Systematic review with meta-analysis: prompt endoscopy as the initial management strategy for uninvestigated dyspepsia in Asia

Health economics evaluation of diagnostic strategies for gastro-oesophageal reflux disease with reflux symptoms in China: a modelling study

OBJECTIVES

American College of Gastroenterology (ACG) and Chinese expert consensus recommended different algorithmic approaches for the diagnosis of gastro-oesophageal reflux disease (GERD) are not yet defined. We compared the two recommended diagnostic processes using a Chinese population-based health economics analysis.

METHODS

Our analysis considered a hypothetical cohort of patients with typical reflux symptoms. We constructed a decision tree model to compare the two recommended diagnostic processes described in ACG clinical guidelines (stratified endoscopy strategy) and Chinese expert consensus (endoscopy-first strategy). The first strategy begins with hazard stratification based on alarm symptoms. Patients with alarm symptoms directly undergo endoscopic examination, while patients without alarm symptoms receive proton pump inhibitors as diagnostic treatment. In the second strategy, all patients with reflux symptoms complete an endoscopic examination. Sensitivity analysis was performed to evaluate a range of cost and probability estimates on costs and health outcomes over a 1-year time horizon from the healthcare system perspective.

RESULTS

The total expected costs were US$122.51 for the stratified endoscopy strategy and US$150.12 for the endoscopy-first strategy. The incremental cost-effectiveness ratio (ICER) comparing the endoscopy-first strategy with the stratified endoscopy strategy was US$440.39 per additional correct case of GERD. The rates of detecting upper gastrointestinal carcinoma of the two strategies were 0.0088 and 0.0120, and the ICER was US$8561.34.

CONCLUSIONS

The use of endoscopy for all patients with reflux symptoms was more effective but with an increased cost compared with the strategy recommended in international guidelines.

Prevalence and factors associated with organic dyspepsia in older adults with dyspepsia

This study aimed to report findings from EGD investigations in older adults with dyspepsia and identify factors associated with organic dyspepsia in this population. We conducted a retrospective cross-sectional study at a tertiary care center in Northern Thailand. Medical records of adults aged 50 years and older presenting with dyspepsia who underwent initial EGD between January 2018 and December 2022 were reviewed. Organic dyspepsia includes erosive esophagitis, ulcer, mass, and cancerous lesions. Multivariable logistic regression was used to identify factors associated with organic dyspepsia. Data from 466 patients were analyzed. Functional dyspepsia was the predominant diagnosis (94.0%), while organic dyspepsia was diagnosed in 6.0% of patients. Gastric/duodenal ulcer, erosive esophagitis, and gastric malignancy accounted for 1.9%, 1.7%, and 1.1% of cases, respectively. After adjustment for covariates, a low body mass index (BMI of less than 18.5 kg/m2) and male gender significantly increased the likelihood of organic dyspepsia, with an adjusted odds ratio (OR) of 4.34; 95% CI 1.45-12.09, p=0.009 and adjusted OR of 2.64; 95% CI 1.13-6.17, p=0.024, respectively. There were no significant associations found between other factors and organic dyspepsia, including age, smoking, alcohol use, symptom duration, H. pylori infection, and NSAID use.

Participation and Yield of Gastric Cancer Screening Programs: A Systematic Review and Meta-analysis

BACKGROUND & AIMS

Hundreds of gastric cancer (GC) screening programs have been launched worldwide over the past 3 decades. However, no comprehensive study evaluating the outcomes of these programs has been conducted.

METHODS

This meta-analysis aimed to evaluate the temporal and geographical patterns of three key indicators in GC screening programs: endoscopic uptake rate (EUR), GC detection rate (GCDR), and early GC detection rate (EGCDR). The search was conducted until September 20, 2023. Pooled random-effect estimates of the indicators were computed, with further subgroup analysis stratified by study period, country, screening setting, local GC age-standardized incidence, and pre-screening modality.

RESULTS

A total of 67 studies were included in the analysis. Of these, 42 reported an EUR of 46% (95% confidence interval [CI], 41%-52%), 47 reported a GCDR of 0.76% (95% CI, 0.55%-0.96%), and 27 reported an EGCDR of 59% (95% CI, 49%-70%). Developed countries demonstrated notably superior performance in EUR (51% vs 37%; P = .009) and EGCDR (78% vs 44%; P < .001) compared with developing countries. A gradual increase in the EUR was found, rising from 46% pre-2010 to 48% post-2010 (P = .739). In contrast, both GCDR and EGCDR exhibited a slight decline, with GCDR decreasing from 0.78% pre-2010 to 0.75% post-2010 (P = .905), and EGCDR from 65% pre-2010 to 56% post-2010 (P = .404). Multivariate meta-regression analysis revealed that a higher local GC incidence and studies conducted in Japan were independently associated with higher values of both EUR (P = .010 and P = .027, respectively) and EGCDR (P = .008 and P = .002).

CONCLUSIONS

The participation and yield of GC screening programs were comprehensively assessed using 3 indicators proposed in this study.

Alarm symptoms and the risk of upper gastrointestinal cancer in patients below the age of 60

BACKGROUND AND STUDY AIM

Current guidelines recommend against routine Upper gastrointestinal (GI) endoscopy in patients under 60 with alarm symptoms due to the perceived low risk of malignancy. This study aimed to evaluate the diagnostic yield of upper GI endoscopy in patients under 60 years presenting with alarm symptoms and to compare these findings with a cohort of patients with dyspepsia without alarm symptoms.

METHODS

We analyzed data from a multicenter endoscopy database. We included and compared all upper GI endoscopy patients under 60 with alarm symptoms to patients with only dyspepsia under 60. The primary outcomes were major endoscopic findings, including GI cancer, ulcers, strictures, and severe esophagitis. Logistic regression assessed the association between alarm symptoms and outcomes.

RESULTS

A total of 7209 patients with alarm symptoms and 13,978 with dyspepsia were included. The prevalence of major endoscopic findings was significantly higher in the alarm symptoms cohort (9.5 % vs. 3.7 %, P < 0.001), with a higher incidence of GI cancer (1.7 % vs. 0.3 %, P < 0.001). Dysphagia, unintentional weight loss, and persistent vomiting were significantly associated with cancer, while dysphagia and gastrointestinal bleeding were significantly associated with major endoscopic findings.

CONCLUSIONS

Our findings question current guideline recommendations and show a significantly increased yield of major endoscopic findings, including malignancy, in patients under 60 with alarm symptoms.

Spectrum of Upper Gastrointestinal Diseases in Patients Presenting with Dyspepsia-A First Report from Myanmar

Background

Dyspepsia is associated with a variety of benign and malignant gastrointestinal diseases. The aim of the study was to evaluate the spectrum of upper gastrointestinal endoscopic findings in patients presenting with dyspepsia.

Methods

This is a retrospective study on consecutive patients with dyspepsia undergoing upper gastrointestinal endoscopy at the gastroenterology department of Thingangyun General Hospital, University of Medicine 2, Yangon, from January 1, 2017, to December 31, 2019.

Results

In this study, 1650 patients were recruited retrospectively. Forty-nine patients were excluded due to incomplete data entry. There were 883 female (55%) out of 1601 patients. The mean age was 50.5 ± 15.82 years. The endoscopic findings were gastric/duodenal erosion (10.8%), erosive esophagitis (5.1%), duodenal ulcer (3.5%), gastric ulcer (4.4%), gastroesophageal varices (3.49%), esophageal cancer (0.8%), and gastric cancer (5.3%); in which early-onset gastric cancer contributed for 17.6%. Miscellaneous diagnoses were 4.2%, and findings were normal at 62.5%. Significant endoscopy findings were diagnosed in patients over 45 years of age. Helicobacter pylori infection was found in 40.6% of the total study population, 52% of gastric cancers, 50% of gastric ulcers, 51.2% of duodenal ulcers, and 49.3% of gastric/duodenal erosions.

