What role does Helicobacter pylori play in dyspepsia and nonulcer dyspepsia? Arguments for and against H. pylori being associated with dyspeptic symptoms

Disorders of the brain-gut interaction and eating disorders

BACKGROUND

Eating disorders (ED) involve both the nervous system and the gastrointestinal tract. A similar double involvement is also found in disorders of the brain-gut interaction (DGBI) and symptoms are sometimes similar.

AIM

To find out where there is an association and a cause-effect relationship, we looked for the comorbidity of DGBI and ED.

METHODS

A systematic review was undertaken. A literature search was performed. Inclusion criteria for the articles retained for analysis were: Observational cohort population-based or hospital-based and case-control studies, examining the relationship between DGBI and ED. Exclusion criteria were: Studies written in other languages than English, abstracts, conference presentations, letters to the Editor and editorials. Selected papers by two independent investigators were critically evaluated and included in this review.

RESULTS

We found 29 articles analyzing the relation between DGBI and ED comprising 13 articles on gastroparesis, 5 articles on functional dyspepsia, 7 articles about functional constipation and 4 articles on irritable bowel syndrome.

CONCLUSION

There is no evidence for a cause-effect relationship between DGBI and ED. Their common symptomatology requires correct identification and a tailored therapy of each disorder.

Effects of the Rome IV Criteria to Functional Dyspepsia Symptoms in Saudi Arabia: Epidemiology and Clinical Practice

Background/Aims

Limited data is available in Saudi Arabia (SA) regarding the prevalence of functional dyspepsia (FD) symptoms and its subtypes, as defined by the ROME IV criteria. This study evaluated the burden of self-reported FD symptoms in the adult general population of SA and the current clinical practices.

Methods

A web-based national cross-sectional health survey of the general population of SA was conducted using the Rome IV Diagnostic Questionnaire for Functional Gastrointestinal Disorders in Adults with additional questions on the presence of symptoms compatible with functional heartburn (FH) and irritable bowel syndrome (IBS). The quality of life and somatization questionnaires were also included.

Results

Overall, 3,114 adults completed the questionnaire, but 303 (9.7%) were excluded due to inconsistent responses. Of the 2,811 consistent responders, 532 (18.3%) fulfilled the Rome IV criteria for FD symptoms. These were distributed into the FD subtypes as follows: 208 (7.4%) had postprandial distress syndrome, 228 (8.1%) had epigastric pain syndrome, and 96 (3.4%) had the overlapping variant. IBS-like symptoms were reported in 232 (44%) and FH in 102 (19%) 19% (102) of the subjects with functional dyspepsia. H. pylori-associated dyspepsia was reported by 25% (87/348). High somatization, lower quality of life scores, younger age, and female sex were associated more with the FD symptoms participants than those without. Approximately 1/5 respondents used over-the-counter medications to relieve the FD symptoms.

Conclusions

In this population-based survey, FD affected almost 1/5 of the responding adult population in SA, which was less than previously reported.

The Efficacy of Hypnotherapy in the Treatment of Functional Dyspepsia

BACKGROUND

Functional dyspepsia (FD) is one of the most frequent functional gastrointestinal disorders and is defined using the Rome IV criteria as any combination of the following symptoms: postprandial fullness, early satiety, epigastric pain, and epigastric burning that are severe enough to interfere with the usual activities and occur at least 3 days per week over the past 3 months with an onset of at least 6 months before the presentation. The purpose of this systematic review is to analyze all the relevant studies in the literature that investigate the efficiency of hypnotherapy in FD.

AREAS OF UNCERTAINTY

FD refractory to conservative treatment is a therapeutic challenge, and alternative treatment options are needed. Gut-oriented hypnotherapy has been reported an effective treatment for irritable bowel syndrome, but poorly tested in FD.

DATA SOURCES

We performed a search in 6 bibliographic databases (PubMed, Embase, Cochrane Library, Web of Science, Scopus, and LILACS) using customized search strategies for each engine. The search strategy included the following terms: (hypnosis, hypnotherapy, hypnotherapies, hypnogenesis, hypnotism, hypnotist, hypnotical suggestion, suggestion, and mesmerism) and {[functional and (dyspepsia or dyspeptic)] or FD}.

RESULTS

Taking the aforementioned criteria into account, the result was a review of 4 articles analyzing the efficacy of hypnotherapy in the treatment of FD, published in the past 20 years. The initial search identified 398 articles, of which 37 potentially appropriate articles were reviewed. Of these 37 articles, 4 articles were included in the review. The benefits observed by numerous studies go beyond the field of digestive pathology, patients describing a general improvement in physical and mental health.

CONCLUSIONS

Current studies analyzing the efficacy of hypnotherapy in FD provide encouraging data, but additional randomized controlled trials are needed before a firm position on the effectiveness of hypnosis in FD.

Exhaled nitric oxide as a potential marker for detecting non-ulcer dyspepsia and peptic ulcer disease

Nitric oxide (NO) plays a key role in the development of peptic ulcer disease (PUD). Conversely, the gastric pathogen Helicobacter pylori colonizes the human stomach and contributes to the development of non-ulcer dyspepsia (NUD) and PUD. However, the underlying relation between molecular NO in exhaled breath and H. pylori-associated NUD and PUD remains largely unknown. Here, we found that the excretion kinetics of NO profiles in exhaled breath are altered markedly in H. pylori-infected NUD and PUD subjects. In our observations, PUD led to considerably higher enrichments of NO in exhaled breath compared to NUD, thus revealing a potential link between exhaled NO and ulcer and non-ulcer complications. Our findings therefore suggest that molecular NO in exhaled breath could be used as a potential biomarker for non-invasive diagnosis and selective differentiation of NUD from PUD. Our observations also highlight that alterations of NO in the gastric environment can play an important role in the pathogenesis of peptic ulcers and thus may provide a new strategy for precise evolution of the actual disease state without the need for endoscopic biopsy, even after the eradication of H. pylori infection.

Pattern of psychotropic medications use in a cohort of patients with uninvestigated dyspepsia undergoing upper endoscopy: A retrospective study

The prevalence of psychotropic drugs usage is growing in the general population. Moreover, patients with dyspeptic symptoms are increasingly referred to the use of psychiatric and antianxiety drugs in addition to the primary medical treatment. The focus of this observational retrospective study was to investigate the burden of psychotropic drugs usage in a cohort of patients with uninvestigated dyspepsia scheduled for esophagogastroduodenoscopy.Medical records of 11,275 patients (4377 men and 6898 women, age range 18-96 years) referred to the Gastroenterology Unit of the University of Sassari, Sardinia, between January 1995 and December 2013 were reviewed. Information regarding any taken medications including psychiatric and antianxiety drugs was collected. Age- and gender-specific frequency of drug usage was calculated, and their association with marital status, smoking habits, place of residence, socioeconomical status, and polypharmacy was investigated by multiple logistic regression analysis.Psychiatric drugs usage was detected in 531 out of 11,275 (4.7%) patients, with preponderance of women (6.1% vs 2.6%, P < 0.0001). The most prescribed drug categories were selective serotonin-reuptake inhibitors and tricyclic antidepressants.The frequency of antianxiety medication use was 9.8% (1009/11,275) and increased with aging, whereas psychiatric drugs reached the plateau in the fifth decade. The cohort effect was remarkable for psychiatric drugs usage in patients born after 1950 compared to those born before (odds ratio: 1.47), whereas it was absent for antianxiety drugs. Conditions significantly associated with psychotropic drugs usage were assumption of more than 2 nonpsychotropic drugs, aging, female gender, smoking, marriage, widowhood, divorce, and socioeconomic status. In contrast, place of residence did not increase the consumption of psychotropic drugs. The influence of marriage and widowhood disappeared after adjusting for all covariates.Our study confirmed the frequent use of psychotropic medications with uninvestigated dyspepsia. However, the pattern of consumption was different for antianxiety and psychiatric drugs.

