Sustained Weight Loss with Vagal Nerve Blockade but Not with Sham: 18-Month Results of the ReCharge Trial

BACKGROUND/OBJECTIVES

Vagal block therapy (vBloc) is effective for moderate to severe obesity at one year.

SUBJECTS/METHODS

The ReCharge trial is a double-blind, randomized controlled clinical trial of 239 participants with body mass index (BMI) of 40 to 45 kg/m or 35 to 40 kg/m with one or more obesity-related conditions. Interventions were implantation of either vBloc or Sham devices and weight management counseling. Mixed models assessed percent excess weight loss (%EWL) and total weight loss (%TWL) in intent-to-treat analyses. At 18 months, 142 (88%) vBloc and 64 (83%) Sham patients remained enrolled in the study.

RESULTS

18-month weight loss was 23% EWL (8.8% TWL) for vBloc and 10% EWL (3.8% TWL) for Sham (P < 0.0001). vBloc patients largely maintained 12-month weight loss of 26% EWL (9.7% TWL). Sham regained over 40% of the 17% EWL (6.4% TWL) by 18 months. Most weight regain preceded unblinding. Common adverse events of vBloc through 18 months were heartburn/dyspepsia and abdominal pain; 98% of events were reported as mild or moderate and 79% had resolved.

CONCLUSIONS

Weight loss with vBloc was sustained through 18 months, while Sham regained weight between 12 and 18 months. vBloc is effective with a low rate of serious complications.

Gastrointestinal symptoms are closely associated with depression in iron deficiency anemia: a comparative study

BACKGROUND AND OBJECTIVES

Until now, very few studies evaluated the association between gastrointestinal and psychiatric symptoms in iron deficiency anemia (IDA). The study investigated the frequency of functional dyspepsia (FD) in IDA patients and determined its association with depression and somatization.

DESIGN AND SETTINGS

The study was conducted at the Hematology Department of Trakya University Medical Faculty, which is a tertiary referral center in northwestern Turkey. It was a case-control study.

MATERIALS AND METHODS

A total of 125 consecutive IDA patients and 57 healthy control subjects were included. Patients and controls were questioned about the severity of their gastrointestinal system (GIS)-related symptoms and the presence of constipation and associated symptoms using a visual analog scale. In addition, IDA patients were administered a validated depression scale (Beck Depression Inventory, BDI) and somatization symptoms checklist.

RESULTS

IDA patients had more frequent self-reported constipation compared with controls (56% vs 22.8%, P < .001). The mean scores of bloating, dyspepsia, and constipation-related quality of life (QoL) disturbance were significantly higher in the IDA group than in the control group (all P values.

Are clinical features able to predict Helicobacter pylori gastritis patterns? Evidence from tertiary centers

Outcome of Helicobacter pylori infection is different according to gastritis extension (i.e. antrum-restricted gastritis or pangastritis). The aim of this study is to evaluate whether different gastritis patterns are associated with specific gastrointestinal symptoms or clinical signs that could be suggestive of the topography of gastritis. 236 consecutive symptomatic outpatients were recruited in two tertiary centers. They filled in a validated and self-administered Rome III modular symptomatic questionnaire, and underwent gastroscopy with histological sampling. 154 patients with Helicobacter pylori infection were included. Clinical presentation did not differ between antrum-restricted gastritis and pangastritis, gastro-esophageal reflux disease being present in 48.2 and 54.1 % of patients and dyspepsia in 51.8 and 45.9 %, respectively. However, pangastritis statistically differed from antrum-restricted gastritis in that the presence of clinical signs (p < 0.0001) was observed in 33.7 % of the patients, consisting of iron deficiency (31.6 %), iron deficiency-anemia (20.4 %) and levothyroxine malabsorption (3.1 %). Symptoms are not helpful in suggesting gastritis pattern whereas their association with signs, accurately detected, is indicative for the presence of pangastritis.

Benefit of supplements in functional dyspepsia after treatment of Helicobacter pylori

AIM

Functional dyspepsia, though benign, leads to deterioration of the quality of life and high costs for healthcare systems. The optimal therapy for functional dyspepsia is still to be defined because of its multifactorial pathogenesis. In an open multicentric study of patients with functional dyspepsia, we prospectively evaluated the benefit of treatment with a food supplement composed of sodium alginate, carbonate calcium, pineapple, papaya, ginger, α-galactosidase and fennel (Perdiges, Bioten Snc, Turin, Italy).

