Treatment of Functional Dyspepsia

The Efficacy of Hypnotherapy in the Treatment of Functional Dyspepsia

BACKGROUND

Functional dyspepsia (FD) is one of the most frequent functional gastrointestinal disorders and is defined using the Rome IV criteria as any combination of the following symptoms: postprandial fullness, early satiety, epigastric pain, and epigastric burning that are severe enough to interfere with the usual activities and occur at least 3 days per week over the past 3 months with an onset of at least 6 months before the presentation. The purpose of this systematic review is to analyze all the relevant studies in the literature that investigate the efficiency of hypnotherapy in FD.

AREAS OF UNCERTAINTY

FD refractory to conservative treatment is a therapeutic challenge, and alternative treatment options are needed. Gut-oriented hypnotherapy has been reported an effective treatment for irritable bowel syndrome, but poorly tested in FD.

DATA SOURCES

We performed a search in 6 bibliographic databases (PubMed, Embase, Cochrane Library, Web of Science, Scopus, and LILACS) using customized search strategies for each engine. The search strategy included the following terms: (hypnosis, hypnotherapy, hypnotherapies, hypnogenesis, hypnotism, hypnotist, hypnotical suggestion, suggestion, and mesmerism) and {[functional and (dyspepsia or dyspeptic)] or FD}.

RESULTS

Taking the aforementioned criteria into account, the result was a review of 4 articles analyzing the efficacy of hypnotherapy in the treatment of FD, published in the past 20 years. The initial search identified 398 articles, of which 37 potentially appropriate articles were reviewed. Of these 37 articles, 4 articles were included in the review. The benefits observed by numerous studies go beyond the field of digestive pathology, patients describing a general improvement in physical and mental health.

CONCLUSIONS

Current studies analyzing the efficacy of hypnotherapy in FD provide encouraging data, but additional randomized controlled trials are needed before a firm position on the effectiveness of hypnosis in FD.

Development and validation of a high throughput UPLC-MS/MS method for simultaneous quantification of esomeprazole, rabeprazole and levosulpiride in human plasma

A high throughput ultra pressure liquid chromatography–mass spectrometry (UPLC–MS/MS) method with good sensitivity and selectivity has been developed and validated for simultaneous quantification of esomeprazole, rabeprazole and levosulpiride in human plasma using lansoprazole as internal standard (IS). The extraction method based on liquid–liquid extraction technique was used to extract the analytes and IS from of 50 µL of human plasma using methyl tert-butyl ether:ethyl acetate (80:20, v/v), which offers a high recovery. Chromatographic separation of analytes and IS was achieved on a Hypersil gold C₁₈ column using gradient mobile phase consisting of 2 mM ammonium formate/acetonitrile. The flow rate was set at 0.5 mL/min to elute all the analytes and IS within 1.00 min runtime. Detection of target compounds was performed on a triple quadruple mass spectrometer by multiple reaction monitoring (MRM) mode via positive electrospray ionization (ESI). Method validation results demonstrated that the developed method has good precision and accuracy over the concentration ranges of 0.1–2000 ng/mL for each analyte. Stability of compounds was established in a battery of stability studies, i.e., bench top, autosampler, dry extract and long-term storage stability as well as freeze-thaw cycles. The validated method has been successfully applied to analyze human plasma samples for application in pharmacokinetic studies.

Relationship between functional dyspepsia and Helicobacter pylori infection

AIM: To investigate the correlation between functional dyspepsia (FD) and Helicobacter pylori (H. pylori) infection.

METHODS: A total of 1570 FD patients with H. pylori infection were recruited. Four hundred FD patients with H. pylori infection who did not have abnormal social psychological factors were divided randomly into either a treatment group or a control group. The treatment group was further divided into an eradication success group or an eradication failure group by H. pylori eradication status one month after the eradication therapy. Twelve months after treatment, improvement of symptoms and the average cost of rescue medication were analyzed and compared between groups.

RESULTS: In the H. pylori eradication success group, the symptoms improved more significantly compared with the H. pylori eradication failure group and control group one month after treatment, and the proportion of patients with symptomatic improvement ≥ 50% in the H. pylori eradication success group was significantly higher than those in the other two groups 12 mo after treatment. The average cost of rescue medication in the H. pylori eradication success group was significantly less than that in the control group and the H. pylori eradication failure group one month before the end of follow-up.

CONCLUSION: H. pylori has a certain relevance to FD. H. pylori eradication in H. pylori positive FD patients who are not associated with abnormal social psychological factors can achieve good treatment effects.

