Functional gastroduodenal disorders

While widely used in research, the 1991 Rome criteria for the gastroduodenal disorders, especially symptom subgroups in dyspepsia, remain contentious. After a comprehensive literature search, a consensus-based approach was applied, supplemented by input from international experts who reviewed the report. Three functional gastroduodenal disorders are defined. Functional dyspepsia is persistent or recurrent pain or discomfort centered in the upper abdomen; evidence of organic disease likely to explain the symptoms is absent, including at upper endoscopy. Discomfort refers to a subjective, negative feeling that may be characterized by or associated with a number of non-painful symptoms including upper abdominal fullness, early satiety, bloating, or nausea. A dyspepsia subgroup classification is proposed for research purposes, based on the predominant (most bothersome) symptom: (a) ulcer-like dyspepsia when pain (from mild to severe) is the predominant symptom, and (b) dysmotility-like dyspepsia when discomfort (not pain) is the predominant symptom. This classification is supported by recent evidence suggesting that predominant symptoms, but not symptom clusters, identify subgroups with distinct underlying pathophysiological disturbances and responses to treatment. Aerophagia is an unusual complaint characterized by air swallowing that is objectively observed and troublesome repetitive belching. Functional vomiting refers to frequent episodes of recurrent vomiting that is not self-induced nor medication induced, and occurs in the absence of eating disorders, major psychiatric diseases, abnormalities in the gut or central nervous system, or metabolic diseases that can explain the symptom. The current classification requires careful validation but the criteria should be of value in future research.

Management of uninvestigated and functional dyspepsia: a Working Party report for the World Congresses of Gastroenterology 1998

BACKGROUND

The management of dyspepsia is controversial.

METHODS

An international Working Party was convened in 1998 to review management strategies for dyspepsia and functional dyspepsia, based on a review of the literature and best clinical practice.

RESULTS

Dyspepsia, defined as pain or discomfort centred in the upper abdomen, can be managed with reassurance and over-the-counter therapy if its duration is less than 4 weeks on initial presentation. For patients with chronic symptoms, clinical evaluation depends on alarm features including patient age. The age cut off selected should depend on the age specific incidence when gastric cancer begins to increase, but in Western nations 50 years is generally an acceptable age threshold. In younger patients without alarm features, Helicobacter pylori test and treatment is the approach recommended because of its value in eliminating the peptic ulcer disease diathesis. If, after eradication of H. pylori, symptoms either are not relieved or rapidly recur, then an empirical trial of therapy is recommended. Similarly, in H. pylori-negative patients without alarm features, an empirical trial (with antisecretory or prokinetic therapy depending on the predominant symptom) for up to 8 weeks is recommended. If drugs fail, endoscopy should be considered because of its reassurance value although the yield will be low. In older patients or those with alarm features, prompt endoscopy is recommended. If endoscopy is non-diagnostic, gastric biopsies are recommended to document H. pylori status unless already known. While treatment of H. pylori is unlikely to relieve the symptoms of functional dyspepsia, the long-term benefits probably outweigh the risks and treatment can be considered on a case-by-case basis. In H. pylori-negative patients with documented functional dyspepsia, antisecretory or prokinetic therapy, depending on the predominant symptom, is reasonable, assuming reassurance and explanation are insufficient, unless patients have already failed this approach. Other treatment options include antidepressants, antispasmodics, visceral analgesics such as serotonin type 3 receptor antagonists, and behavioural or psychotherapy although these are all of uncertain efficacy. Long-term drug treatment in functional dyspepsia should be avoided; intermittent short courses of treatment as needed is preferred.

CONCLUSION

The management of dyspepsia recommended is based on current best evidence but must be tailored to local factors such as practice setting, the background prevalence of H. pylori and structural disease, and costs.

[The effect of chelidonium- and turmeric root extract on upper abdominal pain due to functional disorders of the biliary system. Results from a placebo-controlled double-blind study]

BACKGROUND

Right upper abdominal pain may often be caused by biliary dyskinesia. Choleretica and cholekinetica are widely used for medical treatment of complaints due to biliary dyskinesia despite of a lack of randomized clinical trials which may prove their efficacy and potency.

PATIENTS AND METHODS

The present prospective multicenter pilot study analyzes the effects of Cholagogum F Nattermann (dried extracts from Schöllkraut and Curcuma) in comparison with placebo in patients with dumpy or colicky abdominal pain in the right upper quadrant due to biliary dyskinesia. Cholagogum was given in 39 patients and placebo in 37 patients for 3 weeks, respectively.

