Cimetidine in the management of symptomatic patients with duodenitis: a double-blind controlled trial

WITHDRAWN: Pharmacological interventions for non-ulcer dyspepsia

BACKGROUND

The commonest cause of upper gastrointestinal symptoms is non-ulcer dyspepsia (NUD) and yet the pathophysiology of this condition has been poorly characterised and the optimum treatment is uncertain. It is estimated that £450 million is spent on dyspepsia drugs in the UK each year.

OBJECTIVES

This review aims to determine the effectiveness of six classes of drugs (antacids, histamine H2 antagonists, proton pump inhibitors, prokinetics, mucosal protecting agents and antimuscarinics) in the improvement of either the individual or global dyspepsia symptom scores and also quality of life scores patients with non-ulcer dyspepsia.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2005), MEDLINE (1966 to January 2006), EMBASE (1988 to January 2006), CINAHL (1982 to January 2006), SIGLE, and reference lists of articles. We also contacted experts in the field and pharmaceutical companies. Trials were located through electronic searches of the Cochrane Controlled Trials Register (CCTR), MEDLINE, EMBASE, CINAHL and SIGLE, using appropriate subject headings and text words, searching bibliographies of retrieved articles, and through contacts with experts in the fields of dyspepsia and pharmaceutical companies.

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing drugs of any of the six groups with each other or with placebo for non-ulcer dyspepsia (NUD).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility, trial quality and extracted data.

MAIN RESULTS

We included 73 trials: prokinetics (19 trials with dichotomous outcomes evaluating 3178 participants; relative risk reduction (RRR) 33%; 95% confidence intervals (CI) 18% to 45%), H(2)RAs (12 trials evaluating 2,183 participants; RRR 23%; 95% CI 8% to 35%) and PPIs (10 trials evaluating 3,347 participants; RRR 13%; 95% CI 4% to 20%) were significantly more effective than placebo. Bismuth salts (six trials evaluating 311 participants; RRR 40%; 95% CI -3 to 65%) were superior to placebo but this was of marginal statistical significance. Antacids (one trial evaluating 109 participants; RRR -2%; 95% CI -36% to 24%) and sucralfate (two trials evaluating 246 participants; RRR 29%; 95% CI -40% to 64%) were not statistically significantly superior to placebo. A funnel plot suggested that the prokinetic results could be due to publication bias or other small study effects.

AUTHORS' CONCLUSIONS

There is evidence that anti-secretory therapy may be effective in NUD. The trials evaluating prokinetic therapy are difficult to interpret as the meta-analysis result could have been due to publication bias. The effect of these drugs is likely to be small and many patients will need to take them on a long-term basis so economic analyses would be helpful and ideally the therapies assessed need to be inexpensive and well tolerated.

Increased CD8+ intraepithelial lymphocyte infiltration and reduced surface area to volume ratio in the duodenum of patients with ulcerative colitis

OBJECTIVE

Recent evidence suggests the involvement of the upper gastrointestinal tract in ulcerative colitis (UC). By conducting a prospective controlled study, we explored the immunological abnormalities in the duodenal mucosa of UC patients.

METHODS

Duodenal and colonic biopsies were collected from 24 corticosteroid-free UC patients and 21 controls. Colonization by Helicobacter pylori and positivity for anti-endomysial antibodies was an exclusion criteria. The severity of duodenal and colonic inflammation was determined by endoscopic and histologic scores. Morphometry was performed to measure the surface area to volume ratio (SV). Duodenal CD3(+) and CD8(+) intraepithelial lymphocytes (IELs) and lamina propria mononuclear cells (LPMCs) were detected by immunohistochemistry.

RESULTS

Fifteen UC patients and 14 controls were Helicobacter pylori and anti-endomysial antibody negative and were thus included in the study. Microscopic duodenitis was reported in 4 of the 15 UC patients (26.6%), and in none of the controls. A significantly higher number of CD3(+) and CD8(+) IELs and LPMCs was found in UC patients than in controls. A significant positive correlation between the percentage of both CD3(+) and CD8(+) IELs and disease activity was found in UC patients. SV was significantly reduced in UC patients compared to controls, and inversely correlated with the percentage of CD8(+) IELs.

