Dyspepsia: current understanding and management

Current status of peptic ulcer disease in Port Harcourt metropolis, Nigeria

Background

Epidemiological studies on peptic ulcer disease (PUD) have shown a recent decrease in hospital admissions in Western countries.

Objective

This paper aimed to study the current status and risk factors of PUD in a Nigerian metropolis.

Methods

A cross-sectional study of symptomatic patients at upper gastrointestinal (GI) endoscopy diagnosed with PUD from February 2014 to September 2019 at a referral endoscopy facility in Port Harcourt, Niger delta region of Nigeria. The variables studied included demographics, symptoms and duration, blood group, chronic non-steroidal anti-inflammatory (NSAID) use, smoking, endoscopic and histology findings. Statistical analysis was performed using SPSS version 20.

Results

A total of 434 upper GI endoscopies were performed during the study period with thirty-one diagnosis of PUD made. The mean age of gastric ulcer (GU) and duodenal ulcer (DU) cases were 54.4 ± 20.2yrs and 48.1 ± 14.5yrs respectively (p = 0.367). GU to DU ratio was 1.4:1. H. pylori infection, chronic NSAID use and blood group O were seen in 7(22.5%), 8(25.8%) and 18(72.0%) respectively. Major indication in 21(67.7%) cases was gastrointestinal bleeding.

Conclusion

There is a low diagnostic rate of PUD (6.7%) with pre-pyloric antral gastric ulcers as most common type and multifactorial aetiology.

Overdiagnosis of gastro-esophageal reflux disease and underdiagnosis of functional dyspepsia in a USA community

BACKGROUND

There is symptom overlap between gastro-esophageal reflux disease (GERD) and functional dyspepsia (FD). We aimed to test the hypothesis that FD cases are now more likely mislabeled as GERD.

METHODS

In subjects from Olmsted County, MN seen at Mayo Clinic: (i) Investigation of GERD and FD diagnosis rates between 1985 and 2009. (ii) Assessment of survey-based upper gastrointestinal symptoms between 1988 and 2009. (iii) Analysis of patients reporting GERD and/or FD symptoms and subsequently receiving a consistent diagnosis of GERD and/or FD during a medical encounter. (iv) Assess the association between PPI use and GERD and/or FD symptoms and between actual diagnoses received.

KEY RESULTS

(i) Yearly GERD diagnosis rates rose between 1985 and 2009 (325-1866 per 100 000). FD diagnosis rates rose from 45 in 1985, to 964 in 1999 but decreased to 452 per 100 000 in 2009. (ii) Reported GERD symptoms did not significantly change between three survey waves in the years 1988-2009 (p = 0.052), whereas FD symptoms slightly increased (p = 0.01). (iii) 62.9% of subjects reporting GERD symptoms received a GERD diagnosis, however only 12.5% of subjects reporting FD symptoms received a FD diagnosis. (iv) PPI use was associated with documented GERD diagnosis (p < 0.001), however there was no significant association between GERD symptoms and PPI use (p = 0.078).

CONCLUSIONS & INFERENCES

We have found evidence supporting a systematic bias away from diagnosing FD, favoring a GERD diagnosis.

Doubtful outcome of the validation of the Rome II questionnaire: validation of a symptom based diagnostic tool

Background

Questionnaires are used in research and clinical practice. For gastrointestinal complaints the Rome II questionnaire is internationally known but not validated. The aim of this study was to validate a printed and a computerized version of Rome II, translated into Swedish. Results from various analyses are reported.

Methods

Volunteers from a population based colonoscopy study were included (n = 1011), together with patients seeking general practice (n = 45) and patients visiting a gastrointestinal specialists' clinic (n = 67). The questionnaire consists of 38 questions concerning gastrointestinal symptoms and complaints. Diagnoses are made after a special code. Our validation included analyses of the translation, feasibility, predictability, reproducibility and reliability. Kappa values and overall agreement were measured. The factor structures were confirmed using a principal component analysis and Cronbach's alpha was used to test the internal consistency.

Results and Discussion

Translation and back translation showed good agreement. The questionnaire was easy to understand and use. The reproducibility test showed kappa values of 0.60 for GERS, 0.52 for FD, and 0.47 for IBS. Kappa values and overall agreement for the predictability when the diagnoses by the questionnaire were compared to the diagnoses by the clinician were 0.26 and 90% for GERS, 0.18 and 85% for FD, and 0.49 and 86% for IBS. Corresponding figures for the agreement between the printed and the digital version were 0.50 and 92% for GERS, 0.64 and 95% for FD, and 0.76 and 95% for IBS. Cronbach's alpha coefficient for GERS was 0.75 with a span per item of 0.71 to 0.76. For FD the figures were 0.68 and 0.54 to 0.70 and for IBS 0.61 and 0.56 to 0.66. The Rome II questionnaire has never been thoroughly validated before even if diagnoses made by the Rome criteria have been compared to diagnoses made in clinical practice.

