Nonulcer dyspepsia. Current concepts and management

Gastritis and dyspepsia: differentiation as the cornerstone of pharmacotherapy

Chronic gastritis is a complex, polyetiological pathology with no clear clinical presentation. The most significant etiological factor of gastritis to date is H. pylori infection. A common clinical manifestation is the dyspepsia syndrome, which is caused by impaired motility. Symptoms can significantly affect a patient’s quality of life, necessitating rapid and effective pharmacotherapy. This paper discusses the algorithm of the physician actions in the case of a patient with uninvestigated dyspepsia. PPI has significant negative impact on the accuracy of H. pylori diagnostic test results. In this regard, it is proposed to use empirical therapy with prokinetics before diagnostic test would be performed. Among the prokinetics available on the Russian market, itopride hydrochloride stands out due to its high safety profile and proven efficacy. Current evidence supports the use of the prokinetic Ganaton® (itopride hydrochloride) as empirical therapy for dyspepsia of undetermined etiology, including patients with a preliminary diagnosis of gastritis. Due to its dual mechanism of action, itopride hydrochloride alleviates dyspeptic symptoms by improving gastric evacuation and can be used for an extended period. Several studies have shown the superiority of itopride in treating functional dyspepsia compared to other prokinetics, including metoclopramide and domperidone. Thus, prescribing the prokinetic Ganaton® (itopride hydrochloride) as empirical therapy for dyspepsia of undetermined etiology, including patients with a preliminary diagnosis of gastritis, is a pathogenetically justified approach aimed at improving the patient’s condition in the short term before establishing a final clinical diagnosis.

Gastritis and dyspepsia: differentiation as the cornerstone of pharmacotherapy

Chronic gastritis is a complex, polyetiological pathology with no clear clinical presentation. The most significant etiological factor of gastritis to date is H. pylori infection. A common clinical manifestation is the dyspepsia syndrome, which is caused by impaired motility. Symptoms can significantly affect a patient’s quality of life, necessitating rapid and effective pharmacotherapy. This paper discusses the algorithm of the physician actions in the case of a patient with uninvestigated dyspepsia. PPI has significant negative impact on the accuracy of H. pylori diagnostic test results. In this regard, it is proposed to use empirical therapy with prokinetics before diagnostic test would be performed. Among the prokinetics available on the Russian market, itopride hydrochloride stands out due to its high safety profile and proven efficacy. Current evidence supports the use of the prokinetic Ganaton® (itopride hydrochloride) as empirical therapy for dyspepsia of undetermined etiology, including patients with a preliminary diagnosis of gastritis. Due to its dual mechanism of action, itopride hydrochloride alleviates dyspeptic symptoms by improving gastric evacuation and can be used for an extended period. Several studies have shown the superiority of itopride in treating functional dyspepsia compared to other prokinetics, including metoclopramide and domperidone. Thus, prescribing the prokinetic Ganaton® (itopride hydrochloride) as empirical therapy for dyspepsia of undetermined etiology, including patients with a preliminary diagnosis of gastritis, is a pathogenetically justified approach aimed at improving the patient’s condition in the short term before establishing a final clinical diagnosis.

Prevalence of gastrointestinal disease in US Military Veterans under outpatient care at the Veterans Health Administration

Objectives:

There are currently no reliable estimates of the prevalence of gastrointestinal disease in the US Military Veterans. Hence, the study aims to determine its prevalence in military Veterans in the United States.

Methods:

This study utilized a retrospective, correlational design using a patient record database from the Department of Veteran’s Affairs. The participants in the study were Veterans diagnosed with gastrointestinal disease. Specific gastrointestinal diseases include more than 500,000 ambulatory care visits annually in the United States, which included peptic ulcer disease, gastroesophageal reflux disease, diverticular disease, ulcerative colitis, Crohn’s disease, irritable bowel syndrome, and functional dyspepsia, as well as the symptoms of constipation and nausea/vomiting. This study revealed the exact prevalence of gastrointestinal disease diagnosed in Veterans served in outpatient settings by the Veterans Health Administration and broke down this prevalence over time and by the Veteran period of service.

Results:

Findings revealed that gastrointestinal disease prevalence among Veterans varied according to their period of service.

Conclusions:

Findings may help improve screening for Veterans with this increased risk factor. However, further research should be performed to verify the prevalence of gastrointestinal disease in Veterans as compared to the general American population.

Impact of Helicobacter pylori infection and microscopic duodenal histopathological changes on clinical symptoms of patients with functional dyspepsia

AIM

To evaluate the microscopic histopathological changes in duodenal tissue and its relationship to the severity of symptoms in patients with functional dyspepsia while taking the effect of Helicobacter pylori (H. pylori) infection into account.

METHODS

Several gastric and duodenal biopsy specimens were obtained in 217 patients with functional dyspepsia and were evaluated for H. pylori infection and histopathological changes. Severity of symptoms was assessed by Leeds Dyspepsia Questionnaire (LDQ) and its relationship to histopathological changes and H. pylori infection status was assessed.

