Thailand Dyspepsia Guidelines: 2018

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

Normal Values of High-Resolution Manometry in Supine and Upright Positions in a Thai Population

BACKGROUND

Although cut-off values used in high-resolution manometry (HRM) to diagnose esophageal motility disorders are based on representative samples of the US population and assume a supine position, differences in population and body positioning can reportedly affect results.

AIMS

To establish normal HRM values for Thai people in both supine and upright positions.

METHODS

Forty-one healthy subjects were recruited, each of whom underwent solid-state HRM with ten 5-mL swallows of water in both the supine and upright positions. Measuring parameters according to the Chicago classification criteria (CC v3.0) were included, for which the mean, median and 5th and 95th percentiles (PCTLs) were calculated.

RESULTS

The results corresponded with the CC v3.0 criteria, except for the mean, and 5th PCTL of the distal contractile integral (DCI), which were lower for this population. In the upright position, the mean and median values for DCI, intrabolus pressure and integrated relaxation pressure were significantly decreased, whereas the length of the transitional zone was significantly increased. The limitations of this study include: (1) the relatively low number of participants, (2) the limited recruitment of participants only at Ramathibodi Hospital and (3) the limited recruitment of only young and middle-aged participants.

CONCLUSIONS

We established normal values for the HRM parameters in a representative sample of the Thai population. Our supine results still prove that the use of the CC v3.0 is preferable. HRM testing in patients measured in the upright position should be analyzed based on the normative values obtained from upright swallow studies.

Normal Solid Gastric Emptying Values Measured by Scintigraphy Using Asian-style Meal:A Multicenter Study in Healthy Volunteers

BACKGROUND/AIMS

To report gastric emptying scintigraphy, normal values should be established for a specific protocol. The aim of this study was to provide normal gastric emptying values and determine factors affecting gastric emptying using Asian rice-based meal in healthy volunteers.

METHODS

One hundred and ninety-two healthy volunteers were included at 7 tertiary care centers across Thailand. Gastric emptying scintigraphy was acquired in 45 degree left anterior oblique view immediately after ingestion of a 267 kcal steamed-rice with technetium-99m labeled-microwaved egg meal with 100 mL water for up to 4 hours.

RESULTS

One hundred and eighty-nine volunteers (99 females, age 43 ± 14 years) completed the study. The medians (5-95th percentiles) of lag time, gastric emptying half time (GE T1/2) and percent gastric retentions at 2 and 4 hours for all volunteers were 18.6 (0.5-39.1) minutes, 68.7 (45.1-107.8) minutes, 16.3% (2.7-49.8%) and 1.1% (0.2-8.8%), respectively. Female volunteers had significantly slower gastric emptying compared to male (GE T1/2, 74 [48-115] minutes vs. 63 (41-96) minutes; P < 0.05). Female volunteers who were in luteal phase of menstrual cycle had significantly slower gastric emptying compared to those in follicular phase or menopausal status (GE T1/2, 85 [66-102] mintes vs. 69 [50-120] minutes or 72 [47-109] minutes, P < 0.05). All of smoking volunteers were male. Smoker male volunteers had significantly faster gastric emptying compared to non-smoker males (GE T1/2, 56 [44-80] minutes vs. 67 [44-100] minutes, P < 0.05). Age, body mass index and alcohol consumption habits did not affect gastric emptying values.

CONCLUSIONS

A steamed-rice with microwaved egg meal was well tolerated by healthy volunteers. Gender, menstrual status and smoking status were found to affect solid gastric emptying.

The study of allergic skin test in patients with globus pharyngeus: a preliminary report

BACKGROUND

Globus pharyngeus is the lump sensation in the throat associated with various conditions including somatoform disorder and gastroesophageal reflux disease. However, many patients with unrelated causes were found to respond to anti-allergic treatment.

OBJECTIVE

Determine the results of allergic skin test in globus pharyngeus patients who had unidentified causes.