Conclusion

The accuracy of the Swedish version of the Rome II is of doubtful value for clinical practice and research. The results for reproducibility and reliability were acceptable but the outcome of the predictability test was poor with IBS as an exception. The agreement between the digital and the paper questionnaire was good.

Abuse in women and men with and without functional gastrointestinal disorders

We aimed to investigate the history of abuse in childhood and adulthood and health-related quality of life (HRQL) in women and men with FGID in the general adult population. A cross-sectional study in a random population sample (n = 1,537, 20-87 years) living in Osthammar municipality, Sweden, in 1995 was performed. Persons with FGID (n = 141) and a group of abdominal symptom-free controls (SSF, n = 97) were selected by means of a validated questionnaire assessing gastrointestinal symptoms (the ASQ). Abuse, anxiety and depression (the HADS) and HRQL (the PGWB) were measured. Women with FGID had a higher risk of having a history of some kind of abuse, as compared with the SSF controls (45% vs.16%, OR = 2.0, 95% CI: 1.01-3.9; SSF = 1), in contrast to men (29% vs. 24% n.s.). Women with a history of abuse and FGID had reduced HRQL 91 (95% CI 85-97) as compared with women without abuse history 100 (95% CI 96-104, P = 0.01, "healthy" = 102-105 on PGWB). Childhood emotional abuse was a predictor for consulting with OR = 4.20 (95% CI: 1.12-15.7.7). Thus, previous abuse is common in women with FGID and must be considered by the physician for diagnosis and treatment of the disorder.

Functional dyspepsia affects women more than men in daily life: a case-control study in primary care

BACKGROUND

Little is known about possible gender differences among patients with functional dyspepsia (FD). Few studies have measured health-related quality of life (HRQoL) in patients with FD using a population-based control group as a reference.

OBJECTIVES

This study aimed to determine the degree of HRQoL impairment among patients with FD, to assess the self-reported health impact resulting from the disease, and to analyze any gender differences.

METHODS

A questionnaire that included the HRQoL Short Form 36 (SF-36) Health Survey, Hospital Anxiety and Depression Scale, and other measurements was mailed to patients with FD identified from medical records. The control group was randomly selected from the general population in the same geographical area. Responses to the SF-36 were transferred to a standard scale ranging from 0 (the worst possible score) to 100 (the best possible score).

RESULTS

Responders were assigned to 2 gender-specific subgroups, each with 88 patients with FD and 344 randomly matched controls, all aged 18 to 65 years. Compared with the controls, the HRQoL of patients with FD was impaired in all SF-36 dimensions except one -- role limitations caused by emotional problems. Female patients with FD had a significantly lower SF-36 score in the physical functioning dimension than did male patients (82.4 vs 90.5, respectively; P < 0.01). Both groups of patients with FD had impaired HRQoL compared with their respective control group in the dimensions of bodily pain (women: 69.3 vs 80.6, P < 0.001; and men: 75.8 vs 84.8, P < 0.001) and general health (women: 62.0 vs 75.6, P < 0.001; and men: 70.6 vs 78.6, P < 0.001). Additionally, women with FD had significant impairment compared with their respective control group in the dimensions of physical functioning (82.4 vs 89.3; P < 0.01) and physical role limitations (72.1 vs 85.9; P < 0.001). Depression was significantly more common among male patients with FD than among male controls (6.8% vs 2.0%, respectively; P < 0.05). More gastrointestinal comorbidity was reported among patients of both sexes compared with controls.

CONCLUSIONS

This population-based case-control study reported HRQoL impairment overall among patients with FD. This impairment was more apparent in female patients than in female controls. Females with FD tended to be more negatively affected in their daily life than their male counterparts. These gender differences should be investigated further in future studies.

Predictors and non-predictors of symptom relief in dyspepsia consultations in primary care

OBJECTIVE

We aimed to evaluate if the course of dyspepsia is influenced by medical consultation in primary care.

DESIGN, SETTING AND PATIENTS

Australian general practitioners (n = 27) recruited 157 dyspeptic patients, of whom 94 were eligible for follow-up. Dyspepsia, comorbidity, quality of life, emotional status, locus of control and consultation satisfaction were measured at baseline and follow-up (mean 3 months).

MAIN OUTCOME MEASURE

Response was defined as improvement of dyspepsia over time on the Nepean Dyspepsia Index score.

