Review article: current and emerging therapies for functional dyspepsia

Efficacy and Safety of Shenqu Xiaoshi Oral Liquid Compared With Domperidone Syrup in Children With Functional Dyspepsia

Background: Treatment of functional dyspepsia (FD) in children is generally symptomatic and unsatisfactory. Traditional Chinese medicines, such as Shenqu Xiaoshi Oral Liquid (SXOL), have been recommended to alleviate dyspeptic symptoms. However, evidence of their safety and efficacy remains limited to date. AIM: To assess whether 2 weeks of therapy with SXOL was non-inferior to domperidone syrup in children with FD.

Methods: In this randomized, double-blind, double-simulated, non-inferiority, multi-center clinical trial, we recruited children (3–14 years) with FD according to the Rome IV criteria from 17 tertiary medical centers across China. Patients were randomly allocated (1:1) to receive SXOL or domperidone syrup for 2 weeks. We compared the participants’ clinical scores from both groups based on the severity and frequency of dyspepsia symptoms according to Rome IV criteria (0, 1, 2, and 4 weeks after randomization). The primary endpoint was the total response rate, which was defined as the proportion of patients with a decrease of 30% or more in the FD symptoms clinical score from baseline, at the end of the 2-weeks treatment. A non-inferiority margin of -10% was set. Secondary endpoints and adverse events were assessed. This trial is registered with www.Chictr.org.cn, number ChiCTR1900022654.

Results: Between February 2019 and March 2021, a total of 373 patients were assessed for eligibility, and 356 patients were enrolled and randomized. The clinical response rate at week two was similar for SXOL [118 (83.10%) of 142] and domperidone [128 (81.01%) of 158]; difference 2.09; 95% CI −6.74 to 10.71, thereby establishing non-inferiority. The total FD symptom scores were significantly improved in the two groups at 1-, 2-, and 4-weeks follow-up periods (p < 0.005). The decrease in symptom score compared with the baseline were similar between these two groups. Over the total study period, 10 patients experienced at least one treatment-related adverse event [six (3.37%)] in the SXOL group, four [(2.25%) in the domperidone group], although no serious adverse event was noted.

Conclusion: Treatment with SXOL effectively improves dyspeptic symptoms and is well tolerated. In addition, it is not inferior to domperidone syrup and leads to sustained improvement in Chinese children with FD.

Improving Clinician-Patient Communication Alleviates Stigma in Patients With Functional Dyspepsia Receiving Antidepressant Treatment

Background/Aims

Antidepressants are effective in patients with functional dyspepsia (FD). However, stigma associated with FD and antidepressants may affect treatment adherence. This study aims to explore possible communication strategies to alleviate stigma and improve adherence in patients with FD.

Methods

In this randomized, single-center, and single-blind trial, 160 patients with FD initiating antidepressant treatment were recruited. Different communication strategies were performed when prescribing antidepressants. Participants in Group 1 were told that brain is the “headquarters” of gut, and that antidepressants could act as neuromodulators to relieve symptoms of FD through regulating the functions of gut and brain. Participants in Group 2 were told that antidepressants were empirically effective for FD. Stigma scores, medication-related stigma, treatment compliance, and efficacy were analyzed.

Results

After 8-week antidepressant treatment, the proportion of patients with FD with decreased stigma scores in Group 1 was significantly higher than in Group 2 (internalized stigma 64.10% vs 12.00%; perceived stigma 55.13% vs 13.33%; P < 0.01). Medication-related stigma was lower in Group 1 than in Group 2 (P < 0.05 for 3 of 4 questions). Concurrently, patients in Group 1 had better treatment compliance (0.71 ± 0.25 vs 0.60 ± 0.25, P < 0.01) and efficacy. In Group 1, participants with decreased post-treatment stigma scores showed better treatment compliance and efficacy than those with non-decreased scores. Decrease in stigma scores positively correlated with treatment compliance.

Conclusion

Improving knowledge of patients with FD of the disease and antidepressants via proper communication may be an effective way to alleviate stigma and promote adherence.

Herbal medicine for functional dyspepsia: Network meta-analysis of placebo-controlled randomised trials

ETHNOPHARMACOLOGICAL RELEVANCE

Conventional treatments for functional dyspepsia (FD) are limited. Herbal medicine (HM) use is prevalent despite unclear comparative effectiveness among different formulae.

AIM OF THE STUDY

This network meta-analysis (NMA) aimed to evaluate the comparative effectiveness of HM formulae for FD against placebo.

MATERIALS AND METHODS

Seven international and Chinese databases were searched for randomised controlled trials (RCTs) on HM versus placebo. Risk of bias among RCTs was assessed using Cochrane Risk-of-Bias Tool 2. Data from RCTs were extracted for random-effect pairwise meta-analyses. NMAs were performed to evaluate the comparative effectiveness of HM formulae. GRADE partially contextualised framework was adopted to facilitate NMA result interpretation.

RESULTS

Twelve different HM formulae were identified from fifteen RCTs of mediocre quality. At 8-week follow-up, pairwise meta-analyses indicated that HM was superior to placebo in alleviating global symptoms (pooled risk difference (RD): 0.20; 95% confidence interval (CI): 0.11-0.29), with effect size larger than the minimally clinically important difference of 0.20 RD. Sensitivity analysis showed no significant impact on results attributable to risk of bias. NMAs demonstrated that Xiao Yao Pill and Modified Ban Xia Xie Xin Decoction probably have a large beneficial effect on alleviating global symptoms (RD: 0.37; 95% CI: 0.03-0.99) and postprandial fullness (standardised mean difference: -0.93; 95% credible interval: -1.61 to -0.06), respectively. No serious adverse events were reported.

CONCLUSIONS

Xiao Yao Pill and Modified Ban Xia Xie Xin Decoction may be considered as an alternative among patients unresponsive to conventional treatments. The comparative effectiveness of these two formulae should be evaluated in future trials.

History-taking, Clinical Signs, Tests and Scores for Detection of Non-organic Dyspepsia (NOD) Among Patients With Acute Abdominal Pain (AAP)

BACKGROUND/AIM

The diagnostic accuracy of history-taking, clinical signs and tests and diagnostic scores (DSs) for patients with non-organic dyspepsia (NOD) have been rarely evaluated.

PATIENTS AND METHODS

A cohort of 1333 patients presenting with acute abdominal pain (AAP) were studied, including 50 patients with confirmed NOD. The most significant diagnostic variables (in multivariate logistic regression analysis) were used to construct six different DS models and their diagnostic accuracy was compared with clinical symptoms and signs and tests. Meta-analytical techniques were used to detect the summary sensitivity (Se) and specificity (Sp) estimates for each data set (symptoms, signs and tests as well as DS models).

RESULTS

In hierarchical summary receiver operating characteristic (HSROC) analysis, the area under curve (AUC) values for i) symptoms ii) signs and tests iii) DS were as follows: i) AUC=0.608 [95% confidence interval (CI)=0.550-0.666]; ii) AUC=0.621 (95% CI=0.570-0.672) and iii) AUC=0.877 (95% CI=0.835-0.919). The differences between these AUC values (roccomp analysis) are as follows: between i) and ii) p=0.715; between i) and iii) p<0.0001; between ii) and iii) p<0.0001.

CONCLUSION

The present study is the first to provide evidence that the DS could be used in diagnosis of NOD. The major advantage of our DS is that this model does not need radiology or endoscopy to reach high diagnostic accuracy.