RESULTS

The reduction of dumpy and colicky pain was more rapid during the first treatment week in patients who received Cholagogum F when compared to those who received placebo. The reduction of other complaints (feeling of being filled up, food intolerance, nausea, vomiting, meteorism) (secondary variables) was similar in patients who received Cholagogum F versus placebo during the whole treatment period. The were no side-effects in patients who received Cholagogum.

CONCLUSIONS

The study presents the first solid indication that extracts from Schöllkraut/Curcuma (Cholagogum F Nattermann) which have widely been used in daily practice for many decades have beneficial effects on pain due to biliary dyskinesia.

Functional dyspepsia has a good prognosis irrespective of H. pylori status. Long-term follow-up of symptoms after anti H. pylori treatment

AIM

A prospective study with anti H. pylori therapy was done in patients with functional dyspepsia.

METHODS

Inclusion criterion was the absence of any macroscopic abnormality in oesophagus, stomach, and duodenum, irrespective whether H. pylori was present or not. A questionnaire and a symptom score on a five-point Likert scale were used. Antral biopsy specimens were taken for detection of H. pylori. Treatment consisted of omeprazole 20 mg bid and amoxicilline 500 mg tid during 14 days. Patients were followed during 12 months. At follow-up the questionnaire and the symptom score were used. The main endpoint of the study was clinical remission after 1 year of follow-up.

RESULTS

In 1 year 163 patients were included (85 men, 78 women, mean age 47 years, range 21-83 years). H. pylori was present in 91 patients. In the H. pylori positive group 38 patients showed a decrease in IgG antibody titre of more than 50% during follow-up of 3-12 months, 26 showed no change or increase following initial decrease. Overall there was no difference in presence or absence of specific complaints at inclusion and final follow-up. The symptom score decreased significantly in all groups (P < 0.001).

CONCLUSION

The symptoms of functional dyspepsia improved to a similar extent in both H. pylori positive dyspeptics and the control group. This symptom improvement was irrespective of the change of IgG H. pylori antibodies after therapy.

Dyspepsia and heartburn

Dyspepsia and heartburn are the two cardinal symptoms of foregut dysfunction. When confronting such a problem, that physician must first learn to discern between the two, because treatment can be quite different for the conditions presenting with these symptoms. This article details the approach to work-up and treatment of patients presenting with dyspepsia or heartburn.

One-week ranitidine bismuth citrate in combinations with metronidazole, amoxycillin and clarithromycin in the treatment of Helicobacter pylori infection: the RBC-MACH study

BACKGROUND

We have previously shown that ranitidine bismuth citrate (RBC)-based triple therapy is comparable to proton pump inhibitor-based triple therapy in eradicating Helicobacter pylori infection.

AIM

To test the efficacy of different combinations of antimicrobials with RBC in the treatment of H. pylori infection.

METHODS

Dyspeptic patients with H. pylori infection were prospectively randomized to receive one of the following regimens: (i) RBC 400 mg, amoxycillin 1 g, clarithromycin 500 mg [RAC]; (ii) RBC 400 mg, metronidazole 400 mg, clarithromycin 500 mg [RMC]; (iii) RBC 400 mg, metronidazole 400 mg, tetracycline 1 g [RMT] (all given twice daily for 1 week); or (iv) RBC 400 mg plus clarithromycin 500 mg twice daily for 2 weeks [RC-2]. Endoscopy (rapid urease test and culture) and 13C-urea breath test (UBT) were performed before randomization. Four weeks after finishing medication, the 13C-UBT was repeated in all cases and endoscopy was offered to patients with peptic ulcers.

RESULTS

Four hundred patients were randomized but in two (one in the RAC group and one in the RMC group) H. pylori infection was not confirmed. Successful eradication of H. pylori (intention-to-treat analysis and 95% CI) of RAC (86% [79-93%]), RMC (90% [84-96%]), RMT (79% [71-87%]) and RC-2 (82% [75-90%]) were comparable, with a trend favouring clarithromycin-containing triple therapy regimens. Among 276 isolates tested for antibiotic sensitivity, primary resistance to metronidazole, clarithromycin and amoxycillin was found in 56%, 2% and 0.4%, respectively. When given RMC or RMT, patients infected by metronidazole-resistant H. pylori had success in eradicating H. pylori similar to patients infected by metronidazole-sensitive H. pylori.