RESULTS

Helicobacter pylori infection was associated with presence and severity of microscopic duodenitis (p < 0.001). In H. pylori-infected patients, the presence of microscopic duodenitis was independent of microscopic gastritis (p = 0.74). Severity of dyspepsia symptoms was not higher in H. pylori-infected patients than non-infected patients (p = 0.15), but in the presence of H. pylori infection and microscopic gastritis, microscopic duodenitis significantly worsened the LDQ symptom severity score (p < 0.001). In multivariate analysis, the odds of experiencing severe symptoms in patients with severe microscopic duodenitis was 2.22 times greater than in individuals with very mild, mild, or moderate duodenitis.

CONCLUSIONS

Microscopic duodenitis in H. pylori-infected patients may play a major role in producing and aggravating symptoms in FD patients and may be a determinant factor to consider in whether to treat H. pylori infection in functional dyspepsia.

Role of Helicobacter pylori in functional dyspepsia

The aetiology of dyspepsia is unknown in the majority of patients. Helicobacter pylori (H pylori) is the cause in a subset of patients. A non invasive test to assess the presence of H pylori is recommended in the management of patients under the age of 50 presenting to a family practitioner with dyspepsia. A urea breath test or a stool antigen test are the most reliable non invasive tests. Eradication of H pylori will reduce the risk to the patient with dyspepsia of developing a peptic ulcer, reduce the complication rate if prescribed non-steroid anti-inflammatory drugs and later reduce the risk of gastric cancer. The recommended treatment for non ulcer dyspepsia associated with a H pylori infection should be a 10-d course of treatment with a PPI and two antibiotics. Treatment efficacy should be assessed four weeks after completing treatment with a urea breath test or a stool antigen test.

Detailed characterization of epidemiology of uninvestigated dyspepsia and its impact on quality of life among African Americans as compared to Caucasians

BACKGROUND AND AIMS

We wished to study the prevalence as well as the sociodemographic characteristics and quality of life (QoL) of African American patients with uninvestigated dyspepsia (UD) among the population at large and compare it to the Caucasians.

METHODS

A total of 990 adults from nine different sites in the Jackson, Mississippi metropolitan area (670 African Americans and 320 Caucasians), completed self-administered questionnaires providing sociodemographic information, and details regarding bowel habits and associated symptoms for diagnosing the presence or absence of UD based on ROME II criteria. QoL was assessed by the SF-12 questionnaire.

RESULTS

Of the 990 participants 247 had UD, giving a total sample prevalence of 24.9% (African Americans = 24.3%, Caucasians = 26.2%). Adjusting for other risk factors in a reduced logistic regression model, we found female sex (OR 1.8; CI 1.2-2.6; p < 0.01), lower education (p < 0.01), and larger size of household (p = 0.01) to be important correlates of UD prevalence whereas the lower household income showed a trend toward statistical significance (p = 0.057). Using the adjusted odds ratio as an estimate of relative risk, Caucasians were 1.5 (95% CI = 11.1-2.1; p = 0.017) more likely than African Americans to have UD. In terms of an index for QoL on SF-12 (possible score = 1-44, with 44 being ideal), the adjusted mean score was significantly lower for adults with UD compared to non-UD adults (30.4 vs 35.0; p < 0.01). However, there was no difference in impairment of life in Caucasians versus African Americans (32.9 vs 32.5; p = 0.36).

CONCLUSIONS

UD occurs less frequently among African Americans. While UD affects QoL among both Caucasians and African Americans, the degree of impairment is similar.

Sensitization of Mechanosensitive Gastric Vagal Afferent Fibers in the Rat by Thermal and Chemical Stimuli and Gastric Ulcers

In the present study we examined the effects of acute thermal and chemical stimuli and gastric ulceration on mechanosensitive gastric vagal afferent fibers. Single-fiber recordings were made from the cervical vagus nerve. Mechanosensitive afferent fibers were identified by response to gastric distension (GD). Intragastric pressure was maintained below 3 mmHg during intragastric instillation of saline, heated saline, HCl, or glycocholic acid. Responses to graded GD (5–60 mmHg, 20 s, 4-min interval) were determined before and after 30-min exposure to thermal or chemical stimuli. All mechanosensitive fibers studied were C-fibers (mean CV: 1.07 ± 0.07 m/s). Saline (37°C) did not affect resting activity or alter responses to GD, but exposure to heated saline (46°C) significantly increased resting activity and sensitized responses to GD. The decrease in resting activity was hydrochloric acid concentration dependent (0.025–0.2 N), but responses to GD were sensitized after 30-min exposure to 0.1 N HCl ( n = 7). The bile acid glycocholic acid significantly increased resting activity and desensitized responses to GD at an intragastric pH of 7, and similarly increased resting activity but sensitized responses to GD ( n = 6) at an intragastric pH of 1.2. Vagal afferents recorded in rats with gastric ulcers had significantly greater resting activity and responses to GD than sham ulcer rats; intragastric instillation of glycocholic acid (pH 1.2) further increased afferent fiber excitability. These findings indicate that acute gastric thermal and chemical stimuli alter the response characteristics of mechanosensitive vagal afferents in the absence of inflammation or structural damage. Accordingly, acute sensitization of gastric afferents through different stimulus modalities may contribute to the development of dyspeptic symptoms. In the presence of gastric inflammation, mechanosensitive vagal afferents exhibit a further increase in excitability.