Efficacy and Safety of Fingerroot (Boesenbergia rotunda) Extract in Patients with Functional Dyspepsia: A Randomized, Placebo-Controlled Trial

BACKGROUND

Functional dyspepsia (FD) is a common upper gastrointestinal disorder, but the current treatments are still unsatisfactory. Fingerroot (Boesenbergia rotunda [L.] Mansf.; BR) is used as a traditional medicine for dyspepsia despite a lack of proven evidence.

OBJECTIVE

This study aimed to evaluate the efficacy and safety of BR extract in the treatment of patients with FD.

METHODS

In a randomized, double-blinded, placebo-controlled trial, 160 patients with FD based on Rome IV criteria were to be recruited and randomly assigned (1:1 ratio) to receive BR (350 mg extract powder) or placebo 3 times daily for 4 weeks. Primary end point was change in the summed total score of Short-Form Leeds Dyspepsia Questionnaire. Secondary end points were the rate of symptom relief, the reduction of blood inflammatory markers and the improvement in gastric histology according to the Updated Sydney System.

RESULTS

One hundred sixty patients (62 [38.8%] men, aged 56.9 ± 14.8 years) were randomized to the BR group (n = 80) and placebo group (n = 80), and 138 patients completed this study. Overall symptom improvement was significantly greater in the BR group than in the placebo group (-7.1 ± 2.0 vs. -3.7 ± 0.8, repeated measures ANOVA, p < 0.05). Total symptom scores significantly improved with decrease in blood inflammatory markers in the BR group compared with the placebo group (p < 0.05). Proportion of responders was higher in the BR group (58%) than in the placebo group (34.6%) according to the intention-to-treat analysis (p < 0.05) with the number needed to treat calculated as 4.3. No difference in gastric histology was observed in both groups. BR extract was well tolerated with few adverse events. These effects were associated with acute phase reactants reduction.

CONCLUSIONS

BR extract represents an effective and safe alternative to manage dyspepsia symptoms in FD patients.

Effect of Massa Medicata Fermentata on the Gut Microbiota of Dyspepsia Mice Based on 16S rRNA Technique

Massa Medicata Fermentata (MMF) is a traditional Chinese medicine (TCM) for treating indigestion and its related disorders. This study analyzes the effect of MMF on intestinal microorganisms in dyspepsia mice based on 16S rRNA technology. We take a dyspepsia model caused by a high-protein, high-calorie, high-fat diet. The 60 specific-pathogen free Kunming (SPF KM) mice were randomly divided into a model group (n=12), an MMF group (LSQ group, n=12), a Jianweixiaoshi group (JWXS group, n=12), a domperidone group (DP group, n=12), and a blank group (n=12). On the seventh day of administration, mice were fasted and deprived of water. After 24 h, take the second feces of stress defecation in mice under strict aseptic conditions and quickly transfer them to a sterile cryotube. This study comprehensively evaluates the α-diversity, β-diversity, flora abundance and composition of each group of mice's intestinal microorganisms, and their correlation with functional dyspepsia based on the 16S rRNA gene sequencing technology. After modeling, some dyspepsia reactions, proximal gastric relaxation reduction, and intestinal microflora changes were noted. Dyspepsia mice showed dyspepsia reactions and proximal gastric relaxation reduction, characterized by a significant decrease of contents of gastrin (P < 0.01) and cholinesterase (P < 0.01). MMF can improve dyspepsia symptoms and promote proximal gastric relaxation. Significant intestinal flora disorders were found in dyspepsia mice, including downregulation of Bacteroidetes, Lactobacillus, and Prevotellaceae and upregulation of Proteobacteria, Verrucomicrobia, Epsilonbacteraeota, Firmicutes, Lachnospiraceae NK4A136 group, and Lachnospiraceae. MMF could alleviate intestinal microflora disturbance, and the regulation effect of MMF on Bacteroidetes, Verrucomicrobia, and Epsilonbacteraeota was more reliable than that of Jianweixiaoshi tables and domperidone. The intestinal microflora may be correlated with the promoted digestion of MMF.

Shenling Baizhu San improves functional dyspepsia in rats as revealed by 1H-NMR based metabolomics

Functional dyspepsia (FD), a common gastrointestinal disorder around the world, is driven by multiple factors, making prevention and treatment a major challenge. Shenling Baizhu San (SBS), a classical prescription of traditional Chinese medicine, has been proven to be effective in gastrointestinal disorders. However, studies on SBS improving FD are few. Thus, our study aimed to evaluate the effect of SBS on FD and further to explore the mechanism underlying the interactions between FD and SBS by the metabolomics approach. A FD rat model was induced by multiple forms of mild stimulation, and proton nuclear magnetic resonance (1H-NMR) spectroscopy and multivariate data analysis were used to profile the fecal and urinary metabolome in the FD rats during SBS intervention. Significant dyspeptic symptoms such as weight loss, poor appetite, reduced gastrointestinal motility and decreased absorptive capacity were observed in the FD rats, which were subsequently improved by SBS. Additionally, the levels of citrate, branched chain acids and pyruvate decreased, and the levels of choline, trimethylamine and taurine increased in the FD rats. Furthermore, the metabolic disorders were amended with SBS intervention mainly by modulating the metabolic pathways involved in energy metabolism, amino acid metabolism, and gut microbiota and host co-metabolism. Overall, our study highlighted the effect of SBS on the disturbed metabolic pathways in the FD rats, providing new insight into the mechanism of SBS treatment for FD from the perspective of metabolomics.

Benefit of small dose antidepressants for functional dyspepsia: Experience from a tertiary center in eastern China

BACKGROUND

Traditional treatment of functional dyspepsia (FD) is unsatisfactory in a subgroup of patients with FD, and the potential role of antidepressant medications also has not been definitely clarified. To provide more evidence for future optimal practice recommendations, we reviewed a 1-year clinical database of antidepressant agents applied in outpatients with FD.

METHODS

Clinical presentations, treatment course, and outcomes were determined by chart review of patients referring to the functional gastrointestinal disorders specialist clinic. One hundred thirty patients with FD were included for further analysis.

RESULTS

Patients were treated with different antidepressant drugs according to individual symptoms. The most commonly used drugs were flupenthixol melitracen and fluoxetine. Improvement and complete remission occurred in 93.8% and 54.6% of patients, respectively. There was a trend toward superior outcome for citalopram compared to sulpiride and mirtazapine in overall analysis. Meanwhile, regimens containing fluoxetine had significant increased remission rate compared to any other antidepressant regimens in postprandial distress syndrome subgroup analysis. Furthermore, older patients were more likely to achieve remission. However, sex and symptom duration were not associated with symptom remission. Finally, 11.5% of patients experienced adverse events.

CONCLUSIONS

This retrospective cohort study indicated that small dose antidepressant therapy, especially citalopram and fluoxetine, is an effective and well tolerated treatment option for refractory FD.

Acute restraint stress induces cholecystokinin release via enteric apelin

Stress increases the apelin content in gut, while exogenous peripheral apelin has been shown to induce cholecystokinin (CCK) release. The present study was designed to elucidate (i) the effect of acute stress on enteric production of apelin and CCK, (ii) the role of APJ receptors in apelin-induced CCK release depending on the nutritional status. CCK levels were assayed in portal vein blood samples obtained from stressed (ARS) and non-stressed (NS) rats previously injected with APJ receptor antagonist F13A or vehicle. Duodenal expressions of apelin, CCK and APJ receptor were detected by immunohistochemistry. ARS increased the CCK release which was abolished by selective APJ receptor antagonist F13A. The stimulatory effect of ARS on CCK production was only observed in rats fed ad-libitum. Apelin and CCK expressions were upregulated by ARS. In addition to the duodenal I cells, APJ receptor was also detected in CCK-producing myenteric neurons. Enteric apelin appears to regulate the stress-induced changes in GI functions through CCK. Therefore, apelin/APJ receptor systems seem to be a therapeutic target for the treatment of stress-related gastrointestinal disorders.

