Anxiety but not depression determines health care-seeking behaviour in Chinese patients with dyspepsia and irritable bowel syndrome: a population-based study

Sex difference in the associations among risk factors with gastroesophageal reflux disease in a large Taiwanese population study

BACKGROUND

Gastroesophageal reflux disease (GERD) is a common global health issue. Previous studies have revealed a higher prevalence of GERD in females than in males, however few studies have investigated sex differences in the risk factors associated with GERD. Therefore, the aim of this population-based study was to examine sex differences in the risk factors for GERD in a large cohort of over 120,000 Taiwanese participants.

METHODS

We enrolled 121,583 participants (male: 43,698; female: 77,885; mean age 49.9 ± 11.0 years) from the Taiwan Biobank. The presence of GERD was ascertained using self-reported questionnaires. Sex differences in the risk factors associated with GERD were examined using multivariable logistic regression analysis.

RESULTS

The overall prevalence of GERD was 13.7%, including 13.0% in the male participants and 14.1% in the female participants (p < 0.001). Multivariable analysis showed that older age, hypertension, smoking history, alcohol history, low fasting glucose, and low uric acid were significantly associated with GERD in the male participants. In the female participants, older age, diabetes, hypertension, smoking history, alcohol history, low systolic blood pressure, low fasting glucose, high hemoglobin, high total cholesterol, low high-density lipoprotein cholesterol (HDL-C), low low-density lipoprotein cholesterol, and low uric acid were significantly associated with GERD. Significant interactions were found between sex and age (p < 0.001), diabetes (p < 0.001), smoking history (p < 0.001), fasting glucose (p = 0.002), triglycerides (p = 0.001), HDL-C (p = 0.001), and estimated glomerular filtration rate (p = 0.002) on GERD.

CONCLUSIONS

Our results showed a higher prevalence of GERD among females compared to males. Furthermore, sex differences were identified in the risk factors associated with GERD, and older age, diabetes, smoking history, and low HDL-C were more closely related to GERD in females than in males.

Effect of Chaihu-Shugan-San on functional dyspepsia and gut microbiota: A randomized, double-blind, placebo-controlled trial

ETHNOPHARMACOLOGICAL RELEVANCE

Chaihu-Shugan-San (CSS) is a classic traditional Chinese medicine (TCM) formula from the Ming Dynasty "Jingyue's Complete Works". In China, it is prevalent for the treatment of a wide range of ailments, with a particular emphasis on functional gastrointestinal disorders (FGIDs). Clinical evidence suggests that CSS has been found to be a highly effective therapeutic approach for the treatment of Functional Dyspepsia (FD), however, there is a limited amount of high-quality clinical evidence, particularly randomized, double-blind, placebo-controlled trials to support this claim.

AIM OF THE STUDY

To evaluate the therapeutic efficacy of Chaihu-Shugan-San (CSS) for treating functional dyspepsia (FD) by comparing it to placebos, as well as to investigate the impact of CSS on the gut microbiota in individuals diagnosed with FD.

MATERIALS AND METHODS

This was a randomized double-blind, placebo-controlled clinical trial implemented at Shuguang Hospital in Shanghai. Between May 2021 and December 2022, 94 participants satisfying the Rome IV diagnostic criteria for FD were enrolled. They were assigned randomly to either the CSS group or the placebo group, with an equal allocation ratio of 1:1. Patients in both groups received the intervention for four weeks. The primary outcome was the dyspepsia symptom scores evaluated by using single dyspepsia symptom scale (SDS) after four weeks of treatment. The secondary outcomes were the solid gastric empties rate measured by a barium strip method, Hamilton anxiety scale (HAMA), Hamilton depression scale (HAMD), and Functional dyspepsia Quality of life scale (FDDQL). In addition, after unblinding, 30 patients in the CSS group were randomly selected and divided into before and after treatment of the FD groups (FD1, FD2), and 30 healthy participants were selected as healthy control group (HC), and the gut microbiota was analyzed by 16S rRNA sequencing.

RESULTS

After four weeks of treatment, the SDS score exhibited a significant improvement in the CSS group compared to the placebo group (t = 4.882; P ＜0.001). The difference in barium strip gastric emptying rate in the CSS group showed a significant ascent compared to the control group (P < 0.01). The HAMA, HAMD, and FDDQL scores in the CSS group showed a statistically significant increase compared to the control group (all P < 0.01). The results of 16S rRNA sequencing revealed that FD patients had less diverse and abundant microbiota than the healthy people. Additionally, the application of CSS resulted in the modulation of certain bacterial populations, leading to both up-regulation and down-regulation of their quantities.

CONCLUSIONS

These findings suggested that CSS is more effective compared to a placebo in treating FD, relieves anxiety and depression, increases gastric emptying rate in FD patients, and that CSS also affects the bacterial community structure in FD patients.

TRIAL REGISTRATION

ChiCTR, ChiCTR2100045793. Registered 25 Mach 2021.

Association of vitamin D and functional dyspepsia: a case-control study

Background

Vitamin D plays a key role in responses of brain-gut axis. It has been suggested that functional dyspepsia (FD) may be associated with decreased levels of vitamin D. Hence this study wished to find the association between vitamin D in patients with FD.

Materials and methods

This case-control study was done at a tertiary care hospital with 150 cases and 150 controls. FD was diagnosed by the ROME IV criteria. Demographic profile and serum vitamin D levels including Perceived Stress Score (PSS) and salivary amylase were determined for both cases and controls.

Results

Majority of the FD cases were males (57.3%). Post-prandial distress syndrome represented the major type of FD cases (69.3%). A higher mean BMI was found among the control group (23.2 vs. 21.2, P<0.05) and higher percentage of obese individuals in the control group (42.7% vs. 29.3%, P= 0.05). Majority of the cases are from rural background (89.3% vs. 74%, P<0.001). Comparison of PSS showed that cases had significantly higher grades of PSS than control (P<0.001). However, no significant association was found in the levels of salivary amylase between the groups (P=0.728). Hypovitaminosis D (<30 ng/ml) was found significantly more among cases than controls (73.3% vs. 60%; P<0.05) with an odds ratio of 1.833 (CI 95%= 1.126-2.985). After adjustment of age, place of residence and BMI, vitamin D levels were significantly associated with FD in the regression analysis.

Conclusion

This study shows significant association of vitamin D deficiency in FD patients. It also opens up new avenues for further research into the role of vitamin D supplementation to further improve the management of such cases.

Impact of anxiety and depression on the swallowing process among patients with neurological disorders and head and neck neoplasia: systemic review

Background

Dysphagia is associated with depression and anxiety due to the severity, impact of symptoms itself or secondary to the underlying cause. This is more recognizable to brain diseases that has consequences common to the neural supply of the swallowing act and the cognition and behavior. Limited data are available to explore, quantitate and monitor these neurological outcomes. Our aim of this research to review the literature pertinent to depressive disorders, anxiety, and/or the quality of life (QoL) and psychological well-being. Search of Medline and Google Scholar databases for relevant articles had revealed a total of 1568 citations; 30 articles met the inclusion and exclusion criteria.

Results

Data about the direct effect of dysphagia on psychiatric aspects are limited. Studies of the relationship between severity of dysphagia and depressive symptoms demonstrated that several evaluation tools are available for objective and subjective assessment. The severity and progression of dysphagia was significantly associated with increased depressive symptoms.

Conclusion

Dysphagia is associated with and positively correlated to depression and anxiety scores observed in Parkinson disease (PD), multiple sclerosis (MS) and stroke. Similar association is observed in patients with head and neck cancer, tongue cancer and oral cancer. A bidirectional positive correlation exists with a vicious circle that loops between dysphagia and psychological disease. Moreover, the severity of dysphagia shows correlation with depression and/or anxiety scores (Fig. 1, Graphical abstract).

Graphical Abstract

Herbal Medicine Yukgunja-Tang for Functional Dyspepsia: A Protocol for a Randomized, Controlled, Multicenter Clinical Trial

The herbal medicine Yukgunja-tang has been widely used for the treatment of functional dyspepsia (FD) in the clinical setting of East Asian traditional medicine. This paper presents a protocol for a randomized, assessor-blind, controlled, multicenter, three-arm parallel clinical trial comparing the effectiveness, safety, and cost-effectiveness of Yukgunja-tang with Pyeongwi-san and usual care. A total of 140 participants with Rome IV-diagnosed FD will be randomly assigned to either the Yukgunja-tang (n = 56), Pyeongwi-san (n = 56), or usual care (n = 28) groups. All participants will be educated on dietary guidelines for FD patients. Participants in the Yukgunja-tang and Pyeongwi-san groups will take investigational products for 6 weeks. All participants will be assessed for clinical parameters at weeks 0, 3, 6, 9, and 24. The primary outcome will be measured on the total dyspepsia symptom scale, and the secondary outcome will include the single dyspepsia symptom scale, overall treatment effect, the visual analog scale for dyspepsia, FD-related quality of life, hospital anxiety and depression scale, EuroQol-5 dimension, pattern identification, and serum levels of acyl-ghrelin and deacyl-ghrelin. Adverse events and laboratory tests will be monitored for safety assessment. The results will provide evidence of the effectiveness, safety, and cost-effectiveness of Yukgunja-tang in the treatment of FD.