RESULTS

Dyspepsia improved in 82% (n = 77). There was no significant change in non-gastrointestinal symptoms. Half were worried or stressed by their symptoms, and 85% wanted reassurance, a need that (univariately) differentiated responders from non-responders (p = 0.02). Most patients seen in primary care with dyspepsia improved. If the doctor believed it was likely that the patient would follow their recommendations, the patient was nearly five times as likely to be a responder (OR 4.9, 95% CI 1.2-19.0). The only other significant predictor was acid suppression therapy (OR 3.5, 95% CI 1.1-10.9).

CONCLUSION

Most primary care visits for dyspepsia are followed by improvement, which may be predicted in part by indicators of patient compliance. Prescription of acid suppression therapy may also improve outcome in dyspepsia.

Detection of early gastric cancer: misunderstanding the role of mass screening

BACKGROUND

The proportion of early gastric cancer (EGC) increased from 15% during the 1960s to 50% recently, leading to a remarkable improvement of the 5-year survival rate of gastric cancer patients from 40% to 70%. This has been attributed to mass screening together with extended lymphadenectomy. However, more and more patients with EGC are diagnosed outside of mass screening. The aim of this study was to determine whether patients are symptomatic at the time of early detection and the method of tumor detection.

METHODS

From 2001 to 2003, a total of 1226 patients (male/female 2.2 : 1.0, age 26-95 years) with EGC were treated at the National Cancer Center Hospital, Tokyo. We reviewed their medical records.

RESULTS

Of these 1226 patients, 512 (41.8%) were symptomatic, and 714 (58.2%) reported no symptoms. Among the symptomatic patients, 468 (91.4%) were examined at outpatient clinics, 39 (7.6%) by private health assessment clinics, and 5 (1.0%) by mass screening. In total, 91.6% of the symptomatic patients directly underwent esophagogastro-duodenoscopy (EGD). Of the asymptomatic patients, 320 (44.8%) were examined at outpatient clinics, 306 (42.9%) by private health assessment clinics, and 88 (12.3%) by mass screening. EGD was the initial assessment in 67.8% and radiography in 32.2% of asymptomatic patients.

CONCLUSION

Most patients with EGC were detected outside of mass screening. This suggests that the Japanese public and physicians are well aware of the risk of gastric cancer and the importance of early detection. The effect of mass screening is misunderstood.

Luminal stimuli acutely sensitize visceromotor responses to distension of the rat stomach

Inflammation can enhance responses to different stimuli consistent with the development of hypersensitivity. To determine whether sequentially applied stimuli interact, we determined visceromotor responses (VMR) to gastric distension, measured at baseline and 60 min after instillation of saline, glycocholic acid (GCA) or ethanol through a gastrostomy in controls and rats with gastric ulcers. In another series of experiments, chemicals were administered before and 60 min after repeated distension of the stomach. Ethanol, but not saline or GCA, increased VMR in controls with a more significant rise in rats with gastric ulcerations. GCA increased responses to gastric distension in controls, whereas GCA and ethanol enhanced responses to gastric distensions in rats with gastric ulcers. Responses to saline, GCA, or ethanol were not affected by repeated noxious distension of the stomach. Luminal stimuli can trigger visceromotor responses and sensitize gastric afferents to mechanical stimulation, thus potentially contributing to dyspeptic symptoms.

Peptic ulcer disease in a general adult population: the Kalixanda study: a random population-based study

The authors' aim in this study was to explore the prevalence, symptomatology, and risk factors for peptic ulcer in a general adult population. Between December 1998 and June 2001, the authors surveyed a random sample (n=3,000) of the adult population (n=21,610) in two communities in northern Sweden using a validated questionnaire, the Abdominal Symptom Questionnaire (response rate=74%). A subsample (n=1,001) of the responders was randomly invited to undergo esophagogastroduodenoscopy and symptom assessment (response rate=73%). The prevalence of peptic ulcer was 4.1% (20 gastric ulcers and 21 duodenal ulcers). Nausea and gastroesophageal reflux were significant predictors of peptic ulcer disease, but epigastric pain/discomfort was not. Six persons with gastric ulcer and two persons with duodenal ulcer were asymptomatic. Eight subjects with duodenal ulcer (38%) lacked evidence of current Helicobacter pylori infection. Five (25%) of the gastric ulcers and four (19%) of the duodenal ulcers were idiopathic (no use of aspirin or nonsteroidal antiinflammatory drugs, no H. pylori infection). Smoking, aspirin use, and obesity were risk factors for gastric ulcer; smoking, low-dose (<or=160 mg) aspirin use, and H. pylori infection were risk factors for duodenal ulcer. Peptic ulcer disease often coexists with atypical symptoms or no symptoms at all, and idiopathic duodenal ulcer may be more common than anticipated.

