Pharmacological treatment of eosinophilic gastrointestinal disorders

INTRODUCTION

Eosinophilic gastrointestinal disorders (EGIDs) are increasingly prevalent chronic inflammatory diseases characterized by eosinophilic infiltration of the gastrointestinal (GI) tract, in the absence of other known causes of eosinophilia.

AREAS COVERED

Clinical management of EGIDs is challenging, as there are currently limited therapeutic options available. The most common EGID is eosinophilic esophagitis (EoE), and rarer forms are eosinophilic gastritis, eosinophilic gastroenteritis, and eosinophilic colitis. Clinical presentation depends on the affected GI site. Recently duodenal eosinophilia has been recognized to commonly be present in patients with functional dyspepsia. This review will provide an overview of the pathogenesis and therapeutic management of EGIDs, with particular focus on the pharmacological strategies for these conditions. Expert commentary: Despite the considerable progress made in understanding the pathogenesis of EGIDs, there is still an urgent need for the development of specific and effective therapeutic approaches. Therapeutic management protocols are required that are based on rigorous clinical investigation in large prospective controlled trials to better understand the risks, benefits and limitations of each therapy. More well-defined and consistent end-points are also required to assess treatment outcomes, as there has been variability between patient reported outcomes, clinical outcomes, and histological outcomes in the studies to date.

Case of gastric intestinal metaplasia in an old patient with previous gastric surgery

An 87-year-old woman with multiple medical disorders presented with dyspeptic symptoms of long duration. She has a history of peptic ulcer disease for which she has partial gastrectomy (Billroth I) in the past. Oesophagogastroduodenoscopy (OGD) was performed which revealed erythematous mucosa in the lower part of the gastric remnant with areas of whitish mucosal patches in the distal stomach close to the gastroduodenal anastomosis. Biopsies were taken from the whitish mucosal patches and sent for histopathological examination. The result of the biopsy confirmed the presence of marked intestinal metaplasia. This case report summarises the presentation, diagnoses and treatment of gastric intestinal metaplasia (GIM).

Common Functional Gastroenterological Disorders Associated With Abdominal Pain

Although abdominal pain is a symptom of several structural gastrointestinal disorders (eg, peptic ulcer disease), this comprehensive review will focus on the 4 most common nonstructural, or functional, disorders associated with abdominal pain: functional dyspepsia, constipation-predominant and diarrhea-predominant irritable bowel syndrome, and functional abdominal pain syndrome. Together, these conditions affect approximately 1 in 4 people in the United States. They are associated with comorbid conditions (eg, fibromyalgia and depression), impaired quality of life, and increased health care utilization. Symptoms are explained by disordered gastrointestinal motility and sensation, which are implicated in various peripheral (eg, postinfectious inflammation and luminal irritants) and/or central (eg, stress and anxiety) factors. These disorders are defined and can generally be diagnosed by symptoms alone. Often prompted by alarm features, selected testing is useful to exclude structural disease. Identifying the specific diagnosis (eg, differentiating between functional abdominal pain and irritable bowel syndrome) and establishing an effective patient-physician relationship are the cornerstones of therapy. Many patients with mild symptoms can be effectively managed with limited tests, sensible dietary modifications, and over-the-counter medications tailored to symptoms. If these measures are not sufficient, pharmacotherapy should be considered for bowel symptoms (constipation or diarrhea) and/or abdominal pain; opioids should not be used. Behavioral and psychological approaches (eg, cognitive behavioral therapy) can be helpful, particularly in patients with chronic abdominal pain who require a multidisciplinary pain management program without opioids.

The impact of fever/hyperthermia in the diagnosis of Fabry: A retrospective analysis

BACKGROUND

Fabry disease (FD) is an X-linked lysosomal storage disorder caused by a deficiency of alpha-galactosidase A enzyme, which leads to the accumulation of its substrate, the globotriaosylceramide or Gb3, in many organs and tissues. Main clinical manifestations of FD are neuropathic pain, angiokeratomas, proteinuria and renal failure, left ventricular hypertrophy and stroke. Fever is also a possible symptom at the onset of the disease during childhood and adolescence, but it is frequently misdiagnosed, causing a delay in FD diagnosis.