Finding relief for the self-conscious esophagus: laparoscopic anti-reflux surgery and the esophageal hypersensitivity and anxiety scale

INTRODUCTION

Measures of mood and effective coping strategies have notable correlations with quality of life and treatment responses. There is evidence that patients with previously diagnosed anxiety disorders have less improvement in patient-reported outcome measures (PROMs) after laparoscopic anti-reflux surgery (LARS) and that objective pathology does not correlate well with symptom severity. We were interested in investigating whether anxiety and hypervigilance, as measured preoperatively with the esophageal hypervigilance anxiety scale (EHAS), is associated with the improvement in GERD-specific PROMs and EHAS scores 6 months after LARS.

METHODS

We performed a retrospective cohort study of 102 adult patients (31% men, average age 64) who underwent LARS. In the preoperative evaluation, baseline gastroesophageal reflux disease-health-related quality of life (GERD-HRQL), laryngopharyngeal reflux symptom index (LPR-RSI) and EHAS scores were collected in addition to the standard reflux workup, including endoscopy, manometry, barium swallow, and pH study. For all three surveys, a higher score represents worse symptom severity. At 6 months postoperatively, 70 patients completed repeat GERD-HRQL, LPR-RSI, and EHAS surveys. We then analyzed for surgical and patient-related factors associated with improvement in the 6-month postoperative GERD-HRQL and LPR-RSI scores.

RESULTS

There was a statistically significant decrease in the GERD-HRQL (25 vs. 2, p < 0.001), LPR-RSI (17 vs. 3, p < 0.001) and EHAS (34 vs. 15, p < 0.001) 6 months after LARS. On multivariable linear regression, a higher baseline EHAS score was independently associated with a greater improvement in GERD-HRQL (β 0.35, p < 0.001) and LPR-RSI (β 0.19, p = 0.03) 6-months after LARS. Additionally, the degree of improvement in EHAS, GERD-HRQL, and LPR-RSI was not influenced by the type of LARS performed or by the severity of disease.

CONCLUSION

These findings are consistent with literature suggesting that measures of psychoemotional health correlate better with symptom intensity than objective pathology. We found that patients with a higher EHAS score have greater symptom severity and lower quality of life at baseline. Novel findings to this study are that patients with a higher preoperative EHAS, a measure of psychoemotional health, actually benefitted more from surgery and not less, which has been the traditional view in the literature. Future studies are warranted to establish directionality and explore the role of preoperative cognitive behavioral therapy with LARS for patients with significant symptoms of hypervigilance and anxiety.

Functional dyspepsia leads to more healthcare utilization in secondary care compared with other functional gastrointestinal disorders

OBJECTIVE

Functional gastrointestinal disorders (FGIDs) are known to have a significant impact on patients' quality of life and lead to a greater healthcare burden. In this study we aimed to investigate whether this healthcare burden differs among various types of FGIDs in secondary care.

METHODS

A retrospective study of consecutive adults with luminal gastrointestinal (GI) diseases in a secondary healthcare gastroenterology clinic was conducted. The frequency of FGIDs and differences in healthcare utilization among different types of FGIDs were explored.

RESULTS

Among 1206 patients with luminal GI disease, 442 (36.7%) had FGIDs. FGIDs patients were older (67 y vs 62 y, P < 0.001) with a higher proportion of women (61.8% vs 50.4%, P < 0.001) than those without FGIDs. Functional dyspepsia (FD) was the most common FGIDs (36.9%), followed by irritable bowel syndrome (IBS) (30.3%). A high healthcare burden (defined as over one GI endoscopy or imaging examination over 5 years, or  one or more unscheduled visit to general practitioner or emergency department or hospitalization annually) was observed among 53.8% of the FGIDs patients. FD was associated with a high healthcare burden (high vs low burden: 43.7% vs 28.9%, P = 0.001) while IBS was associated with lower healthcare burden (high vs low burden: 25.2% vs 36.3%, P = 0.012). On multivariate analysis, only FD was significantly associated with high healthcare burden (adjusted odds ratio 1.996, 95% confidence interval 1.117-3.567, P = 0.020).

CONCLUSION

Compared with other FGIDs, FD was the most common condition in secondary care, and it was associated with the greatest healthcare burden.

The Influence of Psychological Status on Acupuncture for Postprandial Distress Syndrome: A Subgroup Analysis of a Multicenter, Randomized Controlled Trial

BACKGROUND

Postprandial distress syndrome (PDS) is accompanied by a high incidence of mood disorder. Acupuncture is an effective method in relieving dyspepsia symptoms; however, the impact of psychological status on acupuncture for PDS remains mysterious.

METHODS

This secondary analysis of a multicenter, randomized controlled trial aims to evaluate the influence of anxiety and depression on acupuncture for PDS. 138 patients received the same acupuncture treatment and were followed up until week 16. The 2 primary outcomes were the response rate based on overall treatment effect and the elimination rate of all 3 cardinal symptoms after 4 weeks of treatment.

RESULTS

Of 114 patients, 31 were anxiety patients and 83 were nonanxiety patients or 32 were depressive patients and 82 were nondepressive patients. The response rate and elimination rate at week 4 were 77.4% and 9.7% in anxiety patients versus 84.3% and 27.7% in nonanxiety patients, respectively (P = 0.388; P = 0.041). No significant difference was noted in the response rate (P = 0.552) and elimination rate (P = 0.254) at week 4 between nondepressive and depressive patients. There was no significant intergroup difference in the response rate and elimination rate between non-mood-disorder and mood disorder patients (P > 0.05) during the 12-week post-treatment follow-up, except for the response rate at week 8 (P < 0.05).

CONCLUSION

The effect of acupuncture on response rate was similar for both non-mood-disorder and mood disorder patients. However, anxiety but not depression had a negative influence on the elimination rate, especially in postprandial fullness.

United European Gastroenterology (UEG) and European Society for Neurogastroenterology and Motility (ESNM) consensus on functional dyspepsia

BACKGROUND

Functional dyspepsia (FD) is one of the most common conditions in clinical practice. In spite of its prevalence, FD is associated with major uncertainties in terms of its definition, underlying pathophysiology, diagnosis, treatment, and prognosis.

METHODS

A Delphi consensus was initiated with 41 experts from 22 European countries who conducted a literature summary and voting process on 87 statements. Quality of evidence was evaluated using the grading of recommendations, assessment, development, and evaluation (GRADE) criteria. Consensus (defined as >80% agreement) was reached for 36 statements.

RESULTS

The panel agreed with the definition in terms of its cardinal symptoms (early satiation, postprandial fullness, epigastric pain, and epigastric burning), its subdivision into epigastric pain syndrome and postprandial distress syndrome, and the presence of accessory symptoms (upper abdominal bloating, nausea, belching), and overlapping conditions. Also, well accepted are the female predominance of FD, its impact on quality of life and health costs, and acute gastrointestinal infections, and anxiety as risk factors. In terms of pathophysiological mechanisms, the consensus supports a role for impaired gastric accommodation, delayed gastric emptying, hypersensitivity to gastric distention, Helicobacter pylori infection, and altered central processing of signals from the gastroduodenal region. There is consensus that endoscopy is mandatory for establishing a firm diagnosis of FD, but that in primary care, patients without alarm symptoms or risk factors can be managed without endoscopy. There is consensus that H. pylori status should be determined in every patient with dyspeptic symptoms and H. pylori positive patients should receive eradication therapy. Also, proton pump inhibitor therapy is considered an effective therapy for FD, but no other treatment approach reached a consensus. The long-term prognosis and life expectancy are favorable.

CONCLUSIONS AND INFERENCES

A multinational group of European experts summarized the current state of consensus on the definition, diagnosis and management of FD.

Effect of moderate aerobic exercises on symptoms of functional dyspepsia

BACKGROUND

Functional dyspepsia (FD) is a commonly encountered entity worldwide and is difficult to treat. Most of the treatment modalities have low-quality evidence for use, except for proton pump inhibitors. Aerobic exercise has been shown to improve the symptoms, but its direct effect on symptoms has never been studied. The objective was to study the effects of moderate aerobic exercise on symptoms of FD and to compare the effect of conventional treatment alone vs. exercise plus conventional treatment.

METHODS

Out of 112 patients, 72 were randomly divided into controls (conventional treatment; n=36) and experimental (aerobic exercise for 30 min per session, 5 times a week for 6 weeks with conventional treatment; n=36) groups. Both the groups were assessed on day 1 and at the end of 6 weeks, using Glasgow Dyspepsia Severity Score (GDSS), Depression Anxiety Stress Scales-42 (DASS-42), and visual analogue scale (VAS).

RESULTS

Pre-treatment GDSS, DASS-42, and VAS in the experimental group were significantly different as compared to the post-treatment scores (p=0.00019, p=0.0002, p=0.00019, respectively). Even in the control group, pre- and post-treatment GDSS, DASS-42, and VAS scores were significantly different (p=0.00019, p=0.0002, p=0.00019, respectively). However, on the head-to-head comparison of the 2 groups, scores at the end of 6 weeks were significantly different (p< 0.05), in favor of the experimental group.

CONCLUSION

Aerobic exercise as an auxiliary therapy to conventional treatment has better outcomes in the functional well-being of dyspepsia.

United European Gastroenterology (UEG) and European Society for Neurogastroenterology and Motility (ESNM) consensus on functional dyspepsia

BACKGROUND

Functional dyspepsia (FD) is one of the most common conditions in clinical practice. In spite of its prevalence, FD is associated with major uncertainties in terms of its definition, underlying pathophysiology, diagnosis, treatment, and prognosis.

