[Gastrointestinal syndromes (3): flatulence (2)]

The second part of the article on flatulence reviewed aspects of the pathogenesis, diagnosis and treatment of this syndrome.

[Gastrointestinal syndromes (3): flatulence (1)]

Now we expose important data on definition and cardinal symptoms of the flatulence syndrome and, besides, on accumulated knowledge in relation to digestive tract gases.

[Major gastrointestinal syndromes (2): dyspepsia or syndrome of the upper digestive system related with food (2)]

We expose, this time, our ideas and findings on the etiopathogenesis, diagnosis and treatment of the dyspeptic syndrome.

[Common gastrointestinal syndromes (2): dyspepsia or upper digestive tract syndrome related to food (I)]

We expose, this time, our ideas and findings on the definition, the classification and the cardinal symptoms of the dyspeptic syndrome.

[Major gastrointestinal syndromes (1): general remarks]

We will review concepts of the maladies of the people, focusing the problems as "great" syndromes, that are those that include the greater number of gastrointestinal symptoms. We begin this series of articles, reviewing aspects of the multifactorial genesis of the diseases, the real core of the diagnosis and the classification of the organic and "functional" gastrointestinal disorders.

[The high fermentative capacity of colonic bacteria in the origin of flatulence and its sensibility to bismuth subsalicylate]

Using a previously described technique, "in vitro" determinations were carried out for faecal fermentation (FF): basal faecal fermentation (BFF), i.e, only with faeces, with faeces and lactulose (LFF) and with faeces, lactulose and bismuth subsalicylate (BiLFF) in 34 patients with flatulence. The media+d.s. of the difference between the LFFand BFF levels (LFF-BFF) in patients with flatulence was significant and markedly higher than the respective media +d.s. in 30 normal control patients previously studied (9.1+4.7 vs. 3.9+3.2 ml gas/24 hrs; p<0.000001 respectively). And, although FF was reduced by adding bismuth salicylate in only 24% (70.6%) of the patients with flatulence but not in the remaining 10 (29.4%), in total the media+d.s. of the differences between the levels BiLFF and BFF (BiLFFBFF) was significantly lower that the media+d.s. of the differences between the LFF and BFF levels (LFF-BFF) (6.0+4.2 vs 9.1+4.7 ml gas/24 hrs; p<0.01 respectively). These results confirm that: 1) The fermentative capacity of the colonic bacteriae is most likely to be abnormally intense in peoples with flatulence and 2) Bismuth subsalicylate can be useful in the control of excessive colonic fermentation and flatulence; they raise, furthermore, the interesting possibility that we may have found the way to predict when the use of bismuth subsalicylate could be effective in the treatment of a patient with flatulence.

[Gastroesophageal reflux symptoms: their association with dyspepsia]

The clinical histories of 364 patients with heartburn and/or regurgitations, that is, with symptoms of gastroesophageal reflux (GER), were reviewed to determine the frequencies with which these symptoms appeared in isolated form or associated with manifestations of dyspepsia. Only 41 (11.3%) of the patients presented symptoms of GER in isolated form; in the remaining 323 (88.7%), the symptoms appeared associated with manifestations of dyspepsia. In view of these results and various reasons exposed in the present article, we question the decision of the Rome Working Group of separating the GER from the dyspeptic syndrome.

[Basal fecal fermentation and with lactulose in patients with flatulence]

Determinations of the fecal fermentation in subjects may be very useful to know the fermentative capacity of his colonic bacteria. Determinations of basal fecal fermentation (FFB) and fecal fermentation with lactulose (FFL) were done in 30 normal subjects and 126 patients with flatulence, especially meteorism. The media +/- s.d. of FFB was significantly higher in the normal subjects than in the patients with flatulence (1.82 +/- 1.55 vs. 1.24 +/- 1.40 ml of gas/24 h; P: 0.015). On the contrary, in patients with flatulence the obtained media +/- s.d. of FFL and of the differences between FFL and FFB (FFL-FFB) were significantly and markedly higher than in the normal subjects (respectively: 8.84 +/- 5.55 vs. 5.72 +/- 3.72 ml of gas/24 h, P: 0.004; and 7.60 +/- 5.05 vs. 3.91 +/- 3.22 ml of gas/24 h, P<0.00001). The obtained results seem to indicate that patients with flatulence tend to have a colonic flora with high fermentative capacity.