CONCLUSION

One-week RBC triple therapy is effective in curing H. pylori infection.

Different prevalences of reflux oesophagitis and hiatus hernia among dyspeptic patients in England and Singapore

OBJECTIVE

To compare the frequency of reflux oesophagitis and hiatus hernia in dyspeptic patients in England with that in Singapore.

DESIGN

Demographic, clinical and endoscopic findings in consecutive dyspeptic patients seen in England and Singapore by the same clinician were compared. The association of various factors with the occurrence of hiatus hernia and oesophagitis was analysed by logistic regression.

SETTING

District general hospital in England and university hospital in Singapore.

PARTICIPANTS

The English series comprised 212 consecutive patients, and 173 patients were seen in Singapore.

RESULTS

Reflux oesophagitis and hiatus hernia were found in 52 (25%) and 50 (49%) of the English patients, and 12 (6%) and 7 (4%) of the Singapore patients, respectively (P<0.005 in each case). Race, body mass index and age were independently associated with hiatus hernia (odds ratios 3.07, 1.08 and 1.04, respectively). The risk factors for oesophagitis were race, sex, body mass index and age (odds ratios 4.04, 2.37, 1.11 and 1.02, respectively). If hiatus hernia was included in the analysis, the risk factors were hiatus hernia, sex, race and body mass index (odds ratios 20.10, 3.07, 2.81 and 1.09, respectively).

CONCLUSIONS

Reflux oesophagitis and hiatus hernia are more common in English dyspeptic patients compared to those in Singapore. The most important risk factor for both oesophagitis and hiatus hernia is race.

Diagnosis and management of dyspepsia--clinical guideline, 1999. Dyspepsia Working Group, South African Medical Association, South African Gastroenterology Society Working Group

OBJECTIVE

To outline an approach for the effective, practical and safe diagnosis and management of uninvestigated dyspepsia at a primary level of care appropriate to South Africa. The target group for guideline use included general practitioners and other primary health care providers in the public and private sectors. The guideline includes referral points to higher levels of care.

OPTIONS

Two main treatment options for the management of patients with uninvestigated dyspepsia were considered to be relevant to South Africa: Empiric medical therapy (often based on the dominant symptom or symptom complex) with further investigation reserved for 'empiric treatment failures'. Immediate diagnostic evaluation (endoscopy/radiology) of all cases and targeting of therapy based on results.

EVIDENCE

Literature review of relevant studies. However, there are insufficient South African data to make fully evidence-based recommendations.

VALUES

The working group considered that immediate investigation (by endoscopy/radiology) was not a practical option in the South African setting, owing to a lack of resources. The group stressed the importance of adequate initial evaluation to identify the 'high-risk' patient.

RECOMMENDATIONS

Early identification of 'high-risk' patients needing immediate referral to a higher level of care and for further investigation. The remaining 'low-risk' patients should be offered acceptable symptomatic management of dyspepsia. As there is no single ideal first choice drug, selection is often empiric after considering the following: level of contact and care, dominant dyspepsia symptom, availability and cost of medicines, individual preferences. Drug treatment should continue for a finite period (2-4 weeks) and response should be monitored. If treatment fails after a trial of a second drug, then further investigation should be considered as for the 'at-risk' patient. All patients should be given advice on lifestyle changes. A diagnosis of non-ulcer dyspepsia should only be considered when further investigation has not shown specific pathology. When indicated, endoscopy is the preferred method of investigation, but if not available then a barium meal is recommended. The role of Helicobacter pylori in dyspepsia is poorly understood. Empiric H. pylori eradication therapy is not recommended.

VALIDATION

Endorsement by the South African Gastroenterology Society, SAMA and other groups that sent representatives to a multidisciplinary consensus meeting to consider the draft guideline and its later modifications. FINANCIAL SPONSOR: Development supported by an unrestricted educational grant by Janssen-Cilag to SAMA.

Predominant symptoms identify different subgroups in functional dyspepsia

OBJECTIVE

Dyspepsia is a common syndrome that often defies diagnosis. Whether the unexplained (or "functional") dyspepsia represents a homogeneous syndrome or includes different subgroups with specific clinical features has not been clarified. The aim of this study was to investigate the relationship between symptom severity, demographic features, and gastric dysmotility in a large series of patients with functional dyspepsia.

