The role of psychosocial factors and psychiatric disorders in functional dyspepsia

Novel concepts in the pathophysiology and treatment of functional dyspepsia

Emerging data increasingly point towards the duodenum as a key region underlying the pathophysiology of functional dyspepsia (FD), one of the most prevalent functional GI disorders. The duodenum plays a major role in the control and coordination of gastroduodenal function. Impaired duodenal mucosal integrity and low-grade inflammation have been associated with altered neuronal signalling and systemic immune activation, and these alterations may ultimately lead to dyspeptic symptoms. Likely luminal candidates inducing the duodenal barrier defect include acid, bile, the microbiota and food antigens although no causal association with symptoms has been convincingly demonstrated. Recognition of duodenal pathology in FD will hopefully lead to the discovery of new biomarkers and therapeutic targets, allowing biologically targeted rather than symptom-based therapy. In this review, we summarise the recent advances in the diagnosis and treatment of FD with a focus on the duodenum.

Differences in Fecal Microbiomes and Metabolomes of People With vs Without Irritable Bowel Syndrome and Bile Acid Malabsorption

BACKGROUND & AIMS

Irritable bowel syndrome (IBS) is a heterogeneous disorder, but diagnoses and determination of subtypes are made based on symptoms. We profiled the fecal microbiomes of patients with and without IBS to identify biomarkers of this disorder.

METHODS

We collected fecal and urine samples from 80 patients with IBS (Rome IV criteria; 16-70 years old) and 65 matched individuals without IBS (control individuals), along with anthropometric, medical, and dietary information. Shotgun and 16S ribosomal RNA amplicon sequencing were performed on feces, whereas urine and fecal metabolites were analyzed by gas chromatography and liquid chromatography-mass spectrometry. Co-occurrence networks were generated based on significant Spearman correlations between data. Bile acid malabsorption (BAM) was identified in patients with diarrhea by retention of radiolabeled selenium-75 homocholic acid taurine.

RESULTS

Patients with IBS had significant differences in network connections between diet and fecal microbiomes compared with control individuals; these were accompanied by differences in fecal metabolomes. We did not find significant differences in fecal microbiota composition among patients with different IBS symptom subtypes. Fecal metabolome profiles could discriminate patients with IBS from control individuals. Urine metabolomes also differed significantly between patients with IBS and control individuals, but most discriminatory metabolites were related to diet or medications. Fecal metabolomes, but not microbiomes, could distinguish patients with IBS with vs those without BAM.

CONCLUSIONS

Despite the heterogeneity of IBS, patients have significant differences in urine and fecal metabolomes and fecal microbiome vs control individuals, independent of symptom-based subtypes of IBS. Fecal metabolome analysis can be used to distinguish patients with IBS with vs those without BAM. These findings might be used for developing microbe-based treatments for these disorders.

Non-pharmacological Approach in the Management of Functional Dyspepsia

Functional dyspepsia (FD) is a common functional gastrointestinal disease which bears a significant burden on society and individuals. Despite the high prevalence of FD, its pathophysiology remains poorly understood and the treatment options are limited and unsatisfactory. In the absence of effective pharmacological treatments for FD, non-pharmacological approaches, including: reassurance, lifestyle modification, psychotherapy, dietary interventions, medical food, acupuncture, and electrical stimulation and modulation are sought after by many physicians and FD patients. In this article, we review clinical studies which investigate nonpharmacological therapies for FD. We will also discuss potential mechanisms involved in the therapeutic effects of these nonpharmacological approaches. Though the evidences to support the routine use of the non-pharmacological management is still lacking, the non-invasive nature and potentially minimal side-effects of these therapies may be attractive in the FD management. In order to confirm the clinical effectiveness of these non-pharmacological approaches, more well-conducted, methodologically rigorous, and large-scaled clinical trials are required.

Imaging of Morphological Background in Selected Functional and Inflammatory Gastrointestinal Diseases in fMRI

The study focuses on evaluation of the Default Mode Network (DMN) activity in functional magnetic resonance imaging (fMRI) in resting state in patients with functional dyspepsia (FD) and irritable bowel syndrome (IBS), Crohn's disease and colitis ulcerosa (IBD) in comparison to healthy volunteers. We assume that etiology of both functional and non-specific inflammatory bowel diseases is correlated with disrupted structure of axonal connections. We would like to identify the network of neuronal connections responsible for presentation of symptoms in these diseases. 56 patients (functional dyspepsia, 18; Crohn's disease and colitis ulcerosa, 18; irritable bowel syndrome, 20) and 18 healthy volunteers underwent examination in MRI of the brain with assessment of brain morphology and central nervous system activity in functional imaging in resting state performed in 3T scanner. Compared to healthy controls' DMN in patients with non-specific digestive tract diseases comprised additional areas in superior frontal gyrus of left hemisphere, in left cingulum and in the left supplementary motor area. Discovered differences in the DMNs can be interpreted as altered processing of homeostatic stimuli. Our study group involved patients suffering from both functional and non-specific inflammatory bowel diseases. Nevertheless a spectrum of changes in the study group (superior frontal gyrus of the left hemisphere, in the left cingulum and in the left supplementary motor area) we were able to find common features, differentiating the whole study group from the healthy controls.

Unaltered Brain GABA Concentrations and Resting fMRI Activity in Functional Dyspepsia With and Without Comorbid Depression

BACKGROUND

GABA-deficit characterizes depression (MDD), which is highly comorbid with Functional Dyspepsia (FD). We examined brain GABA concentrations and resting activities in post-prandial distress subtype FD (FD-PDS) patients with and without MDD.

METHODS

24 female age/education-matched FD-PDS with comorbid MDD (FD-PDS-MDD), non-depressed FD-PDS, and healthy controls each were compared on GABA concentrations, resting fMRI (fALFF) in bilateral pregenual anterior cingulate (pgACC), left dorsolateral prefrontal cortex (DLPFC), insula, and somatosensory cortex (SSC).

RESULTS

FD-PDS-MDD patients had mild though elevated depressive symptoms. FD-PDS patients had generally mild dyspeptic symptoms. No significant between-group differences in GABA or fALFF were found. No significant correlations were found between GABA and depressive/dyspeptic symptoms after Bonferroni correction. In patients, GABA correlated positively with left insula fALFF (r = 0.38, Bonferroni-corrected p = .03).