Conclusion

Significant endoscopic findings in dyspeptic patients are frequent in our data. A considerable number of gastric cancer were diagnosed in patients under 45 years of age. H. pylori is prevalent in our dyspepsia population. The age threshold of 40-45 years for both males and females could be reasonable for the use of endoscopy in patients with dyspepsia in our population.

Epidemiology of Disorders of the Gut-Brain Interaction: An Appraisal of the Rome IV Criteria and Beyond

Disorders of the gut-brain interaction (DGBIs) are presently classified into mutually exclusive anatomical area-related symptom-based categories according to the Rome IV criteria. The pathophysiology of visceral nociception, which contributes to the wide range of symptoms of DGBIs, involves complex psychobiological processes arising from the bidirectional interactions of multiple systems at the gut and brain levels, which affect symptom expression and illness behaviors. The attitude toward an illness and expression of pain and bowel habit vary across cultures with variable interpretation based on sociocultural beliefs, which may not tally with the medical definitions. Thus, psychological factors impact DGBI definitions, their severity and health care utilization. Due to the poor localization and multisegment referral of visceral pain, the anatomical site of pain may not correspond to the affected segment, and there may be a variable degree of overlap among symptoms. The somewhat restrictively defined Rome IV criteria assume one-to-one correlation of symptoms with underlying pathophysiology and ignore overlapping DGBIs, nonstandardized symptom categories, and change or shift in category over time. The microorganic nature of DGBIs resulting from systemic, metabolic or motility disorders, gut dysbiosis and inflammation are not addressed in the Rome IV criteria. Although there is a multidimensional clinical profile that does address these factors, it is not followed rigorously in practice. Threshold changes for diagnostic criteria or addition/deletion of symptoms leads to wide variation among different DGBI criteria resulting in uncertain comparability of results. Although the Rome IV criteria are excellent for research studies and therapeutic trials in homogenous populations, further improvement is needed for their wider applicability in clinical practice.

Diagnostic yield of upper gastrointestinal endoscopy in patients attending a UK centre with symptoms compatible with Rome IV functional dyspepsia

Background

Dyspeptic symptoms are common and mainly due to functional dyspepsia (FD). The Rome IV criteria mandate a normal upper gastrointestinal (UGI) endoscopy before diagnosing FD. However, endoscopies are costly, resource-intensive procedures that generate substantial waste. Hence, simpler means of diagnosing FD are desirable.

Objectives

To determine what proportion of UGI endoscopies are represented by patients with symptoms compatible with Rome IV FD, and the diagnostic yield in this cohort stratified according to alarm features.

Methods

Adult patients attending a UK centre for outpatient UGI endoscopy completed a preprocedure questionnaire on demographics, medical history, alarm features, mood, somatisation and GI symptoms. Alarm features were defined as age ≥55 years, dysphagia, anaemia, unintentional weight loss, UGI bleed or a family history of UGI cancer. Clinically significant endoscopic findings were cancers, Barrett's oesophagus, erosive oesophagitis, peptic ulcers or strictures.

Results

Of 387 patients attending for an outpatient non-surveillance diagnostic UGI endoscopy, 221 had symptoms compatible with FD whereas 166 did not. Approximately 80% in both groups had alarm features, with a similar prevalence of clinically significant endoscopic findings at ~10%. UGI endoscopy was normal in a cohort of 9% (n=35) with symptoms compatible with FD and no alarm features, while benign peptic ulcer was noted in two of 29 cases without FD symptoms and no alarm features.

Conclusion

1-in-10 UGI endoscopies are performed in patients with symptoms compatible with FD and no alarm features, in whom there is no diagnostic yield. We recommend such patients receive a positive diagnosis of FD without endoscopy.

Dyspepsia with alarm symptoms in patients aged less than 60 years: Is upper gastrointestinal endoscopy justified in Indian scenario?

BACKGROUND

Newer American College of Gastroenterology (ACG) and Canadian Association of Gastroenterology (CAG) guidelines do not suggest endoscopy to investigate alarm features for dyspepsia patients under the age of 60 to exclude upper gastrointestinal (GI) neoplasia. The validity of this recommendation has not been evaluated in our population. So, this study was conducted to assess the utility of upper GI endoscopy to investigate alarm features in dyspepsia patients less than 60 years of age to exclude upper GI neoplasia.

METHODS

This prospective observational study evaluated consecutive patients of dyspepsia between 18 and 60 years of age, with at least one or more of the alarm symptoms (unintentional weight loss; loss of appetite; GI bleeding; anemia; recurrent or persistent vomiting; dysphagia with predominant epigastric pain; and family history of upper GI cancer) with upper GI endoscopy to exclude any organic lesion and malignancy.

RESULTS

Of total 294 patients evaluated with endoscopy, 34.7% (n=102) had normal endoscopy (functional dyspepsia [FD]) while 65.3% (n=192) had abnormal endoscopic findings (organic dyspepsia [OD]). Of 192 patients with OD, 146 patients (49.6% of the total study population) had benign abnormality (benign OD) while 46 patients (15.6% of the total study population) had malignancy of the upper GI tract (malignant OD).

CONCLUSION

The investigation of alarm features in dyspepsia patients less than 60 years of age with upper GI endoscopy leads to detection of organic lesion (65.3%) including malignancy (15.6%) in a significant percentage of patients.

Seroreactivity against Helicobacter pylori VacA,50kDa and 30kDa along with alarm features may improve the diagnostic approach to uninvestigated dyspepsia: A pilot study

Background/Aim. Alarm features (AF) are of limited utility in predicting endoscopic findings, and the majority of patients with uninvestigated dyspepsia will have no organic pathology identified at upper gastrointestinal endoscopy. In our previous study, we highlighted seroreactivity against Helicobacter pylori (HP) antigens VacA, 50 kDa, and 30 kDa as biomarkers for gastric cancer, peptic ulcers, and functional dyspepsia. We designed and conducted this pi-lot study in order to compare the diagnostic utility of seroreactivity against HP VacA, 50 kDa, and 30 kDa with AF and investigate the possibility and adequacy of its synchronous application. Method. A careful history and physical examination with special attention to AF, esophagogastroduodenoscopy with biopsy, abdominal ultra-sound or computer tomography, complete blood count (CBC) and blood biochemistry, a Western Blot IgG against HP antigens VacA, 50 kDa, and 30 kDa, were per-formed in 123 patients with dyspepsia: 31 with gastric cancer, 31 with duodenal ulcer, 31 with gastric ulcer, and 30 with gastritis and functional dyspepsia. AF vs various combinations of seroreactivity against HP VacA, 50 kDa, and 30 kDa in patients with functional dyspepsia and others were analyzed in this study. Synchronous and alternative seroreactivity against VacA, 50 kDa, and 30 kDa, along with/without AF in patients with functional dyspepsia and other groups of patients were also analyzed. Results. VacA and 50 kDa seropositivity or AF had excellent case-findings clinical utility index for investigating dyspepsia. The absence of AF and seroreactivity against VacA either with: 50 kDa or 30 kDa seropositivity or 50 kDa and 30 kDa seropositivity had an excellent screening clinical utility index for investigating dyspepsia. Conclusion. Se-roreactivity against HP antigens VacA, 50 kDa, and 30 kDa might improve our approach to patients in investigating dyspepsia if used along with AF.