CONCLUSIONS

The duodenum of UC patients is infiltrated by a higher number of CD8(+) IELs which correlates with the degree of villous flattening and disease activity, but not with extent of the colonic lesions. Further studies are needed to clarify whether the duodenum is a target organ in UC.

Pharmacological interventions for non-ulcer dyspepsia

BACKGROUND

The commonest cause of upper gastrointestinal symptoms is non-ulcer dyspepsia (NUD) and yet the pathophysiology of this condition has been poorly characterised and the optimum treatment is uncertain. It is estimated that pound450 million is spent on dyspepsia drugs in the UK each year.

OBJECTIVES

This review aims to determine the effectiveness of six classes of drugs (antacids, histamine H(2) antagonists, proton pump inhibitors, prokinetics, mucosal protecting agents and antimuscarinics) in the improvement of either the individual or global dyspepsia symptom scores and also quality of life scores patients with non-ulcer dyspepsia.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2005), MEDLINE (1966 to January 2006), EMBASE (1988 to January 2006), CINAHL (1982 to January 2006), SIGLE, and reference lists of articles. We also contacted experts in the field and pharmaceutical companies. Trials were located through electronic searches of the Cochrane Controlled Trials Register (CCTR), MEDLINE, EMBASE, CINAHL and SIGLE, using appropriate subject headings and text words, searching bibliographies of retrieved articles, and through contacts with experts in the fields of dyspepsia and pharmaceutical companies.

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing drugs of any of the six groups with each other or with placebo for non-ulcer dyspepsia (NUD).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility, trial quality and extracted data.

MAIN RESULTS

We included 73 trials: prokinetics (19 trials with dichotomous outcomes evaluating 3178 participants; relative risk reduction (RRR) 33%; 95% confidence intervals (CI) 18% to 45%), H(2)RAs (12 trials evaluating 2,183 participants; RRR 23%; 95% CI 8% to 35%) and PPIs (10 trials evaluating 3,347 participants; RRR 13%; 95% CI 4% to 20%) were significantly more effective than placebo. Bismuth salts (six trials evaluating 311 participants; RRR 40%; 95% CI -3 to 65%) were superior to placebo but this was of marginal statistical significance. Antacids (one trial evaluating 109 participants; RRR -2%; 95% CI -36% to 24%) and sucralfate (two trials evaluating 246 participants; RRR 29%; 95% CI -40% to 64%) were not statistically significantly superior to placebo. A funnel plot suggested that the prokinetic results could be due to publication bias or other small study effects.

AUTHORS' CONCLUSIONS

There is evidence that anti-secretory therapy may be effective in NUD. The trials evaluating prokinetic therapy are difficult to interpret as the meta-analysis result could have been due to publication bias. The effect of these drugs is likely to be small and many patients will need to take them on a long-term basis so economic analyses would be helpful and ideally the therapies assessed need to be inexpensive and well tolerated.

Pharmacological interventions for non-ulcer dyspepsia

BACKGROUND

The commonest cause of upper gastrointestinal symptoms is non-ulcer dyspepsia (NUD) and yet the pathophysiology of this condition has been poorly characterised and the optimum treatment is uncertain. It is estimated that 450 million pounds is spent on dyspepsia drugs in the UK each year.

OBJECTIVES

This review aims to determine the effectiveness of six classes of drugs (antacids, histamine H2 antagonists, proton pump inhibitors, prokinetics, mucosal protecting agents and antimuscarinics) in the improvement of either the individual or global dyspepsia symptom scores and also quality of life scores patients with non-ulcer dyspepsia.

SEARCH STRATEGY

Trials were located through electronic searches of the Cochrane Controlled Trials Register (CCTR), MEDLINE, EMBASE, CINAHL and SIGLE, using appropriate subject headings and text words, searching bibliographies of retrieved articles, and through contacts with experts in the fields of dyspepsia and pharmaceutical companies.

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing drugs of any of the six groups with each other or with placebo for non-ulcer dyspepsia (NUD).

DATA COLLECTION AND ANALYSIS

Data were collected on dyspeptic symptom scores either individual or global symptom assessments and also quality of life scores and adverse effects.