METHODS

Ninety-one consecutive patients were included, suffering from functional dyspepsia, who had been previously submitted to therapy to eradicate the infection from Helicobacter pylori (H. pylori) and were waiting to perform the Urea Breath Test (UBT). The primary goal was to establish the percentage of patients who continued to abstain from proton pump inhibitors (PPI) as they waited to carry out the UBT, differentiating between patients who were treated (N.=55) with Perdiges and those who were not (N.=36). Our secondary goal was to document the differences within the 2 groups in terms of symptoms perceived between the start and end of the observation period. The wellness reported, during or in absence of treatment with Perdiges, was evaluated by the use of the VAS scale (Visual Analogical Scale) completed before the start of the treatment and after 30 days.

RESULTS

All the patients treated with Perdiges (55/55, 100%) and 31/36 (86.1%) patients who were not (P=0.008) continued to abstain from PPI in the period awaiting the UBT. The VAS scale of those who took Perdiges improved on average by 1.78 points versus a worsening of 0.08 points of those who did not take it (P<0.0001). Furthermore, while among those who took Perdiges there was a statistically significant improvement (P<0.0001) in the VAS scale, between the baseline and the end of treatment, a worsening of 0.08 points (P=0.78) was noticed among the patients who did not take it.

CONCLUSION

Perdiges is significantly effective in the period following treatment to eradicate the infection from H. pylori in patients with functional dyspepsia. This allows to reduce the need to use antisecretive drugs. Further randomised studies, with wide ranging case histories, must assess its long-term efficacy.

Xiaoyao pill for treatment of functional dyspepsia in perimenopausal women with depression

AIM: To evaluate the efficacy and safety of the Xiaoyao pill for treatment of functional dyspepsia (FD) associated with perimenopausal depression.

METHODS: This was a double-blind, randomized, controlled trial including 180 patients with FD accompanied by depression that were divided into two groups of 90. Patients in the treatment group received oral administration of the Xiaoyao pill for soothing the liver and activating the spleen, and patients in the control group received a placebo. This trial included an 8-wk therapy period with a follow-up period of 6 mo. The total efficacy and degree of depression, as assessed by the Hamilton Rating Scale for Depression (HRSD), were evaluated. Plasma levels of motilin and gastrin were measured and a gastric emptying test was conducted in each participant.

RESULTS: The Xiaoyao pill had a good therapeutic effect and improved the symptoms in patients with perimenopausal FD as assessed by the HRSD score, motilin and gastrin levels, and rate of gastric emptying. The total effective rate of the Xiaoyao pill in the treatment group was significantly superior to that of the placebo in the control group. In the control group, the initial HRSD score was 12.12 ± 2.29 and decreased to 7.14 ± 1.67 after therapy (P < 0.01). In the treatment group, the initial HRSD score was 11.44 ± 2.15, which significantly decreased to 6.20 ± 2.08 after therapy (P < 0.01). Moreover, the HRSD score in the treatment group was significantly lower than in control group after 8 wk (P < 0.01). Motilin and gastrin levels in both groups were significantly increased after the 8-wk therapy (P < 0.05). The gastric emptying rate was also improved in both groups after therapy (P < 0.05), and the improvement was significantly better in the treatment group compared to the controls (P < 0.05). These results confirm the therapeutic effects of the Xiaoyao pill in perimenopausal FD patients and indicate that it is worthy of clinical promotion.

CONCLUSION: The Xiaoyao pill is effective and safe for the treatment of perimenopausal women with FD associated with depression.

Rumen transfaunation

The aim of this invited mini-review is to summarize the rumen transfaunation literature. Rumen transfaunation using the cud from a healthy donor animal to treat a sick recipient animal was practiced long before our understanding of rumen microorganisms. Around the mid-1900 s, scientists began to explore the benefits of rumen transfaunation and the associated microbial populations. Rumen transfaunation has been used clinically to treat indigestion and to enhance the return of normal rumen function following surgical correction of a left-displaced abomasum. Rumen transfaunation was also used to introduce unique rumen microorganisms into animals that were exposed to toxic compounds in plants. Rumen liquor contains chemical constituents that likely contribute to the beneficial effects of re-establishing a normal reticulo-rumen anaerobic fermentation. Recommendations for collecting rumen fluid, storage and volumes transferred are discussed. Rumen transfaunation is a common practice to treat indigestion on dairy and livestock operations. The support of a healthy microbial community in the digestive tract is also used for humans. Fecal microbiota transplantation has been used to treat digestive disorders in humans. Rumen transfaunation, although not widely studied with respect to mode of action, is an effective, practical, and easy method to treat simple indigestion of ruminants.