MATERIAL AND METHOD

Fifty-four globus pharyngeus patients were enrolled and referred for complete physical examination, screening psychological status, videostroboscopy, and reflux finding score assessment. All patients including 38 controlled subjects underwent skin prick test and/or intradermal test. The globus patients who had positive test were recommended to have anti allergic treatment. Barium swallowing study, ambulatory double-probe pH monitoring, or plain film cervical spine was done in patients with negative skin tests and in non-response to medication.

RESULTS

There was statistically significant difference of positive skin test results between globus and the control group (77.8% vs. 28.6% OR = 13.12, p < 0.001). In positive skin test-globus group, globus symptom was improved in 64.3% after allergic treatment, which 85.2% had moderate and excellent improvement. In patients with negative skin test and non-response group show various conditions including gastroesophageal reflux disease (18.52%), abnormal esophageal manometry (40.74%), and myofascial pain syndrome (3.71%).

CONCLUSION

Due to high prevalence of positive skin test in globus pharyngeus patients, this symptom should be considered as one of the atypical allergic manifestations.

Vocal cord dysfunction concurrent with a nutcracker esophagus and the role of gastroesophageal reflux disease

BACKGROUND

Psychological disorders were originally thought to be the sole cause of vocal cord dysfunction (VCD). Subsequently, other organic diseases, including structural laryngeal abnormalities, have also been reported to be associated with VCD.

OBJECTIVES

To describe the first patient with VCD concurrent with a nutcracker esophagus and to establish the association between VCD and gastroesophageal reflux disease (GERD) by using the Bernstein test.

METHODS

Symptom assessments, neuropsychiatric evaluations, fiberoptic laryngoscopy, pulmonary function tests, allergic skin prick tests, radiographs of the chest and sinuses, esophageal manometry (including 24-hour ambulatory esophageal pH monitoring), and the Bernstein test were performed.

RESULTS

A 36-year-old woman had dyspnea, hoarseness, chest pain, and wheezes without relief for a decade. Neuropsychiatric evaluations disclosed mild depression. Fiberoptic laryngoscopy showed posterior laryngitis and paradoxical vocal cord adduction with audible inspiratory stridor. Pulmonary function tests showed attenuation of the inspiratory limb with notching in both flow-volume loops and a mid-vital capacity expiratory to inspiratory flow ratio of 4. All the symptoms except chest pain were improved dramatically by speech therapy and empirical treatment for GERD. Esophageal manometry revealed a nutcracker esophagus; 24-hour ambulatory esophageal pH monitoring demonstrated multiple short reflux episodes. The Bernstein test was conducted, and all the manifestations were reproduced with 0.1 N hydrochloric acid but not with isotonic sodium chloride infusion.

CONCLUSIONS

This is the first human case report confirming that GERD can trigger an acute attack of VCD and may induce chest pain as a nutcracker esophagus in patients with VCD. It strengthens this association and expands our knowledge of diverse manifestations of this clinical entity.

Validation of Rome II criteria for functional gastrointestinal disorders by factor analysis of symptoms in Asian patient sample

BACKGROUND

It has been unclear as to whether the Rome II criteria could be applied to patients in the Asia region with functional gastrointestinal (GI) diseases. The aim of the present study was to determine if symptoms of Asian patients with functional gastrointestinal disorders formed groups which corresponded to the Rome II diagnostic criteria.

METHODS

A modified English version of Talley's bowel disease questionnaire was developed in collaboration with various research teams in accordance with the Rome II criteria. This instrument was translated into the local languages of the following nine Asian regions: China, Hong Kong, Indonesia, Korea, Malaysia, Singapore, Taiwan, Thailand and Vietnam. From September to December 2001, newly enrolled outpatients attending 14 GI or medical clinics in these regions were invited to complete the questionnaire. From these respondents, patients with functional gastrointestinal disorders fulfilling the '12 weeks out of 12 months' criteria were separated for further analysis. Principal component factor analysis with varimax rotation was used to identify symptom clusters or factors. These factors were compared with the existing classification of functional GI diseases derived from the Rome II criteria.