MAIN RESULTS

A total of 11796 citations were obtained. 157 trials were retrieved and 98 trials fulfilled our eligibility criteria. However, subsequent data extraction was not possible in 31 trials. The final 67 trials were included in the meta-analysis. Prokinetics (14 trials with dichotomous outcomes generating 1053 patients; relative risk reduction [RRR] = 48%; 95% confidence intervals [CI] = 27% to 63%), H2RAs (11 trials generating 2,164 patients; RRR = 22%; 95% CI = 7% to 35%) and PPIs (8 trials generating 3,293 patients; RRR = 14%; 95% CI = 5% to 22%) were significantly more effective than placebo. Bismuth salts (6 trials generating 311 patients; RRR = 40%; 95% CI = -3 to 65%) were superior to placebo but this was of marginal statistical significance. Antacids (one trial generating 109 patients; RRR = -2%; 95% CI = -36% to 24%) and sucralfate (two trials generating 246 patients; RRR = 29%; 95% CI = -40% to 64%) were not statistically significantly superior to placebo. A funnel plot suggested that the prokinetic and H2RA results could be due to publication bias.

REVIEWERS' CONCLUSIONS

There is evidence that anti-secretory therapy may be effective in NUD. The trials evaluating prokinetic therapy are difficult to interpret as the meta-analysis result could have been due to publication bias. The effect of these drugs is likely to be small and many patients will need to take them on a long-term basis so economic analyses would be helpful and ideally the therapies assessed need to be inexpensive and well tolerated.

Systematic review: the methodological quality of trials affects estimates of treatment efficacy in functional (non-ulcer) dyspepsia

AIM

To evaluate treatment efficacy using objective quality criteria.

METHODS

A systematic review was performed of randomized controlled trials of endoscopically investigated dyspepsia (1979-2003) using the Jadad score and Rome II guidelines. The Jadad score differentiated studies as 'high quality' (score 4-5/5) vs. 'poor quality' (score 1-3/5). Three key Rome II guidelines on study design (cut-off of 0/3 or > 0/3) were also compared with the Jadad score.

RESULTS

Poor quality trials suggested a benefit of prokinetic therapy [relative risk (RR) of remaining dyspeptic, 0.47; 95% confidence interval (CI), 0.39-0.56), which was not confirmed in high quality trials (RR, 1.0; 95% CI, 0.84-1.19). There was a marked benefit of H2-receptor antagonist therapy in poor quality trials (RR, 0.68; 95% CI, 0.61-0.76), but a marginal benefit in good quality trials (RR, 0.87; 95% CI, 0.79-0.97). Trial quality did not affect the small statistically significant benefit seen with Helicobacter pylori eradication. Two high quality trials suggested a limited benefit with the use of proton pump inhibitors, with no poor quality trials to provide a comparison. Separation of the studies by the Rome II criteria had a similar impact on the calculated treatment estimates.

CONCLUSIONS

The magnitude of benefit of prokinetic and H2-receptor antagonist therapies reported in previous meta-analyses has been over-estimated. The quality of trials has an impact on the efficacy estimates of treatment. The Rome II criteria for study methodology may be appropriate for judging study quality.

H2-receptor antagonists in the treatment of functional (nonulcer) dyspepsia: a meta-analysis of randomized controlled clinical trials

AIM

To perform a meta-analysis evaluating the efficacy of H2-receptor antagonists in functional (nonulcer) dyspepsia.

SELECTION OF STUDIES

A Medline search was used to identify placebo controlled randomized clinical trials, using the subject headings dyspepsia and H2-receptor antagonist.

OUTCOME MEASURES

Global assessment by the patient of dyspepsia symptoms, improvement of epigastric pain and complete relief of epigastric pain.

RESULTS

Twenty-two studies met the inclusion criteria, 15 of which reported the active drug to be superior to placebo. Many studies suffered from suboptimal study design. The odds ratio in favour of active drug was 1.48 (95% confidence interval: 0.9-2.3) for global assessment of dyspepsia symptoms, 2.3 (95% CI: 1.6-3.3) for improvement of epigastric pain, and 1.8 (95% CI: 1.2-2.8) for complete relief of epigastric pain.

CONCLUSION

There is some evidence that H2-receptor antagonists are superior to placebo in functional dyspepsia, but larger studies evaluating higher doses of H2-receptor antagonists and of longer duration are necessary to determine the exact effect size.