METHODS

A Delphi consensus was initiated with 41 experts from 22 European countries who conducted a literature summary and voting process on 87 statements. Quality of evidence was evaluated using the grading of recommendations, assessment, development, and evaluation (GRADE) criteria. Consensus (defined as >80% agreement) was reached for 36 statements.

RESULTS

The panel agreed with the definition in terms of its cardinal symptoms (early satiation, postprandial fullness, epigastric pain, and epigastric burning), its subdivision into epigastric pain syndrome and postprandial distress syndrome, and the presence of accessory symptoms (upper abdominal bloating, nausea, belching), and overlapping conditions. Also, well accepted are the female predominance of FD, its impact on quality of life and health costs, and acute gastrointestinal infections, and anxiety as risk factors. In terms of pathophysiological mechanisms, the consensus supports a role for impaired gastric accommodation, delayed gastric emptying, hypersensitivity to gastric distention, Helicobacter pylori infection, and altered central processing of signals from the gastroduodenal region. There is consensus that endoscopy is mandatory for establishing a firm diagnosis of FD, but that in primary care, patients without alarm symptoms or risk factors can be managed without endoscopy. There is consensus that H. pylori status should be determined in every patient with dyspeptic symptoms and H. pylori positive patients should receive eradication therapy. Also, proton pump inhibitor therapy is considered an effective therapy for FD, but no other treatment approach reached a consensus. The long-term prognosis and life expectancy are favorable.

CONCLUSIONS AND INFERENCES

A multinational group of European experts summarized the current state of consensus on the definition, diagnosis and management of FD.

Efficacy of modified Banxia Xiexin decoction in the management of Wei-Pi syndrome (postprandial distress syndrome): study protocol for a randomized, waitlist-controlled trial

BACKGROUND

Postprandial distress syndrome manifests as a feeling of fullness and early satiation that can significantly reduce the quality of life of the patients. In Chinese medicine (CM), the syndrome is traditionally regarded as the Wei-Pi syndrome, and Banxia Xiexin decoction (BXD) has been used in the empirical treatment of the same for a long time. The current study aims to evaluate the efficacy of modified BXD in the management of Wei-Pi syndrome.

METHODS/DESIGN

A randomized, waitlist-controlled trial will be conducted. A total of 84 patients with Wei-Pi syndrome will be randomized into the BXD or waitlist control group in a ratio of 1:1. The patients in the BXD group will receive the semi-individualized BXD on the basis of the syndrome differentiation in CM, for a duration of 3 weeks and will be under follow-up for further 3 weeks after the completion of therapy. Conversely, the patients in the waitlist control group will undergo the same intervention and follow-up after a 3-week waiting period. In the current study, the primary outcome will be the variation in the scores pertaining to the global scale of the Quality of Life Questionnaire for Functional Digestive Disorders after 3 weeks. The secondary outcomes include the variations in the scores pertaining to the Hospital Anxiety and Depression Scale and the EuroQoL 5-dimension 5-level Questionnaire and the results of the liver and kidney function tests.

DISCUSSION

This trial will assess the efficacy of modified BXD in improving the clinical symptoms and quality of life of the patients suffering from Wei-Pi syndrome.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04398888 . Registered on May 21, 2020.

Psychoemotional factors and their influence on the quality of life in patients with GERD

Patient-reported outcomes (PROs) are integral to determining the success of foregut surgical interventions and psychoemotional factors have been hypothesized to impact the quality of life of patients. This study evaluates the correlation between PROs-specifically the Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL) and the Laryngopharangeal Reflux Symptom Index (LPR-RSI)-and the recently validated Esophageal Hypervigilance Anxiety Scale (EHAS). We hypothesize that patients with higher EHAS scores have significantly elevated GERD-HRQL LPR-RSI compared to those with normal scores. EHAS has been developed and validated in chronic esophageal disorders, but clinical impact is unknown. In this retrospective study, 197 patients (38% men, average age 56 ± 16) completed the following surveys:(1) EHAS, (2) GERD-HRQL, and (3) LPR-RSI. All patients referred for surgical evaluation of GERD completed the surveys as part of their pre-operative workup and post-operative follow-up In bivariate analysis, EHAS correlated with both GERD-HRQL (r 0.53, P = <0.001) and LPR-RSI (r 0.36, P = 0.009). Accounting for potential confounding with sex and age in multivariable linear regression models, a higher GERD-HRQL score (β 0.38; 95% CI 0.29 to 0.48; P = <0.001; Semipartial R² 0.20) and a higher LPR-RSI score (β 0.21; 95% CI 0.13 to 0.29; P = <0.001; Semipartial R² 0.08) were independently associated with higher EHAS. The observed relationship between mental health and GERD symptom intensity is consistent with the biopsychosocial paradigm of illness. Future studies focused on post-surgical outcomes following the incorporation of EHAS into perioperative care is needed to evaluate its effectiveness as a clinical decision support tool in ARS.

Systematic review with meta-analysis: global prevalence of uninvestigated dyspepsia according to the Rome criteria

BACKGROUND

Prevalence of uninvestigated dyspepsia varies across cross-sectional surveys. This may be due to differences in definitions used or study methodology, rather than global variability.

AIM

To determine the global prevalence of uninvestigated dyspepsia according to Rome criteria.

METHODS

MEDLINE and EMBASE were searched to identify population-based studies reporting prevalence of uninvestigated dyspepsia in adults (≥18 years old) according to Rome I, II, III or IV criteria. Prevalence of uninvestigated dyspepsia was extracted, according to criteria used to define it. Pooled prevalence, according to study location and certain other characteristics, odds ratios (OR), and 95% confidence intervals (CIs) were calculated.

RESULTS

Of 2133 citations evaluated, 67 studies fulfilled eligibility criteria, representing 98 separate populations, comprising 338 383 subjects. Pooled prevalence ranged from 17.6% (95% CI 9.8%-27.1%) in studies defining uninvestigated dyspepsia according to Rome I criteria, to 6.9% (95% CI 5.7%-8.2%) in those using Rome IV criteria. Postprandial distress syndrome was the commonest subtype, occurring in 46.2% of participants using Rome III criteria, and 62.8% with Rome IV. Prevalence of uninvestigated dyspepsia was up to 1.5-fold higher in women, irrespective of the definition used. There was significant heterogeneity between studies in all our analyses, which persisted even when the same criteria were applied and similar methodology was used.

CONCLUSIONS

Even when uniform symptom-based criteria are used to define the presence of uninvestigated dyspepsia, prevalence varies between countries. This suggests that there are environmental, cultural, ethnic, dietary or genetic influences determining symptoms.

Reflux Hypersensitivity: How to Approach Diagnosis and Management

PURPOSE OF REVIEW

This paper aims to review the definition and diagnostic criteria for reflux hypersensitivity and comment on the present and future management of this condition.

RECENT FINDINGS

In 2016, the Rome IV criteria redefined reflux hypersensitivity as characterized by typical reflux symptoms, absence of endoscopic mucosal disease, absence of pathologic gastroesophageal reflux, and positive symptom correlation between reflux and heartburn episodes. Though uncertain, TPRV1 receptors have been implicated in the pathophysiology of reflux hypersensitivity. Recent studies have shown neuromodulators like SSRIs, SNRIs, and TCAs may be the future of managing this condition. With the release of the Rome IV criteria and availability of continuous pH monitoring, the diagnosis of reflux hypersensitivity has become more streamlined. Though there is no definitive therapy for reflux hypersensitivity, several anti-secretory agents and neuromodulators have shown some efficacy in therapeutic trials. The lack of large-scale, randomized controlled trials, however, reinforces the need for further research into the pharmacotherapy of reflux hypersensitivity.

Health Beliefs, Health Anxiety, and Diagnostic Type in Food Hypersensitivity in Adults

Abstract. Background: Food hypersensitivity is often self-diagnosed, and research into barriers to help-seeking is scarce. Aims: This study in the United Kingdom sought to establish the relationship between health beliefs, health anxiety, and diagnostic type (medically diagnosed vs. self-diagnosed) in individuals with food hypersensitivity, and qualitatively explored attitudes of self-diagnosed individuals and their barriers to attaining a medical diagnosis. Method: A mixed-methods design involving 107 participants with food hypersensitivity (64 medically diagnosed and 43 self-diagnosed). Participants completed an adapted version of the health belief model questionnaire and a health anxiety questionnaire. A subset of six self-diagnosed participants took part in semi-structured interviews. Results: Binary logistic regression showed that health anxiety, perceived susceptibility, and perceived severity were significantly associated with diagnostic type. Qualitative thematic analysis of interviews yielded three themes: control over food, diagnosis, and treatment; judgment regarding feeling judged negatively on one’s choice of food, and being compared to fad-dieters; and the public’s and participants’ own lack of perceived severity of food hypersensitivity. Limitation: The sample was self-selected and therefore not necessarily representative of the population; however, an adult population was examined in an area that has so far largely studied children. Conclusion: Health psychologists should become involved in developing and testing interventions to help those with food hypersensitivity to control and reduce distress. Further researching the issues of control, judgment, and perceived severity could help tackle barriers to help-seeking behavior.