Prokinetic effect of gut-oriented hypnosis on gastric emptying

BACKGROUND

No data are available on the effect of hypnosis on gastric emptying.

AIM

To determine the effect of a hypnosis session on gastric emptying and dyspeptic symptoms.

METHODS

We studied emptying by ultrasonography and epigastric sensations in 11 healthy subjects and in 15 patients affected by functional dyspepsia under three conditions according to a fixed schedule: (a) basal, (b) after cisapride and (c) during a 90 min hypnotic trance. Eight healthy subjects repeated an emptying study listening to relaxing music. Statistical analysis was performed using the Friedman test or RM-ANOVA.

RESULTS

In dyspeptics, the postprandial increase in the antral area was significantly smaller during the hypnosis trance than under the basal and the cisapride conditions. For the patients gastric emptying was significantly shortened by cisapride, and even more by hypnosis (basal 274 +/- 16.8 min; cisapride 227 +/- 13.2; hypnosis 150 +/- 9.7) whereas for healthy subjects it was shortened only by hypnosis. The repeated study in healthy subjects listening to relaxing music showed no significant difference compared with the basal. Epigastric sensations were improved in dyspeptics by hypnosis, but not by cisapride.

CONCLUSIONS

Gut-oriented hypnosis is effective in shortening gastric emptying both in dyspeptic and in healthy subjects.

Psychological illness is commonly associated with functional gastrointestinal disorders and is important to consider during patient consultation: a population-based study

BACKGROUND

Some individuals with functional gastrointestinal disorders (FGID) suffer long-lasting symptoms without ever consulting their doctors. Our aim was to study co-morbidity and lifestyle differences among consulters and non-consulters with persistent FGID and controls in a defined adult population.

METHODS

A random sample of the general adult Swedish population was obtained by a postal questionnaire. The Abdominal Symptom Questionnaire (ASQ) was used to measure GI symptomatology and grade of GI symptom severity and the Complaint Score Questionnaire (CSQ) was used to measure general symptoms. Subjects were then grouped for study by their symptomatic profiles. Subjects with long-standing FGID (n = 141) and subjects strictly free from gastrointestinal (GI) symptoms (n = 97) were invited to attend their local health centers for further assessment.

RESULTS

Subjects with FGID have a higher risk of psychological illness [OR 8.4, CI95(4.0-17.5)] than somatic illness [OR 2.8, CI95(1.3-5.7)] or ache and fatigue symptoms [OR 4.3, CI95(2.1-8.7)]. Subjects with psychological illness have a higher risk of severe GI symptoms than controls; moreover they have a greater chance of being consulters. Patients with FGID have more severe GI symptoms than non-patients.

CONCLUSION

There is a strong relation between extra-intestinal, mental and somatic complaints and FGID in both patients and non-patients. Psychological illness increases the chance of concomitantly having more severe GI symptoms, which also enhance consultation behaviour.

Serum leptin level in patients with functional dyspepsia

BACKGROUND/GOAL: Previous studies have shown that leptin plays a major role in the amount of food consumption. Recently, leptin and its receptors have been found in the human gastric mucosa. The aim of this study was to seek any possible correlation between serum leptin level and subtypes and pathological findings in functional dyspepsia.

MATERIALS AND METHODS

In a prospective study, we randomly select 44 patients as dysmotility-like and ulcer-like dyspepsia (according to ROME II criteria) in two equivalent groups and compared them with 22 healthy volunteers control group who matched the patients in relation to age, sex and body mass index. From each patient, a fasting blood sample for leptin level and two antral biopsies for evaluating the intensity of gastritis and Helicobacter pylori infection were provided and compared with the control group.

RESULTS

Compared to the control group, serum leptin level was significantly higher in patients with dysmotility-like dyspepsia (P < 0.05). Leptin level were also significantly correlated with the presence of gastritis and H. pylori infection (P < 0.05).

CONCLUSION

Leptin may have a role in the pathogenesis of the dysmotility variety of non-ulcer dyspepsia through mechanisms other than H. pylori infection. Further studies based on gastric leptin immunohistochemistry may need correlation between symptoms of functional dyspepsia and gastric leptin expression.

Empirically derived symptom sub-groups correspond poorly with diagnostic criteria for functional dyspepsia and irritable bowel syndrome. A factor and cluster analysis of a patient sample

AIM

To determine how clusters (groups) of patients with respect to symptoms compare with a clinical diagnosis in patients with irritable bowel syndrome and non-ulcer dyspepsia.