METHODS

We retrospectively analysed the medical records in our series of 58 Fabry patients, focusing on the proportion of patients who exhibited fever as the main symptom at the onset of FD in order to evaluate the diagnostic delay in these patients.

FINDINGS

In our series, we found a significant proportion of patients with a history of fevers at the beginning of their medical history (20.7%; 12/58). 83% of patients with fever also exhibited acroparesthesias (10/12). Inflammatory markers were elevated in few of those cases (2/12). The mean diagnostic delay was 15.6±SD 12.8years.

INTERPRETATION

Fever emerged to be common as part of the FD clinical spectrum and it significantly contributed to the diagnostic delay encountered with this rare disease. Furthermore, our retrospective analysis indicated that FD patients commonly exhibit episodes of fever in association with other symptoms suggestive of FD (such as episodic pain crisis, acroparesthesias, hypo/anhydrosis, heat intolerance, fatigue and gastrointestinal distress). A careful analysis of the medical history in patients suffering fever could lead to an early and correct FD diagnosis. We believe that fever/hyperthermia, acroparesthesias and angiokeratoma should be considered for inclusion in the algorithm for Intermittent Fever of Unknown Origin (FUO) in order to improve the recognition of FD.

[Dyspepsia, Ulcer Disease – Helicobacter pylori, Gastroesophageal Reflux Disease]

Prevalence of H. pylori (HP) is declining, whereas reflux disease and the proportion of non-steroidal antiinflammatory drugs (NSAR) to HP-induced ulcers increase. Eradication heals HP-ulcer disease, interrupts cancerous progression and can improve dyspeptic symptoms. NSAR-ulcers heal under proton pump inhibitor (PPI) therapy but tend to recur after reexposition. Anticoagulants and antiplatlet agents increase the risk additionally. PPI reduces NSAR-ulcer recurrence. Reflux patients with severe inflammation and complications often need long-term therapy. Barrett’s esophagus patients are at risk of esophageal adenocarcinoma.

[Functional dyspepsia in students of eigth peruvians medical schools. Influence of the habits]

Functional dyspepsia impacts on quality of life. Due to its multifactorial etiology its characterization proves difficult, especially in populations at risk such as medical students.

OBJETIVES

To determine if behavioral and harmful habits of medical students from eight universities of Peru were associated to functional dyspepsia.

METHODS

Multicentric, cross-sectional study. A self-administered questionnaire was taken among students enrolled in eight medical faculties in Peru. Functional dyspepsia was measured using a validated test; diet characteristics, alcohol, tobacco, coffee or energy drinks consumption were considered behavioral habits. Furthermore, others from the social and educational sphere were measured. Bivariate and multivariate statistical analyses were made.

RESULTS

From a total of 1.923 students, the median of the ages was 20, 55% were women and 24% suffered from functional dyspepsia. Factors which diminished the frequency of functional dyspepsia were masculine gender (aPR:0,75; 95%CI:0.64-0.87; p < 0,001), hours spent studying (aPR:0,97; 95%CI:0,96-0,99; p < 0,001) and eating following a fixed schedule (aPR:0,80; 95%CI:0,67- 0,95; p = 0,013); however, having failed a course increases the frequency of functional dyspepsia (aPR:1.24; 95%CI:1.13-1.37; p < 0,001)adjusted for age, as well as difficulties to fall asleep and depression.

CONCLUSION

Many medical students suffered from functional dyspepsia, this being related to several behavioral variables; therefore further studies as well as educational institutions’ intervention is required, due to the short and long term problems that may arise from this situation.

Outpatient management of inflammatory bowel disease

Inflammatory bowel disease is a conglomeration of disorders of unclear etiology and pathogenesis. Confirming the diagnosis of active disease may be difficult but is critical to judicious therapy. Sulfasalazine (Azulfidine) and its newer derivatives mesalamine (Asacol, Rowasa) and olsalazine sodium (Dipentum) are used for treatment of mild disease and maintenance. Corticosteroid therapy controls moderate disease in most patients, but withdrawal may be difficult. Immunosuppression or surgery may be necessary in severe or refractory cases. The risk of cancer as a complication of inflammatory bowel disease is often exaggerated but cannot be ignored.