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.

Association between metabolic profile and microbiomic changes in rats with functional dyspepsia

Functional dyspepsia (FD) is one of the most prevalent functional gastrointestinal disorders (FGIDs). Accumulated evidence has shown that FD is a metabolic disease that might relate to gut microbiota, but the relationship between microbiome and the host metabolic changes is still uncertain. To clarify the host–microbiota co-metabolism disorders related to FD, an integrated approach combining ¹H NMR-based metabolomics profiles, polymerase chain reaction-denaturing gradient gel electrophoresis (PCR-DGGE) and 16S rRNA gene sequencing was used to investigate the relationship among FD, metabolism of gut microbiota and the host. 34 differential urinary metabolites and 19 differential fecal metabolites, which affected the metabolism of energy, amino acids, nucleotides and short chain fatty acids (SCFAs), were found to have associated with FD. Based on the receiver operating characteristic (ROC) analysis, 10 biomarkers were screened out as diagnostic markers of FD. Meanwhile, the concentrations of Flintibacter, Parasutterella, Eubacterium and Bacteroides significantly increased in the FD group, whereas Eisenbergiella, Butyrivibrio, Intestinimonas, Saccharofermentans, Acetivibrio, Lachnoanaerobaculum and Herbinix significantly decreased. Furthermore, the above altered microbiota revealed a strong correlation with the intermediate products of the tricarboxylic acid (TCA) cycle, amino acids and SCFAs. In our study, it suggested that the energy metabolism was mainly disturbed in FD rats. Our findings also demonstrated that FD might be the result of gut microbiota and metabolism disorders, which was potentially valuable to enrich our understanding of the pathogenesis of FD.

Functional dyspepsia (FD) is one of the most prevalent functional gastrointestinal disorders (FGIDs). The aim of our study was to evaluate the effects of FD on the microbiota and its metabolic profiles in feces and urine.

Efficacy and safety of Xiangsha Liujunzi granules for functional dyspepsia: A multi-center randomized double-blind placebo-controlled clinical study

AIM

To assess the efficacy and safety of a Chinese herbal medicine (CHM), Xiangsha Liujunzi granules, in the treatment of patients with functional dyspepsia (FD).

METHODS

We performed a randomized, double-blind, placebo-controlled trial with patients from three centers. Two hundred and sixteen subjects diagnosed with FD according to ROME III criteria and confirmed by upper gastrointestinal endoscopy and spleen-deficiency and Qi-stagnation syndrome were selected to receive Xiangsha Liujunzi granules or placebo for 4 wk in a 2:1 ratio by blocked randomization. The subjects also received follow-up after the 4-wk intervention. Herbal or placebo granules were dissolved in 300 mL of water. Participants in both groups were administered 130 mL (45 °C) three times a day. Participants were evaluated prior to and following 4 wk of the intervention in terms of changes in the postprandial discomfort severity scale (PDSS) score, clinical global impression (CGI) scale score, hospital anxiety and depression scale (HADS) score, traditional Chinese medicine symptoms score (SS), scores of various domains of the 36-item short form health survey (SF-36), gastric emptying (GE) and any observed adverse effects.

RESULTS

Compared with the placebo group, patients in the CHM group showed significant improvements in the scores of PDSS, HADS, SS, SF-36 and CGI scale (P < 0.05 or P < 0.01). They also showed the amelioration in the GE rates of the proximal stomach and distal stomach (P < 0.05 or P < 0.01).

CONCLUSION

Xiangsha Liujunzi granules offered significant symptomatic improvement in patients with FD.

Peripheral apelin-13 administration inhibits gastrointestinal motor functions in rats: The role of cholecystokinin through CCK1 receptor-mediated pathway

Apelin is the endogenous ligand of the G protein-coupled receptor APJ. The APJ receptor is widely expressed in gastrointestinal (GI) tissues including stomach and small intestine. Apelin administration was shown to induce the release of cholecystokinin (CCK) which is a well-known alimentary hormone with its inhibitory actions on GI motor functions through CCK₁ receptors on vagal afferent fibers. We investigated whether; (i) peripherally injected apelin-13 alters GI motor functions, (ii) apelin-induced changes are mediated by APJ receptor or CCK₁ receptor and (iii) vagal afferents are involved in inhibitory effects of apelin. Solid gastric emptying (GE) and colon transit (CT) were measured, whereas duodenal phase III-like contractions were recorded in rats administered with apelin-13 (300μg/kg, ip). CCK₁ receptor antagonist lorglumide (10mg/kg, ip) or APJ receptor antagonist F13A (300μg/kg, ip) was administered 30min prior to the apelin-13 injections. Vagal afferent denervation was achieved by systemic administration of vanilloid receptor agonist capsaicin (125mg/kg, sc). Apelin-13 administration significantly (p<0.01) increased the CCK level in portal venous plasma samples. Compared with vehicle-treated rats, apelin-13 significantly delayed both GE (p<0.001) and CT (p<0.01). Pretreatment of lorglumide or F13A completely abolished the apelin-13-induced inhibitory effects on GE and CT, moreover, apelin-13 was found ineffective in rats underwent afferent denervation. F13A administration alone significantly accelerated the basal CT. Apelin-13 noticeably disturbed the duodenal fasting motor pattern by impairing phase III-like contractions while increasing the amplitudes of phase II contractions which were prevented by pretreatment of lorglumide and capsaicin. Compared with vehicle-treated rats, lorglumide and capsaicin significantly (p<0.05) reduced the apelin-13-induced increases in phase II motility index. Peripherally administered apelin-13 inhibits GI motor functions through CCK-dependent pathway which appears to be mediated by CCK₁ receptors on vagal afferents. Peripheral apelin might contribute to the motility changes occurred in postprandial period.

Opposite effects of central oxytocin and arginine vasopressin on changes in gastric motor function induced by chronic stress

Hypothalamic oxytocin (OXT) and arginine vasopressin (AVP) are known to act oppositely on hypothalamic-pituitary-adrenal (HPA) axis, stress response and gastrointestinal (GI) motility. In rodents, exposure to restraint stress (RS) delays gastric emptying (GE), however, repeated exposure to the same stressor (chronic homotypic stress (CHS)), the delayed GE is restored to basal level, while hypothalamic OXT is upregulated. In contrast, when rats are exposed to chronic heterotypic stress (CHeS), these adaptive changes are not observed. Although the involvement of central OXT in gastric motor adaptation is partly investigated, the role of hypothalamic AVP in CHeS-induced maladaptive paradigm is poorly understood. Using in-vivo brain microdialysis in rats, the changes OXT and AVP release from hypothalamus were monitored under basal non-stressed (NS) conditions and in rats exposed to acute stress (AS), CHS and CHeS. To investigate the involvement of central endogenous OXT or AVP in CHS-induced habituation and CHeS-induced maladaptation, chronic central administration of selective OXT receptor antagonist L-371257 and selective AVP V_1b receptor antagonist SSR-149415 was performed daily. OXT was measured higher in AS and CHS group, but not in CHeS-loaded rats, whereas AVP significantly increased in rats exposed to AS and CHeS. Additionally, the response of the hypothalamic OXT- and AVP-producing cells was amplified following CHS and CHeS, respectively. In rats exposed to AS for 90min solid GE significantly delayed. The delayed-GE was completely restored to the basal level following CHS, however, it remained delayed in CHeS-loaded rats. The CHS-induced restoration was prevented by L-371257, whereas SSR-149415 abolished the CHeS-induced impaired GE. A significant correlation was observed between GE and (i) OXT in CHS-loaded rats (rho=0.61, p<0.05, positively), (ii) AVP in CHeS-loaded rats (rho=0.69, p<0.05, negatively). Under long term stressed conditions, the release of AVP and OXT from hypothalamus may vary depending on the content of the stressors. Central AVP appears to act oppositely to OXT by mediating CHeS-induced gastric motor maladaptation. Long term central AVP antagonism might be a pharmacological approach for the treatment of stress-related gastric motility disorders.