Age Cutoff and Yield of Prompt Esophagogastroduodenoscopy to Detect Malignancy in Vietnamese with Upper Gastrointestinal Symptoms: An Endoscopic Database Review of 472,744 Patients from 2014 to 2019

BACKGROUND AND AIMS

Age cutoff is an important factor in deciding whether esophagogastroduodenoscopy (EGD) is necessary for patients presenting with upper gastrointestinal symptoms. However, the cutoff value is significantly different across populations. We aimed to determine the age cutoff for EGD that assures a low rate of missing upper gastrointestinal malignancy (UGIM) and to assess the yield of prompt EGD in Vietnamese patients presenting with upper gastrointestinal symptoms.

METHODS

All EGDs performed in outpatients during a 6-year period (2014-2019) at a tertiary hospital that provided an open-access endoscopy service were retrospectively reviewed. Repeat or surveillance EGDs were excluded. Different age cutoffs were evaluated in terms of their prediction of the absence of UGIM. The yield of endoscopy to detect one malignancy (YoE) was also calculated.

RESULTS

Of 472,744 outpatients presenting with upper gastrointestinal symptoms, there were 2198 (0.4%) patients with UGIM. The median age and male-to-female ratio of patients with UGIMs were 57.9 ± 12.5 years and 2.5 : 1, respectively. The YoEs in patients <40, 40-60, and >60 years of age were <1, 1-10, and >10 per 1000 EGDs, respectively. The age cutoffs of 30 years in females and 35 years in males could detect 98.2% (95% CI: 97.7%-98.8%) of UGIM cases with a YoE of about 1 per 1000 EGDs.

CONCLUSIONS

The age cutoff for EGD in Vietnamese should be lower than that recommended by current international guidelines. The strategy of prompt EGD showed a low YoE, and its cost-effectiveness requires further investigation.

Functional gastrointestinal disorders. Overlap syndrome Clinical guidelines of the Russian Scientific Medical Society of Internal Medicine and Gastroenterological Scientific Society of Russia

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Value of age and alarm features for predicting upper gastrointestinal malignancy in patients with dyspepsia: an endoscopic database review of 4664 patients in Thailand

OBJECTIVE

Age and alarm features are commonly used as indicators for endoscopy in dyspeptic patients; however, the age cut-off and the predictive value of these parameters for identifying upper gastrointestinal (UGI) malignancies are uncertain.

DESIGN

Cross-sectional study.

SETTING

Data were extracted from the Gastrointestinal Endoscopy Centre of Siriraj Hospital, Thailand, during 2005-2011.

PARTICIPANTS

Consecutive patients underwent a first-time upper endoscopy for dyspepsia. Patients with previous surgery, suspected UGI malignancy by imaging, or indefinite biopsy results on prior examination were excluded.

MAIN OUTCOME MEASURES

Alarm features included dysphagia, unintentional weight loss, GI bleeding/anaemia, and persistent vomiting. The diagnostic performance of each alarm feature and different age cut-off values were evaluated.

RESULTS

A total of 4664 patients (mean age: 52.0±14.4 years, 66% female) were included. Alarm symptoms were presented in 21.6%. The prevalence of active Helicobacter pylori infection was 26.3%. Fifty-eight (1.2%) patients had UGI malignancy. The prevalence of malignancy significantly increased with increasing age (0.6% in patients aged <50 years, and 1.8% in patients aged >60 years (p<0.001)). Cancer was found in two patients aged <50 years who did not have alarm features. Patients with alarm features had a higher prevalence of malignancy (OR 22.3, 95% CI 10.5 to 47.4; p<0.001) than those without. The pooled sensitivity, specificity, positive predictive value and negative predictive value of alarm features for UGI malignancy were 87.0%, 79.1%, 4.7% and 99.8%, respectively. Among all age groups, persistent vomiting had a positive likelihood ratio (PLR) >10, while dysphagia and GI bleeding/anaemia had a PLR >10 in patients <50 years old.

CONCLUSION

Despite the overall limited value of age and alarm features, persistent vomiting, dysphagia, and GI bleeding/anaemia are strong predictors for malignancy in patients aged <50 years. Without these symptoms, cancer prevalence is negligible; thus, they are worthy guidance for endoscopic evaluation in this age group.

Sharing With Patients the Uncertainties Regarding the Management of Dyspepsia

Background: The management of patients with dyspepsia is uncertain. Some authors advocate endoscopy for all; others restrict endoscopy only to patients at high risk of gastric cancer, namely to those above an age threshold, or with a family history, dysphagia, loss of weight, anemia, or a childhood in Asian countries. Still others recommend various combinations between test-and-treat for Helicobacter pylori, anti-secretory treatment, and/or endoscopy.

Objective: To highlight the uncertainties in the choice between the various strategies and argue that these uncertainties should be shared with the patient.

Method: An overview of reported life expectancy, patient satisfaction, gastric cancer detection rates, symptom relief, and cost effectiveness of the management strategies for dyspepsia.

Main Findings: There are no randomized controlled trials of the effect of screening by endoscopy on mortality of patients with gastric cancer. Lower grades of evidence suggest that early diagnosis reduces this mortality. Analyses, which assume a survival benefit of early diagnosis, indicate that mass screening in countries of high incidence gastric cancer (> 10 cases per 100,000) and targeted screening of high-risk persons in countries of low-intermediate incidence (<10 cases per 100,000) is cost-effective at a willingness to pay of $20,000–50,000 per QALY. Prompt endoscopy appears to be best for patient satisfaction and gastric cancer detection, and test-and-treat for H pylori—for symptom relief and avoiding endoscopies.

Conclusions: The gain in life expectancy is the main source of uncertainty in the choice between management strategies. This choice should be shared with the patients after explaining uncertainties and eliciting their preferences.

Gastroscopy in younger patients: an analysis of referrals and pathologies

BACKGROUND AND AIM

Diagnostic guidelines for the investigation of dyspepsia for patients <50 years have been implemented. However, it is unsure whether these guidelines are used appropriately. We aimed to investigate the adherence to the national guidelines of uninvestigated dyspepsia and to examine the prevalence of upper gastrointestinal pathology in patients 18-50 years. We also aimed to detect any possible risk factors for pathology in esophagogastroduodenoscopy referrals and to evaluate differences between referrals from the hospital and primary health care.

METHOD

This is a retrospective review of medical records including patients who underwent esophagogastroduodenoscopy between January 2019 and April 2020 (n = 1809). Odds ratios (OR), positive predictive values (PPV), negative predictive values (NPV), chi-square and Mann-Whitney U-tests were applied.

RESULTS

In total 1708 patients were included, of whom 43.6% (n = 744) had a pathologic finding. Age group 41-50 years showed the highest prevalence with an OR 1.34 [95% confidence interval (CI), 1.07-1.69]. Helicobacter pylori testing was performed in 21.1% (n = 167) of patients with dyspepsia lacking alarm symptoms (n = 791). PPV and OR were generally low for a pathologic esophagogastroduodenoscopy. The absence of alarm symptoms showed a high NPV for significant pathology (98.7-99.6%). Significant pathology was almost exclusively found in hospital-based referrals.

CONCLUSIONS

Esophagogastroduodenoscopy is widely performed in young adults, often without significant findings. Adherence to the national guidelines was poor. No referral factors were associated with a significant risk for a pathologic finding. Esophagogastroduodenoscopy based on primary healthcare referrals demonstrated almost exclusively benign pathology. Significant pathology was only found via hospital-based referrals.

Epidemiological and clinical features of functional dyspepsia in a region with a high incidence of esophageal cancer in China

Background:

Functional dyspepsia (FD) has rarely been investigated in areas with a high prevalence of esophageal squamous cell carcinoma (ESCC). This study aims to reveal the epidemiological and clinical features of FD and organic dyspepsia (OD) in such a population.