Many patients continue using proton pump inhibitors after negative results from tests for reflux disease

BACKGROUND & AIMS

Ambulatory reflux testing is used to evaluate symptoms of gastroesophageal reflux disease (GERD) refractory to protein pump inhibitors (PPIs). We investigated the prevalence of PPI use in patients with negative results from Bravo pH or multichannel intraluminal impedance-pH (MII-pH) tests and factors that might predict the use of PPIs.

METHODS

We analyzed data from patients who had undergone Bravo pH monitoring or MII-pH testing at Northwestern University, without evidence of reflux disease. Demographics, endoscopy findings, pathology results, and provider recommendations were obtained via chart review. Eligible patients (n = 90) were contacted by telephone, and a cross-sectional survey was administered with questions about symptom severity, demographics, medication use, and health behaviors. Patients were compared by current PPI use, and statistical analyses were performed by using SAS version 9.2 software.

RESULTS

Thirty-eight patients (42.2%) reported current PPI use despite a negative result from a pH study. Only 17 patients (18.9%) recalled being instructed to stop taking PPIs; chart review showed documented instructions to stop PPI therapy for 15 patients (16.7%). There were no significant differences in demographic or clinical characteristics among patients compared by current PPI use. Patients taking a PPI were more likely than those not taking a PPI to report troublesome symptoms that affected their daily life, as measured by a questionnaire for the diagnosis of GERD (the GerdQ).

CONCLUSIONS

More than 42% of patients with negative results from pH monitoring studies continue PPI therapy despite physiological data that they do not have GERD.

Effectiveness and safety of levosulpiride in the treatment of dysmotility-like functional dyspepsia

The objective of this study was to assess the effectiveness and safety of levosulpiride in patients with dysmotility-like functional dyspepsia including nonerosive reflux esophagitis in conditions of daily practice. The study was conducted as a prospective, open-label, multicenter design in 342 patients with dysmotility-like functional dyspepsia (n=279) and nonerosive reflux disease (n=63), who received levosulpiride 25 mg 3 times daily orally for 4 weeks. Individual symptoms (pain/discomfort, fullness, bloating, early satiety, pyrosis, regurgitation, and nausea/vomiting) and a global symptom score were assessed at 15, 30, and 60 days after starting treatment. Adverse events also were recorded. There were 151 men and 191 women (mean age 38.8 years) who referred dyspeptic symptoms for a mean of 10.2 (10.7) months. A total of 66.4% patients were treated with 75 mg/day levosulpiride and 33.6% with 50 mg/day. At the 15-day visit, a decrease greater than 50% in the global symptom score was observed. The frequency and intensity of individual symptoms showed a statistically significant decrease (p<0.001) at all visits compared with baseline. At the 30-day visit, all symptoms had almost disappeared, a trend that was maintained until the last visit. Treatment with levosulpiride was well tolerated and only 40 adverse events were recorded (galactorrhea 26.7%, somnolence 17.8%, fatigue 11.1%, headache 11.5%) and no patient had to abandon the study due to side effects. In conclusion, levosulpiride is an effective and safe drug in the treatment of dysmotility-like functional dyspepsia and non-erosive reflux disease.

Effect of the 5-HT3 receptor antagonist, ondansetron, on gastric size in dyspeptic patients with impaired gastric accommodation

BACKGROUND

A reduction of gastric accommodation after a meal has been documented in patients with idiopathic dyspepsia. In these patients the administration of a 5-HT3 receptor antagonist may reduce some of the dyspeptic symptoms; it is not clear however, whether these drugs influence gastric adaptation to distension as well.

AIM

To evaluate the effects of the 5-HT3 receptor antagonist, ondansetron, on gastric distension after a liquid meal in dyspeptic patients with reduced gastric accommodation.

METHODS

Before and after a 500 ml water load, gastric accommodation (area of the proximal and distal stomach) was evaluated using real-time ultrasonography in 21 idiopathic dyspepsia patients and 26 healthy controls. In dyspeptic patients, the test was repeated twice: after the administration of placebo and after ondansetron 8 mg i.v. (in both cases, 15 min prior to the water load). Secondary outcomes were epigastric pain, fullness and nausea as assessed by a visual analogue scale at basal and after ondansetron.

RESULTS

Fasting gastric size was similar in dyspeptic and controls. Compared with controls, dyspeptic patients showed a statistically significant smaller area of the proximal stomach (14.7+/-1.2 cm(2) vs. 18.6+/-1.4 cm(2), respectively; p=0.0247). In dyspeptic patients, gastric proximal and distal size did not change significantly following placebo, whereas after the administration of ondansetron the mean area of the proximal and distal stomach significantly increased (proximal stomach: 14.6+/-1.6 cm(2) placebo, 20.4+/-1.9 cm(2) ondansetron, p=0.0095; distal stomach: 8.9+/-0.9 placebo, 11.4+/-1.2cm(2) ondansetron, p=0.0409). Of the symptoms, only nausea was significantly reduced after ondansetron.