Motility Evaluation in the Patient with Inflammatory Bowel Disease

Patients with inflammatory bowel disease (IBD) suffer frequently from functional bowel diseases (FBD) and motility disorders. Management of FBD and motility disorders in IBD combined with continued treatment of a patient's IBD symptoms will likely lead to better clinical outcomes and improve the patient's quality of life. The goals of this review were to summarize the most recent literature on motility disturbances in patients with IBD and to give a brief overview of the ranges of motility disturbances, from reflux disease to anorectal disorders, and discuss their diagnosis and specific management.

Effect of clinician-patient communication on compliance with flupentixol-melitracen in functional dyspepsia patients

AIM: To explore whether clinician-patient communication affects adherence to psychoactive drugs in functional dyspepsia (FD) patients with psychological symptoms.

METHODS: A total of 262 FD patients with psychological symptoms were randomly assigned to four groups. The patients in Groups 1-3 were given flupentixol-melitracen (FM) plus omeprazole treatment. Those in Group 1 received explanations of both the psychological and gastrointestinal (GI) mechanisms of the generation of FD symptoms and the effects of FM. In Group 2, only the psychological mechanisms were emphasized. The patients in Group 3 were not given an explanation for the prescription of FM. Those in Group 4 were given omeprazole alone. The primary endpoints of this study were compliance rate and compliance index to FM in Groups 1-3. Survival analyses were also conducted. The secondary end points were dyspepsia and psychological symptom improvement in Groups 1-4. The correlations between the compliance indices and the reductions in dyspepsia and psychological symptom scores were also evaluated in Groups 1-3.

RESULTS: After 8 wk of treatment, the compliance rates were 67.7% in Group 1, 42.4% in Group 2 and 47.7% in Group 3 (Group 1 vs Group 2, P = 0.006; Group 1 vs Group 3, P = 0.033). The compliance index (Group 1 vs Group 2, P = 0.002; Group 1 vs Group 3, P = 0.024) with the FM regimen was significantly higher in Group 1 than in Groups 2 and 3. The survival analysis revealed that the patients in Group 1 exhibited a significantly higher compliance rate than Groups 2 and 3 (Group 1 vs Group 2, P = 0.002; Group 1 vs Group 3, P = 0.018). The improvement in dyspepsia (Group 1 vs Group 2, P < 0.05; Group 1 vs Group 3, P < 0.05; Group 1 vs Group 4, P < 0.01) and psychological symptom scores (anxiety: Group 1 vs Group 2, P < 0.01; Group 1 vs Group 3, P < 0.05; Group 1 vs Group 4, P < 0.01; depression: Group 1 vs Group 2, P < 0.01; Group 1 vs Group 3, P < 0.01; Group 1 vs Group 4, P < 0.01) in Group 1 were greater than those in Groups 2-4. The compliance indices were positively correlated with the reduction in symptom scores in Groups 1-3.

CONCLUSION: Appropriate clinician-patient communication regarding the reasons for prescribing psychoactive drugs that emphasizes both the psychological and GI mechanisms might improve adherence to FM in patients with FD.

Efficacy and safety of jollab to treat functional dyspepsia: a randomized placebo-controlled clinical trial

BACKGROUND

Functional dyspepsia (FD) is a common gastrointestinal disease that is highly prevalent worldwide. Because of its heterogeneous pathophysiology, treatment options for FD can be difficult to choose; in this context, complementary and alternative medicine modalities have been suggested as promising options.

AIM

To evaluate the efficacy of a traditional Persian medicine, jollab, in reducing patients' FD symptoms.

METHODS

In a double-blind randomized clinical trial, 160 patients with a diagnosis of FD were enrolled and treated with either jollab or placebo (15ml, t.i.d., four weeks, orally). The outcomes reported were changes in symptom frequency and severity as recorded in patients' diaries and evaluated with the Short Form of the Leeds Dyspepsia Questionnaire (SF-LDQ), and physical examination.

RESULTS

The response rate was higher in the treatment group (78%) than in the placebo group (31%) according to per-protocol sample analysis (P < .001). Symptoms of FD disappeared significantly more frequently, and the rate of concomitant synthetic drug consumption was significantly lower, in the jollab group compared to the placebo group at the end of the trial. Mean total symptom frequency and severity according to the SF-LDQ score was 1.55 ± 2.78 in the treatment group versus 5.61 ± 3.80 in the placebo group at the last follow-up time point (P < .001). A promising safety profile for jollab was observed throughout the trial.

CONCLUSIONS

In patients with FD, jollab appeared to be more effective than the placebo. Complementary and alternative therapies such as the use of this traditional medicinal substance may be beneficial in relieving symptoms of dyspepsia [ACTRN12613000584730].

Health benefits of fermented milk containing Bifidobacterium bifidum YIT 10347 on gastric symptoms in adults

We conducted a preliminary open trial (trial 1) and a double-blind, placebo-controlled, crossover trial (trial 2) to examine how fermented milk containing the probiotic Bifidobacterium bifidum YIT 10347 affects gastric and lower abdominal symptoms in adults taking no medication. In trial 1, subjects with or without gastric and lower abdominal symptoms ingested fermented milk containing B. bifidum YIT 10347 daily for 2 wk. In trial 2, subjects with gastric symptoms ingested fermented milk containing B. bifidum YIT 10347 (active preparation) or placebo daily for 2 wk, followed by crossover for 3 wk after a washout period. Before (baseline) and 1 and 2 wk after ingestion, subjects completed a questionnaire. In trial 1 (305 subjects), the prevalence of gastric and lower abdominal symptoms was 46 and 58%, respectively, at baseline. Ingestion of B. bifidum YIT 10347 significantly decreased the prevalence of gastric and lower abdominal symptoms from 45 to 33% at 1 wk and to 28% at 2 wk, and from 57 to 40% at 2 wk, respectively. In subjects with gastric symptoms at baseline, the average gastric symptom score per subject significantly decreased by 0.9 at 1 wk and 1.2 at 2 wk. In trial 2 (27 subjects), ingestion of the active preparation significantly decreased the average gastric symptoms score per subject by 1.0 at 1 wk and 1.1 at 2 wk, but ingestion of placebo milk had no effect. No side effects were reported by any subjects in either trial. We conclude that fermented milk containing B. bifidum YIT 10347 has the potential to provide health benefits by alleviating gastric symptoms in subjects taking no medication.

Effects of GC7101, a Novel Prokinetic Agent on Gastric Motor Function: Ex Vivo Study

Background/Aims

GC7101, an extract of Lonicera Flos, is a novel developing drug for reflux esophagitis and functional dyspepsia. However, the drug’s exact pharmacological mechanism of action remains unclear. This study assessed the effects of GC7101 on gastrointestinal (GI) motor function.

Methods

We used male guinea pigs to evaluate the effects of GC7101 on GI motility. The contraction of antral circular muscle in the presence of different doses of GC7101 was measured in a tissue bath. The prokinetic effects of GC7101 were tested using the charcoal transit assay from the pylorus to the most distal point of migration of charcoal mixture. To clarify the mechanism of action of GC7101, atropine, dopamine and the selective 5-hydroxytryptamine 4 receptor antagonist, GR113808 were used.