Gastric emptying rates in idiopathic dyspepsia with and without "hunger pain"

It has been previously observed that in dyspeptic patients with "hunger pain", that is, with pain suggestive of the presence of peptic ulcer, only 12% had an endoscopically demonstrated ulcer, the remaining 88% showing absence of important macroscopically detectable lesions (idiopathic dyspepsia). In order to investigate the possibility of a relationship between "hunger pain" and some alteration in gastroduodenal motility, the gastric emptying rates of patients presenting idiopathic dyspepsia with and without "hunger pain" were compared with those of normal control subjects. The study was conducted in 40 patients presenting idiopathic dyspepsia, 20 with and 20 without "hunger pain", and 30 voluntary apparently normal control subjects. The patients and the controls ingested, with a standard breakfast, a gelatine capsule containing 10 radioopaque polyurethane markers, and the gastric emptying of the markers was evaluated taking 3 x-ray films of the abdomen at 1.5, 3.0 and 4.5 hours after the breakfast. The gastric emptying rates of the markers were significantly higher in the patients with "hunger pain", and significantly lower in the patients without "hunger pain", than in the normal control subjects. In idiopathic dyspepsia with and without "hunger pain" there are, respectively, abnormally increased and abnormally decreased gastric emptying rates of undigestible solid markers. Our findings could help to better understand the pathogenesis of those different types of dyspepsia and, consequently, to improve their treatment.

A new questionnaire for the diagnosis of dyspepsia

A questionnaire to diagnose dyspepsia was created. The questionnaire consists in 9 items written in very clear and understandable language and related to the cardinal symptoms of dyspepsia (easy sensation of fullness, postprandial epigastric fullness, heartburn, regurgitation, nausea, vomiting, postprandial epigastric pain, excessive belching and hunger pain). The questionnaire also includes a system of quantification levels for each symptom, taking into account its frequency and intensity of presentation in the previous two weeks: 1 point, if the symptom did not bother at all or only infrequently; 2 points, if it bothered only a little; 3 points, if it bothered moderately; and 4 points, if it bothered a lot. The questionnaire was applied to 40 patients with dyspepsia and 20 healthy control subjects, and their answers were compared with data obtained by anamnesis. For the comparison, three criteria were considered to define, with the questionnaire, the existence of dyspepsia: A) Presence of a minimum of 2 symptoms, and at least one of them with a quantification level of 2 points or more; B) Presence of a minimum of 2 symptoms, and at least one of them with a quantification level of 3 points or more; and C) Presence of a minimum of 2 symptoms with a quantification level of 3 points or more. Of these three criteria, criterion B was found to be the best, and following it, the sensitivity and specificity of the questionnaire were, respectively, 95% and 100%. The new questionnaire will be, for sure, a useful instrument to accurately investigate dyspepsia, specially in large population groups.

Geographic factors probably modulating alternative pathways in Helicobacter pylori-associated gastroduodenal pathology: a hypothesis

It is hypothesized that probable geographic factors of nutritional type, nonrelated to development or socioeconomic level, may modulate the conversion of Helicobacter pylori-associated active chronic gastritis from its early stages to chronic atrophic gastritis (CAG). The factors could be diets low in antioxidant vitamins and other micronutrients such as selenium. In regions of the world where these modulating factors are not present, active chronic gastritis tends to stay in its early stages and to predispose individuals to duodenal ulcer. On the contrary, in regions where the modulating factors are present, the frequency of CAG increases markedly. When CAG becomes severe and extensive, hypochlorhydria ensues. Hypochlorhydria decreases the predisposition to duodenal ulcer, while CAG, a precancerous lesion, predisposes individuals to gastric cancer of the intestinal type. The hypothesis could be tested in a multicenter, multiregional study to (1) determine endoscopically and histologically the prevalence rates of duodenal ulcer, gastric ulcer, gastric cancer, and H. pylori-associated CAG in large series of dyspeptic patients and (2) correlate these prevalence rates with blood levels of micronutrients in these patients.