RESULTS

Factor analysis of symptoms from 1012 functional GI patients supported the Rome II classification of the following groups of functional GI disorders: diarrhea-predominant irritable bowel syndrome, functional constipation, functional dyspepsia, functional abdominal pain syndrome, functional heartburn, and functional vomiting. Functional diarrhea was combined with functional anorectal disorders, and globus merged with functional dysphagia into one factor. Some of the functional dyspepsia, abdominal bloating and belching symptoms were loaded into one factor.

CONCLUSIONS

Factor analysis of symptoms from a sample of Asian patients with functional GI disorders partially supported the use of the Rome II classification.

The organization of Kidney Transplantation Services at Ramathibodi Hospital: fourteen years experience on waiting list, kidney donors and kidney transplantation

The Kidney Transplantation Program at Ramathibodi Hospital was established in 1985. By the end of 1998, there were 1,614 patients on the cumulative waiting list. The first kidney transplantation (KT) was started in 1986 by using kidney from living-related donor (LD) while cadaveric KT (CD-KT) was started in 1987. A total of 528 KT were done, 278 cases (52.7%) were CD-KT and 250 cases (47.3%) were LD-KT. Six patients had two kidney transplants. 278 kidneys were donated from 189 cadaveric donors. Fifty cadaveric donors (26.4%) were from Ramathibodi Hospital while the rest were from other hospitals and the Organ Donation Center, Thai Red Cross Society. For LD, 233 out of 250 (93.2%) were from living-related, more than 50 per cent of these donors were from siblings. 17 spousal donors have been accepted for KT at Ramathibodi Hospital since 1997. Concerning the recipient pools, 522 patients (32.3%) were transplanted, 123 patients (7.6%) died without KT, 111 patients (6.9%) underwent KT at other hospitals, and 78 patients (4.8%) changed to waiting lists at other hospitals. The rest were lost to follow-up. At present, only 265 patients are still actively waiting (send serum every month). The number of KT and living donors has gradually increased, whereas, the number of cadaveric donors has decreased. However, cooperation with the "Organ Donation Center" has improved the number of cadaveric donation in the last two years. Sufficient organ donations and an active working team will provide a good kidney transplant service for the patients.

Disorders of esophageal motility

Patients with esophageal motility disorders usually have dysphagia and many also have chest pain similar to angina. The diagnosis is suggested by the clinical presentation, and supporting evidence is often provided by contrast roentgenography. Esophageal manometry is usually necessary to confirm the diagnosis. Conservative therapy using pharmacologic agents is often useful as an initial trial, although many patients who continue to be symptomatic ultimately require surgical intervention.

Treatment of carcinoma of the proximal esophagus

Selection of therapy for carcinoma of the proximal esophagus is controversial. We reviewed our experience with 41 patients with carcinoma of the esophagus within 24 centimeters of the incisor teeth to address this issue. Thirty-seven patients had squamous cell carcinoma, three had adenocarcinoma and one patient had a mucoepidermoid carcinoma. Seventeen patients underwent surgical therapy, which consisted of a resection in 15, colonic bypass in one patient and extracorporeal bypass in one. Ten patients underwent postoperative radiation therapy. Radiation therapy was the primary treatment in 23 patients and chemotherapy alone in one patient. The three month mortality rate was similar for patients with tumor resection and for those receiving radiation therapy as the primary treatment. Median survival time for patients undergoing resection and adjuvant radiation therapy was 12 months and seven months for those receiving only irradiation. Statistical analyses were not performed because patients with radiation only had more advanced disease, invalidating comparison. In terms of palliation, ten of the patients who had radiation therapy could eat solid food, seven could only swallow liquids and six had persistent, complete obstruction. All 12 of the survivors who had a resection were able to eat solid food. Although the one month mortality rate is higher for those treated surgically than with radiation therapy, the three month mortality rates are similar. Surgical treatment provides better palliation and a reasonable survival time and is preferred for patients with resectable disease who are physiologically fit enough to undergo operation. A benefit of postoperative adjuvant radiation therapy is undefined but probably present.