Results

The maximal amplitude of circular muscle contraction was induced by 5 mg mL⁻¹ GC7101. The area under the curve of contraction was significantly increased at 5 mg mL⁻¹ GC7101. Addition of 10⁻⁶ M atropine, 10⁻⁸ M dopamine or 10⁻⁷ M GR 113808 to GC7101 5 mg mL⁻¹ decreased the amplitude and area under curve compared to GC7101 5 mg mL⁻¹ alone. GC7101 accelerated GI transit in a dose dependent manner except 100 mg kg⁻¹. Delayed GI transit caused by atropine, dopamine and GR 113808 was restored by GC7101 50 mg kg⁻¹.

Conclusions

GC7101, an extract of Lonicera Flos, exerts a gastric prokinetic effect in guinea pig through cholinergic, antidopaminergic and serotonergic mechanisms. Therefore, GC7101 might be a novel drug for the treatment of functional dyspepsia.

Overlap in patients with dyspepsia/functional dyspepsia

Patients with dyspepsia/functional dyspepsia (FD) show frequent overlapping of other gastrointestinal (GI) diseases, such as irri-table bowel syndrome, and non-GI diseases, in addition to internal subgroup overlapping. These overlap patients have more frequent or more severe symptoms, poorer health-related quality of life and higher somatization scores, and they are more like-ly to experience anxiety, depression or insomnia compared to non-overlap patients. The higher prevalence of overlap in patients with dyspepsia/FD is not by chance, indicating common pathogeneses, including visceral hypersensitivity, altered GI motility, in-fection, and stressful early life events. There are few clinical trials targeting overlap in patients with dyspepsia/FD, and no ther-apeutic strategy has been established. Further studies in this research area are needed. In this review, we describe the epidemi-ology, pathogenesis and treatment of overlap in patients with dyspepsia/FD.(J Neurogastroenterol Motil 2014;20:447-457).

Glyphosate, pathways to modern diseases II: Celiac sprue and gluten intolerance

Celiac disease, and, more generally, gluten intolerance, is a growing problem worldwide, but especially in North America and Europe, where an estimated 5% of the population now suffers from it. Symptoms include nausea, diarrhea, skin rashes, macrocytic anemia and depression. It is a multifactorial disease associated with numerous nutritional deficiencies as well as reproductive issues and increased risk to thyroid disease, kidney failure and cancer. Here, we propose that glyphosate, the active ingredient in the herbicide, Roundup(®), is the most important causal factor in this epidemic. Fish exposed to glyphosate develop digestive problems that are reminiscent of celiac disease. Celiac disease is associated with imbalances in gut bacteria that can be fully explained by the known effects of glyphosate on gut bacteria. Characteristics of celiac disease point to impairment in many cytochrome P450 enzymes, which are involved with detoxifying environmental toxins, activating vitamin D3, catabolizing vitamin A, and maintaining bile acid production and sulfate supplies to the gut. Glyphosate is known to inhibit cytochrome P450 enzymes. Deficiencies in iron, cobalt, molybdenum, copper and other rare metals associated with celiac disease can be attributed to glyphosate's strong ability to chelate these elements. Deficiencies in tryptophan, tyrosine, methionine and selenomethionine associated with celiac disease match glyphosate's known depletion of these amino acids. Celiac disease patients have an increased risk to non-Hodgkin's lymphoma, which has also been implicated in glyphosate exposure. Reproductive issues associated with celiac disease, such as infertility, miscarriages, and birth defects, can also be explained by glyphosate. Glyphosate residues in wheat and other crops are likely increasing recently due to the growing practice of crop desiccation just prior to the harvest. We argue that the practice of "ripening" sugar cane with glyphosate may explain the recent surge in kidney failure among agricultural workers in Central America. We conclude with a plea to governments to reconsider policies regarding the safety of glyphosate residues in foods.

[Clinical practice guideline on the management of patients with dyspepsia. Update 2012]

The aim of the Clinical Practice Guideline (CPG) on the Management of Patients with Dyspepsia is to generate recommendations on the optimal approach to dyspepsia in the primary care and specialized outpatient setting. The main objective of this CPG is to help to optimize the diagnostic process, identifying patients with a low risk of a serious organic disease (mainly tumoral), who could be safely managed without the need for invasive diagnostic tests and/or referral to a specialist. The importance of this aim lies in the need to accurately diagnose patients with esophagogastric cancer and correctly treat peptic ulcer while, at the same time, reduce negative endoscopies in order to appropriately use the available healthcare resources. This CPG reviews the initial strategies that can be used in patients with uninvestigated dyspepsia and evaluates the possible decision to begin empirical therapy or to investigate the existence of a lesion that could explain the symptoms. This CPG also discusses functional dyspepsia, which encompasses all patients with dyspepsia with no demonstrable cause on endoscopy. Recommendations for the diagnosis and treatment of peptic ulcer and Helicobacter pylori infection are also made. To classify the scientific evidence and strengthen the recommendations, the GRADE (Grading of Recommendations Assessment, Development and Evaluation Working Group) system has been used (http://www.gradeworkinggroup.org/).

[Clinical practice guideline on the management of patients with dyspepsia. Update 2012]

The aim of the Clinical Practice Guideline (CPG) on the Management of Patients with Dyspepsia is to generate recommendations on the optimal approach to dyspepsia in the primary care and specialized outpatient setting. The main objective of this CPG is to help to optimize the diagnostic process, identifying patients with a low risk of a serious organic disease (mainly tumoral), who could be safely managed without the need for invasive diagnostic tests and/or referral to a specialist. The importance of this aim lies in the need to accurately diagnose patients with esophagogastric cancer and correctly treat peptic ulcer while, at the same time, reduce negative endoscopies in order to appropriately use the available healthcare resources.This CPG reviews the initial strategies that can be used in patients with uninvestigated dyspepsia and evaluates the possible decision to begin empirical therapy or to investigate the existence of a lesion that could explain the symptoms. This CPG also discusses functional dyspepsia, which encompasses all patients with dyspepsia with no demonstrable cause on endoscopy. Recommendations for the diagnosis and treatment of peptic ulcer and Helicobacter pylori infection are also made. To classify the scientific evidence and strengthen the recommendations, the GRADE (Grading of Recommendations Assessment, Development and Evaluation Working Group) system has been used (http://www.gradeworkinggroup.org/).

Electrogastrography associated with symptomatic changes after prokinetic drug treatment for functional dyspepsia

AIM: To evaluate the effect of prokinetic drugs on electrogastrography (EGG) parameters according to symptomatic changes in patients with functional dyspepsia (FD).

METHODS: Seventy-four patients with FD were prospectively enrolled in this study between December 2006 and December 2010. We surveyed the patients using a questionnaire on dyspeptic symptoms before and after an 8-wk course of prokinetic drug treatment. We also measured cutaneous pre-prandial and post-prandial EGG recordings including percentage of gastric waves (normogastria, bradygastria, tachygastria), dominant frequency (DF), dominant power (DP), dominant frequency instability coefficient (DFIC), dominant power instability coefficient (DPIC), and the ratio of post-prandial to fasting in DP before and after the 8-wk course of prokinetic drug treatment.