Is laparoscopic cholecystectomy effective in relieving dyspepsia in patients of cholelithiasis? A prospective study

BACKGROUND

Laparoscopic cholecystectomy (LC) is routinely done for symptomatic gallstone disease; however, its role in relieving dyspeptic symptoms in cholelithiasis is controversial.

AIM

The study was designed to assess the role of laparoscopic cholecystectomy in relieving dyspeptic symptoms in patients having cholelithiasis with only dyspeptic symptoms.

METHODS

Patients with cholelithiasis having only dyspeptic symptoms not attributable to other causes (like Helicobacter pylori) were subjected to laparoscopic cholecystectomy. Dyspepsia scores (Dyspepsia Severity Assessment Score-DSAS and Gastrointestinal Quality of Life Index- GIQLI) were measured before and after surgery and analyzed using Greenhouse-Geisser, McNemar’s and ANOVA tests.

RESULTS

27 patients (M:F=1:26, mean age=40.48±10.60 years) having dyspepsia with asymptomatic gallstones were included in the study. There was significant improvement in DSAS (20.11±4.36 vs 28.63±3.42; p<0.001) and GIQLI(106.11±5.77 vs 122.56±7.95; p<0.001) after 2 months of LC. All symptoms improved individually; relief in early satiety and vomiting was the maximum (outcome benefit ratios=0.954, p=0.007 and 0.937, p=0.005 respectively). Multiple gallstones caused more dyspepsia than single (p=0.005). There was no significant difference between H. pylori positive and negative groups in terms of improvement of DSAS and GIQLI scores after LC (p=0.897 and p=0.375 respectively; however dyspepsia was seen to improve significantly within both groups).

CONCLUSION

Dyspepsia may be a symptom of gallstone disease, and these patients can benefit from LC especially when early satiety and vomiting are the main symptoms. A larger sample size may offer more insight.

Abdominal Migraine in a Middle-aged Woman

A 52-year-old woman presented with recurrent, severe abdominal pain. Laboratory tests and imaging were insignificant, and treatment for functional dyspepsia was ineffective. The poorly localized, dull, and severe abdominal pain, associated with anorexia, nausea, and vomiting, was consistent with abdominal migraine. The symptoms were relieved by loxoprofen and lomerizine, which are used in the treatment of migraine. We herein report a case of abdominal migraine in a middle-aged woman. Abdominal migraine should be considered as a cause of abdominal pain as it might easily be relieved by appropriate treatment.

THE FREQUENCY OF DYSPEPTIC DISORDERS FOLLOWING CHOLECYSTECTOMY PATIENTS ACCORDING TO THE 10-YEAR STUDY

AIM

To evaluate gastrointestinal symptoms during 10 years after cholecystectomy in patients with symptomatic and asymptomatic gallstone disease and to identify predictors of them.

MATERIALS AND METHODS

The work is the part of a prospective long-term monitoring of patients with symptomatic (1) and asymptomatic (2) gallstone disease after cholecystectomy (CE). The study included 145 patients: 115 (80.7%) with initially symptomatic disease (1) and 30(21.5%) asymptomatic (2) disease.

RESULTS

The frequency of heartburn increased from 15.9% to 63.7% during 10 years (p = 0.015) after CE especially in the group (1) (from 2.24% to 68.53% (p 0.037). The frequency of "bitter taste in the mouth" raised from 46.9% before the CE to 69.02% after CE (p < 0.001). The frequency of diarrhea increased from 0.88% to 38.2% in both groups. (p = 0.046).

CONCLUSION

The frequency of heartburn, "bitter taste in the mouth", diarrhea increased in patients after 10 years in patients with symptomatic and asymptomatic gallstone disease after CE. A common risk factors are presence symptomps at baseline and the presence of these symptoms at the 6rst years after CE.

[MODERN PROBLEMS OF DIAGNOSTICS AND TREATMENT OF FUNCTIONAL (UNULCEROUS) DYSPEPSIA]

This review elucidates the data on etiology and pathogenesis of functional (unulcerous) dyspepsia, clinical features, diagnostic, therapeutic and prophylactic approaches to this pathology.