Methods:

A middle-aged and elderly population-based study was conducted in a region with a high incidence of ESCC. All participants completed the Gastroesophageal Reflux Disease Questionnaire and Functional Gastrointestinal Disease Rome III Diagnostic Questionnaire, and they underwent gastroscopy. After exclusion of gastroesophageal reflux disease, uninvestigated dyspepsia (UID) was divided into OD and FD for further analyses.

Results:

A total of 2916 participants were enrolled from July 2013 to March 2014 in China. We detected 166 UID cases with questionnaires, in which 17 patients with OD and 149 with FD were diagnosed via gastroscopy. OD cases presented as reflux esophagitis (RE), ESCC, and duodenal ulcer. Heartburn (52.94%) and reflux (29.41%) were common in OD, but no symptomatic differences were found between FD and OD. Male sex, low education level, and liquid food were the risk factors for OD, while frequent fresh vegetable consumption was a protective factor. FD included 56 (37.58%) cases of postprandial distress syndrome (PDS), 52 (34.89%) of epigastric pain syndrome (EPS), nine (6.04%) of PDS + EPS, and 32 (21.48%) of FD + functional esophageal disorders. The Helicobacter pylori infection rate in FD patients was not higher than that in the control group (34.23% vs. 42.26%, P = 0.240). Frequent spicy food consumption was associated with PDS (odds ratio [OR]: 2.088, 95% confidence interval [CI]: 1.028–4.243), while consumption of deep well water was protective for PDS (OR: 0.431, 95% CI: 0.251–0.741).

Conclusions:

The prevalence of FD was 5.11% in the studied population. Gastroscopy should be prescribed for dyspepsia patients in case that ESCC and RE would be missed in UID cases diagnosed solely by the Rome III questionnaire.

Trial Registration:

ClinicalTrials.gov, NCT01688908; https://clinicaltrials.gov/ct2/show/record/NCT01688908.

Recent Advances in the Definition and Management of Functional Dyspepsia

In 2016, the Rome criteria were updated as Rome IV, and only minor changes were introduced for functional dyspepsia (FD). The major symptoms of FD now include not only postprandial fullness, but also epigastric pain and burning, and early satiation at above the "bothersome" level. Investigations into the effect of meal ingestion on symptom generation have indicated that not only postprandial fullness and early satiety but also epigastric pain and burning sensation and nausea (not vomiting) may increase after meals. Helicobacter pylori infection is considered to be the cause of dyspepsia if successful eradication leads to sustained resolution of symptoms for more than 6 months, and such a condition has been termed H. pylori-associated dyspepsia. Prompt esophagogastroduodenoscopy and H. pylori "test and treat" may be beneficial, especially in regions with a high prevalence of gastric cancer, such as east Asia. In terms of treatment, acotiamide, tandospirone, and rikkunshito are newly listed in Rome IV as treatment options for FD. Clinical studies in the field of FD should be strictly based on the Rome IV criteria until the next Rome V is published in 2026.

Incidence, Survival and Prognostic Factors of Oesophagogastric Cancer

INTRODUCTION

Oesophagogastric cancer is one of the leading causes of cancer death worldwide due to its aggressive nature. Despite the high mortality rate, there is limited information regarding this cancer in Brunei.

AIM

To estimate the incidence and survival duration of oesophagogastric cancer patients, to identify prognostic factors of oesophagogastric cancer and associated factors for late-stage oesophagogastric cancer detection.

METHODS

A retrospective study on all oesophagogastric cancer patients registered in the population-based national cancer registry in Brunei from January 2010 to December 2018. Kaplan-Meier and Cox proportional hazard regression survival analyses and multiple logistic regression were applied.

RESULTS

Sixty-eight oesophagogastric cancer patients' data were retrieved from the registry. The incidence was 2.75 cases per 100,000 adults per year. Median survival time was 1.18 years (95% CI: 0.77, 1.80) and the 3-year survival rate was 26.3%. Age (61-70 years) (adjusted HR = 0.38; 95% CI: 0.17, 0.89; p = 0.025) and those who have undergone chemotherapy (adj. HR = 0.40; 95% CI: 0.18, 0.90; p = 0.026) have a significantly lower mortality risk. Obesity (adj. HR = 11.94; 95% CI: 1.94, 73.36; p = 0.007), and stage 4 (advanced stage) cancer (adj. HR=4.11; 95% CI: 1.97, 8.58; p< 0.001) have a significantly higher mortality risk. Females have 3-time odds (adj. OR = 3.05; 95% CI: 1.09, 9.02; p = 0.038) of presenting with stage 4 cancer. Smokers have 13-time odds (Adj. OR=12.99; 95% CI: 1.92, 262.0; p = 0.025) of presenting with stage 4 cancer.

CONCLUSION

Prognosis of oesophagogastric cancer remains poor. Addressing late detection and improve endoscopic surveillance and awareness of symptoms may help improve prognosis and mortality.

Rome III, Rome IV, and Potential Asia Symptom Criteria for Functional Dyspepsia Do Not Reliably Distinguish Functional From Organic Disease

INTRODUCTION

Although the Rome criteria were created primarily for research purposes, it was an important question whether the Rome criteria can distinguish organic dyspepsia from functional dyspepsia (FD). We evaluated the accuracy of the Rome IV criteria in identifying patients with FD and compared the differences between the Rome IV, Rome III, and potential Asia criteria in identifying patients with FD.

METHODS

In this cross-sectional study, we analyzed data from patients who met the inclusion and exclusion criteria from March 2018 to January 2019 at 2 tertiary hospitals.

RESULTS

A total of 600 patients were enrolled in this study, including 381 individuals met the Rome IV criteria for FD, 438 individuals met the Rome III criteria for FD, and 525 individuals met the potential Asia criteria for FD. The Rome IV criteria identified patients with FD with 67.3% sensitivity and 38.4% specificity, and the positive and negative likelihood ratios of FD identified by Rome IV criteria were 1.09 (95% confidence interval 0.97-1.24) and 0.85 (95% confidence interval 0.67-1.08), respectively. There was no significant difference in the area under Rome IV, Rome III, or potential Asia criteria receiver operating characteristic curves in identifying FD (P > 0.05).

DISCUSSION

The Rome IV criteria were no better than the Rome III or potential Asia criteria in identifying FD and were not helpful in identifying patients with FD. Hence, although the Rome criteria remain useful for defining patients with FD for inclusion into clinical treatment trials, they should not be used for diagnosing FD.

Design characteristics of comparative effectiveness trials for the relief of symptomatic dyspepsia: A systematic review

Background

Dyspepsia represents a symptom domain rather than a diagnostic condition and covers a wide range of complex, underlying pathophysiologies that are not well understood. The review explores comparative effectiveness interventions for the treatment of symptomatic dyspepsia along a pragmatic-explanatory continuum. The aim is to identify relevant design characteristics applicable to future upper gastrointestinal comparative effectiveness research employing integrative medicine.

Methods

Medline, CINAHL, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL) and WHO Clinical Trials were systematically searched until January 2019. Included articles were original research with two or more comparative intervention arms for the primary outcome; relief of symptomatic dyspepsia. Evaluation of the studies was conducted using the pragmatic-explanatory continuum indicator summary (PRECIS-2) tool.

Results

Thirty-six articles were included in the review. A total of 68 Patient Reported Outcome Measurements (PROMs), utilizing 50 different formats were deployed across the studies. The appraisal process revealed eligibility, flexibility in adherence, flexibility in delivery and organization domains further aligned towards an explanatory design.