METHODS

All patients who attended a gastroenterology practice at Nepean Hospital were included in the study. All patients received the previously validated Bowel Disease Questionnaire, and were independently assessed by the gastroenterologist. Factor analysis and a k-means cluster analysis were completed.

RESULTS

The study population comprised 897 patients [320 males (36%) and 577 females (64%)]. Factor analysis identified nine symptom factors: (1) diarrhoea; (2) constipation; (3) dysmotility; (4) dyspepsia/reflux; (5) nausea/vomiting; (6) bowel; (7) meal-related pain; (8) weight loss; and (9) abdominal pain. A k-means cluster analysis identified seven distinct subject groups, which included an undifferentiated group: (1) diarrhoea; (2) meal-related pain; (3) abdominal pain; (4) faecal indicators; (5) nausea/vomiting/weight loss; and (6) constipation. The majority of irritable bowel syndrome patients fitted into two cluster groups [diarrhoea (25%) and constipation (20%)], whereas those with non-ulcer dyspepsia predominantly fitted into the undifferentiated cluster (34%) and the nausea/vomiting cluster (18%).

CONCLUSION

This study supports the concept of symptom subgroups, including the subdivision of patients into diarrhoea- and constipation-predominant irritable bowel syndrome.

Gastric inflammation triggers hypersensitivity to acid in awake rats

BACKGROUND & AIMS

Changes in visceral sensation contribute to the development of dyspepsia. Nonhuman models have previously focused on responses to mechanical stimulation. We studied the response to acid stimulation in the normal and inflamed stomach in rats.

METHODS

A balloon and gastrostomy catheter were implanted into the stomach. Electromyographic responses to gastric balloon distention or acid administration through the gastrostomy were recorded from the acromiotrapezius muscle. To characterize chemonociceptive pathways, 0.75 mL HCl (0.05-0.3 N) or saline were given intragastrically in controls and animals after vagotomy, splanchnic nerve resection, or chemical denervation with capsaicin. The effect of inflammation was examined after induction of mild diffuse gastritis using iodoacetamide or creating gastric ulcers by injecting 60% acetic acid for 45 seconds into a clamped area of the stomach.

RESULTS

Visceromotor electromyographic responses increased within 2 minutes after HCl administration (0.15 and 0.3 mol/L) but not saline or lower acid concentrations. Vagotomy and pretreatment with capsaicin but not splanchnic nerve resection abolished this response. Prior acid administration did not acutely sensitize animals to subsequent gastric distention. Gastritis and gastric ulcers enhanced the visceromotor responses to intragastric acid.

CONCLUSIONS

In awake rats, visceromotor responses to intragastric acid are quantifiable, reliable, and reproducible. Aversive responses to acute noxious chemical stimuli primarily require vagal but not spinal sensory pathways. Injury-induced sensitization to intragastric acid administration is consistent with a potential role of chemical stimulation in triggering dyspeptic symptoms.

Effects of a bicarbonate-alkaline mineral water on gastric functions and functional dyspepsia: a preclinical and clinical study

The present study was performed in order to evaluate: (1) the influence of a bicarbonate-alkaline mineral water (Uliveto) on digestive symptoms in patients with functional dyspepsia; (2) the effects of Uliveto on preclinical models of gastric functions. Selected patients complained of dyspeptic symptoms in the absence of digestive lesions or Helicobacter pylori infection within the previous 3 months. They were treated with Uliveto water (1.5 l day(-1)) for 30 days. Frequency and severity of symptoms were assessed at baseline and day 30 by a score system. Preclinical experiments were carried out on rats, allowed to drink Uliveto or oligomineral water for 30 days. Animals then underwent pylorus ligation to evaluate gastric secretion of acid, pepsinogen, and mucus. In separate experiments, gastric emptying was assessed. Crenotherapy was associated with a relief of epigastric pain, retrosternal pyrosis, postprandial fullness and gastric distention. At preclinical level, Uliveto water increased acid and pepsinogen secretions as well as gastric emptying, without changes in bound mucus. The enhancing actions of Uliveto on gastric secretions and emptying were prevented by L-365,260, an antagonist of gastrin/CCK-2 receptors. These findings indicate that a regular intake of Uliveto favors an improvement of dyspeptic symptoms. The preclinical study suggests that the clinical actions of Uliveto water depend mainly on its ability to enhance gastric motor and secretory functions.

Immune-mediated neural dysfunction in a murine model of chronic Helicobacter pylori infection

BACKGROUND & AIMS

Neuromuscular changes producing dysmotility and hyperalgesia may underlie symptom generation in functional gastrointestinal disorders. We investigated whether chronic Helicobacter pylori-induced gastritis causes neuromuscular dysfunction.