Rumen transfaunation

The aim of this invited mini-review is to summarize the rumen transfaunation literature. Rumen transfaunation using the cud from a healthy donor animal to treat a sick recipient animal was practiced long before our understanding of rumen microorganisms. Around the mid-1900 s, scientists began to explore the benefits of rumen transfaunation and the associated microbial populations. Rumen transfaunation has been used clinically to treat indigestion and to enhance the return of normal rumen function following surgical correction of a left-displaced abomasum. Rumen transfaunation was also used to introduce unique rumen microorganisms into animals that were exposed to toxic compounds in plants. Rumen liquor contains chemical constituents that likely contribute to the beneficial effects of re-establishing a normal reticulo-rumen anaerobic fermentation. Recommendations for collecting rumen fluid, storage and volumes transferred are discussed. Rumen transfaunation is a common practice to treat indigestion on dairy and livestock operations. The support of a healthy microbial community in the digestive tract is also used for humans. Fecal microbiota transplantation has been used to treat digestive disorders in humans. Rumen transfaunation, although not widely studied with respect to mode of action, is an effective, practical, and easy method to treat simple indigestion of ruminants.

Clinical presentations of gastric small gastrointestinal stromal tumors mimics functional dyspepsia symptoms

AIM: To explore whether clinical presentations of gastric small gastrointestinal tumors (GISTs) mimics gastrointestinal dyspepsia symptoms.

METHODS: The endosonographic data of 167 patients who underwent endoscopic submucosal dissection at the Tianjin Medical University General Hospital, China between 2009 and 2011 were analyzed. GISTs and leiomyomas had a similar intragastric distribution and similar locations within the gastric wall. Therefore, patients with GISTs were chosen as the study group and those with leiomyomas were chosen as the control group. Dyspepsia symptom questionnaires were used to investigate and compare the gastrointestinal symptoms of patients with GISTs and those with gastric leiomyomas before and after endoscopic submucosal dissection (ESD). The questionnaires evaluated symptoms such as epigastric pain, heartburn, regurgitation, epigastric discomfort, nausea and vomiting, abdominal bloating, and eructation. Symptoms were assessed using a four-point scoring scale.

RESULTS: GISTs were the most common gastric submucosal lesion (67 cases, 40.12%), followed by leiomyomas (38 cases, 22.75%). Both groups were similar in terms of gender distribution (P = 0.49), intragastric location (P = 0.525), and originating layer within the gastric wall (P = 0.449), but leiomyomas were more commonly found in the proximal fundus (P < 0.05). Overall, 94.2% of the patients with small GISTs and 93.5% of those with gastric leiomyomas experienced some dyspepsia; however, total symptom scores were significantly lower in the GIST group than in the leiomyoma group (1.34 ± 1.27 vs 2.20 ± 1.70, P < 0.05). Each component of the symptom score demonstrated a statistically significant improvement in the GIST patients after ESD (P < 0.05), including epigastric pain (0.80 ± 0.90 vs 0.13 ± 0.46), heartburn (0.63 ± 1.08 vs 0.13 ± 0.41), regurgitation (0.55 ± 0.87 vs 0.22 ± 0.57), epigastric discomfort (0.70 ± 0.98 vs 0.32 ± 0.47), nausea and vomiting (0.27 ± 0.62 vs 0.05 ± 0.21), abdominal bloating (0.70 ± 0.90 vs 0.27 ± 0.49), and eructation (0.36 ± 0.61 vs 0.21 ± 0.46). For leiomyoma patients, symptoms such as heartburn, nausea, vomiting, and eructation improved after treatment; however, these improvements were not statistically significant (P > 0.05). Thus, the pathophysiology of dyspepsia symptoms may be different between the two groups.

CONCLUSION: Symptoms of gastric small GISTs may mimic those of functional dyspepsia. An alternative diagnosis should be considered in patients with functional dyspepsia and treatment failure.

Effect of reversible intermittent intra-abdominal vagal nerve blockade on morbid obesity: the ReCharge randomized clinical trial

IMPORTANCE

Although conventional bariatric surgery results in weight loss, it does so with potential short-term and long-term morbidity.

OBJECTIVE

To evaluate the effectiveness and safety of intermittent, reversible vagal nerve blockade therapy for obesity treatment.