[GASTROESOPHAGEAL REFLUX DISEASE – A MULTIFACETED DISEASE]

Gastric content reflux to the esophagus is a physiological phenomenon that occasionally occurs after meal. Gastroesophageal reflux disease (GERD) is a state that appears when the quantity of gastric content surpasses its physiological elimination from the esophagus and causes difficulties with or without associated esophageal mucosa damage, as well as alarming symptoms. The symptoms are defined as alarming if they disturb the patient’s well-being and are the reason for a visit to the physician. The prevalence of GERD in the Western world is 10%-20% and is based on the estimation of the heartburn incidence as the leading symptom. The dominant symptoms are heartburn and regurgitation, especially after a heavy meal, and are highly specific for GERD. Extraesophageal reflux disease represents a wide range of symptoms connected to the upper and lower respiratory system, such as cough, laryngitis, asthma, chronic obstructive pulmonary disease, hoarseness, sinusitis-postnasal drip syndrome, otitis media, recurrent pneumonia and laryngeal carcinoma. The following tests are used in the reflux differential diagnosis: esophagogastroscopy, laryngoscopy and 24-hour pH monitoring. Patients suspected to suffer from GERD are initially treated with empirical proton pump inhibitor therapy twice a day for one to two months.

Dental erosion in patients seeking treatment for gastrointestinal complaints: a case series

INTRODUCTION

Eating disorders which embrace anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified can be life-threatening due to general medical complications; however, the diagnosis of eating disorder is often delayed due to a low suspicion index. Gastroenterologists are health care providers who may come into contact with patients with undiagnosed eating disorders; it has been previously demonstrated that patients with eating disorders frequently have a significant association with functional dyspepsia. Signs of dental erosion have been described in patients with eating disorders; hence, they may help to identify eating disorders in patients who present with functional dyspepsia and deny having an eating disorder.

CASE PRESENTATION

In this report we describe three cases (a 25-year-old white woman, a 24-year-old white woman, and a 40-year-old white man) with undiagnosed eating disorders, in which a more comprehensive approach, such as the recognition of dental erosion joined with a careful gastrointestinal investigation, was performed to reach a final diagnosis of an eating disorder.

CONCLUSIONS

The screening for dental erosion in patients seeking or receiving medical treatment for dyspeptic symptoms in a gastrointestinal out-patient clinic could be an aid for gastroenterologists to recognize the presence of an underlying eating disorder. A close collaboration with dentists, in addition to psychiatrists, could provide a more favorable treatment outcome.

Helicobacter pylori Infection in Rural and Urban Dyspeptic Patients from Venezuela

The goal of this work was to assess the Helicobacter pylori prevalence in a rural mestizo population and compare it to an urban population from Venezuela. The study was performed in gastric juice samples of 71 dyspeptic patients from Caracas (urban) and 39 from Tucupita (rural), in the Orinoco Delta region. Helicobacter pylori was detected by amplification of 16S rRNA, glmM, and ureA genes in 55.0% patients from urban and 87.2% from rural populations. cagA was found positive in 51% and 62% urban and rural patients, respectively. Non-H. pylori Helicobacter species were not detected in the urban population, but was found in 7.7% of patients in the rural study site. Frequency values of the 16S rRNA, glmM, and ureA genes were higher in the rural population. The odds ratio for each gene was 15.18 for 16S rRNA, 2.34 for glmM, 2.89 for ureA, and 1.53 cagA, showing significant differences except for cagA when gene frequency was compared in both populations. These results demonstrate a higher frequency of H. pylori and gastric non-H. pylori Helicobacter infection in a rural mestizo population with low hygienic standards as compared with city dwellers, representing a potential risk for the development of gastroduodenal diseases.

[Functional gastrointestinal disorders]

Functional gastrointestinal complaints are very common in daily clinic practice. Functional gastrointestinal disorders are characterized in disturbances of motility patterns and/or of visceral hypersensitivity. The main functional gastrointestinal disorders are functional dyspepsia and irritable bowel syndrome. There is no causative therapy, but we have many medication and also non-medication therapeutic options which all can be tried on an indivual basis.

[Overlap of irritable bowel syndrome and functional dyspepsia based on Rome III criteria in medical students from a private university in Lima, Peru]

AIMS

To determine the prevalence of irritable bowel syndrome and functional dyspepsia in medical students from a private university in Lima, Peru. Furthermore, to determine the associated factors with these diseases.