CONCLUSION

In dyspeptic patients with impaired gastric accommodation, ondansetron reverts gastric accommodation to within the range of controls.

Pathogenesis and therapy for idiopathic dyspepsia

Functional dyspepsia (FD) is one of the most common gastrointestinal disorders. This review summarizes recent progress in our understanding of the pathogenesis and therapy for FD. Although distinction among FD, irritable bowel syndrome, and reflux disease is difficult in population-based studies, separate entities can be recognized in patients who seek medical attention. The pathogenesis of FD remains unclear, but recent studies have demonstrated a role for acute gastrointestinal infection in triggering FD and in genetic polymorphisms of G-proteins in predisposing to FD. The role of abnormalities in gastric motor function, visceral hypersensitivity, and psychosocial factors in the pathophysiology of dyspeptic symptoms has been the topic of multiple studies. Treatment options for FD remain limited. Recent studies have focused on acid-suppressive drugs and on novel prokinetics. Progress in our understanding of the pathogenesis and pathophysiology of FD may lead to new or improved treatment modalities. Areas of major advances are the role of infection and genetic predisposition and studies on the role of abnormalities in gastric motility and sensitivity.

Nutrients and dyspepsia: paradigms and reality

PURPOSE OF REVIEW

Dyspepsia is a common disorder that presents as persistent or recurrent abdominal pain or discomfort in the upper abdomen and originates from organic or functional causes. Heterogeneous disorders, physiopathological, psychosomatic, sociocultural, demographic and genetic components have a great impact on its presentation. Physiopathological elements and the influence of nutrients on symptomatology are discussed to help establish clearer guidelines for treatment.

RECENT FINDINGS

Gastric emptying is affected by physiological, pharmacological and dietary factors and is translated into symptoms and signs such as anorexia, nausea, vomiting, weight loss and abdominal pain. Liquid or solid meals may cause early or delayed emptying, which is associated with symptoms of postprandial fullness. Abnormal glucose and electrolyte serum values may also cause transitory emptying delay. Fatty and acid nutrients have also been reported to aggravate symptoms of functional dyspepsia, especially after large meals. Studies have also pointed at food sensibility and the effect of Helicobacter pylori infection on gastric emptying in symptomatic patients. Patients may suffer antral hypomotility and total/partial postingestion pattern conversion. Spinal brain axis dysfunction caused by peripheral inflammation is associated with gastric dysmotility. An association between symptoms and functional polymorphisms is pending further clarification. It has been questioned whether the genotype is associated with a specific physiopathological mechanism, postinfectious functional disorders or psychological/social alterations.

SUMMARY

The treatment of dyspepsia is empiric and is directed at improving symptoms associated with alterations in emptying, postprandial accommodation, hypersensibility and hyperalgesia. Further studies are required to correlate symptoms with food kinetics at the initial postfood ingestion stages.

Review article: the overlap between functional dyspepsia and irritable bowel syndrome -- a tale of one or two disorders?

Functional dyspepsia and irritable bowel syndrome are currently considered to be two separate nosological entities. However, the overlap of symptoms and the evidence of a number of common pathophysiological characteristics suggest that functional dyspepsia and irritable bowel syndrome may be different presentations of the same disorder. In this review, we critically appraise points in common, as well as differences, in the epidemiology, pathophysiology and response to treatment of functional dyspepsia and irritable bowel syndrome. Population-based studies and large case series show that one- to two-thirds of subjects with irritable bowel syndrome have symptoms that overlap with functional dyspepsia. Symptom analyses have generally failed to support functional dyspepsia and irritable bowel syndrome as separate entities. An exaggerated motor response to meals, delayed gastric emptying and abnormal small bowel and colonic transit can all be found in subsets of functional dyspepsia and irritable bowel syndrome, and are not exclusive to either condition. Visceral hypersensitivity is a common feature to both entities and seems unlikely to be site or disease specific. There is good evidence for the post-infectious development of irritable bowel syndrome, and this may also apply in functional dyspepsia. Psychiatric comorbidities are similar in functional dyspepsia and irritable bowel syndrome. Several common drug classes (prokinetics, visceral analgesics, psychoactive agents) may similarly improve both functional dyspepsia and irritable bowel syndrome symptoms. The evidence available suggests that at least subsets of functional dyspepsia and irritable bowel syndrome represent different manifestations of a single entity. The identification of common pathophysiological targets for therapy should be pursued in future research.