Effect of Helicobacter pylori eradication in Iranian patients with functional dyspepsia: a prospective, randomized, placebo-controlled trial

INTRODUCTION

Whether patients with functional dyspepsia (FD) should receive Helicobacter pylori (H. pylori) eradication therapy remains controversial. The objective of this trial was to evaluate the effect of H. pylori eradication therapy on dyspeptic symptoms of patients with FD.

MATERIAL AND METHODS

A prospective, randomized, placebo-controlled trial of H. pylori eradication for FD was conducted. A total of 720 FD patients diagnosed by Rome III criteria were consecutively enrolled. We randomly assigned 186 H. pylori infected patients with FD to receive quadruple therapy for 14 days and 173 such patients to receive identical-appearing placebos. Severity of abdominal symptoms was assessed with the Glasgow Dyspepsia Severity Score (GDSS), and eradication of H. pylori by (13)C-urea breath test was evaluated during one year.

RESULTS

The rate of eradication of H. pylori infection was 87.1% in the treatment group and 2.9% in the placebo group at 6 weeks (p = 0.001). The mean GDSS at 12 months was 4.9 ±2.8 in the treatment group, as compared to 5.2 ±3.4 in the placebo group (p = 0.064). The scores in both groups were lower than those at baseline. According to the intention-to-treat analysis, at 12 months, there was no significant difference between groups in the rate of successful treatment (48.6% in the treatment group and 51.2% in the placebo group; p = 0.84). There was no significant difference in mean symptom scores between the two treatment groups at any point during follow-up.

CONCLUSIONS

The results of our study provide no evidence that H. pylori eradication leads to relief of symptoms 12 months after treatment, and there is a need for further studies.

Gene polymorphisms associated with functional dyspepsia

Functional dyspepsia (FD) is a constellation of functional upper abdominal complaints with poorly elucidated pathophysiology. However, there is increasing evidence that susceptibility to FD is influenced by hereditary factors. Genetic association studies in FD have examined genotypes related to gastrointestinal motility or sensation, as well as those related to inflammation or immune response. G-protein b3 subunit gene polymorphisms were first reported as being associated with FD. Thereafter, several gene polymorphisms including serotonin transporter promoter, interlukin-17F, migration inhibitory factor, cholecystocynine-1 intron 1, cyclooxygenase-1, catechol-o-methyltransferase, transient receptor potential vanilloid 1 receptor, regulated upon activation normal T cell expressed and secreted, p22PHOX, Toll like receptor 2, SCN10A, CD14 and adrenoreceptors have been investigated in relation to FD; however, the results are contradictory. Several limitations underscore the value of current studies. Among others, inconsistencies in the definitions of FD and controls, subject composition differences regarding FD subtypes, inadequate samples, geographical and ethnical differences, as well as unadjusted environmental factors. Further well-designed studies are necessary to determine how targeted genes polymorphisms, influence the clinical manifestations and potentially the therapeutic response in FD.

An Evidence-Based Approach to the Management of Functional Dyspepsia Associated With Helicobacter pylori Infection

Background

Functional dyspepsia is defined as at least a 3-month history of dyspepsia without structural explanation for the symptoms, and it accounts for most cases of dyspepsia. We designed this study to investigate functional dyspepsia among a Chinese population in Taiwan.

Methods

Data from the medical records of 1,143 adult patients who underwent transoral upper endoscopy for symptoms of dyspepsia in our hospital were retrospectively analyzed between January 2008 and December 2008. Exclusion criteria were structural gastrointestinal and hepatobiliary abnormalities, prior gastric surgery or history of chronic medication use.

Results

Patients were mainly in the third and fourth decades of life. More female patients were noted than male patients (ratio 2:1). The rate of Helicobacter pylori infection was 18.5%. The rate of response to therapeutic agents, including proton pump inhibitors, H2-receptor antagonists and prokinetic agents, ranged from 69% to 77% among all cases. Patients who underwent H. pylori eradication therapy (88.8%) had a significantly higher rate of symptom improvement than those without H. pylori infection (77.5%).

Conclusion

Cases with functional dyspepsia have the characteristics of middle age, female predominance, a relatively lower H. pylori infection rate and a positive response to H. pylori eradication therapy.

To compare the efficacy of two kinds of Zhizhu pills in the treatment of functional dyspepsia of spleen-deficiency and qi-stagnation syndrome: a randomized group sequential comparative trial

BACKGROUND

In Traditional Chinese Medicine (TCM) theory, functional dyspepsia (FD) can be divided into different syndromes according to different clinical symptoms and signs, and the most common one is spleen-deficiency and qi-stagnation syndrome that can be treated by Chinese traditional patent medicine--two kinds of Zhizhu pills, between which the primary difference in ingredients is that one contains immature orange fruit of Citrus aurantium L.(IFCA) and the other contains that of Citrus sinensis Osbeck (IFCS). The trial's objective was to compare the efficacy of two kinds of Zhizhu pills on symptom changes in patients with FD of spleen-deficiency and qi-stagnation syndrome.

METHODS

A randomized, group sequential, double-blinded, multicenter trial was conducted in patients with FD of spleen-deficiency and qi-stagnation syndrome at 3 hospitals in Beijing between June 2003 and May 2005. Participants were randomly allocated into two groups (IFCA group and IFCS group) in a 1:1 ratio, and respectively took one of the two kinds of Zhizhu pills orally, 6 g each time, 3 times a day, for 4 weeks. Statistical analysis was performed with use of a group sequential method, the triangular test (TT).

RESULTS

A total of 163 patients were randomized, and 3 patients were excluded from analysis because of early dropouts, leaving 160 patients (IFCA group: n = 82; IFCS group: n = 78) for statistical analysis. Three interim analyses were done after 62, 116, and 160 patients had completed their 4-week treatment, respectively. At the third interim analysis, the sample path crossed the upper boundary and the trial was stopped, the cure-markedly effective rates were 45% for IFCS group and 67% for IFCA group, respectively, the one-sided p-value was 0.0036, the median unbiased estimate of the odds ratio (OR) for the benefit of IFCA relative to IFCS was 2.91 with 95%CI: 1.40 to 6.06.No adverse events were observed in the two groups.

CONCLUSIONS

Zhizhu pills containing IFCA was superior to Zhizhu pills containing IFCS in the treatment of FD of spleen-deficiency and qi-stagnation syndrome. The application of group sequential analysis in clinical trials of TCM may offer some financial and ethical benefits.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR): ChiCTR-TRC-00000485.

Prospective multi-center trial for the efficacy of ecabet sodium on the relief of dyspepsia in korean patients with chronic gastritis

Anti-peptic and anti-inflammatory actions of ecabet sodium might be beneficial in either improving gastritis or relieving dyspeptic symptoms. This study was designed to evaluate the clinical efficacy of ecabet sodium on dyspeptic symptoms and to elucidate the molecular mechanism attributable to symptom relief in patients with chronic gastritis. Two hundred and sixty eight chronic gastritis patients with persistent dyspepsia received ecabet sodium 1 g b.i.d. for 2 weeks, after which dyspeptic symptoms were reassessed with a questionnaires as before. The changes of interleukin-8 (IL-8), inducible nitric oxide synthase (iNOS), prostaglandin E(2) (PGE(2)), and vascular endothelial growth factor (VEGF) levels in gastric juices were measured by ELISA. The changes of nitrotyrosine in gastric mucosa were measured by immunohistochemical staining. The most common dyspeptic symptom in Korean patients with chronic gastritis was epigastric soreness (76.8%), which was improved significantly after ecabet sodium treatment (81.7%, p<0.001). Ecabet sodium was more effective in patients with epigastric pain than vague abdominal discomfort (p = 0.02), especially in patients with old age. Complete relief of discomfort was more highly achieved in patients with positive Helicobacter pylori than without (p = 0.01). In spite of clear tendency that the decreased levels of IL-8, iNOS, and PGE(2) and increased levels of VEGF were measured in gastric juices after ecabet sodium treatment, no statistical significance was noted, which might be due to high inter-individual variations. The nitrotyrosine expressions were significantly decreased after ecabet sodium treatment than before (p<0.01). In conclusion, ecabet sodium treatment was very useful for the relief of dyspeptic symptoms in chronic gastritis, to which both attenuated inflammatory and enhanced regenerative mechanisms were contributive.

