dyspepsia patients, and their predictability based on history, is unknown.

METHODS

Prompt endoscopy was performed within 10 days of referral, in 1040 adult patients presenting with uninvestigated dyspepsia at 49 Canadian family practitioner centres. Subsequent management strategies during a 6-month follow-up period were determined by the individual family practitioners.

RESULTS

CSFs were identified in 58% (603/1040) of patients. Erosive oesophagitis was most common (43%; N = 451); peptic ulcer was uncommon (5.3%; N = 55). Alarm symptoms were uncommon (2.8%; N = 29). Most patients had at least three dyspepsia symptoms, more than 80% had at least six, and approximately half had eight or more. Based on the dominant symptom, 463 (45%) patients had ulcer-like, 393 (38%) had reflux-like and 184 (18%) had dysmotility-like dyspepsia. The patients' dominant symptom was not predictive of endoscopic findings. Oesophagitis was more common in those with dominant reflux-like symptoms and was the most common finding in all subgroups. The prevalence of gastroduodenal findings was similar in all symptom subgroups. Helicobacter pylori (H. pylori) infection (30%; 301/1013) was associated with gastroduodenal findings.

CONCLUSIONS

Dyspepsia subclassifications, based on dominant symptom, are of limited value in predicting the presence and nature of CSFs. Oesophagitis was by far the most common diagnosis (43% of patients). CSFs were common in uninvestigated dyspepsia patients and their nature suggests patients could be initially treated effectively, without endoscopy, using empirical acid suppressive therapy.

Diagnostic investigation rates and use of prescription and non-prescription medications amongst dyspeptics: a population-based study of 2300 Australians

BACKGROUND

: There is limited knowledge of the diagnostic investigation rates and use of prescription and non-prescription drugs amongst dyspeptics.

AIM

: To assess the investigation rates and use of prescription and non-prescription anti-ulcer medications amongst dyspeptics in the population.

METHODS

: A cross-sectional survey was performed of 2300 Australians.

RESULTS

: Of 748 dyspeptics, 422 (56%) had consulted a doctor regarding dyspepsia at some time in their life. Of the consulters, 64% had undergone investigations at some time: 37% an endoscopy, 54% a barium meal and 27% both. A diagnosis of peptic ulcer was reported by 31% of those investigated. The symptom profile of gastroscopy patients differed significantly from that of uninvestigated dyspeptics. Of the consulters, 36% had taken anti-ulcer prescription drugs in the last 3 months: Histamine-2 receptor antagonists (73% of prescriptions), proton pump inhibitors (17%), cytoprotectants (5%) and prokinetic drugs (5%). Antacids were taken by 30% of non-consulting dyspeptics, 44% of consulters not on prescription drugs and 58% of dyspeptics taking prescription drugs. Advancing age, but not gender, was associated with diagnostic investigation and prescription and non-prescription drug usage.

CONCLUSIONS

: There are high rates of diagnostic investigation amongst dyspeptics who consult doctors. Many individuals with dyspepsia decide to self-medicate with antacids regardless of consulting or prescriptions, suggesting that current management is suboptimal.

Management of dyspepsia

Proper management of uninvestigated dyspepsia is a challenging task for any clinician. Efficient and cost-effective management of such patients requires careful history taking and awareness of the available options.

Evaluation and treatment of dyspepsia

Dyspepsia is a common symptom. Dyspeptic symptoms may be caused by a variety of conditions such as peptic ulcer disease, gastro-oesophageal reflux, and malignancy. Most often, however, no cause is identified and dyspepsia is deemed to be functional. While symptom severity does influence frequency of consultation, dyspeptic consulters also differ from non-consulters with respect to symptom perception and anxiety. This highlights the importance of understanding the patient's agenda early in the course of evaluation. Patients over the age of 55 years or with alarm symptoms should be referred for prompt endoscopy. In the absence of other clinically apparent aetiologies, uninvestigated dyspeptics can be either tested and treated for Helicobacter pylori or empirically treated with proton pump inhibitors. Uninvestigated dyspeptics failing empiric therapy should be referred for evaluation that includes endoscopy. Further therapy with prokinetics, tricyclic antidepressants, fundal relaxants, antidepressants, or psychotherapy is guided by predominant symptoms and assessment of possible psychiatric factors.

Review article: dyspepsia: how to manage and how to treat?

Recent guidelines for dyspepsia, defined as pain or discomfort centred in the upper abdomen, emphasize that in younger patients with no alarm features and not taking nonsteroidal anti-inflammatory drugs, testing for Helicobacter pylori and treatment of the infection if present is a standard of care. If H. pylori is not present, empirical management (e.g. acid suppression) is often prescribed. It is further recommended that if patients relapse or fail to respond to treatment then upper endoscopy be undertaken. However, these guidelines have become controversial for a number of reasons. Firstly, the prevalence of H. pylori infection is falling as is the incidence of peptic ulcer disease due to the infection. Idiopathic peptic ulcer disease is also being increasingly recognized. Furthermore, the cost-effectiveness of endoscoping treatment failures has been questioned, as the yield is low and patient management is usually not altered. Finally, it remains controversial whether the treatment of H. pylori infection in functional dyspepsia is of value, and two recent high quality meta-analyses have reached diametrically opposite conclusions. Alternative strategies, such as initially treating with acid suppression and then considering H. pylori infection in those who fail have been suggested, as has in low H. pylori prevalent regions the abandonment of a test-and-treat strategy. However, appropriate management trials of these alternative strategies in primary care are lacking. The management of patients with functional dyspepsia who fail initial antisecretory therapy is now difficult; prokinetics have fallen into some disrepute. Tricyclic antidepressants (at a low dose) may be useful in a subset, but adequate trials are lacking.