Global Prevalence and Risk Factors of Gastro-oesophageal Reflux Disease (GORD): Systematic Review with Meta-analysis

Although gastro-oesophageal reflux disease (GORD) is a common medical complaint, there is currently no consensus on the global prevalence of GORD. The aim of this study was to conduct a systematic review and meta-analysis on GORD prevalence and risk factors at a global level. MEDLINE, EMBASE, CINAHL, Scopus, Cochrane library, and Google Scholar were systematically searched, without language restrictions, for studies on the prevalence and risk factors of GORD. Data were pooled using a random effects model (95% confidence interval), and the odds ratio and relative risk for each risk factor were calculated. Out of 34,355 search results, 96 records reporting the results from 102 studies fulfilled the inclusion criteria, representing 37 countries and all regions of the UN geoscheme. The global pooled prevalence of GORD was 13.98% and varied greatly according to region (12.88% in Latin America and the Caribbean to 19.55% in North America) and country (4.16% in China to 22.40% in Turkey). Using the United Nations 2017 Revision of World Population Prospects, the estimated number of individuals suffering from GORD globally is 1.03 billion. Multiple risk factors associated with a significant increase in the risk of GORD were also identified. This systematic review and meta-analysis revealed that although a substantial proportion (13.98%) of the global population suffers from GORD, there are significant variations between regions and countries. Risk factors for GORD were also identified which may allow clinicians to recognise individuals most at risk.

Anxiety and Depression Symptom Comorbidity and the Risk of Heart Disease: A Prospective Community-Based Cohort Study

OBJECTIVE

The goal of this study was to examine the independent and joint associations between anxiety and depression symptoms with the risk of heart disease.

METHODS

A total of 30,635 participants from the CARTaGENE community cohort study in Quebec who did not have heart diseases at baseline were included in the study. Baseline anxiety and depression symptoms were assessed using validated questionnaires. Survey data were linked with diagnostic codes from a public insurance database to examine incident heart disease during a 7-year follow-up period. Cox regression analyses were conducted comparing groups with high anxiety only, high depression only, comorbid anxiety and depression, and no/low symptoms of both on the risk of heart disease. Additional analyses examined anxiety and depression using continuous questionnaire symptom scores, data-driven comorbidity groups, and diagnostic codes. Covariates included sociodemographic characteristics, health behaviors, diabetes, and hypertension.

RESULTS

In the main analyses, we found that, although depression without anxiety symptoms was associated with an increased risk of heart disease (hazard ratio = 1.35, 95% confidence interval = 1.04-1.74), there was no significant association for anxiety without depression symptoms (hazard ratio = 1.00, 95% confidence interval = 0.71-1.41). High anxiety assessed with diagnostic codes or by examining latent classes was, however, associated with a higher risk of heart disease.

CONCLUSIONS

The association between anxiety and incident heart disease may be accounted for by comorbid depression, particularly when anxiety and depression symptoms are assessed using self-report questionnaires. Differing methods of assessment and analysis, and adjustment for comorbid depression may explain differences in findings across different studies on anxiety and the risk of heart disease.

Herbal Therapies in Functional Gastrointestinal Disorders: A Narrative Review and Clinical Implication

The pathophysiology of functional gastrointestinal disorders (FGIDs) is still unclear and various complex mechanisms have been suggested to be involved. In many cases, improvement of symptoms and quality of life (QoL) in patients with FGIDs is difficult to achieve with the single-targeted treatments alone and clinical application of these treatments can be challenging owing to the side effects. Herbal preparations as complementary and alternative medicine can control multiple treatment targets of FGIDs simultaneously and relatively safely. To date, many herbal ingredients and combination preparations have been proposed across different countries and together with a variety of traditional medicine. Among the herbal therapies that are comparatively considered to have an evidence base are iberogast (STW-5) and peppermint oil, which have been mainly studied and used in Europe, and rikkunshito and motilitone (DA-9701), which are extracted from natural substances in traditional medicine, are the focus of this review. These herbal medications have multi-target pharmacology similar to the etiology of FGIDs, such as altered intestinal sensory and motor function, inflammation, neurohormonal abnormality, and have displayed comparable efficacy and safety in controlled trials. To achieve the treatment goal of refractory FGIDs, extensive and high quality studies on the pharmacological mechanisms and clinical effects of these herbal medications as well as efforts to develop new promising herbal compounds are required.

Depression, anxiety and stress symptoms in patients presenting with dyspepsia at a regional hospital in KwaZulu-Natal province

Background

Depression, anxiety and stress (DAS) have been shown to be co-morbid with dyspepsia. Local data on the factors associated with these co-morbidities could inform the role of psychiatric intervention in affected patients.

Aim

The aim of this study was to describe the frequency of undiagnosed DAS and their associated protective and risk correlates in a sample of patients undergoing endoscopies for dyspepsia.

Setting

The study was conducted at a regional hospital’s gastro-intestinal unit in KwaZulu-Natal province.

Method

A cross-sectional survey was conducted on 201 in- and outpatients with symptoms of dyspepsia awaiting endoscopy. Information on DAS symptomatology (using the DASS-21 screening questionnaire, as well as socio-demographic and clinical data) were collected.

Analyses

Following a descriptive analysis of the participants’ socio-demographic and clinical details, linear regression models were fitted to identify potential risk and protective correlates linked to DAS symptomatology.

Results

The mean age of participants (N = 201) was 48.89 years, of whom approximately two-thirds (n = 133; 66.17%) were women, 97% (n = 195) were African and 64.68% (n = 130) resided in rural areas. Anxiety was the most prevalent symptom category (n = 149; 74.13%) versus depression (n = 96; 47.76%) and stress (n = 68; 33.83%) in each category of symptom (mild to extremely) severity. In the severe and extremely severe range, anxiety existed without co-morbid depression or stress in 61.19% of anxious patients. Alcohol use was significantly associated with all three symptom categories (p < 0.01).

Conclusions

Given high frequencies of depression and anxiety in patients undergoing endoscopies for dyspepsia, screening for common mental disorders is essential.

Impact of occupational stress on irritable bowel syndrome pathophysiology and potential management in active duty noncombat Greek military personnel: a multicenter prospective survey

INTRODUCTION

Irritable bowel syndrome (IBS) is one of the gut-brain axis interaction disorders. It has global distribution with varying prevalence and particular financial and psychological consequences. IBS has been associated with stress and anxiety, conditions that are usually prevalent in the army. There are scarce data investigating the impact of IBS on noncombat active duty military without reports of Greek military or stress in the occupational environment.

MATERIALS AND METHODS

The main exclusion criteria in our noncombat military multicenter prospective survey were gastrointestinal pathologies, malignancies, hematochezia, recent infections and antibiotics prescription, and pregnancy. Questionnaires included a synthesis of baseline information, lifestyle, and diet, psychological and stress-investigating scales and the IBS diagnosis checklist. Hospital Anxiety and Depression Scale and Rome IV criteria were utilized.

RESULTS

Among 1605 participants included finally, the prevalence of IBS was 8% and 131 cases were identified. Women were more vulnerable to IBS, although male sex was prevalent at a ratio of 3.5 : 1 (male:female) in the entire sample. The mean age of all participants was 23.85 years; most of the IBS patients were older than thirty. Abnormal anxiety scores and high levels of occupational stress were related to an IBS diagnosis.

DISCUSSION

This prospective multicenter survey showed, for the first time, the potential impact of occupational stress on IBS in active duty noncombat Greek Military personnel. The diagnosis of IBS by questionnaire is a quick, affordable way that can upgrade, by its management, the quality of life and relieve from the military burden. Our results are comparable with previous studies, although large-scale epidemiological studies are required for the confirmation of a possible causative relationship.

Second Asian Consensus on Irritable Bowel Syndrome

BACKGROUND/AIMS

There has been major progress in our understanding of the irritable bowel syndrome (IBS), and novel treatment classes have emerged. The Rome IV guidelines were published in 2016 and together with the growing body of Asian data on IBS, we felt it is timely to update the Asian IBS Consensus.

METHODS

Key opinion leaders from Asian countries were organized into 4 teams to review 4 themes: symptoms and epidemiology, pathophysiology, diagnosis and investigations, and lifestyle modifications and treatments. The consensus development process was carried out by using a modified Delphi method.

RESULTS

Thirty-seven statements were developed. Asian data substantiate the current global viewpoint that IBS is a disorder of gut-brain interaction. Socio-cultural and environmental factors in Asia appear to influence the greater overlap between IBS and upper gastrointestinal symptoms. New classes of treatments comprising low fermentable oligo-, di-, monosacharides, and polyols diet, probiotics, non-absorbable antibiotics, and secretagogues have good evidence base for their efficacy.

CONCLUSIONS

Our consensus is that all patients with functional gastrointestinal disorders should be evaluated comprehensively with a view to holistic management. Physicians should be encouraged to take a positive attitude to the treatment outcomes for IBS patients.

A population-based study on prevalence and risk factors of gastroesophageal reflux disease in the Tibet Autonomous Region, China

Objective

To investigate the prevalence and risk factors of gastroesophageal reflux disease (GERD) in the Tibet Autonomous Region, China.

Methods

In this cross-sectional study, a stratified random sampling method was used for collecting samples in the Tibet Autonomous Region. A total of 10,000 individuals were selected from October 2016 to June 2017. A previously-published, validated questionnaire including six items related to the symptoms of GERD was used for evaluating GERD. In addition, basic demographic data, lifestyle, dietary habits, medical history and family history of GERD were investigated to identify risk factors of GERD.