CONCLUSION

We did not find altered GABA concentrations or brain resting activity in FD-PDS or its MDD comorbidity. The neurochemical link between MDD and FD remains elusive.

Animal Models for Functional Gastrointestinal Disorders

Functional gastrointestinal disorders (FGID), such as functional dyspepsia (FD) and irritable bowel syndrome (IBS) are characterized by chronic abdominal symptoms in the absence of an organic, metabolic or systemic cause that readily explains these complaints. Their pathophysiology is still not fully elucidated and animal models have been of great value to improve the understanding of the complex biological mechanisms. Over the last decades, many animal models have been developed to further unravel FGID pathophysiology and test drug efficacy. In the first part of this review, we focus on stress-related models, starting with the different perinatal stress models, including the stress of the dam, followed by a discussion on neonatal stress such as the maternal separation model. We also describe the most commonly used stress models in adult animals which brought valuable insights on the brain-gut axis in stress-related disorders. In the second part, we focus more on models studying peripheral, i.e., gastrointestinal, mechanisms, either induced by an infection or another inflammatory trigger. In this section, we also introduce more recent models developed around food-related metabolic disorders or food hypersensitivity and allergy. Finally, we introduce models mimicking FGID as a secondary effect of medical interventions and spontaneous models sharing characteristics of GI and anxiety-related disorders. The latter are powerful models for brain-gut axis dysfunction and bring new insights about FGID and their comorbidities such as anxiety and depression.

Chronic stress induces hypersensitivity of murine gastric vagal afferents

BACKGROUND

Stress exposure is known to trigger and exacerbate functional dyspepsia (FD) symptoms. Increased gastric sensitivity to food-related stimuli is widely observed in FD patients and is associated with stress and psychological disorders. The mechanisms underlying the hypersensitivity are not clear. Gastric vagal afferents (GVAs) play an important role in sensing meal-related mechanical stimulation to modulate gastrointestinal function and food intake. This study aimed to determine whether GVAs display hypersensitivity after chronic stress, and whether its interaction with leptin was altered by stress.

METHODS

Eight-week-old male C57BL/6 mice were exposed to unpredictable chronic mild stress or no stress (control) for 8 weeks. The metabolic rate, gastric emptying rate, and anxiety- and depression-like behaviors were determined. GVA mechanosensitivity, and its modulation by leptin, was determined using an in vitro single fiber recording technique. QRT-PCR was used to establish the levels of leptin and leptin receptor mRNA in the stomach and nodose ganglion, respectively.

KEY RESULTS

The stressed mice had lower body weight and food intake, and increased anxiety-like behavior compared to the control mice. The mechanosensitivity of mucosal and tension-sensitive GVAs was higher in the stressed mice. Leptin potentiated mucosal GVA mechanosensitivity in control but not stressed mice. The expression of leptin mRNA in the gastric mucosa was lower in the stressed mice.

CONCLUSIONS AND INFERENCES

In conclusion, chronic stress enhances GVA mechanosensitivity, which may contribute to the gastric hypersensitivity in FD. In addition, the modulatory effect of leptin on GVA signaling is lost after chronic stress exposure.

Diabetic Gastroparesis

This review covers the epidemiology, pathophysiology, clinical features, diagnosis, and management of diabetic gastroparesis, and more broadly diabetic gastroenteropathy, which encompasses all the gastrointestinal manifestations of diabetes mellitus. Up to 50% of patients with type 1 and type 2 DM and suboptimal glycemic control have delayed gastric emptying (GE), which can be documented with scintigraphy, 13C breath tests, or a wireless motility capsule; the remainder have normal or rapid GE. Many patients with delayed GE are asymptomatic; others have dyspepsia (i.e., mild to moderate indigestion, with or without a mild delay in GE) or gastroparesis, which is a syndrome characterized by moderate to severe upper gastrointestinal symptoms and delayed GE that suggest, but are not accompanied by, gastric outlet obstruction. Gastroparesis can markedly impair quality of life, and up to 50% of patients have significant anxiety and/or depression. Often the distinction between dyspepsia and gastroparesis is based on clinical judgement rather than established criteria. Hyperglycemia, autonomic neuropathy, and enteric neuromuscular inflammation and injury are implicated in the pathogenesis of delayed GE. Alternatively, there are limited data to suggest that delayed GE may affect glycemic control. The management of diabetic gastroparesis is guided by the severity of symptoms, the magnitude of delayed GE, and the nutritional status. Initial options include dietary modifications, supplemental oral nutrition, and antiemetic and prokinetic medications. Patients with more severe symptoms may require a venting gastrostomy or jejunostomy and/or gastric electrical stimulation. Promising newer therapeutic approaches include ghrelin receptor agonists and selective 5-hydroxytryptamine receptor agonists.

The Diagnosis and Treatment of Functional Dyspepsia

BACKGROUND

Functional dyspepsia (FD) is one of the more common functional disorders, with a prevalence of 10-20%. It affectsthe gastrointestinal tract.

METHODS

This article is based on publications retrieved by a selective search of PubMed, with special attention to controlled trials, guidelines, and reviews.

RESULTS

Typical dyspeptic symptoms in functional dyspepsia include epigastric pain, sensations of pressure and fullness, nausea, and early subjective satiety. The etiology of the disorder is heterogeneous and multifactorial. Contributory causes include motility disturbances, visceral hypersensitivity, elevated mucosal permeability, and disturbances of the autonomic and enteric nervous system. There is as yet no causally directed treatment for functional dyspepsia. Its treatment should begin with intensive patient education regarding the benign nature of the disorder and with the establishment of a therapeutic pact for long-term care. Given the absence of a causally directed treatment, drugs to treat functional dyspepsia should be given for no more than 8-12 weeks. Proton-pump inhibitors, phytotherapeutic drugs, and Helicobacter pylori eradication are evidence-based interventions. For intractable cases, tricyclic antidepressants and psychotherapy are further effective treatment options.

CONCLUSION

The impaired quality of life of patients with functional dyspepsia implies the need for definitive establishment of the diagnosis, followed by symptom-oriented treatment for the duration of the symptomatic interval.