DESIGN, SETTING, AND PARTICIPANTS

A randomized, double-blind, sham-controlled clinical trial involving 239 participants who had a body mass index of 40 to 45 or 35 to 40 and 1 or more obesity-related condition was conducted at 10 sites in the United States and Australia between May and December 2011. The 12-month blinded portion of the 5-year study was completed in January 2013.

INTERVENTIONS

One hundred sixty-two patients received an active vagal nerve block device and 77 received a sham device. All participants received weight management education.

MAIN OUTCOMES AND MEASURES

The coprimary efficacy objectives were to determine whether the vagal nerve block was superior in mean percentage excess weight loss to sham by a 10-point margin with at least 55% of patients in the vagal block group achieving a 20% loss and 45% achieving a 25% loss. The primary safety objective was to determine whether the rate of serious adverse events related to device, procedure, or therapy in the vagal block group was less than 15%.

RESULTS

In the intent-to-treat analysis, the vagal nerve block group had a mean 24.4% excess weight loss (9.2% of their initial body weight loss) vs 15.9% excess weight loss (6.0% initial body weight loss) in the sham group. The mean difference in the percentage of the excess weight loss between groups was 8.5 percentage points (95% CI, 3.1-13.9), which did not meet the 10-point target (P = .71), although weight loss was statistically greater in the vagal nerve block group (P = .002 for treatment difference in a post hoc analysis). At 12 months, 52% of patients in the vagal nerve block group achieved 20% or more excess weight loss and 38% achieved 25% or more excess weight loss vs 32% in the sham group who achieved 20% or more loss and 23% who achieved 25% or more loss. The device, procedure, or therapy-related serious adverse event rate in the vagal nerve block group was 3.7% (95% CI, 1.4%-7.9%), significantly lower than the 15% goal. The adverse events more frequent in the vagal nerve block group were heartburn or dyspepsia and abdominal pain attributed to therapy; all were reported as mild or moderate in severity.

CONCLUSION AND RELEVANCE

Among patients with morbid obesity, the use of vagal nerve block therapy compared with a sham control device did not meet either of the prespecified coprimary efficacy objectives, although weight loss in the vagal block group was statistically greater than in the sham device group. The treatment was well tolerated, having met the primary safety objective.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01327976.

[Pentax-AWS Airwayscope for awake tracheal intubation in the face-to-face sitting position in an emergency patient with acute exacerbation of aortic stenosis]

We report a successful awake tracheal intubation in an emergency patient with acute exacerbation of aortic stenosis using the Pentax-AWS Airwayscope (AWS). An 83-year-old woman was admitted to our emergency department for severe dyspnea due to exacerbation of aortic stenosis. Her Sp(O2) was 92-93% even after administration of 10 l x min(-1) oxygen through a reservoir-attached face mask. As she could not remain in the supine position, emergency tracheal intubation in the sitting position was required. After topical anesthesia with 8% lidocaine and careful administration of midazolam, the AWS was inserted into her mouth in the sitting, face-to-face position. The AWS allowed for visualization of the glottis and safe placement of the tracheal tube. Sufficient spontaneous ventilation was maintained during interventions with minimum vital sign changes. Awake intubation in the sitting position with the AWS may be helpful in resolving cardiovascular crisis in patients unable to maintain the supine position.

UPPER GASTROINTESTINAL ENDOSCOPY FINDINGS IN PATIENTS REFERRED WITH UPPER GASTROINTESTINAL SYMPTOMS IN ELDORET, KENYA: A RETROSPECTIVE REVIEW

BACKGROUND

Dyspepsia is one of the major indications for upper gastrointestinal endoscopy. Other indications include dysphagia, odynophagia and gastrointestinal bleeding. Endoscopy is an expensive procedure that is out of reach of many patients in resource constrained region such as western Kenya. We reviewed endoscopy records from both public and private health institutions spanning ten years.

OBJECTIVE

To determine the pattern of referral and endoscopy diagnoses in patients referred for upper gastrointestinal endoscopy in Eldoret, Kenya.

DESIGN

Retrospective chart review.

SETTING

Moi Teaching and Referral Hospital, private hospitals and private clinics in Eldoret, Kenya.

SUBJECTS

One thousand six hundred and ninety (1690) Patients who underwent upper GI endoscopy from 1993 to 2003 were reviewed after obtaining clearances from the respective institutions. Information on age, sex, symptoms, and endoscopy diagnosis were extracted and subjected to statistical analysis.