Liquid culture medium for the rapid cultivation of Helicobacter pylori from biopsy specimens

The goal of this study was to develop a liquid culture medium for the rapid isolation, cultivation, identification and subsequent antibiotics susceptibility testing of Helicobacter pylori directly from biopsy specimens. Five liquid media were tested: Ham's F-12, Brucella broth, tryptic soybroth, brain heart infusion broth and Mueller-Hinton broth. After optimisation of the medium, it was applied in order to investigate biopsy samples from 150 patients with gastro-duodenal disorders and compared with traditional culture methods, microscopy and an H. pylori-specific TaqMan real-time polymerase chain reaction (PCR). The most reliable and rapid growth of H. pylori, even at a small inoculum size, was obtained in Ham's F-12 medium with 5% horse serum. The developed system allowed the primary isolation of H. pylori in clinical samples and provided 87% sensitivity and 100% specificity.

Helicobacter pylori and benign upper digestive disease

Acute infection with Helicobacter pylori causes hypochlorhydria and gastrointestinal upset. As the infection persists, patients develop chronic antral-predominant or pangastritis. Gastric and duodenal ulcers arise from chronic mucosal inflammation and disordered acid secretion in the stomach. With successful eradication of H. pylori, non-NSAID-related gastric and duodenal ulcers heal even without long-term acid suppression. More importantly, peptic ulcers and their complications rarely recur. Clearing H. pylori infection also reduces the risk of mucosal injury in NSAID and aspirin users; the protective effects are more pronounced in NSAID-naïve and aspirin users. H. pylori is unlikely to be the cause of gastro-oesophageal reflux disease. However, a patient's reflux symptoms may be more difficult to control after clearing the infection. Although there is little evidence to support a causal relationship between H. pylori and non-ulcer dyspepsia, treatment of the infection gives a modest improvement of symptoms.

Helicobacter pylori: present status and future prospects in Japan

The discovery of Helicobacter pylori has already changed the natural history of peptic ulcer disease, with most patients being cured at their first presentation. Similarly, the incidence of gastric cancer and other diseases related to H. pylori are likely to be greatly reduced in the near future. Isolation of the spiral intragastric bacterium H. pylori totally reversed the false dogma that the stomach was sterile, and it taught us that chronic infectious disease can still exist in modern society. Helicobacter pylori's unique location, persistence, and evasion of the immune system offer important insights into the pathophysiology of the gut. Also, the fact that it was overlooked for so long encourages us to think "outside the box" when investigating other diseases with obscure etiologies. We should consider such provocative scientific ideas as bridges to the future disease control.

Pathogenesis of Helicobacter pylori Infection

SUMMARY

Helicobacter pylori is the first formally recognized bacterial carcinogen and is one of the most successful human pathogens, as over half of the world's population is colonized with this gram-negative bacterium. Unless treated, colonization usually persists lifelong. H. pylori infection represents a key factor in the etiology of various gastrointestinal diseases, ranging from chronic active gastritis without clinical symptoms to peptic ulceration, gastric adenocarcinoma, and gastric mucosa-associated lymphoid tissue lymphoma. Disease outcome is the result of the complex interplay between the host and the bacterium. Host immune gene polymorphisms and gastric acid secretion largely determine the bacterium's ability to colonize a specific gastric niche. Bacterial virulence factors such as the cytotoxin-associated gene pathogenicity island-encoded protein CagA and the vacuolating cytotoxin VacA aid in this colonization of the gastric mucosa and subsequently seem to modulate the host's immune system. This review focuses on the microbiological, clinical, immunological, and biochemical aspects of the pathogenesis of H. pylori .

Pathogenesis of Helicobacter pylori Infection

SUMMARY

Helicobacter pylori is the first formally recognized bacterial carcinogen and is one of the most successful human pathogens, as over half of the world's population is colonized with this gram-negative bacterium. Unless treated, colonization usually persists lifelong. H. pylori infection represents a key factor in the etiology of various gastrointestinal diseases, ranging from chronic active gastritis without clinical symptoms to peptic ulceration, gastric adenocarcinoma, and gastric mucosa-associated lymphoid tissue lymphoma. Disease outcome is the result of the complex interplay between the host and the bacterium. Host immune gene polymorphisms and gastric acid secretion largely determine the bacterium's ability to colonize a specific gastric niche. Bacterial virulence factors such as the cytotoxin-associated gene pathogenicity island-encoded protein CagA and the vacuolating cytotoxin VacA aid in this colonization of the gastric mucosa and subsequently seem to modulate the host's immune system. This review focuses on the microbiological, clinical, immunological, and biochemical aspects of the pathogenesis of H. pylori .

Pathogenesis of Helicobacter pylori Infection

SUMMARY

Helicobacter pylori is the first formally recognized bacterial carcinogen and is one of the most successful human pathogens, as over half of the world's population is colonized with this gram-negative bacterium. Unless treated, colonization usually persists lifelong. H. pylori infection represents a key factor in the etiology of various gastrointestinal diseases, ranging from chronic active gastritis without clinical symptoms to peptic ulceration, gastric adenocarcinoma, and gastric mucosa-associated lymphoid tissue lymphoma. Disease outcome is the result of the complex interplay between the host and the bacterium. Host immune gene polymorphisms and gastric acid secretion largely determine the bacterium's ability to colonize a specific gastric niche. Bacterial virulence factors such as the cytotoxin-associated gene pathogenicity island-encoded protein CagA and the vacuolating cytotoxin VacA aid in this colonization of the gastric mucosa and subsequently seem to modulate the host's immune system. This review focuses on the microbiological, clinical, immunological, and biochemical aspects of the pathogenesis of H. pylori .

Pathogenesis of Helicobacter pylori infection

Helicobacter pylori is the first formally recognized bacterial carcinogen and is one of the most successful human pathogens, as over half of the world's population is colonized with this gram-negative bacterium. Unless treated, colonization usually persists lifelong. H. pylori infection represents a key factor in the etiology of various gastrointestinal diseases, ranging from chronic active gastritis without clinical symptoms to peptic ulceration, gastric adenocarcinoma, and gastric mucosa-associated lymphoid tissue lymphoma. Disease outcome is the result of the complex interplay between the host and the bacterium. Host immune gene polymorphisms and gastric acid secretion largely determine the bacterium's ability to colonize a specific gastric niche. Bacterial virulence factors such as the cytotoxin-associated gene pathogenicity island-encoded protein CagA and the vacuolating cytotoxin VacA aid in this colonization of the gastric mucosa and subsequently seem to modulate the host's immune system. This review focuses on the microbiological, clinical, immunological, and biochemical aspects of the pathogenesis of H. pylori.

Subtypes of functional dyspepsia

Functional dyspepsia is a common clinical condition characterised by chronic or recurrent upper abdominal pain or discomfort commonly associated with a variety of associated gastrointestinal symptoms and a normal endoscopy. To standardise research-based approaches, an initial categorisation of into sub groups was agreed to, based on clusters of symptoms. However the early expectation that these subgroups would be associated with distinct pathophysiologies amenable to specific therapy has not been realised. A classification based on the most troublesome symptom has been suggested but the utility of this is also unclear. More recent data suggest that some of the pathophysiologic dysfunctions may be associated with specific symptoms and so provide a better tool for grouping patients. But this approach remains incomplete as current insights into the pathogenesis are still too limited for this to be satisfactory. In conclusion, no classification provides for an adequate treatment-based approach to the syndrome of functional dyspepsia. As a consequence treatment remains largely empiric.