Elucidating the putative link between prefrontal neurotransmission, functional connectivity, and affective symptoms in irritable bowel syndrome

Altered neural mechanisms are well-acknowledged in irritable bowel syndrome (IBS), a disorder of brain-gut-communication highly comorbid with anxiety and depression. As a key hub in corticolimbic inhibition, medial prefrontal cortex (mPFC) may be involved in disturbed emotion regulation in IBS. However, aberrant mPFC excitatory and inhibitory neurotransmission potentially contributing to psychological symptoms in IBS remains unknown. Using quantitative magnetic resonance spectroscopy (qMRS), we compared mPFC glutamate + glutamine (Glx) and γ-aminobutyric acid (GABA+) concentrations in 64 women with IBS and 32 age-matched healthy women (HCs) and investigated their association with anxiety and depression in correlational and subgroup analyses. Applying functional magnetic resonance imaging (fMRI), we explored whether altered neurotransmission was paralleled by aberrant mPFC resting-state functional connectivity (FC). IBS patients did not differ from HCs with respect to mPFC GABA+ or Glx levels. Anxiety was positively associated with mPFC GABA+ concentrations in IBS, whereas Glx was unrelated to psychological or gastrointestinal symptoms. Subgroup comparisons of patients with high or low anxiety symptom severity and HCs revealed increased GABA+ in patients with high symptom severity, and lower mPFC FC with adjacent anterior cingulate cortex (ACC), a crucial region of emotion modulation. Our findings provide novel evidence that altered prefrontal inhibitory neurotransmission may be linked to anxiety in IBS.

Duodenal eosinophilia is associated with functional dyspepsia and new onset gastro-oesophageal reflux disease

BACKGROUND

It is unexplained why functional dyspepsia and gastro-oesophageal reflux disease (GERD) overlap more often than expected by chance. Post-prandial distress syndrome has been linked to impaired gastric fundic accommodation which may induce increased transient lower oesophageal sphincter relaxations and consequent GERD. Duodenal eosinophilia has been linked to functional dyspepsia and post-prandial distress syndrome.

AIM

To identify if there is an association between duodenal eosinophilia in functional dyspepsia and symptoms of GERD and whether post-prandial distress syndrome or epigastric pain syndrome are associated with new onset GERD.

METHODS

Participants (n = 1000) were randomly selected from the national Swedish population register and surveyed by questionnaires and oesophagogastroduodenoscopy in 1999-2001. All eligible subjects (n = 887) were invited to a follow-up study in 2010 (response rate 79%). In a case-control study of 213 subjects (functional dyspepsia vs healthy controls), histology from the duodenum was evaluated at baseline and the possible association of eosinophilia to new onset GERD symptoms was analysed.

RESULTS

Functional dyspepsia (OR 7.6; 95% CI 2.93-19.4, P < 0.001) and post-prandial distress syndrome at baseline (OR 9.0, 95% CI 3.36-24.0, P < 0.001) were associated with an increased risk of GERD at follow-up. Eosinophilia in the second part of duodenum only was independently associated with an increased risk of GERD amongst those with functional dyspepsia (OR 4.2; 95% CI 1.2-4.77, P = 0.024) and post-prandial distress syndrome at baseline (OR 6.0; 95% CI 1.50-23.6, P = 0.011), respectively.

CONCLUSIONS

Duodenal eosinophilia is associated with increased risk of GERD at 10-year follow-up in those with functional dyspepsia and post-prandial distress syndrome at baseline. Duodenal eosinophilia may explain the link between GERD and functional dyspepsia, suggesting subsets of functional dyspepsia and GERD may be part of the same disease spectrum.

ZhiShiXiaoPi tang inhibits autophagy induced by corticosterone and functional dyspepsia through blockade of the mTOR pathway

ETHNOPHARMACOLOGICAL RELEVANCE

ZhiShiXiaoPi Tang (ZSXPT) is a Chinese traditional medicine formula that contains 10 Chinese traditional medicine substances. It has been widely used to treat patients with functional dyspepsia (FD). However, the protective effect of ZSXPT and its molecular mechanisms in FD still remain elusive.

AIM OF THE STUDY

To investigate the protective effect of ZSXPT on autophagy induced by Corticosterone (Cort) in PC12 cells which have typical neuron characteristics and have been widely used as a model system for depression studies and FD rats, and explore its underlying mechanisms.

MATERIALS AND METHODS

In this study, high-performance liquid chromatography fingerprint analysis was performed to characterize the chemical composition of ZSXPT. Depression-induced autophagy, ROS generation, and changes in mitochondrial membrane potential (MMP) were investigated in Cort-induced PC12 cells and in FD rats to evaluate the protective effects of ZSXPT.

RESULTS

Our results show that ZSXPT treatment protects neurons against Cort-induced damage and apoptosis by increasing cell viability and reducing the release of lactate dehydrogenase. ZSXPT decreased Cort-induced ROS generation, increased MMP, and accelerated autophagy through the blockade of the mammalian target of rapamycin (mTOR) pathway. Moreover, we observed similar findings when we studied ZSXPT in a rat model of FD.

CONCLUSIONS

Our in vitro and in vivo results indicate that the neuroprotective effect of ZSXPT against autophagy-induced damage and apoptosis occurs mainly by blocking the mTOR pathway in Cort-induced PC12 cells and in FD rats. Taken together, these data provide reliable experimental evidence and explain the molecular mechanism by which ZSXPT ameliorates FD.

Effect of Chaihu Shugan Powder-Contained Serum on Glutamate-Induced Autophagy of Interstitial Cells of Cajal in the Rat Gastric Antrum

Gastrointestinal (GI) motility disorder is caused by excessive autophagy of the interstitial cells of Cajal (ICC). Chaihu Shugan Powder (CSP) is a traditional Chinese medicine with therapeutic benefits in GI motility disorders; however, the underlying mechanism of its therapeutic effect in GI disorders, especially autophagy of ICC, remains unclear. Thus, this study investigated the effects of CSP-contained serum on glutamate-induced autophagy in rat gastric ICC, exploring its underlying mechanism. In vitro cultured rat stomach ICC were identified by fluorescence microscopy and then stimulated with glutamate (5 mmol/L) for 3 h to establish the autophagy model. These cells were then treated with 10% CSP-containing serum or the autophagy inhibitor 3-methyladenine (3-MA; 5 mmol/L) for 24 h. The control group was cultured with only 10% serum containing physiological saline. The viability of ICC was measured by the CCK-8 assay. The ultrastructure and autophagosomes of ICC were observed using transmission electron microscopy. LC3 expression was detected by immunofluorescence, and LC3, Beclin1, Bcl2, and PI3KC3 expression was detected by western blot analysis. Transmission electron microscopy showed abundant endoplasmic reticulum, mitochondria, and other organelles in the control group, whereas the cells in the autophagy model control group had clear autophagic vacuoles, which were not apparent in both CSP and 3-MA groups. ICC viability was significantly increased by CSP and 3-MA interventions (P < 0.01), accompanied by a decrease in LC3 fluorescence (P < 0.01). Moreover, the expression levels of LC3II/I, Beclin1, and PI3KC3 were significantly decreased (all P < 0.01) with CSP and 3-MA treatment, while Bcl2 expression level was higher than that of the model group (P < 0.01). Thus, CSP can reduce autophagic damage by enhancing Bcl2 expression and downregulating the expression of LC3, Beclin1, and PI3KC3 to protect ICC. These results highlight the potential of CSP in the treatment of GI motility disorders.