Conclusion

This review identified three design characteristics relevant for future comparative effectiveness research for the treatment of upper gastrointestinal disorders in a community setting. Extensive exclusion eligibility criteria limited the generalization of comparative effectiveness study results by removing sub-groups of the target populations more at risk of dyspeptic symptoms. The requirement for entry endoscopy was found to be common and not always pragmatically justifiable. Development of validated PROMs appropriate for a generic application to upper gastrointestinal disorders would be advantageous for future comparative effectiveness research within integrative medicine.

Consensus on eradication of Helicobacter pylori and prevention and control of gastric cancer in China (2019, Shanghai)

BACKGROUND AND AIM

China is a country with high prevalence of Helicobacter pylori (H. pylori) infection, which in turn is closely related to the occurrence of gastric cancer. Therefore, the risks of H. pylori infection and gastric cancer are highly overlapping, and the prevention and treatment of H. pylori infection are necessary to prevent gastric cancer.

METHODS

Based on evidence-based medicine and the Delphi method, the National Clinical Medical Research Center for Digestive Disease along with the National Early Gastrointestinal Cancer Prevention and Treatment Center Alliance organized dozens of experts in the fields of digestive diseases, H. pylori research, gastric cancer surgery, epidemiology, health economics, and health management to discuss the relationship between H. pylori eradication and prevention and the treatment of gastric cancer.

RESULTS

A preliminary consensus on the relationship between H. pylori infection and gastric cancer, H. pylori eradication and gastric cancer prevention, and H. pylori screening and eradication strategy was reached. The consensus further clarified the relationship between H. pylori and gastric cancer and how to formulate future prevention and control strategies for gastric cancer.

CONCLUSIONS

This consensus could provide guidance on early detection, diagnosis, and treatment of H. pylori to reduce the occurrence of gastric cancer in China.

Clinical Practice Guidelines for Functional Dyspepsia in Korea

Functional dyspepsia (FD) is a chronic upper gastrointestinal (GI) symptom complex that routine diagnostic work-up, such as endoscopy, blood laboratory analysis, or radiological examination, fails to identify a cause. It is highly prevalent in the World population, and its response to the various available therapeutic strategies is only modest because of the heterogenous nature of its pathogenesis. Therefore, FD represents a heavy medical burden for healthcare systems. We constituted a guideline development committee to review the existing guidelines on the management of functional dyspepsia. This committee drafted statements and conducted a systematic review and meta-analysis of various studies, guidelines, and randomized control trials. External review was also conducted by selected experts. These clinical practice guidelines for FD were developed based on evidence recently accumulated with the revised version of FD guidelines released in 2011 by the Korean Society of Neurogastroenterology and Motility. These guidelines apply to adults with chronic symptoms of FD and include the diagnostic role of endoscopy, Helicobacter pylori screening, and systematic review and meta-analyses of the various treatment options for FD (proton pump inhibitors, H.pylori eradication, and tricyclic antidepressants), especially according to the FD subtype. The purpose of these new guidelines is to aid the understanding, diagnosis, and treatment of FD, and the targets of the guidelines are clinicians, healthcare workers at the forefront of patient care, patients, and medical students. The guidelines will continue to be revised and updated periodically.

Functional Dyspepsia in the Elderly

PURPOSE OF REVIEW

Functional dyspepsia is a common condition, and the condition is defined by symptoms using Rome IV criteria. This review addresses the issue of functional dyspepsia in elderly patients, epidemiology, investigation, and treatment.

RECENT FINDINGS

Recent studies show that while the prevalence of dyspepsia declines in the elderly, it is still prevalant investigations to confirm the diagnosis (including mandatory upper gastrointestinal endoscopy) must exclude organic disease. These include ulcers (particularly associated with nonsteroidal antiinflammatory drugs), Helicobacter pylori pathologies, cancer, coeliac disease, and autoimmune gastritis. Recent research is unraveling pathophysiology beyond symptom-only definitions, focusing on the duodenum with innate immune disturbance (duodenal eosinophilia) and microbial disruption as possible cause. Management of functional dyspepsia includes making a secure diagnosis, treatment with first-line proton pump inhibitors (PPI), then tricyclic antidepressants, and careful choice of prokinetics. Herbal treatments (peppermint oil) and STW-5 have in this age group limited efficacy. Further studies are needed to define the prevalence of functional dyspepsia in the elderly and of prime importance, to exclude organic disease as a cause for symptoms of dyspepsia.

What Is Appropriate Upper Endoscopic Interval Among Dyspeptic Patients With Previously Normal Endoscopy? A Multicenter Study With Bayesian Change Point Analysis

BACKGROUND/AIMS

Appropriate interval for performing follow-up endoscopy among dyspeptic patients without abnormal findings on previous endoscopy is unclear. We analyzed the multicenter-collected data from the Korean Society of Neurogastroenterology and Motility.

METHODS

We collected clinical data of the patients who visited the gastroenterology department and underwent 2 or more sessions of upper endoscopy during 2012-2017 at 6 university hospitals in Korea. Patients with endoscopic interval between 90 days and 760 days were included. For those with multiple endoscopic sessions, only the first 2 were analyzed. Positive outcome was defined as adenoma or cancer in the upper gastrointestinal tract. To identify the point of change and estimate the properties of the stochastic process before and after the change, we used Bayesian regression with Metropolis-Hastings algorithm.

RESULTS

There were 1595 patients. Mean age was 58.8 years (standard deviation, 12.8). Median interval of endoscopy was 437 days (standard deviation, 153). On follow-up endoscopy, there were 12 patients (0.75%) who had neoplasia (4 with gastric cancer and 8 with gastric adnoma). As with the prior hypothesis, we presumed the change point (CP) of increase in frequency of organic lesion as 360 days. After random-walk Metropolis-Hastings sampling with Markov-Chain Monte Carlo iterations of 5000, the CP was 560 days (95% credible interval, 139-724). Estimated average of frequency of dysplastic lesions increased by a factor of 4.4 after the estimated CP.

CONCLUSION

To rule out dysplastic lesions among dyspeptic patients who had previously normal endoscopy, a 2-year interval could be offered as follow-up interval for repeat upper endoscopy.

Use of alarm features in predicting significant endoscopic findings in Nigerian patients with dyspepsia

Introduction

Dyspepsia is prevalent in the community. Guidelines recommend early endoscopy in dyspeptic patients who are older than 55 years, or have alarm features. There is a lack of data on endoscopy in patients with alarm features in Nigeria.

Methods

A retrospective study of the endoscopic findings in adults with dyspepsia and alarm features, between August 1^st 2017 and July 31^st 2018 in Lagos, Nigeria. Data were analysed using Statistical Package for Social Sciences, version 23.0. The sensitivity, specificity, positive predictive value, and negative predictive value of the alarm features were calculated.

Results

One hundred and fifty-nine gastroscopies were performed during this period, mean age was 47.8 (±14.4) years, 49.1% were male. Dyspepsia was the commonest indication for endoscopy (80.5%), 60.2% of the dyspeptics had at least one alarm feature. The most frequent dyspeptic symptom was epigastric pain/burning sensation (75%), while the commonest alarm features were recent onset dyspepsia in a patient over 45 years (79%) and unexplained weight loss (28.6%). Endoscopy was normal in 26%. The most frequent significant endoscopic findings were gastritis (49%) and gastric ulcer (17%) and they were not associated with alarm features. Upper gastrointestinal bleeding, persistent vomiting and odynophagia were specific for significant endoscopic findings. The pooled sensitivity, specificity, positive predictive value, and negative predictive value of the alarm features were 65%, 49%, 71% and 41% respectively.

Conclusion

Patients with dyspepsia and upper gastrointestinal bleeding, persistent vomiting or odynophagia, should be referred for prompt upper GI endoscopy.