RESULTS: Fifty-two patients (70%) achieved symptomatic improvement after prokinetic drug treatment. Patients who had normal gastric slow waves showed symptom improvement group after treatment. Post-prandial DF showed a downward trend in the symptom improvement group, especially in the itopride group. Post-prandial DP was increased regardless of symptom improvement, especially in the itopride group and mosapride group. Post-prandial DFIC and DPIC in the symptom improvement group were significantly increased after the treatment. The EGG power ratio was increased after treatment in the symptom improvement group (0.50 ± 0.70 vs 0.93 ± 1.77, P = 0.002), especially in the itopride and levosulpiride groups.

CONCLUSION: Prokinetics could improve the symptoms of FD by regulating gastric myoelectrical activity, and EGG could be a useful tool in evaluating the effects of various prokinetics.

Itopride in the treatment of functional dyspepsia in Chinese patients: a prospective, multicentre, post-marketing observational study

BACKGROUND

Prokinetic agents are commonly used in the symptomatic treatment of functional dyspepsia (FD). Safety or efficacy issues associated with the use of available prokinetics, such as metoclopramide, domperidone, cisapride and mosapride, mean there is a need for an effective and well tolerated prokinetic agent. Itopride is a novel prokinetic agent with a dual mode of action, good safety profile and documented efficacy in placebo-controlled trials.

OBJECTIVE

The objective of this study was to assess the effectiveness and safety of itopride in the management of FD.

METHODS

This was a prospective, multicentre, post-marketing observational study carried out in private outpatient clinics throughout China. The study included patients with symptomatic FD aged ≥18 years. Patients were prescribed itopride 50 mg three times daily before meals for 4 weeks, after which there was a 2-week follow-up period during which they did not take itopride. Effectiveness and tolerability data obtained from patients who completed 4 weeks of therapy were analysed. The treatment response rate after 4 weeks was measured by patient global assessment; scores at the end of treatment were compared with baseline scores. Response rate based on symptom scoring was also measured after 4 weeks, with an effective treatment being defined as a symptom improvement of ≥50%.

RESULTS

In total, 587 patients with FD were enrolled. The mean ± SD difference in the total symptom score before and after the 4-week treatment period was -5.62 ± 3.27, corresponding to a 69.23 ± 26.53% reduction from baseline (p < 0.001). The treatment response rates in patients who fulfilled Rome I, II and III criteria for FD were 33.68%, 34.71% and 35.50%, respectively, after 1 week of treatment; 52.82%, 54.61% and 56.51%, respectively, after 2 weeks; 66.67%, 67.23% and 68.64%, respectively, after 3 weeks; and 72.82%, 73.54% and 75.15%, respectively, after 4 weeks. Response rates were significantly different at 1 week versus 4 weeks of treatment. Nine patients (1.54%) had adverse events: four were probably related to the study drug, three were possibly related and two were not related. Of the nine patients with adverse events, two discontinued the study drug, two suspended (i.e. temporarily discontinued the drug until the adverse event subsided) the study drug, and five continued the study drug. Seven of the nine patients with adverse events had adverse reactions (defined as adverse events considered causally related to the study drug): two improved, three recovered and two showed no change. No adverse reactions were serious enough to warrant discontinuation of therapy.

CONCLUSION

Itopride was an effective and well tolerated drug in the management of FD in this patient population.

Review article: current treatment options and management of functional dyspepsia

BACKGROUND

Functional dyspepsia (FD), a common functional gastrointestinal disorder, is defined by the Rome III criteria as symptoms of epigastric pain or discomfort (prevalence in FD of 89-90%), postprandial fullness (75-88%), and early satiety (50-82%) within the last 3 months with symptom onset at least 6 months earlier. Patients cannot have any evidence of structural disease to explain symptoms and predominant symptoms of gastroesophageal reflux are exclusionary. Symptoms of FD are non-specific and the pathophysiology is diverse, which explains in part why a universally effective treatment for FD remains elusive.

AIM

To present current management options for the treatment of FD (therapeutic gain/response rate noted when available).

RESULTS

The utility of Helicobacter pylori eradication for the treatment of FD is modest (6-14% therapeutic gain), while the therapeutic efficacy of proton pump inhibitors (PPI) (7-10% therapeutic gain), histamine-type-2-receptor antagonists (8-35% therapeutic gain), prokinetic agents (18-45%), tricyclic antidepressants (TCA) (response rates of 64-70%), serotonin reuptake inhibitors (no better than placebo) is limited and hampered by inadequate data. This review discusses dietary interventions and analyses studies involving complementary and alternative medications, and psychological therapies.

CONCLUSIONS

A reasonable treatment approach based on current evidence is to initiate therapy with a daily PPI in H. pylori-negative FD patients. If symptoms persist, a therapeutic trial with a tricyclic antidepressant may be initiated. If symptoms continue, the clinician can possibly initiate therapy with an anti-nociceptive agent, a prokinetic agent, or some form of complementary and alternative medications, although evidence from prospective studies to support this approach is limited.

A placebo-controlled trial of an oral capsaicin load in patients with functional dyspepsia

BACKGROUND

The pathophysiology of functional dyspepsia is poorly understood. Visceral hypersensitivity may play a key role. We studied a previously validated test to assess chemical hypersensitivity in functional dyspepsia by applying an oral capsaicin load.

METHODS

A total of 116 outpatients with upper gastrointestinal (GI) symptoms participated in this double-blind, placebo-controlled trial of which 73 patients received a final diagnosis of functional dyspepsia. Patients swallowed a capsule containing 0.75 mg capsaicin or placebo. A graded questionnaire evaluated the severity of nine upper GI symptoms before and after capsule ingestion and an aggregate symptom score was calculated. A final score of >9 was considered as a positive test.

KEY RESULTS

In functional dyspepsia, median perception scores were 10.8 (interquartile range: 4.5-18.8) after ingestion of capsaicin and 0.5 (0.0-2.5) after placebo (P < 0.001). Thirty-seven functional dyspepsia patients (54%) had a positive test after capsaicin ingestion, whereas only four (11%) patients with upper GI symptoms but without functional dyspepsia were capsaicin positive [median perception score: 1.5 (0.0-5.0)]. After placebo, symptom scores were low and not significantly different among patient groups (P > 0.05). Clinical characteristics, age, and gender distribution was similar in capsaicin positive and capsaicin negative functional dyspepsia patients (P > 0.05). The value of patient blinding was good.

CONCLUSIONS & INFERENCES

Half of functional dyspepsia patients had chemical hypersensitivity, determined with an oral capsaicin load. Placebo response was negligible. The results of the capsaicin test were not associated with specific dyspepsia symptoms or Rome subgroups.

Therapeutic strategies for the treatment of dyspepsia

IMPORTANCE OF THE FIELD

Dyspeptic symptoms are highly prevalent in the population and represent a major burden for healthcare systems. The ROME III criteria address and define two separate entities of functional dyspepsia: epigastric pain syndrome and postprandial distress syndrome. The etiology of dyspeptic symptoms is heterogeneous, underlying mechanisms are poorly understood and symptomatic improvement after drug therapy is often incomplete.

AREAS COVERED IN THIS REVIEW

This review of the literature included Medline data being published in the field of functional dyspepsia and different therapies.

WHAT THE READER WILL GAIN

The reader will gain a current, unbiased understanding of the pathophysiological mechanisms underlying functional dyspepsia and of the therapeutic regimens based on randomized, controlled trials and on the meta-analyses that have been published on different therapeutic agents.

TAKE HOME MESSAGE

Before starting medical treatment, a careful physical examination should exclude 'alarm symptoms'. Laboratory data, ultrasound and endoscopy are recommended in patients older than 45 - 55 years (depending on the guidelines being used). In areas with a high prevalence of Helicobacter pylori, the initial strategy includes 'test and treat' for H. pylori in addition to empiric acid suppressive therapy. Many studies have focused on the role of gastrointestinal dysmotility and hypersensitivity for dyspepsia with inconclusive results. Further therapeutic medical strategies include prokinetics, herbal preparations and psycho-/neurotopic drugs as well as additional psycho- or hypnotherapy.