Current indications for acid suppressants in dyspepsia

Anti-secretory drug use is common in patients with uninvestigated and functional dyspepsia, but the value of such agents has been controversial. Four large studies have evaluated the symptomatic outcome after a short course of acid inhibition in patients with uninvestigated dyspepsia presenting in primary care. All of these studies demonstrated a superior symptom response to proton pump inhibitor therapy compared with placebo and acid-alginates or H(2)-receptor antagonists. In patients with documented functional dyspepsia, 17 parallel group trials have evaluated an H(2)-receptor antagonist against placebo, with mixed results. A recent Cochrane review based on eight controlled trials concluded that there was a significant benefit of H(2)-blockers over placebo with a relative risk reduction of 30%, but as gastro-oesophageal reflux disease was not excluded, the conclusions are questionable. Six controlled studies have compared symptom relief after a short course of proton pump inhibitor therapy compared with placebo. Overall, there does appear to be a therapeutic gain with proton pump inhibitors over placebo, although how much of this is explained by undiagnosed gastro-oesophageal reflux disease remains unclear. There is conflicting evidence on the value of symptom subgrouping as a predictor of response to acid suppression. Overall, there is little convincing evidence that Helicobacter pylori infection influences the therapeutic outcome of acid-suppressant therapy. In conclusion, there appears to be a subgroup of patients with functional dyspepsia who will respond to acid suppression over and above placebo, but further work is required to characterize these responders.

Placebo in functional dyspepsia: symptomatic, gastrointestinal motor, and gastric sensorial responses

OBJECTIVE

Therapeutic trials in functional dyspepsia consistently show a substantial placebo response, but there is no clear explanation for such an effect. Our aim was to evaluate symptomatic, gastrointestinal motor, and gastric sensorial responses to placebo treatment in patients with chronic and severe functional dyspepsia who were part of a therapeutic trial.

METHODS

Thirty patients were treated during 8 wk with placebo (white-colored 8-mm tablets containing cellulose) by mouth, 20 min before breakfast, lunch, and dinner. We quantified the symptomatic response to placebo as a change in global health status, and also as a change in the individual and combined (global symptom index) of a five-symptom complex: upper abdominal pain, nausea, vomiting, bloating/fullness, and early satiety. Gastroduodenal motility, during fasting and postprandially, was evaluated by manometry in all patients pretreatment and in 17 patients posttreatment. Gastric sensitivity to distension was evaluated in 18 patients pretreatment and in five patients posttreatment (all of them clinical responders).

RESULTS

Placebo treatment produced a striking symptomatic improvement; by 8 wk 80% of the patients reported an improved global health status and their global symptom index markedly decreased (23.9+/-1.3 pretreatment vs 9.1+/-1.2; p < 0.05). Placebo increased the number of gastric phases III starting in the antrum during the fasting period (1.1+/-0.1 vs 1.6+/-0.2; p < 0.05). As a group, no significant changes in postprandial gastroduodenal motility were observed after placebo treatment. However, after placebo a significant improvement in the antral motility index (MI) was observed in the subset of patients with antral hypomotility (MI pretreatment: 7.9+/-1.0; MI posttreatment: 11.7+/-0.4; p < 0.05). Before placebo treatment, patients with functional dyspepsia showed increased sensitivity to stepwise distension of the stomach relative to healthy individuals. After 8 wk of placebo treatment sensitivity to distension remained unchanged, even though patients' clinical status was markedly improved.

CONCLUSION

In patients with functional dyspepsia, the symptomatic response to placebo is substantial. Some significant changes were also observed in gastric motility: increase in the gastric phase III number as well as in the postprandial antral motility index in those with hypomotility pretreatment. Remarkably, however, clinical improvement seems to occur independently of detectable changes in gastroduodenal motor activity or gastric hypersensitivity to distension.