MATERIAL AND METHODS

Observational descriptive and retrospective cross sectional study. Medical students from a private university in Lima were surveyed using a Rome III questionnaire for functional disorders and the STEPwise auto survey for defining the variables of alcohol and tobacco. For data analysis the Stata 11.0 program was used.

RESULTS

Of the 608 students, 543 answered the questionnaire. The prevalence of Irritable Bowel Syndrome was 12.4%, 16.9% of dyspepsia, and of both diseases simultaneously, a prevalence of 7.1% was found. Alcohol consumption in the total population was 89.4% and 29.0% of tobacco. Association between both disorders was found (OR 10.47, 95% CI 5.08 to 21.55; p < 0.001), dyspepsia was associated with sex (OR: 0.16, 95% CI 0.07 to 0.36 p < 0.001), with alcohol consumption (OR: 5.22, 95% CI 23.99 1,13- p = 0.034) and with irritable bowel syndrome (OR: 9.88, 95% CI 4.78 to 20.46 p <0.001). Both conditions together were associated with sex (OR: 0.20, 95% CI from 0.06 to 0.60 p = 0.004) and daily consumption of tobacco (OR: 3.23, 95% CI 1.17 to 8.89 p = 0.023).

CONCLUSION

A prevalence of 12.4% of Irritable Bowel Syndrome and 16.9% of dyspepsia was determined. An overlap of 7.1% of these diseases was reported.

Pericardial, pleural and peritoneal involvement in a patient with primary gastric mantle cell lymphoma

Primary gastric mantle cell lymphoma is a rare form of gastointestinal tumour. Although peritoneal carcinomatosis accompanied by malignant ascites is relatively common, mantle cell lymphoma presenting with ascites is rare. Also, effusions involving pericardial and pleural cavities are uncommon during the course of lymphomas. We report the first case in which pericardial, pleural and peritoneal effusion of a primary gastric mantle cell lymphoma.

Improving the diagnosis and management of GORD in adults

Gastro-oesophageal reflux disease (GORD) is defined as a condition which develops when the reflux of stomach contents causes troublesome symptoms and/or complications. Many patients with GORD complications such as oesophagitis, and up to a third of patients with Barrett's oesophagus have no reflux or heartburn symptoms. Conversely, patients can be symptomatic even when normal reflux levels are found and there is an absence of mucosal damage. Significant GORD symptoms occur at least once a week in 8.8-26% of Europeans, with equal prevalence of symptoms in men and women. The frequency and severity of symptoms do not accurately predict the degree of oesophageal damage. If patients with GORD also describe symptoms of dyspepsia this should be considered first with H. py/oritesting or direct referral for gastroscopy if the patient is over 55 given the risk of gastric cancer in these patients. Oesophageal disease can account for up to 20% of cases of chronic cough. Symptoms of GORD occur in more than 45% of patients with asthma, and erosive oesophagitis on endoscopy has a 50% higher likelihood of a diagnosis of asthma. GORD is a risk factor for Barrett's oesophagus and oesophageal adenocarcinoma. The risk increases with duration, severity and frequency. Endoscopy should not be routinely offered at initial presentation unless the patient has dysphagia or other symptoms suggestive of upper GI cancer. Smoking cessation and weight loss are beneficial in reducing GORD symptoms. Abdominal obesity causes GORD by elevating intra-abdominal pressure, which promotes reflux and the development of hiatus hernia. GORD symptoms are increased by 70% among daily smokers who have been smoking for more than 20 years.

CLINICAL AND MORPHOLOGICAL CHARACTERISTICS OF THE CHRONIC GASTRITIS WITH FUNCTIONAL DYSPEPSIA IN THE REPUBLIC OF SAKHA (YAKUTIA)

INTRODUCTION

Chronic gastritis with syndrome, functional dyspepsia (SFD) is one of the most pressing problems in medicine. Certain scientific and practical interest is the elucidation of the frequency and clinical manifestations of functional dyspepsia in patients hospitalized in the gastroenterology department YAGKB and frequency combinations of chronic gastritis (including H. pylori) with functional dyspepsia.

AIM

The aim of the study was to investigate the clinical and morphological features of the chronic gastritis with syndrome pattern of functional dyspepsia in native-born and people of the Republic of Sakha (Yakutia), and to assess the effectiveness of treatment, depending on the gastric acid and H. pylori.