RESULTS

The most common symptom was dyspepsia in 1059 (62.7%) followed by dysphagia in 224 (13.3%). Others were referred with diagnosis of cancer of the stomach or oesophagus. Common endoscopy diagnoses were cancer of the oesophagus in 199 (11.8%) and duodenal ulcer in 186 (11.0%). The majority of the patients (30.4%) had normal endoscopy findings. Of the 1059 patients with dyspepsia, only 154 (14.5%) had duodenal ulcer and 34 (3.2%) had gastric ulcers, the majority, 37.2% had normal endoscopy findings.

CONCLUSION

Dyspepsia was main reason for referral, but the majority of such patients had normal findings. Cancer of the oesophagus was the main diagnosis in patients with dysphagia. In view of the cost of endoscopy, only those with dyspepsia and alarm symptoms be referred for the procedure.

[Present status of interventional pulmonology]

Endobronchial intervention has been well established in therapeutic and palliative methods for patients with malignant and benign airway obstruction. Central airway tumor obstruction could lead to significant dyspnea or hemoptysis and dramatically lower the quality of life. Such symptoms can be relieved immediately via bronchoscopic intervention. Endobronchial therapies such as neodymium yttrium aluminum garnet( Nd:YAG) laser therapy, argon plasma coagulation and microwave coagulation or stent placement are well-established treatment options. Each of these modalities has its specific advantages and disadvantages. Laser therapy is direct thermal ablation applied to endobronchial tumors. It has sufficient power to vaporize tissues and produces an excellent coagulation effect. However, the risk of perforation is high. On the other hand, photodynamic therapy has the curative potential for patients with early superficial lung cancer using low power laser. Moreover, it has recently been approved for the treatment of other cancers including advanced lung cancer. Stent placement is an effective treatment to re-establish airway patency and immediately relieve the patient from life-threatening dyspnea. Stent restenosis, migration, mucus plug and hemoptysis are common short-term and longterm problems. It is important to select the appropriate treatment method for each patient to avoid complications and achieve successful results.

[Efficacy of sulpiride and itopride in the treatment of functional dyspepsia in women with emotional and eating disorders]

Functional dyspepsia is often accompanied by emotional disturbances, especially in postmenopausal women. Impaired homeostasis of the dopaminergic system maybe one of the common pathogenetic factors. The aim of the study was to assess the effect of drugs which block dopamine D2 receptors on psychosomatic condition in postmenopausal women.

MATERIAL AND METHODS

The study was conducted in a group of 60 women, aged 53-61 years, with postprandial distress syndrome (PDS) that met the Rome Criteria III. The severity of dyspeptic symptoms was determined statistically using a 10-point Visual Analogue Scale (VAS). The emotional state was estimated with the Hamilton Anxiety Rating Scale (HARS) and the Beck Depression Inventory (BDI), whereas the body mass index (BMI) was the indicator of the nutritional status. Sulpiride (2 x 50 mg) was administered to 30 women for 16 weeks and itopride (2 x 50 mg) to 30 others.

RESULTS

After sulpiride and itopride treatment equal decrease of dyspeptic symptoms was observed, respectively from 9.08 to 4.76 pts and from 9.02 to 4.64 pts. Significant reduction in the level of anxiety (p < 0.001) and depression (p < 0.01) was obtained in both groups, slightly higher after sulpiride. However, no significant change in BMI was found.

CONCLUSIONS

Sulpiride and itopride are effective in the treatment of dyspepsia in the form of postprandial distress syndrome. These drugs in the several-month treatment have no significant effect on body weight.

Surgical management and long-term follow-up of solid pseudopapillary tumor of pancreas: a large series from a single institution

OBJECTIVE

We summarized the diagnosis, surgical strategies, and long-term follow-up outcomes in our large series of solid pseudopapillary tumors (SPTs) of pancreas.

METHODS

In this retrospective analysis, we collected data pertaining to pancreatic SPTs diagnosed in 115 patients between July 2003 and February 2013.We analyzed the demographic characteristics, clinical presentations, operative strategies, perioperative details, and follow-up outcomes.

RESULTS

Abdominal pain was the most frequent symptom (40.0%). The most frequent location of SPT was pancreatic tail (36.5%). We performed 33 cases of pancreaticoduodenectomy, 15 cases of middle pancreatectomy, 19 cases of distal pancreatectomy with spleen preservation, 28 cases of distal pancreatectomy with splenectomy, and 18 cases of enucleation. Two patients suffered tumor recurrence and required a second resection of the recurrent tumor.

CONCLUSIONS

Complete resection of the tumor is associated with good survival, even in patients with vessel involvement or metastases. In patients with tumor recurrence, a second resection resulted in long-term survival.