METHODS

In vitro muscle contractility and acetylcholine release were evaluated in mice before and after H. pylori eradication. H. pylori colonization and gastritis were graded histologically. Substance P (SP)-, vasoactive intestinal polypeptide (VIP)-, and calcitonin gene-related peptide (CGRP) immunoreactivity (IR) and macrophages were studied by immunohistochemistry.

RESULTS

In Balb/c mice, chronic H. pylori infection did not affect muscle function but augmented antral relaxation after nerve electric field stimulation. Infected mice had lower acetylcholine release by electric field stimulation and had higher density of SP-, CGRP-, and VIP-IR nerves in the stomach and of SP- and CGRP-IR in the spinal cord. Cholinergic nerve dysfunction worsened progressively and was associated with increasing macrophage and mononuclear but not polymorphonuclear infiltrate or bacterial colonization. SCID mice had unchanged acetylcholine release despite high H. pylori colonization and macrophage infiltration. Eradication of H. pylori normalized functional and morphologic abnormalities except for increased density of gastric SP- and CGRP-IR nerves.

CONCLUSIONS

H. pylori infection induces functional and morphologic changes in the gastric neural circuitry that are progressive and lymphocyte dependent, and some persist after H. pylori eradication. The data have direct implications regarding the role of H. pylori infection in functional dyspepsia.

Mild gastritis alters voltage-sensitive sodium currents in gastric sensory neurons in rats

BACKGROUND & AIMS

Visceral hypersensitivity can be found in more than one third of patients with dyspeptic symptoms. We hypothesized that peripheral sensitization plays an important role in the development of hypersensitivity.

METHODS

We induced mild gastritis in Sprague-Dawley rats by adding 0.1% iodoacetamide to the drinking water. The stomach was injected with a retrograde label to identify gastric sensory neurons. Nodose and T9, T10 dorsal root ganglia were removed 7 days after initiation of iodoacetamide treatment. The cells were dissociated and cultured for 3-8 hours before recording whole cell currents using the patch-clamp technique.

RESULTS

Iodoacetamide induced a mild gastritis. Although there were no changes in voltage-sensitive inward and outward currents in nodose neurons, the inward currents increased significantly in T9, T10 spinal neurons. A more detailed analysis of sodium currents showed that this was caused by an increase in the tetrodotoxin-resistant sodium current.

CONCLUSIONS

Mild gastritis increases the tetrodotoxin-resistant current in gastric spinal sensory neurons. Considering the importance of sodium currents as determinants of neuron excitability, this change may contribute to peripheral sensitization and enhanced neuron excitability.

Increased prevalence of irritable bowel syndrome in patients with gastroesophageal reflux

GOALS

To determine the prevalence of irritable bowel syndrome (IBS) in subjects with gastroesophageal reflux disease (GERD) compared with non-GERD controls.

STUDY

Two hundred subjects were identified from a list of Cedars-Sinai Medical Foundation patients and gastroenterology motility practice subjects with and without a potential diagnosis of GERD. All subjects were then evaluated independently by two blinded physicians who were asked to identify subjects with GERD based on taking a history (gold standard). A follow-up questionnaire was later mailed to patients. This questionnaire included Rome I criteria for IBS. The prevalence of IBS was compared between GERD and non-GERD subjects. Finally, to further strengthen the method, a retrospective review of all subjects' charts was conducted to identify patients who had had 24-hour pH tests, and the prevalence of IBS was determined in this subgroup.

RESULTS

Of the 200 subjects, 90 (45%) patients returned the questionnaire. After excluding subjects with IBD and incomplete questionnaires, there were 84 subjects (35 with GERD) included in the analysis. Of the 35 GERD subjects, 25 (71%) were Rome I criteria positive for IBS, whereas only 17 of the 49 (35%) non-GERD subjects had IBS (odds ratio = 54.7, CI = 1.7-13.5, p < 0.01). In 11 of the GERD subjects a 24-hour pH study was available and confirmed GERD. Of these 11 subjects, 7 (64%) met Rome I criteria for IBS.

CONCLUSION

There is a higher prevalence of IBS in subjects with GERD compared with subjects without GERD.

Experimental ulcers alter voltage-sensitive sodium currents in rat gastric sensory neurons

BACKGROUND & AIMS

Voltage-dependent Na+ currents are important determinants of excitability. We hypothesized that gastric inflammation alters Na+ current properties in primary sensory neurons.