[Functional Dyspepsia]

Dyspepsia is a common problem, and when dyspeptic symptoms develop within a short period of time, organic diseases such as gastroesophageal reflux disease, peptic ulcer diseases, pancreatoduodenal diseases, and gastrointestinal cancers should be suspected. Furthermore, functional dyspepsia (FD) should be considered if chronic or recurrent symptoms persist after eliminating underlying disease. FD is classified as epigastric pain syndrome (EPS) or postprandial distress syndrome (PDS), but these two conditions may overlap. Patients with the EPS subtype can be treated with proton pump inhibitors (PPIs), whereas patients with the PDS subtype may be managed primarily with prokinetics, and patients with EPS and PDS can be co-administered PPIs and prokinetics. Helicobacter pylori eradication therapy can be administered on a test-and-treat basis when PPIs and prokinetics are ineffective or to younger patients with chronic dyspepsia, and tricyclic antidepressants can be used as a secondary treatment because they are effective in patients with the EPS subtype. In addition, because the pathophysiology of FD is diverse, dietary education and stress management are required in addition to medical therapy, and should substantially aid treatment and long-term management. Here, we introduce and summarize recently published guidelines for the treatment of FD.

Helicobacter pylori infection is an infectious disease and the empiric therapy paradigm should be changed

Helicobacter pylori infection is an infectious disease. Given the alarmingly high antibiotic resistance in H. pylori, gastroenterologists should change the empiric H. pylori treatment paradigm to an antimicrobial susceptibility testing-guided precision treatment. Antimicrobial stewardship programs for H. pylori should be implemented locally, regionally, and nationally to monitor the antibiotic resistance pattern.

Thailand Dyspepsia Guidelines: 2018

The management of dyspepsia in limited-resource areas has not been established. In 2017, key opinion leaders throughout Thailand gathered to review and evaluate the current clinical evidence regarding dyspepsia and to develop consensus statements, rationales, levels of evidence, and grades of recommendation for dyspepsia management in daily clinical practice based on the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. This guideline is mainly focused on the following 4 topics: (1) evaluation of patients with dyspepsia, (2) management, (3) special issues (overlapping gastroesophageal reflux disease/irritable bowel syndrome and non-steroidal anti-inflammatory drug/aspirin use), and (4) long-term follow-up and management to provide guidance for physicians in Thailand and other limited-resource areas managing such patients.

A Review of Gastric Cancer Research in Malaysia

Incidence rates of gastric cancer in Malaysia has declined by 48% among males and 31% among females in the latest reporting period of 13 years. Malays used to have age-standardized-rates only a fifth of those in Chinese and Indians, but the incidence among them is slightly rising even as the rates drop in the other races. Besides ethnicity, a low level of education, high intake of salted fish and vegetables, H pylori infection and smoking are risk factors. Consumption of fresh fruit and vegetable is protective. Variation in the strains of H pylori infection affect gastric cancer risk, with hspEAsia isolates among Chinese appearing linked to a high incidence than with hpAsia2 or hpEurope strains among Indians and Malays. It was reported in the 1980s that only about 3% of patients presented with early gastric cancer, but more encouraging rates reaching 27% with Stage 1 and 2 disease have been reported in the twenty-first century from leading centres. More tumours occur in the distal stomach except in Kelantan, where the incidence is low and main site is the cardia. Prompt endoscopy is advocated and open access, with direct referrals, to such services using a weighted scoring system should be more utilized. In view of the high rate of late disease laparoscopic staging unnecessary laparotomy needs to be avoided. Late presentation of gastric cancer however, is still predominant and the mortality to incidence ratio is relatively high. Besides seeking to reduce risk factors and achieve early detection, implementation of improved care for patients with late disease must be promoted in Malaysia.

A Simple Pre-endoscopy Score for Predicting Risk of Malignancy in Patients with Dyspepsia: A 5-Year Prospective Study

BACKGROUND

The guidelines for performing endoscopy in dyspeptic patients based on clinical parameters alone have shown variable performance, and there is a need for better prediction tools.

AIM

We aimed to prospectively develop and validate a simple clinical-cum-laboratory test-based scoring model to identify dyspeptic patients with high risk of upper gastrointestinal malignancy (UGIM).

METHODS

Adult patients with dyspeptic symptoms were prospectively recruited over 5 years. Clinical details including alarm features were recorded, and blood tests for hemoglobin and albumin were done before endoscopy. The presence of UGIM was the primary outcome. Risk factors for UGIM were assessed, and based on the OR of significant factors, a predictive scoring model was constructed. ROC curve was plotted to identify optimal cutoff score. The model was validated using bootstrapping technique.

RESULTS

The study included 2324 patients (41.9 ± 12.8 years; 33.4% females). UGIM was noted in 6.8% patients. The final model had following five positive predictors for UGIM-age > 40 years (OR 3.3, score 1); albumin ≤ 3.5 g% (OR 3.4, score 1); Hb ≤ 11 g% (OR 3.3, score 1); alarm features (OR 5.98, score 2); recent onset of symptoms (OR 8.7, score 3). ROC curve had an impressive AUC of 0.9 (0.88-0.93), and a score of 2 had 92.5% sensitivity in predicting UGIM. Validation by bootstrapping showed zero bias, which further strengthened our model.

CONCLUSION

This simple clinical-cum-laboratory test-based model performed very well in identifying dyspeptic patients at risk of UGIM. This can serve as a useful decision-making tool for referral for endoscopy.

Value of gastroscopy in dyspepsia patients without warning symptoms

AIM

To assess the clinical diagnostic value of gastroscopy in dyspepsia patients without warning symptoms.

METHODS

Clinical data for patients undergoing gastroscopy for dyspepsia, including demographic information and symptoms, were collected with questionnaires and analyzed by combining with gastroscopic and histopathological findings.

RESULTS

A Total of 521 cases were enrolled, of which 163 (31.3%) had primary lesions that were detectable by gastroscopy, including 95 (18.2%) with erosive esophagitis, 65 (12.5%) with peptic ulcers, and 3 (0.58%) with upper malignancy. Multivariate Logistic regression analysis showed that male gender, epigastric pain, and Helicobacter pylori (H. pylori) infection were independent risk factors for the presence of primary lesions detectable by gastroscopy.

CONCLUSION

Dyspepsia is one of the main reasons for outpatients seeking medical treatment in Department of Gastroen-terology. Gastroscopy is a necessity for these patients even without any warning symptoms, which is especially true for male patients, patients with epigastric pain or H. pylori infection, in order to prevent the omission of organic diseases such as peptic ulcer, reflux esophagitis, and even upper malignancy.

New Medical Approach to Functional Dyspepsia, from Core Symposium 3, Japan Gastroenterological Association 2015-2017

In the annual meeting of the Japan Gastroenterological Association (JGA), the scientific organizing committee selected the serial topics for the core symposium. One of the core symposia held during 2015-2017 was entitled "New medical approach to functional dyspepsia (FD)." In 2015, the subtitle of this symposium was "Helicobacter pylori gastritis and FD." In 2016, the subtitle of this symposium was "overlap with other functional GI disorders." In 2017, the subtitle was "therapeutic approach to FD." During these 3 years, a total of 24 presentations were included in Core Symposium 3 and deep and intensive discussions were carried out.