Modified sequential Helicobacter pylori eradication therapy using high dose omeprazole and amoxicillin in the initial phase in the extensive metaboliser Turkish patients for CYP2C19 polymorphism is ineffective

AIM

To investigate whether the sequential therapy composed of high dose omeprazole and high dose amoxicillin in the first step was effective in eradication of H. pylori and whether there was a relation between effectiveness of the therapy and CYP2C19 gene polymorphism.

METHOD

134 dyspeptic patients with H. pylori were administered a modified sequential therapy composed of omeprazole 40 mg t.i.d. and amoxicillin 1000 mg t.i.d, for the first five days followed by omeprazole 20 mg b.d., metronidazole 500 mg t.i.d. and tetracycline 500 mg t.i.d, for the next five days. CYP2C19 genotype status was determined in patients. Hp eradication status was investigated by C14 UNT four weeks after treatment.

RESULTS

The eradication rates were 64.9% in ITT and 74.3% in PP analysis. In subgroup analyses, eradication rates were 73.8% and 60.8% (p: 0.145) in ITT for peptic ulcer and non-ulcer dyspepsia patients respectively and 86.1% and 69.1% (p: 0.052) in PP analysis for peptic ulcer and non-ulcer dyspepsia patients respectively. The difference was not significant. As for the CYP2C19 gene status, 81.5% of the patients had HoEM and 17.3% of the patients had HeEM, and eradication rates were 72% and 75% in ITT analysis for HoEM and HeEM respectively (p: 0.803) and 73.9% and 85.7% in PP analysis for HoEM and HeEM respectively (p: 0.347). There was not a significant difference in H. pylori eradication rates between the two groups.

CONCLUSION

This modified high-dose sequential therapy was ineffective in a Turkish sample, nearly all of whom had EM in terms of CYP2C19 gene status.

Manometric assessment of esophageal motor function in patients with primary biliary cirrhosis

INTRODUCTION/AIM

Primary biliary cirrhosis is associated with other autoimmune diseases including Sjögren's syndrome, and scleroderma. Esophageal dysmotility is well known in scleroderma, and Sjögren's syndrome. The aim of this study is to investigate whether any esophageal motor dysfunction exists in patients with primary biliary cirrhosis.

METHOD

The study was performed in 37 patients (36 women, mean age: 56.29 ± 10.01 years) who met diagnostic criteria for primary biliary cirrhosis. Thirty-seven functional dyspepsia patients, were also included as a control group. Patients entering the study were asked to complete a symptom questionnaire. Distal esophageal contraction amplitude, and lower esophageal sphincter resting pressure were assessed.

RESULTS

Manometric findings in primary biliary cirrhosis patients vs. controls were as follows: Median lower esophageal sphincter resting pressure (mmHg): (24 vs 20, p=0.033); median esophageal contraction amplitude (mmHg): (71 vs 56, p=0.050); mean lower esophageal sphincter relaxation duration (sc, x ± SD): (6.10 ± 1.18 vs 8.29 ± 1.92, p<0.001); and median lower esophageal sphincter relaxation (%) (96 vs 98, p=0.019); respectively. No significant differences were evident in median peak velocity (sc) (3.20 vs 3.02, p=0.778) between patients with primary biliary cirrhosis and the functional dyspepsia patients. Esophageal dysmotility was found in 17 (45.9%) primary biliary cirrhosis patients (non-specific esophageal motor disorder in ten patients, hypomotility of esophagus in five patients, nutcracker esophagus in one patient and hypertensive lower esophageal sphincter in one patient).

CONCLUSION

Esophageal dysmotility was detected in 45.9% of patients. The study suggests that subclinic esophageal dysmotility is frequent in patients with primary biliary cirrhosis.

Effects of L-thyroxine on gastric motility and ghrelin in subclinical hypothyroidism: a prospective study

INTRODUCTION

Overt hypothyroidism affects the gastrointestinal system. Limited data are available regarding gastric motility in subclinical hypothyroidism (SCH).

OBJECTIVE

The aim of this study was to assess gastric motility-related gastric symptoms and levels of ghrelin in patients with SCH compared with those in healthy control subjects and to evaluate the potential effects of l-thyroxine replacement therapy.

METHODS

Twenty premenopausal women with SCH and 20 age- and body mass index-matched healthy control women were enrolled in the study. The gastroparesis cardinal severity index questionnaire was used to reveal gastrointestinal motility changes, and electrogastrographic activities were measured. Fasting and postprandial ghrelin levels at 30, 60, and 120 minutes were determined during a mixed meal test. All tests were repeated after 6 months when patients were in the euthyroid state.