The treatment of functional dyspepsia with red pepper

AIM

: To decrease the intensity of dyspeptic symptoms by impairing the visceral nociceptive C-type fibres with capsaicin, contained in red pepper powder.

METHODS

: The study was performed on 30 patients with functional dyspepsia and without gastro-oesophageal reflux disease and irritable bowel syndrome. After a 2-week washout period, 15 patients received, before meals randomly and in a double-blind manner, 2.5 g/day of red pepper powder for 5 weeks, and 15 patients received placebo. A diary sheet was given to each patient to record, each day, the scores of individual and overall symptom intensity, which subsequently were averaged weekly and over the entire treatment duration.

RESULTS

: The overall symptom score and the epigastric pain, fullness and nausea scores of the red pepper group were significantly lower than those of the placebo group, starting from the third week of treatment. The decrease reached about 60% at the end of treatment in the red pepper group, whilst placebo scores decreased by less than 30%.

CONCLUSIONS

: Red pepper was more effective than placebo in decreasing the intensity of dyspeptic symptoms, probably through a desensitization of gastric nociceptive C-fibres induced by its content of capsaicin. It could represent a potential therapy for functional dyspepsia.

Dyspepsia: initial evaluation and treatment

OBJECTIVE

To provide recommendations for the initial evaluation and management of dyspepsia.

DATA SOURCES

Articles identified through a MEDLINE search for human studies published in English between 1966 and June 2001, using the primary search term dyspepsia and the secondary search terms diagnosis, complications, and treatment; textbooks with information on the diagnosis and management of gastrointestinal (GI) disorders; and bibliographies of retrieved publications and textbooks.

STUDY SELECTION

Articles that focused on dyspepsia as well as factors suggestive of more complicated GI disorders that would require pharmacists to refer patients to a physician.

DATA EXTRACTION

Performed by the author manually.

DATA SYNTHESIS

Functional dyspepsia (i.e., upset stomach or indigestion with no identifiable lesion) is a common complaint that may be relieved by medications, including antacids, histamine2-receptor antagonists, proton pump inhibitors, and promotility agents. However, therapy should not mask important warning signs and symptoms of more complicated diseases, as that could delay both diagnosis and more definitive treatment. Peptic ulcer disease and gastroesophageal reflux disease each account for about 20% of patients presenting with dyspepsia. Gastric cancer is an important disease to consider in the differential diagnosis of dyspepsia in patients older than 45 years, especially elderly patients (65 years and older).

CONCLUSION

Nonprescription medications can relieve functional dyspepsia, but pharmacists must be aware of common features of diseases that require patient referral to a physician for further evaluation.

Uninvestigated Dyspepsia

Dyspepsia, which is defined as pain or discomfort centered in the upper abdomen, is encountered frequently in primary care and subspecialty practice. Dyspepsia is a symptom complex caused by a heterogeneous group of disorders and diseases. A large fraction of patients with dyspepsia suffer from functional dyspepsia, in which no evidence of organic disease (typically on the basis of upper endoscopy) is found to explain persistent or recurrent symptoms. Initial management strategies for uninvestigated dyspepsia include empiric antisecretory therapy, the "test-and-treat" strategy for Helicobacter pylori, or prompt upper endoscopy. The cost-effectiveness of empiric therapy versus the test-and-treat strategy is dependent upon a number of variables including the prevalence of H. pylori infection, ulcer prevalence, and likelihood that an ulcer is due to H. pylori infection. As the prevalence of H. pylori infection falls and the likelihood of H. pylori negative ulcer increases, empiric antisecretory therapy will become more cost-effective. Upper endoscopy should be reserved for patients older than 45 to 50 years with symptom presentation and those with warning signs. Endoscopy also should be considered in those for whom empiric therapy or an attempt at the test-and-treat strategy fails. Common-sense dietary counseling can be helpful in patients with meal-related symptoms. Highly restrictive diets rarely improve symptoms and may be counterproductive if nutrition is compromised.

Review article: Helicobacter pylori and uninvestigated dyspepsia

Although dyspepsia is a very common disorder, the incidence of Helicobacter pylori infection in Western medical clinics is very low (20-35%). In cases where H. pylori is detected, elimination of it may be cost-effective in the long term, but even eradication is not a guarantee for long-term relief. Further studies to determine the connection between H. pylori and dyspepsia need to be completed before H. pylori eradication becomes the treatment of choice for that minority of patients. The majority of dyspeptic patients are not as simple to diagnose, and may need several empirical trials of therapy, or more specific diagnostic assessment.