Definition, Pathogenesis, and Management of That Cursed Dyspepsia

Dyspepsia is an umbrella term used to encompass a number of symptoms thought to originate from the upper gastrointestinal tract. These symptoms are relatively nonspecific; not surprisingly, therefore, a myriad of conditions may present with any one or a combination of these symptoms. Therein lays the clinician's first challenge: detecting the minority who may have a potentially life-threatening disorder, such as gastric cancer, from a population whose symptoms are, for the most part, considered functional in origin. The second challenge lies in the definition and management of those individuals with functional dyspepsia (FD); the major focus of this review. The Rome process has addressed the issue of FD definition and a look back at the evolution of Rome criteria for this disorder illustrates the complexities that have so frustrated us. There has been no shortage of hypotheses to explain symptom pathogenesis in FD; initially focused on gastric sensorimotor dysfunction, these have now strayed well into the duodenum and have come to entertain such factors as immune responses and the microbiome. FD has proven to be an equally challenging area for therapeutics; while the staple approaches of acid suppression and eradication of Helicobacter pylori have some limited efficacy in select populations, strategies to ameliorate symptoms in the majority of sufferers based on presumed pathophysiology have largely foundered. Lacking a validated biomarker(s) FD continues to be an elusive target and is likely to remain so until we can better define the various phenotypes that it must surely contain.

Fifth Chinese National Consensus Report on the management of Helicobacter pylori infection

BACKGROUND

Since the 'Fourth Chinese National Consensus Report on the management of H. pylori infection' was published in 2012, three important consensuses (Kyoto global consensus report on H. pylori gastritis, The Toronto Consensus for the Treatment of H. pylori Infection in Adults and Management of H. pylori infection-the Maastricht V/Florence Consensus Report) have been published regarding the management of H. pylori infection.

MATERIALS AND METHODS

A Delphi method was adopted to develop the consensus of relevant 'statements'. First, the established 'statements' were sent to experts via email. Second, after undergoing two rounds of consultation, the initial statements were discussed face to face and revised in the conference item by item on 16 December 2016. Finally, 21 core members of conferees participated in the final vote of statements. Voting for each statement was performed using an electronic system with levels of agreements shown on the screen in real time.

RESULTS

Consensus contents contained a total of 48 "statements" and related 6 parts, including indications for H. pylori eradication, diagnosis, treatment, H. pylori and gastric cancer, H. pylori infection in special populations, H. pylori and gastrointestinal microbiota.

CONCLUSIONS

Recommendations are provided on the basis of the best available evidence.

Irritable bowel syndrome in Asia: Pathogenesis, natural history, epidemiology, and management

Historically, the epidemiology of gastrointestinal diseases in Asia was different from that in Western countries. Early studies suggested a low prevalence of irritable bowel syndrome (IBS) in Asia. As the diagnosis of IBS is symptom-based and as symptom perception, expression, and interpretation are influenced by sociocultural perspectives including language, the presentation of IBS is expected to vary in different communities. Furthermore, the pathogenesis is multifactorial with psychosocial (stress, illness, behavior, and diet) and biological (infection, gut microbiota, and immune activation) variables interacting, and so, the present study can anticipate that the development of IBS will vary in different environments. In recognition of this aspect of functional gastrointestinal disorders, the recently published Rome IV documents have provided greater focus on cross-cultural factors. In this review, the present study seeks to highlight Asian perspectives by identifying historical trends and recent publications from the region and comparing these with the observations from Western societies.

The Application of the Rome IV Criteria to Functional Esophagogastroduodenal Disorders in Asia

The Rome criteria were amended as Rome IV. For functional esophageal disorders, the exclusion criteria have been more specifically revised based on further understanding of other esophageal disorders, including eosinophilic esophagitis and spastic and hypercontractile motor disorders. Another revised point is the more restrictive definition of gastroesophageal reflux disease, indicating that sensitivity to a physiological reflux burden may be placed more firmly within the functional group. For functional dyspepsia (FD), only minor changes were introduced, mainly to improve specificity. Among the major symptoms of FD, not only postprandial fullness, but also epigastric pain, epigastric burning, and early satiation should be "bothersome." Investigation on the effect of meal ingestion on symptom generation has indicated that not only postprandial fullness and early satiety, but also epigastric pain, epigastric burning sensation and nausea (not vomiting) may increase after meals. Helicobacter pylori infection is considered a possible cause of dyspepsia if successful eradication leads to sustained resolution of symptoms for more than 6 months, and such status can be termed as "H. pylori-associated dyspepsia." Prompt esophagogastroduodenoscopy and H. pylori testing and treatment would be more beneficial, especially in Asia, which has a high prevalence of gastric cancer. Acotiamide, tandospirone, and rikkunshito are the newly listed as treatment options for FD. For further therapeutic development, clinical studies based on the strict Rome IV criteria should be performed.

Diagnostic value of alarm symptoms for upper GI malignancy in patients referred to GI clinic: A 7 years cross sectional study

BACKGROUND

Early upper gastrointestinal (UGI) cancer detection had led to organ-preserving endoscopic therapy. Endoscopy is a suitable method of early diagnosis of UGI malignancies. In Iran, exclusion of malignancy is the most important indication for endoscopy. This study is designed to see whether using alarm symptoms can predict the risk of cancer in patients.

MATERIALS AND METHODS

A total of 3414 patients referred to a tertiary gastrointestinal (GI) clinic in Isfahan, Iran, from 2009 to 2016 with dyspepsia, gastroesophageal reflux disease (GERD), and alarm symptoms, such as weight loss, dysphagia, GI bleeding, vomiting, positive familial history for cancer, and anorexia. Each patient had been underwent UGI endoscopy and patient data, including histology results, had been collected in the computer. We used logistic regression models to estimate the diagnostic accuracy of each alarm symptoms.

RESULTS

A total of 3414 patients with alarm symptoms entered in this study, of whom 72 (2.1%) had an UGI malignancy. According to the logistic regression model, dysphagia (P < 0.001) and weight loss (P < 0.001) were found to be significant positive predictive factors for malignancy. Furthermore, males were in a significantly higher risk of developing UGI malignancy. Through receiver operating characteristic curve and the area under the curve (AUC) with adequate overall calibration and model fit measures, dysphagia and weight loss as a related cancer predictor had a high diagnostic accuracy (accuracy = 0. 72, AUC = 0. 881). Using a combination of age, alarm symptoms will lead to high positive predictive value for cancer.

CONCLUSION

We recommend to do an early endoscopy for any patient with UGI symptoms and to take multiple biopsies from any rudeness or suspicious lesion, especially for male gender older than 50, dysphagia, or weight loss.

Mexican consensus on dyspepsia

Since the publication of the 2007 dyspepsia guidelines of the Asociación Mexicana de Gastroenterología, there have been significant advances in the knowledge of this disease. A systematic search of the literature in PubMed (01/2007 to 06/2016) was carried out to review and update the 2007 guidelines and to provide new evidence-based recommendations. All high-quality articles in Spanish and English were included. Statements were formulated and voted upon using the Delphi method. The level of evidence and strength of recommendation of each statement were established according to the GRADE system. Thirty-one statements were formulated, voted upon, and graded. New definition, classification, epidemiology, and pathophysiology data were provided and include the following information: Endoscopy should be carried out in cases of uninvestigated dyspepsia when there are alarm symptoms or no response to treatment. Gastric and duodenal biopsies can confirm Helicobacter pylori infection and rule out celiac disease, respectively. Establishing a strong doctor-patient relationship, as well as dietary and lifestyle changes, are useful initial measures. H2-blockers, proton-pump inhibitors, prokinetics, and antidepressants are effective pharmacologic therapies. H.pylori eradication may be effective in a subgroup of patients. There is no evidence that complementary and alternative therapies are beneficial, with the exception of Iberogast and rikkunshito, nor is there evidence on the usefulness of prebiotics, probiotics, or psychologic therapies. The new consensus statements on dyspepsia provide guidelines based on up-to-date evidence. A discussion, level of evidence, and strength of recommendation are presented for each statement.