Meta-analysis of antisecretory and gastrokinetic compounds in functional dyspepsia

In view of therapeutic advances, we carried out meta-analysis of results from 18 randomized, controlled clinical studies to update a previous meta-analysis and to provide an overview of clinical trials involving treatment of functional dyspepsia. The studies were included only if they satisfied inclusion and exclusion criteria and assessed treatment of functional dyspepsia with the antisecretory compounds cimetidine and ranitidine and the gastrokinetic compounds cisapride and domperidone. Outcomes of each of these trials were classified in terms of differences in therapeutic success between active treatment and placebo. For antisecretory treatments, the 95% confidence intervals for the difference in therapeutic success between active treatment and placebo were inconsistent for cimetidine, but analysis of both ranitidine trials gave favorable results. For the gastrokinetic compounds cisapride and domperidone, the differences in success rates were generally higher and more in favor of active treatment than placebo. By combining the results from both antisecretory treatments and comparing them with the combined results for gastrokinetic compounds, we observed that gastrokinetic compounds had a greater difference in success rates than did antisecretory agents. Overall, our meta-analysis shows that antisecretory treatment with cimetidine or ranitidine offers little advantage over placebo, whereas gastrokinetic treatment with cisapride or domperidone is significantly better than placebo for treatment of functional dyspepsia.

Prevalences of endoscopic and histological findings in subjects with and without dyspepsia

OBJECTIVE

To examine the association between dyspeptic symptoms and endoscopic and histological diagnoses.

DESIGN

Cross sectional study of people with dyspepsia and controls matched for age and sex identified by questionnaire survey of all inhabitants aged 20 to 69. Endoscopy and histological examination was performed with the examiner blind to whether or not the patient had dyspepsia.

SETTING

Population based survey in Sørreisa, Norway.

SUBJECTS

All people with dyspepsia and age and sex matched people without dyspepsia were offered endoscopy. A total of 309 people with dyspepsia and 310 without dyspepsia underwent endoscopy, giving 273 matched pairs.

MAIN OUTCOME MEASURES

Prevalences of endoscopic and histological diagnoses made according to internationally accepted standards.

RESULTS

In all, 1802 of 2027 (88.9%) people returned the questionnaire. Of the 163 subjects who refused endoscopy, 114 were controls. Of five endoscopic and four histological diagnoses only peptic ulcer disease, endoscopic duodenitis, and active chronic gastritis were diagnosed significantly more often in people with dyspepsia. In all, 30% to 50% of the diagnoses of mucosal inflammation and peptic ulcer disease were made among subjects without dyspepsia, and only 10% of both those with and those without dyspepsia had normal endoscopic findings.

CONCLUSIONS

The diagnostic findings, with possible exceptions of peptic ulcer disease and endoscopic duodenitis, showed no association of clinical value with dyspeptic symptoms. The small number of "normal" endoscopic findings in both those with and those without dyspepsia challenge well accepted endoscopic and histological diagnostic criteria with relation to the upper gastrointestinal tract.

Secretory abnormalities in functional dyspepsia

During the past 30 years much interest has been focused on gastric acid as a possible causative factor in functional dyspepsia. The similarities to duodenal ulcer with regard to the symptoms, previous reports of a high risk of subsequent ulcer development, and a growing number of clinical therapeutic trials showing a significant advantage for acid-reducing drugs over placebo--although challenged by many investigators--have all contributed to a common notion that the gastric acid may play an equally important pathogenic role in functional dyspepsia as in peptic ulcer disease. However, recent studies in patients with well-defined functional dyspepsia indicate quite clearly that hypersecretion of hydrochloric acid is a rare finding. Available data also contradict the hypothesis that patients with functional dyspepsia are abnormally sensitive to their gastric acid. Those dyspeptic individuals who benefit from antacids purchased over the counter usually do not have functional dyspepsia but rather organic diseases such as esophagitis or peptic ulcer. The association or pathophysiologic parallelism between functional dyspepsia and peptic ulcer implied by the results of some studies of functional dyspepsia in the past might be explained by unintended inclusion of overlooked or subclinical cases of peptic ulcer disease in those studies.

Cimetidine and adverse reactions: a meta-analysis of randomized clinical trials of short-term therapy

PURPOSE

We pooled data from randomized, double-blind, placebo-controlled trials to determine the frequency of adverse reactions among patients treated with cimetidine for acute acid-peptic disorders.

METHODS

Meta-analysis was used to analyze data obtained from a search of English language reports of trials of cimetidine in the ambulatory treatment of acute acid-peptic disorders that were published between January 1982 and April 1987.