Results

A total of 5,680 completed questionnaires were collected and analyzed. The prevalence of GERD in this area was 10.8%. Age (30-40 years vs. under 18 years, odds ratio (OR): 3.025; 40-50 years vs. under 18 years, OR: 4.484), education level (high school vs. primary, OR: 0.698; university vs. primary, OR: 2.804), ethnic group (Han vs. Tibetan, OR: 0.230; others vs. Tibetan, OR: 0.304), altitude of residence (4.0-4.5 km vs. 2.5-3.0 km, OR: 2.469), length of residence (<5 years vs. ≥5 years, OR: 2.218), Tibetan sweet tea (yes vs. no, OR: 2.158), Tibetan barley wine (yes vs. no, OR: 1.271), Tibetan dried meat (yes vs. no, OR: 1.278) and staying up late (yes vs. no, OR: 1.223) were significantly (all P < 0.05) and independently associated with GERD.

Conclusions

The prevalence of GERD is high in the Tibet Autonomous Region, China. Geographic conditions, ethnic group and lifestyle are risk factors for GERD.

Cultural Factors Influencing Functional Gastrointestinal Disorders in the East

Culture forms an integral aspect of environmental factors which influences disease presentation and clinical outcomes in functionalgastrointestinal disorders (FGIDs). In this review, the role of culture in FGIDs in the East is briefly explored with regards to symptompresentation and diagnostic issues, lifestyle and cultural habits, epidemiology, and healthcare seeking behavior. In both functionaldyspepsia and irritable bowel syndrome, symptom presentation and disease sub-typing in Asians are known to differ from their Western counterparts, possibly relating to cultural dietary practices and from cultural perception of symptoms. Dietary patterns, together with defecating practices are explored as factors contributing to a lower prevalence of constipation in the East. An urban-rural difference in the prevalence of FGIDs in Asia is attributed to a change in dietary patterns in rapidly developing urban communities, together with an increased level of psychological morbidity. Lastly, cultural attitudes towards traditional/local remedies, variation in healthcare systems, anxiety regarding organic disease, and religious practices have been shown to influence healthcare seeking behavior among FGID patients in the East.

Rikkunshito simultaneously improves dyspepsia correlated with anxiety in patients with functional dyspepsia: A randomized clinical trial (the DREAM study)

BACKGROUND

Functional dyspepsia (FD), a heterogeneous disorder, involves multiple pathogenetic mechanisms. Developing treatments for FD has been challenging. We performed a randomized, placebo-controlled, double-blind clinical trial to determine the efficacy of rikkunshito, a Japanese herbal medicine, in FD patients.

METHODS

FD patients (n = 192) who met the Rome III criteria without Helicobacter pylori infection, predominant heartburn, and depression were enrolled at 56 hospitals in Japan. After 2 weeks of single-blind placebo treatment, 128 patients with continuous symptoms were randomly assigned to 8 weeks of rikkunshito (n = 64) or placebo (n = 61). The primary efficacy endpoint was global assessment of overall treatment efficacy (OTE). The secondary efficacy endpoints were improvements in upper gastrointestinal symptoms evaluated by the Patient Assessment of Upper Gastrointestinal Disorders-Symptom Severity Index (PAGI-SYM), the Global Overall Symptom scale (GOS), and the modified Frequency Scale for the Symptoms of Gastroesophageal Reflux Disease (m-FSSG), and psychological symptoms evaluated by the Hospital Anxiety and Depression Scale (HADS).

KEY RESULTS

Rikkunshito increased OTE compared to placebo at 8 weeks (P = .019). Rikkunshito improved upper gastrointestinal symptoms (PAGI-SYM, GOS, and m-FSSG) at 8 weeks, especially postprandial fullness/early satiety (P = .015 and P = .001) and bloating (P = .007 and P = .002) of the PAGI-SYM subscales at 4 weeks and 8 weeks. Improvement of HADS at 8 weeks (P = .027) correlated with those of PAGI-SYM (r = .302, P = .001), GOS (r = .186, P = .044), and m-FSSG (r = .462, P < .001), postprandial fullness/early satiety (r = .226, P = .014), dyspepsia (r = .215, P = .019), and PDS (r = .221, P = .016).

CONCLUSION & INFERENCES

Rikkunshito may be beneficial for FD patients to simultaneously treat gastrointestinal and psychological symptoms.

Proton pump inhibitor-refractory gastroesophageal reflux disease: challenges and solutions

A significant percentage of patients with gastroesophageal reflux disease (GERD) will not respond to proton pump inhibitor (PPI) therapy. The causes of PPI-refractory GERD are numerous and diverse, and include adherence, persistent acid, functional disorders, nonacid reflux, and PPI bioavailability. The evaluation should start with a symptom assessment and may progress to imaging, endoscopy, and monitoring of esophageal pH, impedance, and bilirubin. There are a variety of pharmacologic and procedural interventions that should be selected based on the underlying mechanism of PPI failure. Pharmacologic treatments can include antacids, prokinetics, alginates, bile acid binders, reflux inhibitors, and antidepressants. Procedural options include laparoscopic fundoplication and LINX as well as endoscopic procedures, such as transoral incisionless fundoplication and Stretta. Several alternative and complementary treatments of possible benefit also exist.

Global prevalence of, and risk factors for, gastro-oesophageal reflux symptoms: a meta-analysis

OBJECTIVES

Gastro-oesophageal reflux symptoms are common in the community, but there has been no definitive systematic review and meta-analysis of data from all studies to estimate their global prevalence, or potential risk factors for them.

DESIGN

Medline, Embase and Embase Classic were searched (until September 2016) to identify population-based studies that reported the prevalence of gastro-oesophageal reflux symptoms in adults (≥15 years); gastro-oesophageal reflux was defined using symptom-based criteria or questionnaires. The prevalence was extracted for all studies, and according to the criteria used to define it. Pooled prevalence, according to study location and certain other characteristics, OR and 95% CIs were calculated.

RESULTS

Of the 14 132 citations evaluated, 102 reported the prevalence of gastro-oesophageal reflux symptoms in 108 separate study populations, containing 460 984 subjects. Prevalence varied according to country (from 2.5% in China to 51.2% in Greece) and criteria used to define gastro-oesophageal reflux symptoms. When only studies using a weekly frequency of heart burn or regurgitation to define presence were considered, pooled prevalence was 13.3% (95% CI 12.0% to 14.6%). Prevalence was higher in subjects ≥50 years (OR 1.32; 95% CI 1.12 to 1.54), smokers (OR 1.26; 95% CI 1.04 to 1.52), non-steroidal anti-inflammatory drug (NSAID)/aspirin users (OR 1.44; 95% CI 1.10 to 1.88) and obese individuals (OR 1.73; 95% CI 1.46 to 2.06).

CONCLUSIONS

The prevalence of gastro-oesophageal reflux symptoms varied strikingly among countries, even when similar definitions were used to define their presence. Prevalence was significantly higher in subjects ≥50 years, smokers, NSAID users and obese individuals, although these associations were modest.

Prevalence of Dyspepsia in Individuals With Gastroesophageal Reflux-Type Symptoms in the Community: A Systematic Review and Meta-analysis

BACKGROUND & AIMS

Dyspepsia and gastroesophageal reflux are highly prevalent in the general population, but they are believed to be separate entities. We conducted a systematic review and meta-analysis to estimate the prevalence of dyspepsia in individuals with gastroesophageal reflux symptoms (GERS), and to quantify overlap between the disorders.

METHODS

We searched MEDLINE, EMBASE, and EMBASE Classic databases to identify population-based studies reporting the prevalence of dyspepsia and GERS in adults, defined using specific symptom-based criteria or based on answers to questionnaires. We calculated pooled prevalence values, according to study location and criteria used to define weekly GERS or dyspepsia, as well as odds ratios (ORs) with 95% CIs. The degree of overlap between dyspepsia and GERS was examined.

RESULTS

Of 14,132 papers evaluated, 79 reported prevalence of weekly GERS. Nineteen of these study populations, comprising 111,459 participants, also reported the proportion of individuals with dyspepsia. The prevalence of dyspepsia in individuals with weekly GERS was 43.9% (95% CI, 35.1%-52.9%). The pooled OR for dyspepsia in individuals with weekly GERS, compared with those without, was 6.94 (95% CI, 4.33%-11.1%). The OR for dyspepsia in individuals with weekly GERS was significantly higher in all geographical regions studied and for all diagnostic criteria. The pooled degree of overlap between dyspepsia and GERS was 25.9% (95% CI, 19.9%-32.4%).

CONCLUSIONS

The odds of dyspepsia in individuals with weekly GERS is almost 7-fold that of individuals without GERS; dyspepsia and GERS overlap in more than 25% of individuals. Reasons for this remain speculative, but might include shared pathophysiological mechanisms or residual confounding factors. However, patients with GERS should be questioned about coexistent dyspepsia, to optimize treatment approaches.

Symptoms of anxiety and depression in type 2 diabetes: Associations with clinical diabetes measures and self-management outcomes in the Norwegian HUNT study

OBJECTIVE

To determine if symptoms of depression and anxiety are differentially associated with clinical diabetes measures and self-management behaviours in individuals with Type 2 diabetes, and whether these associations vary by patient sex.

RESEARCH DESIGN AND METHODS

A cross-sectional analysis using data from 2035 adults with Type 2 diabetes in the Nord-Trøndelag Health Study. Multivariate logistic regression was used to explore associations between symptoms of depression and anxiety and waist girth, HDL cholesterol, systolic blood pressure, triglycerides, c-reactive protein, glycemic control, diet adherence, exercise, glucose monitoring, foot checks for ulcers, and the subjective patient experience. Analyses were stratified by sex.