METHODS

Severity of individual digestive symptoms, demographic features, and scintigraphic gastric emptying of solids were evaluated in 483 patients with chronic unexplained dyspepsia.

RESULTS

Two main subgroups were identified. The first was characterized by predominant epigastric pain, male gender (61%), and normal gastric emptying. The second subgroup was characterized by predominant nonpainful symptoms, female gender (60%), a high frequency of associated irritable bowel syndrome (30%), and delayed gastric emptying (42%). A third group included approximately one-third of patients who did not present with any predominant symptom, and was characterized by a high frequency of delayed gastric emptying (30%), overlapping irritable bowel syndrome (28%), and gastroesophageal reflux disease (41%).

CONCLUSIONS

Different subgroups exist among patients with functional dyspepsia seen in a referral center. They can be identified by the predominant symptom and are characterized by different demographic, clinical, and pathophysiological features.

Pancreatic supplements reduce symptomatic response of healthy subjects to a high fat meal

In a double-blind, crossover study, we determined whether microencapusulated pancreatic enzymes reduce postprandial symptoms experienced by healthy volunteers after ingestion of a high calorie, high fat meal. At 7 AM, 18 subjects ingested 185 g of cookies (1196 calories and 72 g of fat) with three pancrelipase capsules or a placebo. The severity of gastrointestinal symptoms and flatus passages were recorded for 15-17 hr, and end-alveolar samples were obtained hourly for 10 hr. Ingestion of pancreatic supplements was associated with a significant (P = 0.049) reduction in bloating over the entire recording period, and with significant reductions in bloating, gas, and fullness during the dinner to bedtime period. Pancreatic supplements had no significant effect on breath H2 or CH4 concentration. The finding that pancreatic supplements reduce postprandial symptoms in healthy subjects suggests that these supplements also might be beneficial in irritable bowel syndrome.

[Controversies in the treatment of Helicobacter pylori]

Helicobacter pylori is a worldwide infection. In gastro-duodenal ulcer disease no doubt remains about the necessity of H. pylori eradication. Controversies subsisting in other pathologies such gastro-esophageal reflux, dyspepsia, gastritis, gastric adenocarcinoma or MALT lymphoma are reviewed. Multiple drug combinations have been proposed to cure the infection. These are discussed in the clinical setting of Belgian practice.

What makes the dyspeptic patient feel ill? A cross sectional survey of functional health status, Helicobacter pylori infection, and psychological distress in dyspeptic patients in general practice

BACKGROUND

Dyspepsia is prevalent in about 30% of the general population in Europe, but only 25% of people with complaints consult their general practitioner.

AIMS

To study the relation between the severity of dyspeptic complaints and the health status of patients presenting to the general practitioner; and the relation with patient characteristics, Helicobacter pylori infection, and psychological distress.

METHODS

A cross sectional, general practice based survey of 360 unselected primary care dyspeptic patients from 92 general practices in The Netherlands was conducted. Symptom severity was measured using a validated symptom score, H pylori using a whole blood test, and psychological distress using the GHQ-12 test. Functional health status was assessed using the COOP/Wonca charts.

RESULTS

Symptoms lasting more than three months and presence of relevant psychological distress were both associated with higher levels of dyspepsia. H pylori infection, frequency of symptoms, and age had no influence on dyspepsia severity. Severity of dyspepsia and psychological distress, but not H pylori infection or duration of symptoms, affected health status univariately. Dyspepsia correlated with general health, daily activities, and social activities. In logistic modelling, health status was far better predicted by psychological distress than by dyspepsia severity.

CONCLUSION

The relation between dyspeptic symptom severity and health status is limited. H pylori infection relates neither to functional health status, nor to intensity of dyspepsia. Psychological distress is a major determinant of impaired health of dyspeptic patients in general practice and may be the clue to improvement of health status in many dyspeptic patients.

[The semiotics of the pain and dyspeptic syndromes in motor disorders of the digestive organs in children and adolescents]

Overall 304 children and adolescents with gastro-duodenal pathology were studied for some aspects of clinical manifestations of the pain and dyspeptic syndromes as related to the character of disordered gastroduodenal motility by making use of techniques of phase polygastroduodenometry. Pathogenetic interrelationship was disclosed of clinical manifestations of the pain and dyspeptic syndromes according to the variant of gastroduodenal dysmotility (dysphasic hyper- or hypomotile dyskinesia of the stomach and duodenum).