The gut-brain axis in health neuroscience: implications for functional gastrointestinal disorders and appetite regulation

Over the past few years, scientific interest in the gut-brain axis (i.e., the bidirectional communication system between the gastrointestinal tract and the brain) has exploded, mostly due to the identification of the gut microbiota as a novel key player in this communication. However, important progress has also been made in other aspects of gut-brain axis research, which has been relatively underemphasized in the review literature. Therefore, in this review, we provide a comprehensive, although not exhaustive, overview of recent research on the functional neuroanatomy of the gut-brain axis and its relevance toward the multidisciplinary field of health neuroscience, excluding studies on the role of the gut microbiota. More specifically, we first focus on irritable bowel syndrome, after which we outline recent findings on the role of the gut-brain axis in appetite and feeding regulation, primarily focusing on the impact of subliminal nutrient-related gut-brain signals. We conclude by providing future perspectives to facilitate translation of the findings from gut-brain axis neuroscientific research to clinical applications in these domains.

Efficacy and safety of pinaverium bromide combined with flupentixol-melitracen for diarrhea-type irritable bowel syndrome: A systematic review and meta-analysis

BACKGROUND

There are many trials on the combination of Pinaverium bromide (PB) and Flupentixol-melitracen (FM) in the treatment of diarrhea-type irritable bowel syndrome (IBS-D), but the sample sizes are small, and the research conclusions are inconsistent. Thus, a meta-analysis was performed, aiming to evaluate the efficacy and safety of this combination therapy in patients with IBS-D.

METHODS

A systematic literature search was conducted in 7 databases covering the period up to July 2018 to identify randomized controlled trials (RCTs) of PB combined with FM versus PB alone for IBS-D. The primary outcome was the total symptom relief rate. The other outcomes were the adverse events rate, HAMA/SAS score, and HAMD/SDS score. The methodological quality of the RCTs was assessed independently using 6 criteria according to the Cochrane Collaboration. All data were analyzed using Review Manager 5.3.

RESULTS

Fifteen RCTs with 1487 participants were identified from 2005 to 2018. Compared with PB alone, 15 RCTs showed significant effects of PB plus FM in terms of improved symptom relief in patients with IBS-D (n = 1487, OR = 5.17, 95%CI, 3.79-7.07, P < .00001). Eleven RCTs reported adverse effects in both the PB plus FM and PB groups, there was no statistically significant difference in the adverse events rate between the 2 groups (n = 1207, OR = 2.91, 95%CI, 0.91-9.28, P = 0.07). Two RCTs and 3 RCTs reported HAMA and HAMD scores respectively, and 3 RCTs reported both SAS and SDS scores. After treatment, the above scores in the PB plus FM group were significantly lower than the PB group (all P < .01). However, the trials were deemed to have a medium risk of bias.

CONCLUSIONS

The efficacy of PB combined with FM is superior to PB alone in the treatment of IBS-D, and it is safe for clinical use. However, the conclusions still need to be verified by conducting more large-scale and high-quality RCTs.

Association between prescribed antidepressants and other prescribed drugs differ by gender: a nationwide register-based study in Sweden

BACKGROUND

People with depression are prescribed more drugs than people in general, partly due to comorbidity with other conditions. However, little research has been done on depression-related drug use from a gender perspective.

AIM

Examine the association between antidepressants, other types of prescribed drugs, and polypharmacy, by gender.

METHODS

Data on drugs dispensed October to December 2016 to all Swedish citizens aged 18-84 years were collected from the Swedish prescribed drug register. Logistic regression analyses were performed to examine the associations between antidepressants and other drugs, by gender.

RESULTS

For both men and women, associations were found between antidepressants and drugs for alimentary tract problems, respiratory problems, blood, nervous system, analgesics, and polypharmacy. However, for women, but not men, associations were also found for drugs for diabetes, musculoskeletal problems, dermatological problems, and systemic hormones.

CONCLUSIONS

Associations were found between antidepressants and many other types of drugs for both men and women; indicating comorbidity between depression and other conditions. Further, some of the associations between antidepressants and other drugs were found to be specific among women. Whether this indicates that men and women differ in comorbidity between depression and other conditions cannot be concluded based on this cross-sectional study. However, comorbidity impairs the possibility of recovery; in the somatic condition as well as the depression. Thus, physicians need to be aware that the association between antidepressants and other types of drugs are more common among women than men.

'Neurasthenia gastrica' revisited: perceptions of nerve-gut interactions in nervous exhaustion, 1880-1920

In this paper, some of the medical literature on the historical disease-concept of ‘neurasthenia gastrica’ is reviewed. Neurasthenia gastrica was defined as a sub-unit of the wider category of neurasthenia, also referred to as nervous exhaustion or nervous weakness. Neurasthenia was a commonly used diagnostic label at the end of the nineteenth century and a few decades onwards, and was used to describe a wide variety of symptoms for which no ‘organic’ basis could be found. In neurasthenia gastrica, however, the gastrointestinal symptoms predominated, and there was considerable debate as to how the gut interacted with the central nervous system in the development of these ailments. Some of these discussions may be seen as historical precedents for the current debates on the brain–gut–microbiota axis, particularly in relation to the so-called functional gastrointestinal disorders.

Relationship between job stress and functional dyspepsia in display manufacturing sector workers: a cross-sectional study

Background

Job stress has been reported as a risk factor of psychological changes, which have been shown to be related to gastrointestinal diseases and symptoms such as functional dyspepsia. However, few studies have assessed the relationship between job stress and functional dyspepsia. Therefore, we investigated the relationship between job stress and functional dyspepsia in South Korea.