Role of Helicobacter pylori virulence factor and genotypes in non-ulcer dyspepsia

BACKGROUND AND AIM

The role of Helicobacter pylori (HP) in non-ulcer dyspepsia is debatable. Eradicating HP will help a small group of non-ulcer dyspeptic patients. However, it is unclear which subgroup of patients will benefit from eradication therapy. The aim of the present study was to compare the cagA and cagE status, as well as vacA genotypes, of HP in non-ulcer dyspeptic patients who responded successfully to eradication therapy compared with those patients who did not.

METHODS

Consecutive patients with moderate to severe (Likert 2 or 3) non-ulcer dyspepsia with HP were recruited prospectively. Gastric biopsies were taken, DNA extracted and polymerase chain reaction performed to determine the cagA and cagE status and vacA alleles. Eradication therapy was offered until HP was eradicated successfully. The HP status was checked 1 month after eradication therapy using the [(13)C]-urea breath test. All patients were assessed by one interviewer using Gastrointestinal Symptom Rating Scale (GSRS), a four-point Likert scale, and SF-36 for quality of life over 12 months. Treatment success was defined as minimal or no symptoms (Likert 1 or 0). The cagA, cagE and vacA status was blinded to the investigators until completion of the study.

RESULTS

Seventy-three patients (36 males, 37 females) were recruited to the study. The mean+/-SD patient age was 53.38+/-12.09 years. When the 36 patients who improved (group A) were compared with the 37 (group B) who did not, no significant difference was found in the cagE positive rate (55.6 vs 43.2%, respectively; P=0.638), cagA positive rate (83.1 vs 73.0%, respectively; P=0.247), vacA m1 versus m2 subtype (84.0 vs 55.6%, respectively; P=0.472) or vacA s1a versus s1c (39.4 vs 57.1%, respectively; P=0.166). There was also no significant difference noted in the SF-36 scores between the two groups after the conclusion of eradication therapy.

CONCLUSIONS

Stratification of HP genotypes and virulence factor has no significant impact on the treatment success of non-ulcer dyspepsia.

Management of functional dyspepsia: Unsolved problems and new perspectives

The common characteristic criteria of all functional gastrointestinal (GI) disorders are the persistence and recurrence of variable gastrointestinal symptoms that cannot be explained by any structural or biochemical abnormalities. Functional dyspepsia (FD) represents one of the important GI disorders in Western countries because of its remarkably high prevalence in general population and its impact on quality of life. Due to its dependence on both subjective determinants and diverse country-specific circumstances, the definition and management strategies of FD are still variably stated. Clinical trials with several drug classes (e.g., proton pump inhibitors, H2-blockers, prokinetic drugs) have been performed frequently without validated disease-specific test instruments for the outcome measurements. Therefore, the interpretation of such trials remains difficult and controversial with respect to comparability and evaluation of drug efficacy, and definite conclusions can be drawn neither for diagnostic management nor for efficacious drug therapy so far. In view of these unsolved problems, guidelines both on the clinical management of FD and on the performance of clinical trials are needed. In recent years, increasing research work has been done in this area. Clinical trials conducted in adequately diagnosed patients that provided validated outcome measurements may result in better insights leading to more effective treatment strategies. Encouraging perspectives have been recently performed by methodologically well-designed treatment studies with herbal drug preparations. Herbal drugs, given their proven efficacy in clinical trials, offer a safe therapeutic alternative in the treatment of FD which is often favored by both patients and physicians. A fixed combination of peppermint oil and caraway oil in patients suffering from FD could be proven effective by well-designed clinical trials.

Eradication of Helicobacter pylori for non-ulcer dyspepsia

BACKGROUND

Helicobacter pylori (H pylori) is the main cause of peptic ulcer disease. The role of H pylori in non-ulcer dyspepsia is less clear.

OBJECTIVES

To determine the effect of H pylori eradication on dyspepsia symptoms in patients with non-ulcer dyspepsia.

SEARCH STRATEGY

Trials were identified through electronic searches of the Cochrane Controlled Trials Register (CCTR), MEDLINE, EMBASE, CINAHL and SIGLE, using appropriate subject headings and keywords, searching bibliographies of retrieved articles, and through contacts with experts in the fields of dyspepsia and with pharmaceutical companies. These searches were updated in October 2004.

SELECTION CRITERIA

All parallel group randomised controlled trials (RCTs) comparing drugs to eradicate H pylori with placebo or other drugs known not to eradicate H pylori for patients with non-ulcer dyspepsia.

DATA COLLECTION AND ANALYSIS

Data were collected on individual and global dyspeptic symptom scores, quality of life measures and adverse effects. Dyspepsia outcomes were dichotomised into minimal/resolved versus same/worse symptoms.

MAIN RESULTS

Seventeen randomised controlled trials were included in the systematic review. Fourteen trials compared antisecretory dual or triple therapy with placebo antibiotics +/- antisecretory therapy, and evaluated dyspepsia at 3-12 months. Thirteen of these trials gave results as dichotomous outcomes evaluating 3186 patients and there was no significant heterogeneity between the studies. There was a 8% relative risk reduction in the H pylori eradication group (95% CI = 3% to 12%) compared to placebo. The number needed to treat to cure one case of dyspepsia = 18 (95% CI = 12 to 48). A further three trials compared Bismuth based H pylori eradication with an alternative pharmacological agent. These trials were smaller and had a shorter follow-up but suggested H pylori eradication was more effective than either H2 receptor antagonists or sucralfate in treating non-ulcer dyspepsia.

AUTHORS' CONCLUSIONS

H pylori eradication therapy has a small but statistically significant effect in H pylori positive non-ulcer dyspepsia. An economic model suggests this modest benefit may still be cost-effective but more research is needed.

Definition and epidemiology of functional gastrointestinal disorders

The term 'functional gastrointestinal disorder (FGID)' is used to define several variable combinations of chronic or recurrent gastrointestinal (GI) symptoms that do not have an identified underlying pathophysiology. In the absence of any objective marker, the identification and classification of FGIDs are based on symptoms. The most widely accepted classification is based on the 'Rome diagnostic criteria,' which have classified 24 FGIDs into oesophageal, gastroduodenal, bowel, biliary, anorectal and abdominal pain subcategories. Classification into mutually exclusive categories has been useful for performing epidemiological studies in homogeneous populations, but has inevitably lead to disregarding subjects with overlapping FGIDs, or with a not sufficiently standardised symptom presentation. The epidemiology of FGID is still in its infancy, as indicated by the lack of epidemiological data for many FGIDs and the widely different incidence and prevalence rates reported for the most frequently occurring and investigated FGIDs: irritable bowel syndrome (IBS), dyspepsia, constipation and oesophageal disorders. Epidemiological studies and the definitions of the various FGIDs need to be further improved and standardised.

[Efficacy of Helicobacter pylori eradication in non-ulcer dyspepsia]

BACKGROUND AND OBJECTIVE

The relationship between Helicobacter pylori infection and functional dyspepsia (FD) is disputed. Although there is a greater prevalence of infection by H. pylori in subjects with non-ulcer dyspepsia than in healthy subjects, results regarding the eradication of infection have been inconclusive so far in terms of disease improvement. In this study, we administered eradicating treatment to a group of patients with both FD and infection by H. pylori to determine the possible beneficial effect of such a treatment. Thus, our objective was to study the effectiveness of eradication therapy for H. pylori in the clinical course of FD.

PATIENTS AND METHOD

This was a randomized, double-blind study in 93 consecutive patients diagnosed with FD and infection by H. pylori who received eradicating treatment with omeprazol, amoxicillin and clarythromicin for 7 days (group A, n = 47) vs. placebo, amoxicillin and clarythromicin for 7 days (group B, n = 46). We analyzed the clinical evolution of the disease within the following 9 months.