An Extract of Glycyrrhiza glabra (GutGard) Alleviates Symptoms of Functional Dyspepsia: A Randomized, Double-Blind, Placebo-Controlled Study

A randomized, double-blind, placebo-controlled study was conducted to evaluate the efficacy of GutGard, an extract of Glycyrrhiza glabra, in patients with functional dyspepsia. The primary outcome variables of the study were the change in the severity symptoms and the global assessment of efficacy. The quality of life was evaluated as a secondary outcome measure. The patients received either placebo or GutGard (75 mg twice daily) for 30 days. Efficacy was evaluated in terms of change in the severity of symptoms (as measured by 7-point Likert scale), the global assessment of efficacy, and the assessment of quality of life using the short-form Nepean Dyspepsia Index. In comparison with placebo, GutGard showed a significant decrease (P ≤ .05) in total symptom scores on day 15 and day 30, respectively. Similarly, GutGard showed marked improvement in the global assessment of efficacy in comparison to the placebo. The GutGard group also showed a significant decrease (P ≤ .05) in the Nepean dyspepsia index on day 15 and 30, respectively, when compared to placebo. GutGard was generally found to be safe and well-tolerated by all patients. GutGard has shown significant efficacy in the management of functional dyspepsia.

Effect of an herbal preparation, STW 5, in an acute model of reflux oesophagitis in rats

A multitarget herbal preparation, STW 5, has been used clinically in different gastro-intestinal disorders including functional dyspepsia and irritable bowel syndrome. Previous studies have shown that it possesses properties that may render it useful in gastro-oesophageal reflux disease (GERD). We performed this study to test this compound in an acute model of reflux oesophagitis in rats. Oesophagitis was induced surgically by ligating the pyloric end and fore-stomach. Lower oesophageal pH was measured 3 h later in conscious animals. Five hours after surgery, animals were sacrificed and the oesophagi were examined macroscopically and histologically. Selected markers of inflammation were measured in oesophageal homogenates. STW 5 was given orally for 5 days before induction of oesophagitis. Pantoprazole was used as a reference standard. Ligated animals showed a high incidence of ulcerative lesions associated with a marked increase in myeloperoxidase, thiobarbituric acid-reactive substances, tumor necrosis factor-alpha, and interleukin-1beta. STW 5 did not affect oesophageal pH, but dose-dependently reduced the severity of the oesophageal lesions and normalized the deranged level of the inflammation markers. The beneficial effects were confirmed histopathologically. STW 5 proved to be effective in protecting against inflammatory lesions in this model of oesophagitis, thus warranting further investigation of its potential therapeutic usefulness in GERD.

Long-term tegaserod treatment for dysmotility-like functional dyspepsia: results of two identical 1-year cohort studies

BACKGROUND

Functional dyspepsia (FD) is a chronic disorder that adversely affects health-related quality of life (HRQoL). Published information on its long-term management is minimal and treatment options are limited.

AIM

The aim of this study was to evaluate safety, efficacy and HRQoL with tegaserod 6 mg twice daily over 1 year in women with FD who completed one of two 6-week, randomized, placebo-controlled, double-blind studies.

METHODS

About 780 patients received tegaserod 6 mg twice daily in two identical 1-year extension studies. Scheduled assessments included adverse events, the Short-Form Nepean Dyspepsia Index (SF-NDI), Work Productivity and Activity Impairment-Dyspepsia (WPAI-Dyspepsia) questionnaire, and patient perceptions of treatment efficacy.

RESULTS

Mean tegaserod treatment duration in the two studies was 236 and 222 days. Most adverse events occurred in the first 6 months, were similar to previous reports (commonly diarrhea), and were transient and well tolerated. SF-NDI, WPAI-Dyspepsia scores and perceived symptom relief improved from baseline over the 1-year evaluation.

CONCLUSIONS

The long-term safety profile of tegaserod in women with FD was consistent with that of short-term treatment and accompanied by improvements in HRQoL, work productivity and symptom relief. These long-term results add to the clinical experience with FD and support the potential value of a 5-HT(4) agonist in the management of FD.

Gastroparesis and functional dyspepsia: excerpts from the AGA/ANMS meeting

BACKGROUND

Despite the relatively high prevalence of gastroparesis and functional dyspepsia, the aetiology and pathophysiology of these disorders remain incompletely understood. Similarly, the diagnostic and treatment options for these two disorders are relatively limited despite recent advances in our understanding of both disorders.

PURPOSE

This manuscript reviews the advances in the understanding of the epidemiology, pathophysiology, diagnosis, and treatment of gastroparesis and functional dyspepsia as discussed at a recent conference sponsored by the American Gastroenterological Association (AGA) and the American Neurogastroenterology and Motility Society (ANMS). Particular focus is placed on discussing unmet needs and areas for future research.

Functional dyspepsia: Validation and results of a novel survey instrument to evaluate patient knowledge and perceptions

BACKGROUND

Patients' knowledge and perceptions of functional dyspepsia (FD) may affect illness behavior and healthcare utilization.

AIMS

To develop, validate, and administer a survey instrument to assess symptoms, knowledge, and fears in FD patients.

METHODS

A 66-item questionnaire was generated. Items assessed domains of etiology, diagnosis, natural history, and fears. Face and content validity were established through expert review and a patient focus group. After validation, questionnaires were mailed to a separate group of FD patients. Responses were analyzed using scales and means.

RESULTS

For survey validation, 66 of 80 patients (83%) returned both surveys. Internal consistency was good for most scale level measures (alpha=0.50 to 0.90). Reliability coefficients were good for measures of symptom assessment (intraclass correlation coefficient=0.75 to 0.89) and consulting behaviors (intraclass correlation coefficient=0.76 to 0.89). After survey validation, an additional 223 (62.8%) questionnaires were returned. Misperceptions were noted in the domains of etiology, diagnosis, treatment and risks of FD. Forty-eight percent of the respondents believed FD increases the risk of developing an ulcer and 32% believed there was an increased risk of developing stomach or colon cancer.

CONCLUSIONS

This novel questionnaire demonstrated good validity and reliability in FD patients, and identified significant misperceptions about the etiology, evaluation, treatment, and natural history of FD.

Evaluation of manual acupuncture at classical and nondefined points for treatment of functional dyspepsia: a randomized-controlled trial

PURPOSE

Acupuncture has been used traditionally as a treatment for functional dyspepsia (FD). The goal of this trial was to examine the efficacy of acupuncture at classical points and nondefined points as a treatment for functional dyspepsia.

METHODS

Sixty-eight (68) patients with functional dyspepsia, as defined by Rome-II criteria, were randomized into two groups: classical six-point acupuncture and nondefined-point acupuncture. Acupuncture was conducted three times per week for 2 weeks in a single-blind setting. To assess the effects of acupuncture, symptoms and quality of life were scored according to the Nepean Dyspepsia Index before and after acupuncture treatments.

RESULTS

Acupuncture treatment significantly decreased the dyspepsia symptoms and improved the quality of life. There was no statistical difference between the acupuncture groups treated at classical and nondefined points.

CONCLUSIONS

Our data show that both acupunctures at classical points and nondefined points improved the symptoms of patients with FD. However, we cannot rule out the possibilities of placebo effect in this trial.