Methods

This study was conducted between May 23 and July 6, 2016 and included 901 workers in the display manufacturing sector. Subjects completed self-reported questionnaires, regarding Korean Occupational Stress Scale (KOSS), functional dyspepsia, Insomnia Severity Index-K, and health-related behaviors and job characteristics. Subjects were divided into functional dyspepsia-positive and -negative groups based on the Rome III criteria. The KOSS high-risk group was defined as subjects with KOSS score above the 75 percentile of KOSS reference value. Multiple logistic regression analysis was performed to investigate the association between job stress and functional dyspepsia.

Results

In women, the risk of functional dyspepsia was significantly higher in the high-risk groups of the following KOSS subcategories in unadjusted model: job demand (OR 3.282, 95% CI 1.181–9.126), and occupational climate (OR 2.665, 95% CI 1.041–6.823). Even in adjusted model, the risk was significantly higher in the high-risk groups of the following KOSS subcategories: job demand (OR 3.123, 95% CI 1.036–9.416) and occupational climate (OR 3.304, 95% CI 1.198–9.115). In men, the risk of functional dyspepsia was not significant in all KOSS subcategories.

Conclusions

This study showed that job demand and occupational climates were associated with functional dyspepsia in female display manufacturing sector workers. Therefore, both clinical and mental health approaches should be used in the management of functional dyspepsia in women.

Stress Adaptation Upregulates Oxytocin within Hypothalamo-Vagal Neurocircuits

Stress plays a pivotal role in the development and/or exacerbation of functional gastrointestinal (GI) disorders. The paraventricular nucleus of the hypothalamus (PVN) contains neurons that are part of the hypothalamic-pituitary-adrenal axis as well as preautonomic neurons innervating, among other areas, gastric-projecting preganglionic neurons of the dorsal vagal complex (DVC). The aim of the present study was to test the hypothesis that stress adaptation upregulates oxytocin (OXT) within PVN-brainstem vagal neurocircuitry. The retrograde tracer cholera toxin B (CTB) was injected into the DVC of rats which, after post-surgical recovery, were pair-housed and exposed to either homo- or heterotypic stress for five consecutive days. Fecal pellets were counted at the end of each stress load. Two hours after the last stressor, the whole brain was excised. Brainstem and hypothalamic nuclei were analyzed immunohistochemically for the presence of both OXT-immunopositive cells in identified preautonomic PVN neurons as well as OXT fibers in the DVC. Rats exposed to chronic homotypic, but not chronic heterotypic stress, had a significant increase in both number of CTB+ OXT co-localized neurons in the PVN as well as density of OXT-positive fibers in the DVC compared to control rats. These data suggest that preautonomic OXT PVN neurons and their projections to the DVC increase following adaptation to stress, and suggest that the possible up-regulation of OXT within PVN-brainstem vagal neurocircuitry may play a role in the adaptation of GI responses to stress.

A Randomized, Double-Blind, Multicenter, Placebo-Controlled Trial of Qi-Zhi-Wei-Tong Granules on Postprandial Distress Syndrome-Predominant Functional Dyspepsia

Background:

Functional dyspepsia (FD) is a common upper gastrointestinal disorder worldwide, but the current treatments for FD are still unsatisfactory. The aims of this study were to investigate the efficacy and safety of Qi-Zhi-Wei-Tong granules in patients with postprandial distress syndrome (PDS)-predominant FD.

Methods:

The study was conducted as a randomized, double-blinded, multicenter, placebo-controlled design in 197 patients with PDS. All participants received placebo treatment for 1 week. Patients whose total symptom score decreased by <50% after the placebo treatment were recruited into the 4-week treatment period, in which they were randomly assigned to be treated with either Qi-Zhi-Wei-Tong granules or placebo. The patients were then followed for 2 weeks without any treatment. Dyspeptic symptoms were scored at weeks 2 and 4 during the random treatment period and 2 weeks after the treatment. Anxiety and depression symptoms were also scored and compared.

Results:

(1) The total effective rates in the Qi-Zhi-Wei-Tong granules group at weeks 2 and 4 during the random treatment period and 2 weeks after treatment were all significantly higher than those in the placebo group (38.82% vs. 8.75%, P < 0.001; 69.14% vs. 16.25%, P < 0.001; 77.65% vs. 21.25%, P < 0.001). (2) The total dyspeptic symptoms scores in the Qi-Zhi-Wei-Tong granules group at weeks 2 and 4 and 2 weeks after treatment were significantly lower than those in the placebo group. (3) The severity and frequency of each dyspeptic symptom at weeks 2 and 4 and the follow-up period were all significantly lower than those in the placebo group. (4) The anxiety scores in the Qi-Zhi-Wei-Tong granules group were significantly lower than those in the placebo group. (5) Qi-Zhi-Wei-Tong granules did not have more adverse effects than the placebo.

Conclusion:

Qi-Zhi-Wei-Tong granules offer significant symptomatic improvement in PDS with no more adverse effects than placebo.

Trial Registration:

https://clinicaltrials.gov/, NCT02460601.

Time trends in dyspepsia and association with H. pylori and work-related stress-An observational study in white collar employees in 1996 and 2015

Purpose

We aimed to describe time trends in functional dyspepsia and the association of dyspepsia-related factors, Helicobacter pylori (H. pylori) and work-related stress with functional dyspepsia in white collar employees in 1996 and 2015.

Materials and methods

Repeat cross-sectional study conducted in 1996 (n = 190, response rate = 76.1) and 2015 (n = 195, response rate = 40.2) within a health insurance company in South-West Germany. Dyspeptic symptoms measured according to the Rome III criteria, effort-reward imbalance and further work- or dyspepsia-related factors were assessed by self-administered questionnaire. H. pylori infection as possible factor for dyspeptic symptoms was measured by a ¹³C-urea breath test or an antigen stool test. Kruskal-Wallis tests and multivariable logistic regression models were calculated comparing the upper tertile of dyspeptic symptom scale to the middle and lower tertile.

Results

Mean dyspepsia symptom scores and work-related stress did not differ comparing 1996 and 2015. In bivariate analyses, dyspeptic symptom scores were consistently correlated with sex, age, and using antacids. Further dyspepsia-related factors were smoking and non-leading occupational position in 1996 and non-steroidal anti-inflammatory drugs as well as high effort-reward imbalance in 2015. High intrinsic effort was positively associated with high dyspepsia symptom scores in both studies. Following multivariable adjustment, we observed a consistent association between high intrinsic effort at work and dyspeptic symptoms, although the association was only marginally statistically significant in 1996. Furthermore, a strong association of somatization, only measured in 2015, with dyspeptic symptoms was shown.