RESULTS

Depression was associated with a lower likelihood of avoiding saturated fats (OR=0.20 [95% CI: 0.06, 0.68]) and increased odds of physical inactivity (OR=1.69 [95% CI: 1.37, 2.72]). Anxiety was associated with increased odds of eating vegetables (OR=1.66 [95% CI: 1.02, 2.73]), and an over two-fold increase of feeling that having diabetes is difficult. In women, anxiety was associated with elevated c-reactive protein levels (OR=1.57 [95% CI: 1.05, 2.34]). In men, depressive symptoms were associated with elevated HbA1c (OR=5.00 [95% CI: 1.15, 8.23).

CONCLUSIONS

Symptoms of depression and anxiety were differentially associated with some key diabetes-related measures. Our results suggest sex-specific differences with respect to two important clinical outcomes (i.e., anxiety and CRP in women and depression and glycemic control in men). These findings should alert practitioners to the importance of detection and management of psychological symptoms in individuals with Type 2 diabetes.

Pros and Cons While Looking Through an Asian Window on the Rome IV Criteria for Irritable Bowel Syndrome: Pros

A decade after Rome III, in 2016, Rome IV criteria were published. There are major differences between Rome IV and the earlier iteration, some of which are in line with Asian viewpoints. The clinical applicability of the Rome IV criteria of irritable bowel syndrome (IBS) in Asian perspective is reviewed here. Instead of considering functional gastrointestinal disorders (FGIDs) to be largely psychogenic, Rome IV suggested the importance of the gut over brain (“disorders of gut-brain interaction” not “brain-gut interaction”). The word “functional” is underplayed. Multi-dimensional clinical profile attempts to recognize micro-organic nature, like slow colon transit and fecal evacuation disorders in constipation and dietary intolerance including that of lactose and fructose, bile acid malabsorption, non-celiac wheat sensitivity, small intestinal bacterial overgrowth, and gastrointestinal infection in diarrhea. Overlap between different FGIDs has been recognized as Rome IV suggests these to be a spectrum rather than discrete disorders. Bloating, common in Asia, received attention, though less. Sub-typing of IBS may be more clinician-friendly now as the patient-reported stool form may be used than a diary. However, a few issues, peculiar to Asia, need consideration; Rome IV, like Rome III, suggests that Bristol type I–II stool to denote constipation though Asian experts include type III as well. Work-up for physiological factors should be given greater importance. Language issue is important. Bloating, common in IBS, should be listed in the criteria. Threshold values for symptoms in Rome IV criteria are based on Western data. Post-infectious malabsorption (tropical sprue) should be excluded to diagnose post-infectious IBS, particularly in Asia.

The global prevalence of IBS in adults remains elusive due to the heterogeneity of studies: a Rome Foundation working team literature review

OBJECTIVES

The global prevalence of IBS is difficult to ascertain, particularly in light of the heterogeneity of published epidemiological studies. The aim was to conduct a literature review, by experts from around the world, of community-based studies on IBS prevalence.

DESIGN

Searches were conducted using predetermined search terms and eligibility criteria, including papers in all languages. Pooled prevalence rates were calculated by combining separate population survey prevalence estimates to generate an overall combined meta-prevalence estimate. The heterogeneity of studies was assessed.

RESULTS

1451 papers were returned and 83, including 288 103 participants in 41 countries, met inclusion criteria. The mean prevalence among individual countries ranged from 1.1% in France and Iran to 35.5% in Mexico. There was significant variance in pooled regional prevalence rates ranging from 17.5% (95% CI 16.9% to 18.2%) in Latin America, 9.6% (9.5% to 9.8%) in Asia, 7.1% (8.0% to 8.3%) in North America/Europe/Australia/New Zealand, to 5.8% (5.6% to 6.0%) in the Middle East and Africa. There was a significant degree of heterogeneity with the percentage of residual variation due to heterogeneity at 99.9%.

CONCLUSIONS

The main finding is the extent of methodological variance in the studies reviewed and the degree of heterogeneity among them. Based on this, we concluded that publication of a single pooled global prevalence rate, which is easily calculated, would not be appropriate or contributory. Furthermore, we believe that future studies should focus on regional and cross-cultural differences that are more likely to shed light on pathophysiology.

Endoscopy-Guided Evaluation of Duodenal Mucosal Permeability in Functional Dyspepsia

OBJECTIVES

The pathophysiology of functional dyspepsia (FD) is not fully understood. Impaired duodenal mucosal integrity characterized by increased mucosal permeability and/or low-grade inflammation was reported as potentially important etiologies. We aimed to determine the utility of a recently developed simple catheterization method to measure mucosal admittance (MA), the inverse of mucosal impedance, for evaluation of duodenal mucosal permeability in patients with FD.

METHODS

We conducted two prospective studies. In the first study, duodenal MA of 23 subjects was determined by catheterization during upper endoscopy, and transepithelial electrical resistance (TEER) of duodenal biopsy samples in Ussing chambers was measured to assess the correlation between MA and TEER. In the second study, duodenal MA of 21 patients with FD fulfilling the Rome III criteria was compared with that of 23 healthy subjects.

RESULTS

The mean MA and TEER values were 367.5±134.7 and 24.5±3.7 Ω cm2, respectively. There was a significant negative correlation between MA and TEER (r=-0.67, P=0.0004, Pearson's correlation coefficient). The mean MA in patients with FD was significantly higher than that in healthy subjects (455.7±137.3 vs. 352.1±66.9, P=0.002, unpaired t-test). No procedure-related complications were present.

CONCLUSIONS

We demonstrated the presence of increased duodenal mucosal permeability in patients with FD by MA measurement using a simple catheterization method during upper endoscopy.

Type 2 Diabetes and Comorbid Symptoms of Depression and Anxiety: Longitudinal Associations With Mortality Risk

OBJECTIVE

Depression is strongly linked to increased mortality in individuals with type 2 diabetes. Despite high rates of co-occurring anxiety and depression, the risk of death associated with comorbid anxiety in individuals with type 2 diabetes is poorly understood. This study documented the excess mortality risk associated with symptoms of depression and/or anxiety comorbid with type 2 diabetes.

RESEARCH DESIGN AND METHODS

Using data for 64,177 Norwegian adults from the second wave of the Nord-Trøndelag Health Study (HUNT2), with linkage to the Norwegian Causes of Death Registry, we assessed all-cause mortality from survey participation in 1995 through to 2013. We used Cox proportional hazards models to examine mortality risk over 18 years associated with type 2 diabetes status and the presence of comorbid affective symptoms at baseline.

RESULTS

Three clear patterns emerged from our findings. First, mortality risk in individuals with diabetes increased in the presence of depression or anxiety, or both. Second, mortality risk was lowest for symptoms of anxiety, higher for comorbid depression-anxiety, and highest for depression. Lastly, excess mortality risk associated with depression and anxiety was observed in men with diabetes but not in women. The highest risk of death was observed in men with diabetes and symptoms of depression only (hazard ratio 3.47, 95% CI 1.96, 6.14).

CONCLUSIONS

This study provides evidence that symptoms of anxiety affect mortality risk in individuals with type 2 diabetes independently of symptoms of depression, in addition to attenuating the relationship between depressive symptoms and mortality in these individuals.

Frequency and risk factors of functional gastro-intestinal disorders in a rural Indian population

BACKGROUND AND AIM

As best estimates on functional gastrointestinal disorders (FGIDs) prevalence are expected from community studies, which are scanty from Asia, we evaluated the prevalence and risk factors of FGIDs in a rural Indian community.

METHODS

House-to-house survey was undertaken by trained interviewers using translated-validated Rome III and hospital anxiety and depression questionnaires.

RESULT

Among 3426 subjects ≥ 18 years old from 3 villages in Uttar Pradesh, 84% participated, of whom 80% were finally analyzed. Of these 2774 subjects (age 38.4 ± 16.5 years, 1573 [56.7%] male), 2654 [95.7%] were vegetarian and 120 [4.3%] non-vegetarian. Socioeconomic classes were upper (16.7%), upper middle (15.1%), lower middle (22%), upper lower (22.2%), and lower (24%) using Prasad's Classification; 603 (21.7%) had FGIDs (413 [14.9%] dyspepsia, 75 [2.7%] irritable bowel syndrome (IBS) and 115 [4.1%] dyspepsia-IBS overlap), by Rome III criteria. In subjects with dyspepsia, 49/528 (9%) had epigastric pain, 141 (27%) postprandial distress syndromes (EPS, PDS) and 338 (64%) EPS-PDS overlap. IBS was more often diarrhea than constipation-predominant subtype. On univariate analysis, chewing tobacco, aerated drink, tea/coffee, disturbed sleep, vegetarianism, and anxiety parameters and presence of dyspepsia predicting occurrence of IBS were associated with FGIDs. On multivariate analysis, chewing tobacco, aerated soft drink, tea/coffee, vegetarianism, anxiety parameters, and presence of dyspepsia predicting IBS were significant.

CONCLUSION

Functional gastrointestinal disorders, particularly dyspepsia-IBS overlap, are common in rural Indian population; the risk factors included chewing tobacco, aerated soft drink, tea/coffee, vegetarian diet, disturbed sleep, anxiety, and dyspepsia predicting occurrence of IBS.