RESULTS

The gastroparesis cardinal severity index score, fasting tachygastria ratio, and postprandial/fasting bradygastria ratio in electrogastrography were higher in patients with SCH compared with control subjects (P = .03, P = .04, and P = .04, respectively). All 3 parameters significantly improved after l-thyroxine replacement therapy (P < .001, P = .005, and P =.02 respectively) reaching levels similar to those of control subjects. Baseline and area under the curve for ghrelin during mixed meal tests did not show a difference between patients with SCH and control subjects and before and after l-thyroxine replacement in SCH.

CONCLUSION

Gastric dysmotility and the resultant upper gastrointestinal symptoms can be observed in SCH, and symptomatology related to dysmotility and parameters appear to be improved with thyroid hormone replacement. Our results also suggest that ghrelin levels in response to a meal are similar between women with SCH and healthy women and that normalization of thyroid function by l-thyroxine does not modulate these levels.

Carbon-13 urea breath test for Helicobacter pylori infection in patients with uninvestigated ulcer-like dyspepsia: an evidence-based analysis

BACKGROUND

Dyspepsia is a condition defined by chronic pain or discomfort in the upper gastrointestinal tract that can be caused by Helicobacter pylori. The carbon-13 urea breath test (¹³C UBT) is a non-invasive test to detect H. pylori.

OBJECTIVES

We aimed to determine the diagnostic accuracy and clinical utility of the ¹³C UBT in adult patients with ulcer-like dyspepsia who have no alarm features.

DATA SOURCES

A literature search was performed using Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid Embase, the Wiley Cochrane Library, and the Centre for Reviews and Dissemination database, for studies published between 2003 and 2012.

REVIEW METHODS

We abstracted the sensitivity and specificity, which were calculated against a composite reference standard. Summary estimates were obtained using bivariate random effects regression analysis.

RESULTS

From 19 diagnostic studies, the ¹³C UBT summary estimates were 98.1% (95% confidence interval [CI], 96.3-99.0) for sensitivity and 95.1% (95% CI, 90.3-97.6) for specificity. In 6 studies that compared the ¹³C UBT with serology, the 1¹³C UBT sensitivity was 95.0% (95% CI, 90.1-97.5) and specificity was 91.6 % (95% CI, 81.3-96.4). The sensitivity and specificity for serology were 92.9% (95% CI, 82.6-97.3) and 71.1% (95% CI, 63.8-77.5), respectively. In 1 RCT, symptom resolution, medication use, and physician visits were similar among the ¹³C UBT, serology, gastroscopy, or empirical treatment arms. However, patients tested with ¹³C UBT reported higher dyspepsia-specific quality of life scores.

LIMITATIONS

Processing of the ¹³C UBT results can vary according to many factors. Further, the studies showed significant heterogeneity and used different composite reference standards.

CONCLUSIONS

The ¹³C UBT is an accurate test with high sensitivity and specificity. Compared with serology, it has higher specificity. There is a paucity of data on the ¹³C UBT beyond test accuracy.

PLAIN LANGUAGE SUMMARY

Breath test for detecting bacteria in patients with ulcer-like symptoms. Dyspepsia is a condition that causes long-term pain or discomfort in the upper abdomen. Symptoms can include heartburn, burping, bloating, nausea, or slow digestion. Dyspepsia can be caused by a bacterium that also causes ulcers and stomach cancer. Half of the world's people are believed to be infected with these bacteria. A test has been developed to detect the bacteria in a breath sample. Our review determined the accuracy of this breath test in adults with ulcer-like symptoms. From 19 studies, the breath test correctly identified 98% of patients with the bacteria and 95% of patients without the bacteria, as determined by a reference standard. Six studies compared the breath test to a blood test that is currently used. Both the breath and blood tests performed well in correctly identifying patients with the bacteria. However, the blood test was incorrectly positive in 20 more patients who did not have the bacteria according to the breath test. This means that more patients would have received unnecessary treatment. Thus, the breath test is an accurate test to detect the bacteria in adult patients who have ulcer-like symptoms. But the many differences among the studies in our review included several steps taken to perform the breath test and the reference standards used to compare a blood test with the breath test.