MATERIALS AND METHODS

This study examined 105 patients with functional dyspepsia, including 41 patients with epigastric pain syndrome and 64 patients with postprandial distress syndrome. Considered groups of patients were homogeneous for age, gender, by ethnicity. Of the 105 patients included in the study, I group were 57 indigenous people (80% of them--Yakutia), 11 group--48 people visiting (Caucasians).

RESULTS

Clinical presentation and course of chronic gastritis with functional dyspepsia in the Republic of Sakha (Yakutia) have a number of distinctive features: epigastric pain syndrome occurs in 26.8% of patients and 73.2% of the indigenous population of the visitor, the intensity of pain in the root is much lower than that of visitors--12 and 85% respectively. Postprandial distress syndrome was diagnosed in 71.9% of patients and 28.1% of the indigenous newcomers. At endoscopy in all patients with functional dyspepsia diagnosed chronic gastritis. The native inhabitants of the most common mixed gastritis (54.5%), the newcomers--superficial gastritis (66.7%).

CONCLUSIONS

The found features of a current of functional dyspepsia can be further the basis for the individualized and differentiated approaches to treatment of this disease.

Adverse drug reactions in a primary care population prescribed non-steroidal anti-inflammatory drugs

OBJECTIVE

To determine how often patients with musculoskeletal (MSK) complaints prescribed a non-steroidal anti-inflammatory drug (NSAID) subsequently consult their general practitioner (GP) with a non-serious adverse drug reaction (ADR).

DESIGN

Cohort study.

SETTING

A healthcare database containing the electronic GP medical records of over 1.5 million patients throughout the Netherlands.

PATIENTS

A total of 16 626 adult patients with MSK complaints prescribed an NSAID.

MAIN OUTCOME MEASURES

The patients' medical records were manually assessed for the duration of NSAID use for a maximum of two months, and consultations for complaints predefined as potential ADRs were identified. Subsequently, the likelihood of an association with the NSAID use was assessed and these potential ADRs were categorized as likely, possible, or unlikely ADRs.

RESULTS

In total, 961 patients (6%) consulted their GP with 1227 non-serious potential ADRs. In 174 patients (1%) at least one of these was categorized as a likely ADR, and in a further 408 patients (2.5%) at least one was categorized as a possible ADR. Dyspepsia was the most frequent likely ADR, followed by diarrhoea and dyspnoea (respectively 34%, 8%, and 8% of all likely ADRs).

CONCLUSION

Of the patients with MSK complaints prescribed an NSAID, almost one in 30 patients re-consulted their GP with a complaint likely or possibly associated with the use of this drug. The burden of such consultations for non-serious ADRs should be taken into account by GPs when deciding whether treatment with an NSAID is appropriate.

["Do two walk together unless they have agreed to do so?"--Combining conventional and complementary medicine in the treatment of gastroparesis]

Gastroparesis is a chronic disorder of abnormal gastric motility causing considerable suffering. We describe two cases of gastroparesis which were treated by methods which were not part of routine conventional therapy, but which, nevertheless, led to significant clinical improvement. In the first case, the patient suffered from gastroparesis following a vagal injury while undergoing a lung transplant. During his illness a mega-bezoar formed, a well-described complication of gastroparesis. After conservative measures failed, and in order to avoid a surgical intervention that carried considerable risk under the circumstances, a successful trial consisting of imbibing large amounts of "Coca Cola" and acupuncture was initiated. The bezoar dissolved completely and considerable improvement of the patient's gastric motility was achieved. In the second case, the patient was a young woman suffering from idiopathic gastroparesis, which responded well to treatment with tricyclic antidepressants. Due to her intention to become pregnant, this treatment was discontinued and she was admitted to receive homeopathic treatment. After two failed attempts in finding the right homeopathic remedy to replace the conventional treatment, the third remedy (Sepia) used brought dramatic improvement in her general condition and her dyspepsia. Today, over two years after her successful homeopathic treatment, she is in the middle of her second pregnancy, without any treatment and free of complaints. These two cases are examples of simple solutions for seemingly complicated and complex conditions alleviated by an integration of conventional and complementary/alternative medicine.