Epidemiology and risk factors of uninvestigated dyspepsia, irritable bowel syndrome, and gastroesophageal reflux disease among students of Damascus University, Syria

Uninvestigated dyspepsia (UD), irritable bowel syndrome (IBS), and gastroesophageal reflux disease (GERD) are common disorders universally. Many studies have assessed their epidemiological characteristics around the world. However, such information is not known for Syria. We aim to estimate the epidemiologic characteristics and possible risk factors for UD, IBS, and GERD among students at Damascus University, Damascus, Syria. A cross-sectional study was conducted in July-September 2015 at a campus of Damascus University. A total of 320 students were randomly asked to complete the survey. We used ROME III criteria to define UD and IBS, and Montreal definition for GERD. In total, 302 valid participants were included in the analysis. Prevalence for UD, IBS, and GERD was 25%, 17%, and 16%, respectively. Symptom overlap was present in 46 students (15%), with UD+IBS in 28 (9.3%), UD+GERD in 26 (8.6%), and IBS+GERD in 14 (4.6%) students. Eleven (3.6%) students had symptoms of UD+IBS+GERD. Each of these overlaps occurred more frequently than expected by chance. Significant risk factors included cigarettes smoking, waterpipe consumption, and body mass index <18.5kg/m² for UD; female gender and three cups of coffee/d for IBS; and two cups of tea and one to five cigarettes/d for GERD. Risk factors for these disorders remain poorly characterized and need further investigations.

The overlap of upper functional gastrointestinal disorders with irritable bowel syndrome in Chinese outpatients: A multicenter study

BACKGROUND AND AIM

Irritable bowel syndrome (IBS) is a common functional bowel disease, and the overlap with upper functional gastrointestinal disorders (FGIDs) is popular. However, the coexistent upper GI symptom profiles, upper FGID spectra, and related risk factors among IBS subjects remain unclear in mainland of China.

METHODS

Consecutive patients from the outpatient gastroenterology clinics of three tertiary hospitals in China were enrolled in this multicenter study. All upper GI symptoms occurring at least once a week in the last 3 months were recorded. Diagnostic criteria of functional esophageal, gastroduodenal disorders and IBS were based on Rome III criteria. Risk factors were assessed using a multivariate logistic regression model.

RESULTS

Of the 8906 consecutive patients, 751 patients met Rome III criteria for IBS and 735 IBS patients participated in the interview. Postprandial fullness (30.6%), belching (27.1%), and regurgitation (21.8%) were the three most prevalent upper GI symptoms in IBS. Functional dyspepsia (FD, 36.7%), belching disorders (27.1%), and functional heartburn (16.3%) were the three most frequent upper FGID in IBS patients. Female sex, divorced or widowed versus married status, defecation straining, reduced bowel movement, mixed IBS, abdominal distention, mild abdominal pain, moderate discomfort were positively associated with IBS-FD overlap. Female sex, drinking, moderate discomfort, and mild to moderate distension were independent risk factors for IBS-belching disorder overlap.

CONCLUSIONS

The study provides detailed overlap spectra of upper FGID with IBS. Mixed IBS is an important risk factor for IBS-FD overlap, which deserved more concern.

Zero-Inflated Models for Identifying Relationships Between Body Mass Index and Gastroesophageal Reflux Symptoms: A Nationwide Population-Based Study in China

BACKGROUND AND AIM

That obesity leads to gastroesophageal reflux is a widespread notion. However, scientific evidence for this association is limited, with no rigorous epidemiological approach conducted to address this question. This study examined the relationship between body mass index (BMI) and gastroesophageal reflux symptoms in a large population-representative sample from China.

METHODS

We performed a cross-sectional study in an age- and gender-stratified random sample of the population of five central regions in China. Participants aged 18-80 years completed a general information questionnaire and a Chinese version of the Reflux Disease Questionnaire. The zero-inflated Poisson regression model estimated the relationship between body mass index and gastroesophageal reflux symptoms.

RESULTS

Overall, 16,091 (89.4 %) of the 18,000 eligible participants responded. 638 (3.97 %) and 1738 (10.81 %) experienced at least weekly heartburn and weekly acid regurgitation, respectively. After adjusting for potential risk factors in the zero-inflated part, the frequency [odds ratio (OR) 0.66, 95 % confidence interval (95 % CI) 0.50-0.86, p = 0.002] and severity (OR 0.66, 95 % CI 0.50-088, p = 0.004) of heartburn in obese participants were statistically significant compared to those in normal participants. In the Poisson part, the frequency of acid regurgitation, overweight (OR 1.10, 95 % CI 1.01-1.21, p = 0.038) and obesity (OR 1.19, 95 % CI 1.04-1.37, p = 0.013) were statistically significant. BMI was strongly and positively related to the frequency and severity of gastroesophageal reflux symptoms. Additionally, gender exerted strong specific effects on the relationship between BMI and gastroesophageal reflux symptoms.

CONCLUSIONS

The severity and frequency of heartburn were positively correlated with obesity. This relationship was presented distinct in male participants only.

Functional dyspepsia: new insights into pathogenesis and therapy

One in 10 people suffer from functional dyspepsia (FD), a clinical syndrome comprising chronic bothersome early satiety, or postprandial fullness, or epigastric pain or burning. Postprandial distress syndrome (PDS, comprising early satiety and/or postprandial fullness) and epigastric pain syndrome (EPS) are increasingly accepted as valid clinical entities, based on new insights into the pathophysiology and the results of clinical trials. Diagnosis is based on the clinical history, and exclusion of peptic ulcer and cancer by endoscopy. Evidence is accumulating FD and gastroesophageal ref lux disease are part of the same disease spectrum in a major subset. The causes of FD remain to be established, but accumulating data suggest infections and possibly food may play an important role in subsets. FD does not equate with no pathology; duodenal eosinophilia is now an accepted association, and Helicobacter pylori infection is considered to be causally linked to dyspepsia although only a minority will respond to eradication. In those with EPS, acid suppression therapy is a first line therapy; consider a H2 blocker even if proton pump inhibitor fails. In PDS, a prokinetic is preferred. Second line therapy includes administration of a tricyclic antidepressant in low doses, or mirtazapine, but not a selective serotonin reuptake inhibitor.

Clinical and epidemiological differences in functional dyspepsia between the East and the West

BACKGROUND

Functional dyspepsia (FD) is a common condition, affecting adults in both Western (North America and Europe) and Eastern (Asian) parts of the globe. The prevalence has been reported to range from 5% to 40%, largely due to variation from definition criteria and geographical location. Recent published reports in Western and Eastern populations separately indicate that differences in the epidemiology and clinical patterns of FD may exist. Such differences will have implications for the clinical management of and healthcare strategizing for FD at the local level.

PURPOSE

This review aims to examine the prevalence and clinical patterns of FD in specific groups, namely Western and Eastern populations, based on the Rome criteria. Further differences in the epidemiological associations of FD will be explored between population-based studies in both the East and the West. Finally, the socio-economic consequences of FD, an important measure of the impact of the disease, will be compared between the East and the West.

Gastroesophageal Reflux Disease: Cross-Sectional Study Demonstrating Rising Prevalence in a Chinese Population

BACKGROUND AND AIMS

The prevalence of gastroesophageal reflux disease (GERD) is consistently lower in the Chinese than in white populations. Population-based data tracking the time trend of GERD prevalence in Chinese subjects is conflicting. This study examines the population prevalence, risk factors, and time trend associated with GERD in a Chinese population.

METHODS

A population-based cross-sectional study utilizing a validated GERD questionnaire administered by a telephone survey was performed on 3360 Chinese subjects from Hong Kong. GERD prevalence rates in 2011 were compared with prevalence rates in 2002 and 2006. Multiple logistic regressions were performed to determine the risk factors associated with weekly GERD.

RESULTS

A total of 2074 subjects (mean age, 48.1±18.2 y; range 18 to 94; 63.1% female) completed the survey (response rate 61.7%). The prevalence of GERD as defined by the Montreal definition was 3.8%. The prevalence of weekly GERD had increased by 1.3% between 2002 and 2011, which represents an at least 50% relative increase (P<0.0005). A diagnosis of weekly GERD was associated with noncardiac chest pain [odds ratio (OR), 1.7; 95% confidence interval (CI), 1.034-2.9; P=0.037], dyspepsia (OR, 5.1; 95% CI, 3.0-8.8; P<0.005), and an acid feeling in the stomach (OR, 3.0; 95% CI, 1.8-5.1).

CONCLUSIONS

GERD rates in the ethnic Chinese have risen over the last decade. Despite this, variables associated with a survey diagnosis of GERD remain ostensibly unchanged. GERD research in East Asia should focus on the factors driving the rapid rise in prevalence rates and the association with more atypical symptoms of GERD.

Barriers and enablers to healthcare access and use among Arabic-speaking and Caucasian English-speaking patients with type 2 diabetes mellitus: a qualitative comparative study

OBJECTIVE

The objective of this study was to explore the decision-making processes and associated barriers and enablers that determine access and use of healthcare services in Arabic-speaking and English-speaking Caucasian patients with diabetes in Australia.

STUDY SETTING AND DESIGN

Face-to-face semistructured individual interviews and group interviews were conducted at various healthcare settings-diabetes outpatient clinics in 2 tertiary referral hospitals, 6 primary care practices and 10 community centres in Melbourne, Australia.

PARTICIPANTS

A total of 100 participants with type 2 diabetes mellitus were recruited into 2 groups: 60 Arabic-speaking and 40 English-speaking Caucasian.

DATA COLLECTION

Interviews were audio-taped, translated into English when necessary, transcribed and coded thematically. Sociodemographic and clinical information was gathered using a self-completed questionnaire and medical records.