Upper gastrointestinal symptoms, psychosocial co-morbidity and health care seeking in general practice: population based case control study

BACKGROUND

The pathophysiology of upper gastrointestinal (GI) symptoms is still poorly understood. Psychological symptoms were found to be more common in patients with functional gastrointestinal complaints, but it is debated whether they are primarily linked to GI symptoms or rather represent motivations for health-care seeking. Purpose of our study was to compare co-morbidity, in particular psychological and social problems, between patients with and without upper GI symptoms. In addition, we investigated whether the prevalence of psychological and social problems is part of a broader pattern of illness related health care use.

METHODS

Population based case control study based on the second Dutch National Survey of general practice (conducted in 2001). Cases (adults visiting their primary care physician (PCP) with upper GI symptoms) and controls (individuals not having any of these complaints), matched for gender, age, PCP-practice and ethnicity were compared. Main outcome measures were contact frequency, prevalence of somatic as well as psychosocial diagnoses, prescription rate of (psycho)pharmacological agents, and referral rates. Data were analyzed using odds ratios, the Chi square test as well as multivariable logistic regression analysis.

RESULTS

Data from 13,389 patients with upper GI symptoms and 13,389 control patients were analyzed. Patients with upper GI symptoms visited their PCP twice as frequently as controls (8.6 vs 4.4 times/year). Patients with upper GI symptoms presented not only more psychological and social problems, but also more other health problems to their PCP (odds ratios (ORs) ranging from 1.37 to 3.45). Patients with upper GI symptoms more frequently used drugs of any ATC-class (ORs ranging from 1.39 to 2.90), including psychotropic agents. The observed differences were less pronounced when we adjusted for non-attending control patients. In multivariate regression analysis, contact frequency and not psychological or social co-morbidity was strongest associated with patients suffering from upper GI symptoms.

CONCLUSION

Patients with upper GI symptoms visit their PCP more frequently for problems of any organ system, including psychosocial problems. The relationship between upper GI symptoms and psychological problems is equivocal and may reflect increased health care demands in general.

Could gastric histology be a useful marker for making decision on Helicobacter pylori eradication therapy in patients with dyspepsia?

CONTEXT: It still remains an open debate whether Helicobacter pylori eradication is beneficial or not for the improvement of symptoms in functional dyspepsia. Differences in geographic distribution, the worldwide H. pylori genetic variability and the fact that the outcome of infection is strongly related to the virulence of the infecting strain are factors that might be driving ongoing controversies. OBJECTIVE: To study the correlation between gastric histology and H. pylori serology status in patients with dyspepsia. METHODS: This is a cross-sectional study where 40 consecutive dyspeptic patients (28 women and 12 men, mean age 48.5 years) with endoscopically normal stomachs were selected from the endoscopy unit at a university hospital in Recife, PE, Northeast of Brazil, between March 1998 and July 1999. Patients underwent gastric mucosal biopsy and serological tests (anti-Hp and anti-CagA antibodies). Gastric biopsies were examined using H-E and Giemsa stains and gastritis was classified and graded (mild, moderate or severe) according to "the updated Sydney System - Houston, 1994". RESULTS: Among 40 patients with dyspepsia the gastric histology revealed that about ¼ had moderate (25%) or severe (2.5%) gastritis. This subgroup of patients also had a greater positive frequency of anti-Hp (100% vs 41%; P = 0.0005) and anti-CagA (91% vs 58%; P = 0.09) antibodies when compared with those with normal histology (27.5%) or mild gastritis (45%). CONCLUSION: Since upper gastrointestinal endoscopy is part of the functional dyspepsia investigation and serology for anti-CagA antibody is not available in daily clinical practice, by biopsying gastric mucosa we would only be able to selectively apply H. pylori eradication therapy for those with histology that best correlate with virulent infecting strains (moderate or severe gastritis) - around ¼ of our study patients with dyspepsia.

Gastroprokinetic effects of DA-9701, a new prokinetic agent formulated with Pharbitis Semen and Corydalis Tuber

To develop a therapeutic for functional dyspepsia (FD), a prokinetic agent, DA-9701 has been newly formulated with Pharbitis Semen and Corydalis Tuber and we evaluated the gastroprokinetic effects of DA-9701 in comparison with conventional prokinetics. Oral administration with DA-9701 not only significantly accelerated gastric emptying in normal rats but also restored the delayed gastric emptying caused by apomorphine and cisplatin up to almost normal levels. For gastrointestinal transit, DA-9701 caused FITC-dextran to travel a significantly longer distance than the control, and in the delayed GI transit models induced by laparotomy and atopine, DA-9701 considerably increased the values of mean geometric center (MGC), while the conventional prokinetics rarely showed significant effects. Furthermore, DA-9701 drastically increased the gastric accommodation in Beagle dogs, shifting the pressure-volume curve toward considerably higher volume compared to the control, which was comparable to that of cisapride. These results indicate that DA-9701 has potential as a safe and effective therapeutic for FD patients with abnormalities in GI motor function.

Efficacy and safety of pantoprazole 20 mg once daily treatment in patients with ulcer-like functional dyspepsia

OBJECTIVE

To investigate the efficacy of pantoprazole 20 mg once daily (o.d.) in relieving epigastric pain associated with ulcer-like functional dyspepsia.

RESEARCH DESIGN AND METHODS

In this double-blind, placebo-controlled, multicentre study, patients experiencing ulcer-like functional dyspepsia, with epigastric pain as the predominant symptom, were randomised to receive pantoprazole 20 mg or placebo o.d. for 28 days. Primary endpoint was the complete relief (i.e. absence) from epigastric pain after 28 days' treatment. The odds ratio (OR) for pantoprazole/placebo and its 95% confidence intervals (CIs) were determined. Significant superiority of pantoprazole was concluded if the value 1.0 was above this interval.

RESULTS

Of 419 patients (intention-to-treat [ITT]) randomised to treatment, 207 received pantoprazole and 212 received placebo. Epigastric pain relief was achieved after 28 days' treatment in 55% of pantoprazole recipients and 45% of placebo recipients (per-protocol [PP]: 58% and 47%, respectively). Pantoprazole demonstrated statistically significant superiority compared with placebo in the ITT (OR: 0.68; 95% CI: 0.46-0.99) and PP populations (OR: 0.64; 95% CI: 0.42-0.98). Pantoprazole was more efficacious than placebo in relieving heartburn and acid regurgitation after 7, 14 and 28 days of treatment. The sum score of gastrointestinal symptoms after 28 days was statistically significantly lower in the pantoprazole than placebo group. Fewer patients receiving concomitant psychotropic medication experienced relief from epigastric pain than those not receiving such medication. Adverse events did not significantly differ between pantoprazole and placebo.

CONCLUSIONS

Results of this study suggest that pantoprazole 20 mg is more efficacious than placebo, and is a well-tolerated treatment for relieving epigastric pain in patients with ulcer-like functional dyspepsia. Further research is needed to confirm these findings.

Serotonin pharmacology in the gastrointestinal tract: a review

Serotonin (5-hydroxytryptamine or 5-HT) plays a critical physiological role in the regulation of gastrointestinal (GI) function. 5-HT dysfunction may also be involved in the pathophysiology of a number of functional GI disorders, such as chronic constipation, irritable bowel syndrome and functional dyspepsia. This article describes the role of 5-HT in the enteric nervous system (ENS) of the mammalian GI tract and the receptors with which it interacts. Existing serotonergic therapies that have proven effective in the treatment of GI functional disorders and the potential of drugs currently in development are also highlighted. Advances in our understanding of the physiological and pathophysiological roles of 5-HT in the ENS and the identification of selective receptor ligands bodes well for the future development of more efficacious therapies for patients with functional GI disorders.