METHODS

The stomach was surgically exposed in rats to inject the retrograde tracer 1.1'-dioctadecyl-3,3,3,'3-tetramethylindocarbocyanine methanesulfonate and saline (control) or 20% acetic acid (ulcer group) into the gastric wall. Nodose or thoracic dorsal root ganglia (DRG) were harvested after 7 days to culture neurons and record Na+ currents using patch clamp techniques.

RESULTS

There were no lesions in the control and 3 +/- 1 ulcers in the ulcer group. Na+ currents recovered significantly more rapidly from inactivation in nodose and DRG neurons obtained from animals in the ulcer group compared with controls. This was partially a result of an increase in the relative contribution of the tetrodotoxin-resistant to the peak sodium current. In addition, the recovery kinetics of the tetrodotoxin-sensitive current were faster. In DRG neurons, gastric inflammation shifted the voltage-dependence of activation of the tetrodotoxin-resistant current to more hyperpolarized potentials.

CONCLUSIONS

Gastric injury alters the properties of Na+ currents in gastric sensory neurons. This may enhance excitability, thereby contributing to the development of dyspeptic symptoms.

Dyspepsia: challenges in diagnosis and selection of treatment

BACKGROUND

Despite considerable study, the pathophysiology of dyspepsia remains obscure. This and other factors have impeded development of precise and effective treatment strategies.

OBJECTIVE

This paper provides a brief review of the clinical syndrome of dyspepsia and its pathophysiology, symptoms, diagnosis, and treatment.

METHODS

To identify articles for inclusion in this review, a search of MEDLINE was conducted using the key word dyspepsia. Because the literature on this topic is voluminous and duplicative, the search was limited primarily to literature from the last decade and to articles concerning dyspepsia in adults.

RESULTS

The symptoms of dyspepsia, which may include epigastric pain, heartburn. bloating, and early satiety, defy diagnosis in as many as 50% of patients, even after endoscopy and other appropriate studies. In the other half of patients, such causative disorders as gastroesophageal reflux disease (GERD), peptic ulcer disease, cholecystitis, pancreatitis, and gastric cancer may be diagnosed. Despite controversy regarding the selection of therapy, empiric treatment is common for apparent idiopathic dyspepsia. Histamine2-receptor antagonists, proton pump inhibitors (PPIs), promotility agents, and coating agents have all been used as empiric therapy for dyspeptic symptoms. With empiric treatment, subsequent management is directed by the therapeutic response. In the absence of a definitive diagnosis, treatment is usually selected on the basis of the type and severity of symptoms, a thorough history and physical examination, and factors such as age and the presence of Helicobacter pylori infection. Five PPIs are currently available--lansoprazole, omeprazole, rabeprazole, pantoprazole, and esomeprazole--all with established efficacy in GERD and other acid-mediated disorders. The PPIs can be expected to be useful in certain patients with dyspepsia, and may be prescribed for patients who are found to re- spond to potent antisecretory therapy. Patients' concern about their symptoms, practical considerations, and restrictions imposed by managed care organizations may all affect the choice between empiric therapy and early endoscopy in patients with dyspepsia.

CONCLUSIONS

Despite the variety of therapeutic options available for the symptoms of dyspepsia, the many presentations of this condition and the uncertainty of the response to the currently available therapeutic options continue to pose a substantial clinical challenge.

[New drugs for the treatment of functional dyspepsia]

BACKGROUND

Functional dyspepsia is defined by upper gastrointestinal symptoms without any evidence of structural abnormalities or organic disease. Current pharmacological treatment of functional dyspepsia is largely empirical and involves anti-secretory or prokinetic drugs.

AIMS

To review recent advances in the understanding of the mechanisms involved in symptom production in functional dyspepsia, as well as the development of new drugs that may interfere with these mechanisms, which may lead to more rational and effective treatment of this clinical condition.

METHOD

Systematic review of papers published in English for the last 10 years.

RESULTS

New drugs that increase propulsive gastroduodenal motor activity include new benzamides similar to cisapride, CCK-A blockers, agonists of opiate receptors and motilin agonists similar to erythromycin. A number of agents, including sumatriptan and buspirone, stimulates serotonin receptors in the myoenteric plexuses and have been shown to increase gastric accommodation to a meal. Finally, a number of new drugs that either increase thresholds for visceral perception or modify sensations is currently under investigation. This includes agents of several groups, such as octreotide, loxiglumide, ondansetron and other serotonin blockers, fedotozine and tricyclic antidepressant at low doses.

CONCLUSIONS

Although these new drugs may improve the pharmacological approach to the treatment of functional dyspepsia, there is a need for randomized, controlled trials to assess their efficacy. Moreover, difficulties related to the identification of the mechanisms underlying symptoms may limit the utilization of these new drugs.