PRINCIPAL FINDINGS

Only Arabic-speaking migrants intentionally delayed access to healthcare services when obvious signs of diabetes were experienced, missing opportunities to detect diabetes at an early stage. Four major barriers and enablers to healthcare access and use were identified: influence of significant other(s), unique sociocultural and religious beliefs, experiences with healthcare providers and lack of knowledge about healthcare services. Compared with Arabic-speaking migrants, English-speaking participants had no reluctance to access and use medical services when signs of ill-health appeared; their treatment-seeking behaviours were straightforward.

CONCLUSIONS

Arabic-speaking migrants appear to intentionally delay access to medical services even when symptomatic. Four barriers to health services access have been identified. Tailored interventions must be developed for Arabic-speaking migrants to improve access to available health services, facilitate timely diagnosis of diabetes and ultimately to improve glycaemic control.

Ethnic Differences in Separate and Additive Effects of Anxiety and Depression on Self-rated Mental Health Among Blacks

AIM

The aim of this study was to explore ethnic differences in the separate and additive effects of anxiety and depression on self-rated mental health (SRMH) of Blacks in the USA.

METHODS

With a cross-sectional design, we used data from a national household probability sample of African Americans (n = 3570) and Caribbean Blacks (n = 1621) who participated in the National Survey of American Life, 2001-2003. Demographic factors, socio-economic factors, 12-month general anxiety disorder (GAD) and major depressive disorder (MDD), and current SRMH were measured. In each ethnic group, three logistic regressions were used to assess the effects of GAD, MDD, and their combinations on SRMH.

RESULTS

Among African Americans, GAD and MDD had separate effects on SRMH. Among Caribbean Blacks, only MDD but not GAD had separate effect on SRMH. Among African Americans, when the combined effects of GAD and MDD were tested, GAD but not MDD was associated with SRMH.

CONCLUSION

The separate and additive effects of GAD and MDD on SRMH among Blacks depend on ethnicity. Although single-item SRMH measures are easy methods for the screening of mental health need, community-based programs that aim to meet the need for mental health services among Blacks in the USA should consider within-race ethnic differences in the applicability of such instruments.

Fecal Calprotectin and serum chromogranin A as potential biomarkers of irritable bowel syndrome symptom severity

Irritable bowel syndrome (IBS) is a disorder of the lower gastrointestinal (GI) tract, which manifests as abdominal pain and/or discomfort accompanied by altered bowel function, in the absence of structural pathology. The onset and precipitation of IBS is the result of an interaction among several factors, including psychological distress, altered GI sensation and processing of sensory information as well as GI inflammation. These factors have varying contributions to disorder etiology in different patients, and in line with that, there is now emerging evidence about a low-grade inflammation in a subgroup of IBS patients. Because IBS diagnosis is based on the ROME III criteria, with the exclusion of structural pathology, patients are often exposed to numerous invasive and unpleasant tests. In order to decrease the cost of repeated testing, while simultaneously alleviating patients' anxiety, research should be aimed at detecting cost-effective biomarkers. We hypothesize chromogranin A (CgA) and fecal Calprotectin (FC) could be used to eliminate possible organic causes of IBS symptoms. Also, we hypothesize FC could be helpful in detecting IBS patients with low-grade inflammation. Forty-eight outpatients with IBS (76% females) completed a set of psychosocial measures (HRQoL, STAI, BDI, VSI, SF-36), and their FC and CgA levels were obtained. We found elevated CgA levels in 4 patients, but CgA levels were not related to any of the psychological measures used. Elevated FC levels were found in 12 patients. FC levels significantly correlated with the physical component of health related quality of life (HRQoL) (r48=-.42, p<.01). In addition, one-way ANOVA's were performed to test possible differences in psychosocial measures depending on the patient's FC status. The analysis showed only one significant difference. Patients with the highest levels of FC had significantly lower physical component of HRQoL compared to the other two groups of patients.

Global prevalence of, and risk factors for, uninvestigated dyspepsia: a meta-analysis

OBJECTIVES

Many cross-sectional surveys have reported the prevalence of uninvestigated dyspepsia, but there has been no recent systematic review of data from all studies to determine its global prevalence and risk factors.

DESIGN

MEDLINE, EMBASE and EMBASE Classic were searched (until January 2014) to identify population-based studies that reported the prevalence of uninvestigated dyspepsia in adults (≥ 15 years old); dyspepsia was defined using symptom-based criteria or questionnaires. The prevalence of dyspepsia was extracted for all studies and according to the criteria used to define it. Pooled prevalence, according to study location and certain other characteristics, ORs and 95% CIs were calculated.

RESULTS

Of the 306 citations evaluated, 103 reported the prevalence of uninvestigated dyspepsia in 100 separate study populations, containing 312,415 subjects. Overall pooled prevalence in all studies was 20.8% (95% CI 17.8% to 23.9%). The prevalence varied according to country (from 1.8% to 57.0%) and criteria used to define dyspepsia. The greatest prevalence values were found when a broad definition of dyspepsia (29.5%; 95% CI 25.3% to 33.8%) or upper abdominal or epigastric pain or discomfort (20.4%; 95% CI 16.3% to 24.8%) were used. The prevalence was higher in women (OR 1.24; 95% CI 1.13 to 1.36), smokers (OR 1.25; 95% CI 1.12 to 1.40), non-steroidal anti-inflammatory drug (NSAID) users (OR 1.59; 95% CI 1.27 to 1.99) and Helicobacter pylori-positive individuals (OR 1.18; 95% CI 1.04 to 1.33).

CONCLUSIONS

The overall pooled prevalence of uninvestigated dyspepsia was 21%, but varied among countries and according to the criteria used to define its presence. Prevalence is significantly higher in women, smokers, NSAID users and H. pylori-positive individuals, although these associations were modest.

Systematic review with meta-analysis: post-infectious irritable bowel syndrome after travellers' diarrhoea

BACKGROUND

Gastrointestinal infection is known as a risk factor for the development of the irritable bowel syndrome (post-infectious irritable bowel syndrome, PI-IBS). The incidence of PI-IBS ranges between 3% and over 30% of people after infectious gastroenteritis.

AIM

To perform a meta-analysis pools and report data concerning the relative risk (RR) of PI-IBS after TD.

METHODS

Database search using Medline through PubMed, Scopus, EBM Reviews (Cochrane Database of Systematic Reviews) and PsycINFO was performed to identify relevant studies. Those that met the inclusion criteria were pooled. A random effects model (Mantel-Haenszel) was performed.

RESULTS

Six eligible studies were found. In three of six studies, the authors reported a statistically significant association of TD and PI-IBS. The pooled RR was 3.35 (95% CI: 2.22-5.05) with a significant overall effect (P < 0.00001). Overall PI-IBS incidence was 5.4% in TD subjects and 1.4% in healthy subjects. There was no significant heterogeneity within the pooled studies (I(2)  = 5%). Self-reported TD alone resulted in an over 1.5-fold RR for PI-IBS compared to laboratory-confirmed TD [RR 3.90 (95% CI: 2.35-6.49) vs. RR 2.42 (95% CI: 1.22-4.78)].

CONCLUSIONS

There is a strong association between travellers' diarrhoea and post-infectious irritable bowel syndrome. Self-reports of exposure seem to result in a higher post-infectious irritable bowel syndrome occurrence than laboratory-confirmed cases of travellers' diarrhoea, but further studies are needed to confirm this finding. Finally, potential influences of the selection of an appropriate study population on post-infectious irritable bowel syndrome epidemiology are discussed.

Development, Translation and Validation of Enhanced Asian Rome III Questionnaires for Diagnosis of Functional Bowel Diseases in Major Asian Languages: A Rome Foundation-Asian Neurogastroenterology and Motility Association Working Team Report

BACKGROUND/AIMS

The development-processes by regional socio-cultural adaptation of an Enhanced Asian Rome III questionnaire (EAR3Q), a cultural adaptation of the Rome III diagnostic questionnaire (R3DQ), and its translation-validation in Asian languages are presented. As English is not the first language for most Asians, translation-validation of EAR3Q is essential. Hence, we aimed to culturally adapt the R3DQ to develop EAR3Q and linguistically validate it to show that the EAR3Q is able to allocate diagnosis according to Rome III criteria.

METHODS

After EAR3Q was developed by Asian experts by consensus, it was translated into Chinese, Hindi-Telugu, Indonesian, Korean and Thai, following Rome Foundation guidelines; these were then validated on native subjects (healthy [n = 60], and patients with irritable bowel syndrome [n = 59], functional dyspepsia [n = 53] and functional constipation [n = 61]) diagnosed by clinicians using Rome III criteria, negative alarm features and investigations.

RESULTS

Experts noted words for constipation, bloating, fullness and heartburn, posed difficulty. The English back-translated questionnaires demonstrated concordance with the original EAR3Q. Sensitivity and specificity of the questionnaires were high enough to diagnose respective functional gastrointestinal disorders (gold standard: clinical diagnoses) in most except Korean and Indonesian languages. Questionnaires often uncovered overlapping functional gastrointestinal disorders. Test-retest agreement (kappa) values of the translated questionnaires were high (0.700-1.000) except in Korean (0.300-0.500) and Indonesian (0.100-0.400) languages at the initial and 2-week follow-up visit.

CONCLUSIONS

Though Chinese, Hindi and Telugu translations were performed well, Korean and Indonesian versions were not. Questionnaires often uncovered overlapping FGIDs, which were quite common.