RESULTS

Both groups of treatment were comparable concerning all the variables studied except for the consumption of alcohol, with a greater prevalence in group A, yet no patient consumed more than 40 g per day. The average age of patients was 42 (18-65). Eradication of H. pylori occurred in 65.9% of patients in group A and 4.3% of patients in group B. 40% of all patients included in the study had improved symptoms. In 60.6% of patients whose infection was eradicated, their symptoms improved, as opposed to 25% of patients whose infection was not eradicated (p = 0.001). Among patients whose symptoms improved following eradication, 70% had had an FD duration of less than 3 years and in 30% FD had lasted for more than 3 years (p < 0.05).

CONCLUSIONS

The eradication of H. pylori in patients with short-lasting FD may lead to a significant clinical benefit, especially in those whose duration of symptoms is below 3 years.

Dyspeptic symptoms associated with Helicobacter pylori infection are influenced by strain and host specific factors

BACKGROUND

Dyspepsia can be associated with H. pylori infection.

AIM

To assess dyspeptic symptoms and potentially influencing factors before and up to 6 months following successful H. pylori eradication therapy.

METHODS

Prospective cohort study involving H. pylori positive subjects from ambulatory or hospitalized care. Main outcome measures were symptoms during baseline and follow-up, the proportion of symptom-free patients, and symptom scores.

RESULTS

After successful eradication, the summary score of all dyspeptic symptoms decreased and during follow-up, the proportion of symptom-free patients was higher in the group with peptic ulcers (69.4% vs. 40.9%, P < 0.0001) than with functional dyspepsia (FD). Regardless of diagnosis, virulent strains of H. pylori were associated with a higher prevalence of epigastric pain before treatment: absolute risk-difference (ARD) with Oip-A: 18.2%, Odds Ratio (OR) 2.35 [1.3-4.2, 95%-CI], P = 0.01; with Cag-A: 24.6%, OR 2.81 [1.6-5], P = 0.01. Low-dose aspirin in part was a major risk factor in FD for previous weight loss bdfore study entry. Post-treatment, non-ulcer patients were more likely to suffer from distention/bloating. Likewise, alcohol induced persistence of nausea and vomiting in this population.

CONCLUSIONS

Dyspeptic symptoms in H. pylori infected patients are more common with virulent strains. Symptoms are more likely to persist despite successful eradication if patients initially harboured virulent strains or concomitant aspirin or alcohol intake are present. In one-third of peptic ulcer patients, symptoms will not be cured 3 months after therapy.

Gastritis and carditis

Dyspepsia is a common clinical problem. Its causes include peptic ulcer disease, gastroesophageal reflux, and functional (nonulcer) dyspepsia. A detailed clinical description of pain does not reliably differentiate the cause. Approximately 80% of gastroscopies are performed for the investigation of dyspepsia. "Gastritis" is diagnosed endoscopically in 59% of all stomachs, although in only 3% are the changes severe. Pathologic examination of unselected gastric biopsy specimens reveals that abnormalities are present in 62-73%, but there is only a weak correlation between endoscopic and histologic findings. For these reasons, it is recommended that endoscopic examination should always be accompanied by biopsy. Ideally, biopsies should be taken in a systematic fashion to include sampling of antrum and corpus. Recent evidence suggests that gastric infection by Helicobacter pylori initially presents as a superficial gastritis. Later it may become atrophic with development of intestinal metaplasia. The onset of atrophic changes may be related to the duration of infection, the strain of the infecting organism, associated dietary factors, or as-yet undefined host factors related to immunity. Persistent superficial gastritis predisposes to duodenal ulcer and gastric mucosa-associated lymphoid tissue lymphoma. Atrophic gastritis predisposes to gastric ulcer and adenocarcinoma. Evidence is accumulating that in some patients, pernicious anemia may be an end result of H. pylori-induced atrophic gastritis. Reactive gastropathy is a relatively common finding in gastric biopsies; in most instances it is associated with either reflux of duodenal contents or therapy with nonsteroidal anti-inflammatory drugs. Lymphocytic gastritis, eosinophilic gastritis, and the gastritis associated with Crohn's disease are distinct morphologic entities. Lymphocytic gastritis and eosinophilic gastritis have a variety of clinical associations. Carditis is a controversial topic: currently opinions are divided as to whether it is the result of gastroesophageal reflux or a proximal extension of H. pylori infection from the remainder of the stomach.

The role of esophagogastroduodenoscopy in the diagnosis and management of upper gastrointestinal disorders

Esophagogastroduodenoscopy has revolutionized the clinical management of upper gastrointestinal diseases. Millions of EGDs are performed annually in the United States for many indications, such as gastrointestinal bleeding, abdominal pain, dysphagia, or surveillance of premalignant lesions. Esophagogastroduodenoscopy is very safe, with a low risk of serious complications such as perforation, cardiopulmonary arrest, or aspiration pneumonia. It is a highly sensitive and specific diagnostic test, especially when combined with endoscopic biopsy. Esophagogastroduodenoscopy is increasingly being used therapeutically to avoid surgery. New endoscopic technology such as endosonography, endoscopic sewing, and the endoscopic videocapsule will undoubtedly extend the frontiers and increase the indications for endoscopy.

[Helicobacter pylori infection and functional dyspepsia. Meta-analysis of efficacy of eradication therapy]

BACKGROUND

To establish a causal link between Helicobacter pylori infection and functional dyspepsia it is necessary to demonstrate that H. pylori eradication induces an improvement in dyspeptic symptoms. Our aim was to perform a meta-analysis of randomized studies comparing, in functional dyspepsia, the efficacy of H. pylori eradication treatment with that of treatments with no effect on H. pylori infection.

PATIENTS AND METHODS

DATA SOURCES

PubMed database, Cochrane Controlled Trials Register, and abstracts from congresses until 2001.

SELECTION CRITERIA

a) studies including patients with functional dyspepsia and H. pylori infection; b) randomized trials comparing H. pylori eradication treatment with treatment (control) with no effect on H. pylori infection, and c) follow-up of at least 6 months. The quality of studies was assessed by a validated score.

STATISTICS

the main outcome was the percentage of patients improving in each therapeutic group. A meta-analysis was performed combining the odds ratios (OR) of individual studies in a global OR.

RESULTS

Nine studies fulfilled the inclusion criteria and were thus included in the meta-analysis. Overall, 953 patients received an eradication treatment and 958 received a control treatment. The overall percentage of patients with symptomatic improvement in the eradication group was 43% (95% CI, 40-46%), and it was 39% (95% CI, 36-42%) in the control group. The OR for the effect of the eradication treatment vs. the control treatment was 1.20 (95% CI, 0.91-1.58). The number needed to treat (NNT) with eradication therapy to achieve a symptomatic improvement, compared with the control group, was 25. Although heterogeneity was demonstrated, it disappeared when one study showing positive, clearly discordant results was excluded. Thus, the percentage of patients with symptomatic improvement in the eradication treatment group was 47% (95% CI, 43-50%) and it was 45% (95% CI, 41-48%) in the control group (OR: 1.06; 0.85-1.31; NNT: 50).

CONCLUSIONS

H. pylori eradication treatment is not associated with a statistically significant improvement of symptoms in patients with functional dyspepsia.