RESULTS

Of 161 trials of cimetidine that we identified, 84 provided complete reporting of data on adverse reactions and, of these, 24 employed a randomized, double-blind, placebo-controlled design. Across these 24 trials, the overall rate of reported adverse reactions among 622 patients randomly assigned to receive cimetidine was 10.9%; the corresponding rate among 516 patients randomly assigned to receive placebo was 10.1%. This difference was not statistically significant (p greater than 0.10), nor were any significant differences noted in the frequencies of reported central nervous system or gastrointestinal adverse reactions (p greater than 0.10). Rates of adverse reactions also did not differ by dosage or trial duration. The overall rate of adverse reactions reported in the 60 trials that did not utilize a randomized, double-blind, placebo-controlled design was similar to the rate reported in those that did.

CONCLUSIONS

Our findings suggest that the frequency of adverse reactions among patients receiving cimetidine for acute acid-peptic disorders is not significantly different from that of patients receiving placebo.

Chewable cimetidine versus chewable antacid in dyspepsia: which provides faster pain relief?

A randomized double-blind antacid-controlled study was carried out to investigate the speed of onset of relief from dyspeptic pain with a novel, chewable formulation of cimetidine in 80 patients with persistent dyspepsia. Inclusion and exclusion criteria were chosen to identify patients with an acid-related dyspeptic complex. After the ingestion of either 1 chewable cimetidine (200 mg) tablet or a chewable antacid tablet identical in appearance, dyspeptic pain was recorded by each patient every 10 minutes over a 1-hour period. The times for some improvement and for total disappearance of the pain were noted, as was the appearance of the next attack of dyspepsia. For both treatments, the median times for some improvement were less than 20 minutes and for total pain relief were less than 45 minutes. There was no statistically significant difference between treatments. The duration of pain relief was variable, but 13% of patients who had received antacid reported another attack of dyspepsia in less than 5 hours compared to none of the cimetidine-treated patients.

Cimetidine responders in non-ulcer dyspepsia

The effect of cimetidine and placebo was examined in 123 patients with non-ulcer dyspepsia (NUD) by means of a 12-day multi-crossover model with 5 regular interchanges between cimetidine and placebo. The evaluation of effect in individual patients was based on the number of times cimetidine was associated with less symptoms than the preceding or following placebo period. If cimetidine had no effect, the probability of being defined as a cimetidine responder was 25%. In general, cimetidine was associated with less symptoms than placebo (p less than 0.0001). Forty patients were identified as cimetidine responders (R) and the remaining patients were termed non-responders (NR). Symptoms compatible with gastroesophageal reflux were significantly more frequent in R than in NR, whereas the opposite was true for symptoms of the irritable colon syndrome. The ability of symptoms selected by stepwise logistic regression to predict response to cimetidine showed at best a sensitivity of 75% and a specificity of about 65%. No differences were found between R and NR with regard to acid secretion, endoscopic and histologic findings, or the result of an acid perfusion test. The present study supports the existence of a subgroup of cimetidine responders among patients with NUD characterized by symptoms suggestive of gastroesophageal reflux disease in the absence of confirmatory objective evidence.

Experience with a multi crossover model in dyspepsia

A multi cross over model (MCOM) has been designed for single case studies. The model which is only partly randomized, implies regular interchanges between treatment periods with active drug and placebo. The individual evaluation is based on the number of times the active drug is associated with less symptoms than the preceding or following placebo period (X-score), while the effect in a group is evaluated according to the X-score distribution and a paired t-test. The advantages of the single case approach and the impact of the MCOM is illustrated by the results from a study of the effect of cimetidine in non ulcer dyspepsia. Although there are several statistical objections to the model, the results from the study are reasonable and demonstrate a small degree of violence of preassumptions.

Effect of cimetidine in patients with non-ulcer dyspepsia and erosive prepyloric changes

A double-blind, placebo-controlled trial was performed, using 400-mg cimetidine tablets or placebo twice daily for 4 weeks in 100 patients with non-ulcer dyspepsia (NUD) and erosive prepyloric changes (EPC) grade 2 or 3. Symptomatic assessment was made weekly and endoscopic assessment on completion of the treatment period. Symptomatically, a significant effect of cimetidine versus placebo on epigastric pain/discomfort was recorded after 2 weeks' treatment (p less than 0.05). Endoscopically, there was a significant improvement, according to our grading scale of EPC, in the cimetidine-treated group, as compared to the placebo-treated group (p less than 0.05). On the basis of our findings, patients with NUD and EPC who have epigastric pain/discomfort as a prominent symptom seem to profit from treatment with cimetidine.