Common Gastrointestinal Symptoms: dyspepsia and Helicobacter pylori

The most common diagnoses among patients with dyspepsia are functional dyspepsia, gastroesophageal reflux disease, peptic ulcer, and gastric or esophageal cancer. Helicobacter pylori infection is present in many patients with dyspepsia and is etiologic in some conditions. The evaluation of dyspepsia divides patients into 3 categories: 1) for patients taking nonsteroidal anti-inflammatory drugs (NSAIDs), NSAIDs should be discontinued; if symptoms resolve after discontinuation, no further evaluation is needed; 2) for patients with reflux symptoms, proton pump inhibitors (PPIs) should be prescribed without endoscopy unless alarm symptoms are present; and 3) for patients with no NSAID use or reflux symptoms, evaluation depends on risk. Patients older than 55 years or with alarm symptoms are at high risk and should undergo endoscopy. Those 55 years or younger with no alarm symptoms are at low risk. Those patients should be tested for H pylori and treated if results are positive. If symptoms persist after eradication treatment, PPIs should be prescribed for 4 to 6 weeks; if symptoms persist after treatment, endoscopy should be obtained. If H pylori test results are negative, PPIs should be prescribed for 4 to 6 weeks. Endoscopy should be obtained if symptoms persist. There are several regimens for eradication of H pylori. The most effective is sequential therapy with a PPI and amoxicillin for 5 days followed by a PPI, clarithromycin, and tinidazole for another 5 days.

Diarrhoea is not the only symptom that needs to be treated in patients with microscopic colitis

BACKGROUND

Many patients with microscopic colitis (MC) also suffer from symptoms of irritable bowel syndrome (IBS), but the only treatment given is corticosteroids for the diarrhoea. The aim of this study was to examine how social factors, life style factors and drug treatment affect symptoms and well-being in patients suffering from MC.

METHODS

Women, over the age of 73years, with biopsy-verified MC, at any Departments of Gastroenterology, Skåne, between 2002 and 2010 were invited. The questionnaires Gastrointestinal Symptom Rating Scale (GSRS) and Psychological General Well-being Index (PGWB) were sent by mail, along with questions about social and life style factors, and medical history.

RESULTS

Of 240 invited, 158 patients (66%) were included (median age 63years, range 27-73years). Only 26% had never smoked. Smoking and concomitant IBS were associated with both impaired gastrointestinal symptoms (OR=3.96, 95% CI=1.47-10.66 and OR=4.40, 95% CI=2.09-9.26, respectively) and impaired psychological well-being (OR=2.77, 95% CI=1.04-7.34 and OR=3.82, 95% CI=1.83-7.99, respectively). Treatment with proton pump inhibitors (PPI) was associated with increased gastrointestinal symptoms (OR=3.44, 95% CI=1.45-8.16). Age, social factors, and corticosteroids had no effect on symptoms or well-being. Smoking was the only risk factor associated with IBS (OR=2.68, 95% CI=1.115-6.26).

CONCLUSION

Smoking and IBS are associated with impaired gastrointestinal symptoms and psychological well-being in MC patients. PPI is associated with impaired gastrointestinal symptoms.

Predictors of persistent symptoms and reduced quality of life in treated coeliac disease patients: a large cross-sectional study

BACKGROUND

Evidence suggests that many coeliac disease patients suffer from persistent clinical symptoms and reduced health-related quality of life despite a strict gluten-free diet. We aimed to find predictors for these continuous health concerns in long-term treated adult coeliac patients.

METHODS

In a nationwide study, 596 patients filled validated Gastrointestinal Symptom Rating Scale and Psychological General Well-Being questionnaires and were interviewed regarding demographic data, clinical presentation and treatment of coeliac disease, time and place of diagnosis and presence of coeliac disease-associated or other co-morbidities. Dietary adherence was assessed by a combination of self-reported adherence and serological tests. Odds ratios and 95% confidence intervals were calculated by binary logistic regression.

RESULTS

Diagnosis at working age, long duration and severity of symptoms before diagnosis and presence of thyroidal disease, non-coeliac food intolerance or gastrointestinal co-morbidity increased the risk of persistent symptoms. Patients with extraintestinal presentation at diagnosis had fewer current symptoms than subjects with gastrointestinal manifestations. Impaired quality of life was seen in patients with long duration of symptoms before diagnosis and in those with psychiatric, neurologic or gastrointestinal co-morbidities. Patients with persistent symptoms were more likely to have reduced quality of life.

CONCLUSIONS

There were a variety of factors predisposing to increased symptoms and impaired quality of life in coeliac disease. Based on our results, early diagnosis of the condition and consideration of co-morbidities may help in resolving long-lasting health problems in coeliac disease.