Review article: Helicobacter pylori and nonulcer dyspepsia

Although up to 50% of patients diagnosed with nonulcer dyspepsia (NUD) have Helicobacter pylori infection and underlying chronic gastritis, it remains controversial whether any causal relationship exists. The results of worldwide epidemiological studies have been unconvincing. No clear-cut link has been documented between H. pylori and any specific symptom profile or pathophysiological mechanism in NUD. In the randomized controlled trials, methodological weaknesses may explain in part the conflicting results, but even in the well-conducted trials controversy persists. Although meta-analyses have attempted to resolve the issue, inherent methodological difficulties with meta-analysis remain a problem. Moreover, even the methodologically sound meta-analyses have reported conflicting results. In addition, predictors of treatment response remain obscure, and there continue to be theoretical concerns about the treatment of H. pylori infection in all patients with NUD. Hence, the management of these patients is challenging, but eradication of H. pylori infection may be beneficial in a small subgroup of cases with NUD that cannot be identified before treatment.

Seroprevalence of Helicobacter pylori infection in Siberia

BACKGROUND

Despite many population-based epidemiological studies of Helicobacter pylori prevalence in different parts of the world, Russia still represents a 'blank spot' in this map. The aims of the present study were to evaluate the seroprevalence of H. pylori infection among the population of Siberia and to assess whether there is an association between abdominal symptoms and H. pylori positivity in our population.

METHODS

Six hundred and forty-nine adults from five regions of Siberia and the Far East, and 79 children and adolescents from Novosibirsk participated in the study. Antibodies against H. pylori (IgG) were detected in serum using ELISA.

RESULTS

The total percentage of infected adults varied from 70% to 92% depending on the region, and was somewhat lower in three populations living to the north of the 60th latitude compared with those under the 60th latitude. A lack of association was found between the presence of H. pylori and the gender, age and abdominal symptoms. Almost maximum prevalence of H. pylori infection occurred by 30 years of age with only a minor increase in older age groups. Half the children were infected with H. pylori by the age of 15.

CONCLUSIONS

Helicobacter pylori infection is widespread among the Siberian populations with some trend in its prevalence to decrease northward. In Siberia age-specific prevalence rates of H. pylori infection are similar to those usual for developing countries.

Helicobacter pylori eradication treatment does not benefit patients with nonulcer dyspepsia

OBJECTIVES

The aim of this study was to assess the still controversial role of treatment of Helicobacter pylori (H. pylori) infection in patients with nonulcer dyspepsia.

METHODS

We conducted a double-blind, randomized, placebo-controlled, multicenter trial comparing the efficacy of 7 days of eradication treatment (lansoprazole 15 mg b.i.d., amoxicillin I g b.i.d., and clarithromycin 500 mg b.i.d.) with a control treatment (lansoprazole 15 mg b.i.d. and placebo) in H. pylori-infected patients with nonulcer dyspepsia. 13C breath tests were performed at baseline and during follow-up. We assessed patient symptoms, health status (based on the SF-12 questionnaire), patient satisfaction, drug consumption, health care consultation behavior, and absenteeism related to dyspepsia over a 1-yr period.

RESULTS

A total of 74 patients randomized to eradication treatment and 70 patients randomized to placebo were compared. The rate of eradication of H. pylori infection was 75% in the active treatment group and 4% in the placebo group (p < 0.005). The symptom score improved to a similar extent in the group receiving active treatment (-4.0; 95% CI = -5.0 to -3.0) and placebo (-3.6; 95% CI = -4.5 to -2.7). Treatment response was not related to the severity or duration of initial symptoms or to the severity of gastritis on histology. Quality of life scores were comparable at 12 months. There was no significant difference in dyspepsia-related absenteeism or satisfaction with management of NUD. Patients receiving active treatment were more likely not to have had to use any dyspepsia treatment over the 12 months (60.8% vs 44.3%; p = 0.047).

CONCLUSIONS

This study did not demonstrate any substantial benefit of curing H. pylori infection in patients with nonulcer dyspepsia. The study adds further evidence that H. pylori is not the main pathogenetic or therapeutic target in these patients.

Effect of 2,4,6-trinitrobenzenesulphonic acid (TNBS)-induced ileitis on the motor function of non-inflamed rat gastric fundus

During intestinal inflammation, motility disturbances are not restricted to inflamed regions, but may also occur in remote non-inflamed sites of the gastrointestinal tract. Our aim was to investigate the motor function of the gastric fundus after the induction of terminal ileitis in the rat. Ileal inflammation was induced by intraluminal installation of 2,4,6-trinitrobenzenesulphonic acid (TNBS) into the ileum. Inflammation was assessed both histologically and biochemically. Contractions and relaxations of longitudinal muscle strips from the gastric fundus were studied 36 h and 1 week later. During the acute phase of ileal inflammation (36 h), the non-inflamed stomach was distended. The contractility of longitudinal muscle strips of the gastric fundus was decreased due to a post-receptor defect. In addition, nonadrenergic noncholinergic (NANC) relaxations were inhibited due to neuronal dysfunction. Aortic contractility remained normal and the mere presence of food in the stomach did not account for the disturbed neuromuscular function in the gastric fundus. Ablation of extrinsic primary afferent neurones by capsaicin further impaired gastric fundus contractility. Transection and re-anastomosis of the jejunum reversed the effect of TNBS-induced ileitis on the neuromuscular function of the gastric fundus. One week after TNBS, cholinergic neurotransmission was increased in the gastric fundus. During acute ileitis, smooth muscle cell contractility and inhibitory NANC neurotransmission are inhibited in the non-inflamed gastric fundus. This phenomenon may be mediated by intrinsic connections within the enteric nervous system.

The Loiano-Monghidoro population-based study of Helicobacter pylori infection: prevalence by 13C-urea breath test and associated factors

OBJECTIVES

As part of a cross-sectional study on cholelithiasis, 1533 out of 1840 residents in Loiano/Monghidoro, a rural area in Northern Italy (792 men, 741 women, age range 28-80 years), agreed to be further evaluated in relation to their Helicobacter pylori status.

METHODS

Each participant performed a 13C-urea breath test (13C-UBT) and provided information on sociodemographic, lifestyle and clinical characteristics.

RESULTS

The 13C-UBT was positive in 1041 subjects (67.9%; men: 69%; women: 67%) and was positively associated with increasing age (P < 0.001), alcohol consumption (P < 0.01), a higher number of siblings (P < 0.001) and a personal history of peptic ulcer (P < 0.01), but inversely with a nonmanual occupation (P < 0.001). Overall, H. pylori infection was unrelated to smoking, house pets, and a family history of gastroduodenal diseases. The prevalence of H. pylori infection was 72% in subjects reporting one or more dyspeptic symptoms and 65% among asymptomatic participants (P < 0.001); a multivariate analysis showed that only epigastric pain was significantly, although weakly, associated with 13C-UBT positivity.

CONCLUSIONS

This large population-based study showed a prevalence of H. pylori infection higher than that reported by serologic surveys in urban areas. Current H. pylori infection was strongly associated with indicators of lower socioeconomic status, alcohol consumption and increasing age. A role of H. pylori infection in determining epigastric pain was suggested.

Fish oil (Eicosapen) is less effective than metronidazole, in combination with pantoprazole and clarithromycin, for Helicobacter pylori eradication

BACKGROUND

In vitro omega-3-fatty acids (Eicosapen) are bacteriostatic to Helicobacter pylori and have a variety of immuno-modulating effects.

AIM

To investigate the efficacy and tolerability of eicosapen (E) as an antibiotic-sparing component of a triple H. pylori eradication regimen in non-ulcer dyspepsia patients in a randomized, double-blind trial.

METHODS

Non-ulcer dyspepsia patients (n=199), with a normal upper endoscopy and a positive (13)C-urea breath test (UBT) were randomly assigned to either pantoprazole, clarithromycin and metronidazole (PCM) or pantoprazole, clarithromycin and eicosapen (PCE) for 7 days. Four weeks after treatment, H. pylori eradication was determined by UBT. Symptoms were followed up to 16 months.

RESULTS

In the intention-to-treat population, PCM eradicated infection in 78% but PCE was successful in only 34% (P < 0.001). Symptomatic improvement occurred in both groups, and was not related to H. pylori eradication.