Functional dyspepsia and Helicobacter pylori infection: a recent consensus up to 1999

With accumulated evidence for a close relationship between Helicobacter pylori infection and many gastric disorders, the idea that this infection may invoke dyspeptic symptoms appears realistic. If curative therapy for H. pylori can bring about relief of symptoms in these patients, we would possess a new therapeutic tool for functional dyspepsia. Although there have been many clinical trials on this issue, the benefits of H. pylori treatment have been controversial. However, several large-scale clinical studies have been very recently published, and suggest a specific direction on this clinical question. From these results, the current consensus is that H. pylori infection does not directly affect symptoms in patients with functional dyspepsia. However, most clinical trials have been performed on Western populations, and there are few reports from Asian countries. Our recent study on the Japanese population also supported the consensus, that is, a negative relationship between H. pylori infection and symptoms in functional dyspepsia patients.

A 15-minute [13C]-urea breath test for the diagnosis of Helicobacter pylori infection in patients with non-ulcer dyspepsia

BACKGROUND

Non-ulcer dyspepsia (NUD) accounts for the majority of dyspeptic patients and studies on the epidemiology of Helicobacter pylori infection in NUD depend on a non-invasive and rapid diagnostic test. This study was performed to determine the sensitivity and specificity of a 15-min simplified protocol of the [13C]-urea breath test ([13C]-UBT) for the diagnosis of H. pylori infection in patients with NUD.

METHODS

One hundred and thirty-six patients with a clinical and endoscopic diagnosis of NUD were included. The [13C]-UBT was modified from the European standard protocol. The baseline breath sample was collected 5 min after the patient took a test meal and the 13CO2 was collected 15 min after the patient drank 100 mg [13C]-urea. The gold standard used for comparison was either a positive culture or positive histology + positive rapid urease test sampled on upper gastrointestinal endoscopy.

RESULTS

The prevalence of H. pylori infection in NUD by the gold standard was 59.6%, whereas that calculated by the [13C]-UBT was 60.3%. The sensitivity and specificity of [13C]-UBT was 93.8 and 89.1% compared with the gold standard. The shortened collection time and simplification of the procedure may have led to a decline in specificity.

CONCLUSION

The 15-min [13C]-UBT is a rapid but less specific protocol for detecting the presence of H. pylori infection in patients with NUD.

Nonulcer dyspepsia

Nonulcer dyspepsia, characterized by unexplained persistent or recurrent epigastric pain or discomfort, affects approximately 20% of the general population. Symptom-based diagnostic criteria, first developed by an international group of experts, have been refined in the past year in an effort to increase the applicability of the criteria (Rome II criteria). New disease-specific questionnaires that were developed to measure quality of life in patients with dyspepsia are now available and are expected to be widely used in clinical research studies. Studies on the pathophysiology and management of nonulcer dyspepsia were other major topics in the past year, including three large, well-conducted randomized controlled trials of Helicobacter pylori eradication and symptom resolution.

Helicobacter pylori infection enhances glandular stomach carcinogenesis in Mongolian gerbils treated with chemical carcinogens

Helicobacter pylori (Hp) is thought to be a stomach carcinogen from epidemiological findings. To determine the effects of infection with the bacteria on experimental carcinogenesis, a study of the glandular stomach of Mongolian gerbils (MGs) was performed. Male MGs were treated with N-methyl-N'-nitro-N-nitrosoguanidine followed by inoculation with Hp or infected with Hp followed by N-methyl-N'-nitro-N-nitrosoguanidine administration. Animals were killed at week 50, and their excised stomachs underwent microbiological and histopathological examinations. In addition, a serological investigation was performed. The incidences of adenocarcinomas were significantly higher in animals treated with 60 or 300 p.p.m. N-methyl-N'-nitro-N-nitrosoguanidine for 10 weeks followed by Hp inoculation or Hp followed by 20 p.p.m. N-methyl-N'-nitro-N-nitrosoguanidine for 30 weeks than in the respective controls. Moreover, tumour-bearing animals had higher titres of anti-Hp antibodies than tumour-free animals. Of interest was the finding that a dose of 100 p.p.m. N-methyl-N'-nitro-N-nitrosoguanidine given to infected gerbils eradicated the Hp in about half the animals, with a concomitant reduction in the promoting effect. No tumours were found in animals infected with Hp without N-methyl-N'-nitro-N-nitrosoguanidine or non-treated gerbils. Hp infection enhances glandular stomach carcinogenesis in MGs treated with N-methyl-N'-nitro-N-nitrosoguanidine. Animals with high titres of anti-Hp antibodies are at greatest risk of developing neoplasms.