The Safety of Appropriate Use of Over-the-Counter Proton Pump Inhibitors: An Evidence-Based Review and Delphi Consensus

The availability of over-the-counter (OTC) proton pump inhibitors (PPIs) for the short-term (2 weeks) management of frequent heartburn (≥2 days/week) has increased markedly, yet evidence-based recommendations have not been developed. A panel of nine international experts in gastroesophageal reflux disease developed consensus statements regarding the risks and benefits of OTC PPIs using a modified Delphi process. Consensus (based on ≥80% approval) was reached through multiple rounds of remote voting and a final round of live voting. To identify relevant data, the available literature was searched and summarized. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system terminology was used to rate the quality of evidence and strength of recommendations; consensus was based on ≥2/3 agreement. After 4 rounds of review, consensus was achieved for 18 statements. Notably, the available data did not directly reflect OTC use, but instead, prescription use; therefore, extrapolations to the OTC setting were often necessary. This limitation is regrettable, but it justifies performing this exercise to provide evidence-based expert opinion on a widely used class of drugs. The panel determined that using OTC PPIs according to label instructions is unlikely to mask the symptoms of esophageal or gastric cancer or adversely impact the natural history of related precursor conditions. OTC PPIs are not expected to substantially affect micronutrient absorption or bone mineral density or cause community-acquired pneumonia, Clostridium difficile infection, or cardiovascular adverse events. However, OTC PPI use may be associated with slightly increased risks for infectious diarrhea, certain idiosyncratic reactions, and cirrhosis-related spontaneous bacterial peritonitis. The available evidence does not suggest that OTC PPI use consistent with label instructions is associated with substantial health risks. To minimize potential risks, healthcare professionals and consumers must actively participate in decision making when managing reflux-related symptoms in the self-care setting.

The low-FODMAP diet in the management of functional dyspepsia in East and Southeast Asia

Functional dyspepsia (FD) is a common disorder in East and Southeast Asia where subjects experience post prandial fullness/bloating, early satiety, belching, epigastric pain, and/or burning. A subset of patients with FD experience triggers exclusively related to meals, defined as the post prandial distress syndrome in the Rome IV guidelines. There is significant overlap of symptoms and implicated pathogenic factors with another common functional gastrointestinal disorder, irritable bowel syndrome (IBS) and in fact, a significant proportion of subjects have FD/IBS overlap. The introduction of the low-FODMAP diet has changed the paradigm of treatment for IBS. Like IBS, dietary management appears to be important to patients with FD and clinicians treating the condition. This review aims to examine the current role of diet in the management of FD in East and Southeast Asia, with an exploration of the likely efficacy and mechanisms of action of the low-FODMAP diet in this region.

Diagnostic value of neutrophil infiltration in Helicobacter pylori infection

AIM: To evaluate the value of neutrophil infiltration in the diagnosis of Helicobacter pylori (H. pylori) infection.

METHODS: From March 2015 to March 2016, 140 patients with dyspepsia symptoms who received upper gastrointestinal endoscopy were included in this study. The diagnosis of H. pylori infection was confirmed by¹³C-urea breath test (¹³C-UBT) as the gold standard. The value of neutrophil infiltration in the diagnosis of H. pylori infection was analyzed using Chi-square test.

RESULTS: The sensitivity, specificity, positive predication value (PPV) and negative predication value (NPV) of neutrophil infiltration in the diagnosis of H. pylori infection were 88.5%, 84.8%, 81.8%, and 90.5%, respectively. Neutrophil infiltration of gastric mucosa in histology analysis was strongly associated with H. pylori infection (P = 0.000), with moderate-severe neutrophil infiltration highly hinting H. pylori infection (P = 0.033).

CONCLUSION: Neutrophil infiltration is closely associated with H. pylori infection. The severer the degree of neutrophil infiltration, the higher the value for diagnosis of H. pylori infection.

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.

Functional dyspepsia

PURPOSE OF REVIEW

Structural causes are absent in more than 50% of patients with symptoms referred to the gastroduodenal region when routine diagnostic tests are applied. New knowledge holds the prospect that targeted therapy may more optimally manage subsets of these patients with functional dyspepsia.

RECENT FINDINGS

An understanding of gut-to-brain and brain-to-gut pathways in functional dyspepsia is expanding. Minimal mucosal inflammation with eosinophils (and in some cases mast cells) characterized by ultrastructural changes in the duodenum appears to be present in a substantial subgroup of functional dyspepsia patients as identified now by investigators globally. Although antibiotic therapy targeting Helicobacter pylori appears to be effective in a small proportion of functional dyspepsia patients, eradication therapy may be more effective in functional dyspepsia patients with microscopic duodenal inflammation, a potentially important finding needing to be confirmed. This may suggest that the effects of antibiotics for functional dyspepsia are not simply mediated by the eradication of gastric H. pylori, but have other antibacterial effects (e.g., on the duodenal microbiome). Abnormal visceral sensory function plays a key role not only in the manifestations of functional dyspepsia but also in peptic ulcer disease.

SUMMARY

The pathophysiologic concepts underlying functional dyspepsia and related treatment approaches are shifting from a focus on H. pylori, acid suppression or modulation of motility toward new models. New evidence suggests that minimal duodenal inflammation plays a role in symptom generation in at least a proportion of patients with otherwise unexplained symptoms. This is a paradigm shift and ultimately may change the treatment of many patients with functional gastrointestinal disorders.

Epidemiology and Diagnosis of Helicobacter pylori infection

During the period reviewed, prevalence studies were essentially performed in less economically advanced countries and a high prevalence was found. The traditional risk factors for Helicobacter pylori positivity were mostly found. Transmission studied by molecular typing showed a familial transmission. The eventual role of water transmission was explored in several studies with controversial results. Concerning diagnosis, most of the invasive and noninvasive methods used for the diagnosis of H. pylori infection are long standing with efficient performance. The most interesting recent improvements in H. pylori diagnosis include advances in endoscopy, developments in molecular methods, and the introduction of omics-based techniques. Interpretation of old or newer method should take into account the pretest probability and the prevalence of H. pylori in the population under investigation.

Therapeutic strategies for functional dyspepsia and irritable bowel syndrome based on pathophysiology

Functional gastrointestinal disorders (FGIDs) are common and distressing. They are so named because a defined pathophysiology in terms of structural or biochemical pathways is lacking. Traditionally FGIDs have been conceptualized as brain-gut disorders, with subgroups of patients demonstrating visceral hypersensitivity and motility abnormalities as well as psychological distress. However, it is becoming apparent that there are certain structural or biochemical gut alterations among subsets with the common FGIDs, most notably functional dyspepsia (FD) and irritable bowel syndrome (IBS). For example, a sodium channel mutation has been identified in IBS that may account for 2 % of cases, and subtle intestinal inflammation has been observed in both IBS and FD. Other research has implicated early life events and stress, autoimmune disorders and atopy and infections, the gut microbiome and disordered mucosal immune activation in patients with IBS or FD. Understanding the origin of symptoms in FGIDs will allow therapy to be targeted at the pathophysiological changes, not at merely alleviating symptoms, and holds hope for eventual cure in some cases. For example, there are promising developments in manipulating the microbiome through diet, prebiotics and antibiotics in IBS, and testing and treating patients for Helicobacter pylori infection remains a mainstay of therapy in patients with dyspepsia and this infection. Locally acting drugs such as linaclotide have been an advance in treating the symptoms of constipation-predominant IBS, but do not alter the natural history of the disease. A role for a holistic approach to patients with FGIDs is warranted, as brain-to-gut and gut-to-brain pathways appear to be activated.