CONCLUSION

Eicosapen is unlikely to be useful in H. pylori eradication regimens.

Increased prevalence of Helicobacter pylori in patients with diabetes mellitus

BACKGROUND

Whilst upper gastrointestinal disturbances are frequently observed in patients with diabetes mellitus, little is known about the prevalence of Helicobacter pylori infection and peptic disease in these patients.

AIM

To evaluate prevalence of Helicobacter pylori infection and peptic disease lesions in diabetics with dyspeptic symptoms.

PATIENTS AND METHODS

Study population comprises 74 consecutive diabetes mellitus patients with dyspepsia and 117 consecutive non diabetic dyspeptic patients. Upon enrolment, each patient completed an interview screening questionnaire to obtain information concerning presence and severity of dyspepsia. All patients underwent upper gastrointestinal endoscopy with biopsy specimens being collected from gastric antrum and body Helicobacter pylori was evaluated in each patient by rapid urease test and histology (Giemsa). Gastritis was classified according to the Sydney System. Statistical analysis was performed by chi-square, Fisher exact or t test and logistic regression analysis. A p value <0.05 was considered significant.

RESULTS

Prevalence of Helicobacter pylori infection was found to be significantly higher in diabetics than in controls. The prevalence rate of endoscopic lesions was comparable in the two groups, but the association between endoscopic lesions and Helicobacter pylori infection was significantly higher in diabetics. Overall, the presence of chronic gastritis, both non atrophic and atrophic, as well as intestinal metaplasia were comparable in the two groups of patients, whilst the association between chronic gastritis and Helicobacter pylori infection or gastritis activity were significantly higher in diabetics. In neither group, was any correlation found between severity of dyspepsia and presence of endoscopic lesions, chronic gastritis or Helicobacter pylori infection.

CONCLUSIONS

These data show a higher prevalence of Helicobacter pylori infection in diabetes mellitus patients with dyspepsia. Helicobacter pylori infection was significantly associated both with the presence of endoscopic lesions and chronic gastritis in diabetic patients, but not in the controls.

Systematic review and economic evaluation of Helicobacter pylori eradication treatment for non-ulcer dyspepsia. Dyspepsia Review Group

OBJECTIVES

To evaluate efficacy and cost effectiveness of Helicobacter pylori eradication treatment in patients with non-ulcer dyspepsia infected with H pylori.

DESIGN

Systematic review of randomised controlled trials comparing H pylori eradication with placebo or another drug treatment. Results were incorporated into a Markov model comparing health service costs and benefits of H pylori eradication with antacid treatment over one year.

DATA SOURCES

Six electronic databases were searched for randomised controlled trials from January 1966 to May 2000. Experts in the field, pharmaceutical companies, and journals were contacted for information on any unpublished trials. Trial reports were reviewed according to predefined eligibility and quality criteria.

MAIN OUTCOME MEASURES

Relative risk reduction for remaining dyspeptic symptoms (the same or worse) at 3-12 months. Cost per dyspepsia-free month estimated from Markov model based on estimated relative risk reduction.

RESULTS

Twelve trials were included in the systematic review, nine of which evaluated dyspepsia at 3-12 months in 2541 patients. H pylori eradication treatment was significantly superior to placebo in treating non-ulcer dyspepsia (relative risk reduction 9% (95% confidence interval 4% to 14%)), one case of dyspepsia being cured for every 15 people treated. H pylori eradication cost pound56 per dyspepsia-free month during first year after treatment.

CONCLUSION

H pylori eradication may be cost effective treatment for non-ulcer dyspepsia in infected patients but further evidence is needed on decision makers' willingness to pay for relief of dyspepsia.

The proportion of upper gastrointestinal symptoms in the community associated with Helicobacter pylori, lifestyle factors, and nonsteroidal anti-inflammatory drugs. Leeds HELP Study Group

OBJECTIVE

Upper gastrointestinal disorders are common in the community, yet the determinants of these symptoms are poorly characterized. The association between upper gastrointestinal symptoms and Helicobacter pylori (H. pylori), socioeconomic status, nonsteroidal antiinflammatory drug (NSAID) use, smoking, alcohol, and coffee intake was assessed in a cross-sectional survey.

METHODS

Subjects between the ages of 40-49 yr were randomly selected from the lists of 36 primary care centers. Participants attended their local primary care center and were interviewed by a researcher using a validated dyspepsia questionnaire. H. pylori status was determined by a nonfasting 13C-urea breath test.

RESULTS

A total of 32,929 subjects were invited, and 8,407 (25%) attended and were eligible. Of these, 2,329 (28%) were H. pylori positive and 3,177 (38%) had dyspepsia. Also, 44% of H. pylori-infected participants reported dyspepsia compared with 36% of uninfected subjects [odds ratio = 1.39; 95% confidence interval (CI) 1.26-1.53]. H. pylori infection remained a significant risk factor for dyspepsia in a multiple logistic regression model (odds ratio = 1.21; 95% CI 1.09-1.34), suggesting that 5% of dyspepsia in the population is attributable to H. pylori. NSAIDs, low educational attainment, renting accommodation, absence of central heating, sharing a bed with siblings, and being married were also significantly associated with dyspepsia in this model. Smoking, but not drinking alcohol or coffee, was marginally associated with dyspepsia, but this finding was not robust. These factors were not associated with any dyspepsia subtype.

CONCLUSIONS

H. pylori is significantly associated with dyspepsia and may be responsible for 5% of upper gastrointestinal symptoms in the community.

Effect of population screening and treatment for Helicobacter pylori on dyspepsia and quality of life in the community: a randomised controlled trial. Leeds HELP Study Group

BACKGROUND

Infection with Helicobacter pylori is the main cause of peptic-ulcer disease. Treatment of this infection might lower the prevalence of dyspepsia in the community and improve quality of life. We investigated this possibility in a double-blind randomised controlled trial.

METHODS

Individuals aged 40-49 years were randomly selected from the lists of 36 primary-care centres. A researcher interviewed participants with a validated dyspepsia questionnaire and the psychological general wellbeing index (PGWB). H. pylori status was assessed by the carbon-13-labelled urea breath test. Infected participants were randomly assigned active treatment (omeprazole 20 mg, clarithromycin 250 mg, and tinidazole 500 mg, each twice daily for 7 days) or identical placebo. Participants were followed up at 6 months and 2 years.

FINDINGS

Of 32,929 individuals invited, 8455 attended and were eligible; 2324 were positive for H. pylori and were assigned active treatment (1161) or placebo (1163). 1773 (76%) returned at 2 years. Dyspepsia or symptoms of gastro-oesophageal reflux were reported in 247 (28%) of 880 in the treatment group and 291 (33%) of 871 in the placebo group (absolute-risk reduction 5% [95% CI 1-10]). H. pylori treatment had no significant effect on quality of life (mean difference in PGWB score between groups 0.86 [-0.33 to 2.05]).

INTERPRETATION

Community screening and treatment for H. pylori produced only a 5% reduction in dyspepsia. This small benefit had no impact on quality of life.

Correlation between Helicobacter pylori infection and gastrointestinal symptoms in pregnancy

Nausea, vomiting, and other dyspeptic symptoms are common in pregnancy. This hospital-based, cross-sectional study was designed to determine the role of Helicobacter pylori infection in gastrointestinal (GI) symptoms during pregnancy. Standardized verbal scales were used to evaluate the frequency and severity of GI symptoms in 54 women whose pregnancies were in the first 16 gestational weeks. H. pylori infection was defined as a positive serum immunoglobulin G result on an immunochromatographic assay. The H. pylori seropositivity rate was higher in the pregnant women (69%) than in the general population (approximately 50%-55%), but seropositivity did not correlate with clinical symptoms. Moreover, no specific patterns of GI symptoms were uncovered in the H. pylori-infected patients. Maternal age, body weight, parity, gestational week, and educational level were not associated with H. pylori infection; neither were the prevalence and severity of GI symptoms.