Conclusions

Dyspepsia-related factors may have changed throughout the last decades. Nevertheless, although occupational situations might differ, the intrinsic effort is still strongly associated with dyspeptic symptoms.

Investigation of autophagy and differentiation of myenteric interstitial cells of Cajal in the pathogenesis of gastric motility disorders in rats with functional dyspepsia

Interstitial cells of Cajal (ICC), especially myenteric interstitial cells of Cajal (ICC-MY), are key to gastrointestinal motility. However, their role in the pathogenesis of functional dyspepsia (FD) is unclear. Therefore, autophagy and differentiation of ICC-MY were investigated to elucidate the pathogenesis of gastric motility disorder in FD. FD model was induced by chronic stress via tail clamping in rats, which was assessed by the vital signs of rats, gastric emptying rate result, and histology. The ultrastructure of ICC-MY was examined using transmission electron microscope. In ICC-MY, changes in autophagic biomarkers (Beclin1 and LC3B) and differentiation biomarkers (c-kit and SCF) were evaluated with in situ hybridization, quantitative real time PCR, immunofluorescence, and Western blot, respectively. The FD model was successfully induced in rats, as evidenced by the abnormal vital signs (such as loss of appetite, liquid excreta, less activity, and slower weight gain), the decrease in gastric emptying rates, and little pathological change in gastric antrum tissue. Compared with the control group, FD caused increased organelle denaturation or reduction and increase in vacuolization. FD also promoted generation of autophagosomes in ICC-MY. Moreover, increased the expression of Beclin1 and LC3B, but decreased expression of c-kit and SCF. Excessive autophagy and abnormal differentiation of ICC-MY may contribute to the pathogenesis of gastric motility disorder in FD.

Visceral hypersensitivity is associated with GI symptom severity in functional GI disorders: consistent findings from five different patient cohorts

OBJECTIVE

Our aim was to evaluate the association between visceral hypersensitivity and GI symptom severity in large cohorts of patients with functional GI disorder (FGID) and to adjust for psychological factors and general tendency to report symptoms.

DESIGN

We included five cohorts of patients with FGIDs (IBS or functional dyspepsia; n=1144), who had undergone visceral sensitivity testing using balloon distensions (gastric fundus, descending colon or rectum) and completed questionnaires to assess GI symptom severity, non-GI somatic symptoms, anxiety and depression. Subjects were divided into sensitivity tertiles based on pain/discomfort thresholds. GI symptom severity was compared between sensitivity tertiles in each cohort and corrected for somatisation, and anxiety and depression.

RESULTS

In all five cohorts, GI symptom severity increased gradually with increasing visceral sensitivity, with significant differences in GI symptom severity between the sensitivity tertiles (p<0.0001), with small to medium effect sizes (partial η²: 0.047-0.11). The differences between sensitivity tertiles remained significant in all cohorts after correction for anxiety and depression, and also after correction for non-GI somatic symptom reporting in all of the cohorts (p<0.05).

CONCLUSIONS

A gradual increase in GI symptom severity with increasing GI sensitivity was demonstrated in IBS and functional dyspepsia, which was consistent across several large patient groups from different countries, different methods to assess sensitivity and assessments in different parts of the GI tract. This association was independent of tendency to report symptoms or anxiety/depression comorbidity. These findings confirm that visceral hypersensitivity is a contributor to GI symptom generation in FGIDs.

Attentional and physiological processing of food images in functional dyspepsia patients: A pilot study

The food-related behavior of functional dyspepsia has been attracting more interest of late. This pilot study aims to provide evidence of the physiological, emotional, and attentional aspects of food processing in functional dyspepsia patients. The study was performed in 15 functional dyspepsia patients and 17 healthy controls after a standard breakfast. We measured autonomic nervous system activity using skin conductance response and heart rate variability, emotional response using facial electromyography, and visual attention using eyetracking during the visual stimuli of food/non-food images. In comparison to healthy controls, functional dyspepsia patients showed a greater craving for food, a decreased intake of food, more dyspeptic symptoms, lower pleasantness rating of food images (particularly of high fat), decreased low frequency/high frequency ratio of heart rate variability, and suppressed total processing time of food images. There were no significant differences of skin conductance response and facial electromyography data between groups. The results suggest that high level cognitive functions rather than autonomic and emotional mechanisms are more liable to function differently in functional dyspepsia patients. Abnormal dietary behavior, reduced subjective rating of pleasantness and visual attention to food should be considered as important pathophysiological characteristics in functional dyspepsia.

The stress concept in gastroenterology: from Selye to today

More than eighty years after Hans Selye (1907-1982) first developed a concept describing how different types of environmental stressors affect physiological functions and promote disease development (called the "general adaptation syndrome") in 1936, we herein review advances in theoretical, mechanistic, and clinical knowledge in stress research, especially in the area of gastroenterology, and summarize progress and future perspectives arising from an interdisciplinary psychoneurobiological framework in which genetics, epigenetics, and other advanced ( omics) technologies in the last decade continue to refine knowledge about how stress affects the brain-gut axis in health and gastrointestinal disease. We demonstrate that neurobiological stress research continues to be a driving force for scientific progress in gastroenterology and related clinical areas, inspiring translational research from animal models to clinical applications, while highlighting some areas that remain incompletely understood, such as the roles of sex/gender and gut microbiota in health and disease. Future directions of research should include not only the genetics of the stress response and resilience but also epigenetic contributions.