Evaluation of a multidimensional measure of dyspepsia-related health for use in a randomized clinical trial

In previous work, we developed a multidimensional measure of dyspepsia-related health. To evaluate the adequacy of this instrument as an outcome measure for a large-scale, multicenter, randomized clinical trial, we used Rasch analysis to address three questions: (1) Are the scales interval-level? (2) Do the scales measure precisely across the entire range of dyspepsia outcomes? (3) Do the scales' items have an optimal number of response categories? We found that the scales were not interval-level and that they did not measure effectively at low or high levels of the dyspepsia-related outcomes. Our results also suggest that patients were capable of discriminating among only four- to seven-item response categories. Further studies are needed to identify items that effectively measure high and low levels of dyspepsia-related outcomes and to validate that decreasing the number of response categories improves the psychometric properties of these scales.

Self medication and health habits in the management of upper gastrointestinal symptoms

Upper gastrointestinal symptoms are a common complaint among the general population but only a small proportion of sufferers seek medical advice. The aim of this study was to examine what kind of perceptions persons using self medication have about the causes of their gastrointestinal symptoms, whether they have made any health-related lifestyle changes, and whether visits to a physician are related to lifestyle changes. A pharmacy-based survey was done in 10 pharmacies in the Helsinki area in 1995. The questionnaire was completed by 292 customers. The response rate was 53%. Respondents in a population-based health interview survey (n = 10,410) were used as a comparison group for poor health-behavior (consumption of tobacco, alcohol, coffee). The most common perceived causes of gastrointestinal symptoms were poor diet, coffee, and stress. Ignorance about possible causes of symptoms was especially common among less educated respondents and among those persons who had never visited a physician due to their symptoms. Respondents were significantly more often smokers and they had attempted to reduce their coffee and alcohol consumption more often than the general population. Those who had visited a physician during past year, less often had poor health-behavior and they had better knowledge about the possible causes of their symptoms. They had also made lifestyle changes more often, but after adjustment for background characteristics, physician visits were positively correlated only with coffee reduction. Counseling about healthy lifestyles, especially about smoking, should be increased in physician consultations and in pharmacies for all patients and customers having gastrointestinal problems.

Imaging studies in dyspepsia

Patients with functional dyspepsia have discomfort centred in the upper abdomen in the absence of oesophagitis, ulcer, cancer or other pathology which could have explained the dyspepsia. It is generally accepted that neither endoscopy, nor other imaging modalities give any positive findings supporting the diagnosis. However, recent investigations have shown that both endoscopic and ultrasonographic imaging show changes: erosive prepyloric changes (EPC) and accommodation abnormalities, respectively, in a high percentage of the patients. The diagnostic sensitivity and specificity of the changes are not yet known, but the fact that they are also seen in several other conditions characterised by dyspepsia, for instance in gallstone disease, may simply indicate that they are linked to epigastric discomfort in general, and not to a specific dyspeptic condition. Ultrasonographic imaging is a non-invasive, widely available, convenient, and reliable method for evaluation of gastric emptying, gastric motility, transpyloric flow and accommodation disturbances, which may play a crucial role in the pathogenesis of dyspepsia.

Definitions of dyspepsia: time for a reappraisal

While many definitions exist, dyspepsia is best considered a symptom complex (not a diagnosis) thought to arise in the upper gastrointestinal tract, unrelated to defecation. The symptom complex includes: upper abdominal/epigastric pain or discomfort, postprandial fullness, bloating, belching, early satiety, anorexia, nausea, retching, vomiting, heartburn and regurgitation. Patients with typical gastroesophageal reflux, biliary colic and irritable bowel syndrome should not be considered to have dyspepsia. After investigations, if a cause of dyspepsia is found, this is 'organic or structural' dyspepsia. If no structural cause is found, this is best called 'functional dyspepsia', subclassified into a) ulcer-like b) dysmotility-like c) reflux-like and d) unspecified dyspepsia. This symptom guided classification should be shifted to the first presentation with uninvestigated dyspepsia, prior to any investigations, to define a clinically useful guide to patient care. As there is considerable symptom overlap, it may be useful to combine together the ulcer and reflux-like groups into an acid-related dyspepsia group. In 1998, another approach would be to screen dyspeptic patients with an H. pylori test and classify them as H. pylori positive and negative dyspepsia.