Is Helicobacter pylori eradication associated with gastroesophageal reflux disease?

OBJECTIVES

A recent report has suggested an association between Helicobacter pylori eradication and the development of gastroesophageal reflux disease (GERD). We therefore assessed the incidence of GERD among comparable patients having undergone successful versus failed H. pylori eradication in a controlled trial. We also compared the H. pylori strains in the subjects that developed GERD to those that did not.

METHODS

Patients with a history of proven duodenal ulcer and H. pylori infection were randomised into a H. pylori eradication study. Patients subsequently underwent gastroscopy with gastric biopsies every 3 months for 1 yr. At each visit, the presence of GERD symptoms and endoscopic esophagitis were noted, and the incidence of these variables among patients in whom H. pylori eradication was successful was compared to those in whom it was not. In a subgroup, the presence of the cagA, cagE, and vacA genotypes and of cagA antibodies were determined.

RESULTS

Of 98 patients randomized into this study, 11 dropped out before determination of H. pylori eradication, leaving 87 patients with analyzable results. H. pylori eradication was successful in 63 (72%). By the end of the follow-up period, patients with GERD symptoms or endoscopic esophagitis were more prevalent in the successful than in the failed eradication group (37% [95% CI: 25-50%] vs 13% [95% CI: 3-32%], p = 0.04, 95% CI for the difference: 6-42%), as were patients with GERD symptoms alone (29% [95% CI: 18-41%] vs 8% [95% CI: 1-27%], p = 0.04, 95% CI for the difference: 4-36%) or esophagitis alone (21% [95% CI: 12-33%] vs 4% [95% CI: 0-21%], p = 0.10, 95% CI for the difference: 4-29%, respectively). Multivariate analysis revealed no significant association between the incidence of symptoms or esophagitis and age, gender, Quetelet index, caffeine or alcohol intake, smoking, weight change, or the presence of a hiatus hernia. There were also no differences in the prevalence of H. pylori genotypes from patients who developed GERD as compared to those who did not.

CONCLUSIONS

In this patient population, the incidence of new GERD-type symptoms or endoscopic esophagitis was greater in patients in whom successful eradication was achieved. This difference does not appear to be attributable to weight gain, habits, or specific H. pylori strains.

Common functional gastrointestinal disorders: nonulcer dyspepsia and irritable bowel syndrome

Up to 35% of the world population suffer from functional gastrointestinal disorders (FGD), accounting for about 40% of gastroenterologic and 12% of primary care practice. Society incurs high costs from FGD morbidity in terms of medical workups and absenteeism from work. FGD are characterized by chronic and recurrent symptoms of the gastrointestinal (GI) tract without detectable structural or biochemical abnormalities. In the absence of universal biologic markers, the diagnosis is based on consensus symptom criteria (1). This chapter reviews current knowledge of the pathophysiology and provides a practical approach to patients with functional dyspepsia and irritable bowel syndrome, 2 of the most common functional GI syndromes.

Association of Helicobacter pylori genotype with gastroesophageal reflux disease and other upper gastrointestinal diseases

OBJECTIVE

Helicobacter pylori (H. pylori) is a recognized pathogen, but it may also have a protective effect for gastroesophageal reflux disease (GERD). We compared the prevalence of potential virulence factors (cagA, cagE, vacA genotypes) in GERD to other upper gastrointestinal diseases and controls.

METHODS

A total of 405 patients underwent gastroscopy with H. pylori isolation and serum testing. Patient diagnostic subgroups were prospectively defined. Genotypes were determined by amplification using polymerase chain reaction. CagA antibodies were determined by western blot, enzyme-linked immunosorbent, and flow microsphere immunofluorescent assays.

RESULTS

Patients were grouped as follows: nonulcer dyspepsia (26%), GERD (20%), gastric ulcer (17%), duodenal ulcer (12%), gastric cancer (6%), or controls (19%). The cagA gene was present in 94-97% of subjects in all categories, but the cagA antibody was less prevalent in nonulcer dyspepsia (69%, 95% CI: 48-86%, p = 0.02) and GERD (69%, CI: 39-91%, p < 0.05) than in those with gastroduodenal pathology including gastric ulcer, duodenal ulcer, and gastric cancer (92%, CI: 81-98%). The cagE gene and vacA S1 genotype were more frequent in patients with gastroduodenal pathology (p < 0.01). GERD was associated with a significantly lower rate of vacA S1 genotype than controls (29% (CI: 10-56%) versus 80% (CI: 59-93%), p < 0.01). The vacA S1 genotype was associated with the presence of cagA antibodies.

CONCLUSIONS

The cagE and vacA S1 genotypes are more prevalent in patients with peptic ulcer or gastric cancer, suggesting a potential function in virulence for these genes. However, the vacA S1 genotype was also more prevalent in controls than GERD, suggesting a potential protective effect against GERD.

A 15-minute [13C]-urea breath test for the diagnosis of Helicobacter pylori infection in patients with non-ulcer dyspepsia

BACKGROUND

Non-ulcer dyspepsia (NUD) accounts for the majority of dyspeptic patients and studies on the epidemiology of Helicobacter pylori infection in NUD depend on a non-invasive and rapid diagnostic test. This study was performed to determine the sensitivity and specificity of a 15-min simplified protocol of the [13C]-urea breath test ([13C]-UBT) for the diagnosis of H. pylori infection in patients with NUD.

METHODS

One hundred and thirty-six patients with a clinical and endoscopic diagnosis of NUD were included. The [13C]-UBT was modified from the European standard protocol. The baseline breath sample was collected 5 min after the patient took a test meal and the 13CO2 was collected 15 min after the patient drank 100 mg [13C]-urea. The gold standard used for comparison was either a positive culture or positive histology + positive rapid urease test sampled on upper gastrointestinal endoscopy.

RESULTS

The prevalence of H. pylori infection in NUD by the gold standard was 59.6%, whereas that calculated by the [13C]-UBT was 60.3%. The sensitivity and specificity of [13C]-UBT was 93.8 and 89.1% compared with the gold standard. The shortened collection time and simplification of the procedure may have led to a decline in specificity.

CONCLUSION

The 15-min [13C]-UBT is a rapid but less specific protocol for detecting the presence of H. pylori infection in patients with NUD.

Triple therapy for Helicobacter pylori eradication: a comparison of pantoprazole once versus twice daily

BACKGROUND

Proton pump inhibitor-based triple therapy is recommended as treatment for Helicobacter pylori eradication. The proton pump inhibitor may be given once or twice daily. However, little information is available on how these two treatment strategies compare.

METHODS

H. pylori-positive patients (two positive test results) with endoscopy-proven healed duodenal ulcer or non-ulcer dyspesia were randomly allocated to 1 week of double-blind treatment with pantoprazole 40 mg once or twice daily, plus clarithromycin 250 mg and metronidazole 400 mg twice daily. Eradication was defined as a negative 13C-urea breath test (13C-UBT) and histology, 4-5 weeks post-treatment. The follow-up phase comprised 12 months off therapy, with 13C-UBT at 6 and 12 months.

RESULTS

Two hundred and four patients received treatment: pantoprazole once daily (x1), n=104; twice daily (x2), n=100. Eradication rates were 84% in both the pantoprazole x1 and pantoprazole x2 groups by modified intention-to-treat analysis and 89% and 87%, respectively, by per protocol analysis. Metronidazole resistance was found in 44% of pre-treatment cultures of H. pylori. Eradication rates were similar in susceptible (72%) and resistant (75%) strains. During follow-up, recrudescence of infection occurred in 3/118 patients.

CONCLUSION

When using pantoprazole plus clarithromycin and metronidazole, the proton pump inhibitor can be used once daily without loss of efficacy.