Functional dyspepsia

Functional dyspepsia is one of the most prevalent functional gastrointestinal disorders. Functional dyspepsia comprises three subtypes with presumed different pathophysiology and aetiology: postprandial distress syndrome (PDS), epigastric pain syndrome (EPS) and a subtype with overlapping PDS and EPS features. Functional dyspepsia symptoms can be caused by disturbed gastric motility (for example, inadequate fundic accommodation or delayed gastric emptying), gastric sensation (for example, sensations associated with hypersensitivity to gas and bloating) or gastric and duodenal inflammation. A genetic predisposition is probable but less evident than in other functional gastrointestinal disorders, such as irritable bowel syndrome (IBS). Psychiatric comorbidity and psychopathological state and trait characteristics could also play a part, although they are not specific to functional dyspepsia and are less pronounced than in IBS. Possible differential diagnoses include Helicobacter pylori infection and peptic ulceration. Pharmacological therapy is mostly based on the subtype of functional dyspepsia, such as prokinetic and fundus-relaxing drugs for PDS and acid-suppressive drugs for EPS, whereas centrally active neuromodulators and herbal drugs play a minor part. Psychotherapy is effective only in a small subset of patients, whereas quality of life can be severely affected in nearly all patients. Future therapies might include novel compounds that attempt to treat the underlying gastric and duodenal inflammation.

1H NMR-Based Metabonomic Study of Functional Dyspepsia in Stressed Rats Treated with Chinese Medicine Weikangning

1H NMR-based metabolic profiling combined with multivariate data analysis was used to explore the metabolic phenotype of functional dyspepsia (FD) in stressed rats and evaluate the intervention effects of the Chinese medicine Weikangning (WKN). After a 7-day period of model establishment, a 14-day drug administration schedule was conducted in a WKN-treated group of rats, with the model and normal control groups serving as negative controls. Based on 1H NMR spectra of urine and serum from rats, PCA, PLS-DA, and OPLS-DA were performed to identify changing metabolic profiles. According to the key metabolites determined by OPLS-DA, alterations in energy metabolism, stress-related metabolism, and gut microbiota were found in FD model rats after stress stimulation, and these alterations were restored to normal after WKN administration. This study may provide new insights into the relationship between FD and psychological stress and assist in research into the metabolic mechanisms involved in Chinese medicine.

Certain Dietary Habits Contribute to the Functional Dyspepsia in South China Rural Area

BACKGROUND Functional dyspepsia (FD) refers to a group of upper gastrointestinal syndromes, subdivided into two types: postprandial distress syndrome (PDS) and epigastric pain syndrome (EPS). The etiology of FD remains unclear; however, unhealthy dietary habit is one potential underlying cause. We aim to explore the association of poor dietary habits with FD and its subtypes. MATERIAL AND METHODS A validated epidemiological questionnaire was designed to investigate dietary habits and gastrointestinal syndromes. Citizens in the Baotun community of Dongguan were invited to complete the study questionnaire. All participants were asked to undergo a physical examination and a blinded physician interview. The study was conducted from June 2015 to June 2016. FD was diagnosed using ROME III criteria. The association between investigated dietary habits and dyspeptic symptoms were explored. RESULTS There were 1,304 adult residents recruited for the study survey; 165 residents had existing organic dyspepsia (OD), 203 residents were diagnosed with FD, and the other 936 participants, who were without dyspeptic symptoms or functional gastrointestinal diseases, were regarded as the control group. Subtype diagnosis indicated 61 participants had EPS, 66 participants had PDS, and 76 participants had coexisting EPS and PDS. Unhealthy dietary habits were more prevalent in the FD group than in the control groups (75.86% versus 37.50%; p<0.001). FD was found to be associated with irregular mealtime, dining out, fatty food, sweet food, and coffee (p<0.05). The impact of each dietary factor varied with FD subtypes. CONCLUSIONS Certain types of dietary habits were positively correlated with the prevalence of FD. FD subtypes showed relatively different associations with dietary factors.

Increased Glutamate in Somatosensory Cortex in Functional Dyspepsia

Functional Dyspepsia-Post-prandial Distress Syndrome (FD-PDS) was associated with mood-related increases in resting activity and lowered activation threshold in the somatosensory cortex (SSC), insula and perigenual anterior cingulate cortex(pgACC) in functional imaging studies. The underlying cortical neurochemical changes are unknown. We performed proton Magnetic Resonance Spectroscopy (1H-MRS) on 17 consecutive tertiary clinic-recruited psychotropic-naïve Rome III FD-PDS female and 17 age-sex matched healthy controls. Voxels were placed on bilateral pgACC, left insula and SSC. Water-suppressed spectra were acquired using PRESS with short echo time (TE) (T = 24 ms) to separately quantify glutamate (Glu) and glutamine (Gln). Main outcome measure was regional Glu/Cr + PCr. Severity of depression, anxiety, somatization, and dyspepsia were also assessed. We found significantly increased SSC Glu/Cr + PCr in FD-PDS subjects compared to controls. SSC Glu/Cr + PCr correlated significantly with postprandial distress chronicity, dyspeptic symptoms severity and anxiety. The SSC Glu/Cr + PCr - dyspepsia correlations became insignificant after controlling for anxiety but were independent of depression. Gln/Glu ratio, which indicates glial Glu cycling failure, was unchanged. No between-group differences were noted in other regional metabolite concentrations. Our findings suggested enhanced SSC glutamate transmission in FD-PDS that was linked to post-prandial distress chronicity and severity and anxiety.

Functional dyspepsia is associated with duodenal eosinophilia in an Australian paediatric cohort

BACKGROUND

The pathophysiology of functional dyspepsia (FD) remains unknown. Duodenal eosinophil infiltration has been reported.

AIM

To assess the association between dyspeptic symptoms and duodenal eosinophilia in children undergoing upper gastrointestinal endoscopy.

METHODS

In this retrospective cohort study, children with normal upper endoscopy and routine histology at a single tertiary paediatric centre between 2010 and 2014 were included. FD was defined as epigastric pain or discomfort >2 months without response to acid suppression. Controls presented with nonerosive reflux disease, dysphagia or rumination syndrome. Intramucosal eosinophil counts were compared between the groups using uni- and multivariate regression analyses.

RESULTS

Thirty-six cases and 36 nonmatched controls were identified. Atopic history (39% vs. 25%) and psychological comorbidity (53% vs. 39%; both P = 0.2) were frequent in cases and controls. Self-reported nausea (64% vs. 17%; P < 0.0001), lethargy (19% vs. 0%; P = 0.005) and family functional gastrointestinal disorder(FGID) (28% vs. 3%; P = 0.003) were more common in cases than controls. Duodenal eosinophil counts [median (IQR): 151 (118-207) vs. 76 (60-106) per mm² ; P < 0.001] were significantly higher in cases than controls with >112 eosinophils per mm² predictive for FD (OR: 33.6, 95% CI: 7.1-159.0; P < 0.001). Duodenal eosinophilia was associated with weight loss (OR: 7.1, 95% CI: 1.1-45.5; P = 0.04).

CONCLUSIONS

Functional dyspepsia in children is strongly associated with duodenal eosinophilia, in the absence of endoscopic or routine histological findings. Frequent atopic and psychological comorbidity illustrate likely multifactorial mechanisms.

Mexican consensus on dyspepsia

Since the publication of the 2007 dyspepsia guidelines of the Asociación Mexicana de Gastroenterología, there have been significant advances in the knowledge of this disease. A systematic search of the literature in PubMed (01/2007 to 06/2016) was carried out to review and update the 2007 guidelines and to provide new evidence-based recommendations. All high-quality articles in Spanish and English were included. Statements were formulated and voted upon using the Delphi method. The level of evidence and strength of recommendation of each statement were established according to the GRADE system. Thirty-one statements were formulated, voted upon, and graded. New definition, classification, epidemiology, and pathophysiology data were provided and include the following information: Endoscopy should be carried out in cases of uninvestigated dyspepsia when there are alarm symptoms or no response to treatment. Gastric and duodenal biopsies can confirm Helicobacter pylori infection and rule out celiac disease, respectively. Establishing a strong doctor-patient relationship, as well as dietary and lifestyle changes, are useful initial measures. H2-blockers, proton-pump inhibitors, prokinetics, and antidepressants are effective pharmacologic therapies. H.pylori eradication may be effective in a subgroup of patients. There is no evidence that complementary and alternative therapies are beneficial, with the exception of Iberogast and rikkunshito, nor is there evidence on the usefulness of prebiotics, probiotics, or psychologic therapies. The new consensus statements on dyspepsia provide guidelines based on up-to-date evidence. A discussion, level of evidence, and strength of recommendation are presented for each statement.

Use of neurotransmitter regulators in functional gastrointestinal disorders based on symptom analysis

It has been a great challenge for gastroenterologists to cope with functional gastrointestinal disorders (FGIDs) in clinical practice due to the contemporary increase in stressful events. A growing body of evidence has shown that neuroregulators such as anti-anxiety agents and antidepressants function well on FGIDs, particularly in cases that are refractory to classical gastrointestinal (GI) medications. Among these central-acting agents, small individualized doses of tricyclic antidepressants and selective serotonin reuptake inhibitors are usually recommended as a complement to routine GI management. When these drugs are chosen to treat FGIDs, both their central effects and the modulation of peripheral neurotransmitters should be taken into consideration. In this article we recommend strategies for choosing drugs based on an analysis of psychosomatic GI symptoms. The variety and dosage of the neurotransmitter regulators are also discussed.

Traditional herbal formula Sini Powder extract produces antidepressant-like effects through stress-related mechanisms in rats

Sini Powder (SP), a traditional Chinese herbal formula, has long been used to treat depression in patients, although the underlying mechanisms remain to be elucidated. In the present study, we found that rats treated with SP extract for 7 days showed a significant increase in swimming time and reduction in immobility time in forced swimming test in a dose-dependent manner, without changes in locomotion. These effects could be attributed to SP's modulation of the hypothalamus-pituitary-adrenal axis, because a single pretreatment of SP extract could rescue increased serum corticosterone and plasma adrenocorticotropin levels induced by acute elevated platform stress. A single pretreatment of SP extract could also elevate the mRNA expression of hippocampal glucocorticoid receptors. In conclusion, our results suggest that SP extract may act as an anti-stress medication to produce antidepressant-like effects.

Symptoms and the body: Taking the inferential leap

The relationship between the conscious experience of physical symptoms and indicators of objective physiological dysfunction is highly variable and depends on characteristics of the person, the context and their interaction. This relationship often breaks down entirely in the case of "medically unexplained" or functional somatic symptoms, violating the basic assumption in medicine that physical symptoms have physiological causes. In this paper, we describe the prevailing theoretical approach to this problem and review the evidence pertaining to it. We then use the framework of predictive coding to propose a new and more comprehensive model of the body-symptom relationship that integrates existing concepts within a unifying framework that addresses many of the shortcomings of current theory. We describe the conditions under which a close correspondence between the experience of symptoms and objective physiology might be expected, and when they are likely to diverge. We conclude by exploring some theoretical and clinical implications of this new account.

Learned Fear of Gastrointestinal Sensations in Healthy Adults

BACKGROUND & AIMS

Gastrointestinal symptom-specific fear and anxiety are important determinants of gastrointestinal symptom perception. We studied learning of fear toward innocuous gastrointestinal sensations as a putative mechanism in the development of gastrointestinal symptom-specific fear and anxiety.

METHODS

Fifty-two healthy subjects (26 women) received 2 types of esophageal balloon distention at a perceptible but nonpainful intensity (conditioned stimulus [CS], the innocuous sensation) and at a painful intensity (unconditioned stimulus [US]). Subjects were assigned randomly to 1 of 2 groups. During the learning phase, the innocuous CS preceded the painful US in the experimental group (n = 26). In the control group (n = 26), on the contrary, the US never followed the CS directly. During a subsequent extinction phase, both groups received only CS distention-the painful US was no longer administered. Indexes of fear learning toward the innocuous CS distention included the skin conductance response, fear-potentiated startle (measured by the eye-blink electromyogram), and self-reported expectancy of the US.

RESULTS

During the learning phase, only the experimental group learned to fear the innocuous gastrointestinal CS, based on the increase in US expectancy (compared with the control group, P = .04), increased skin conductance response (compared with the control group, P = .03), and potentiated startle reflex (compared with the control group, P = .001) in response to the CS. The differences between the experimental and control groups in US expectancy and skin conductance, but not fear-potentiated startle, disappeared during the extinction phase.

CONCLUSIONS

Fear toward innocuous gastrointestinal sensations can be established through associative learning in healthy human beings. This may be an important mechanism in the development of fear of gastrointestinal symptoms, implicated in the pathophysiology of functional gastrointestinal disorders.

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.

Effects of disturbed sleep on gastrointestinal and somatic pain symptoms in irritable bowel syndrome

BACKGROUND

Sleep disturbances are common, and perhaps are even more prevalent in irritable bowel syndrome (IBS).

AIMS

To determine the effect of measured sleep on IBS symptoms the following day, IBS-specific quality of life (IBS-QOL) and non-GI pain symptoms.

METHODS

IBS patients' sleep patterns were compared to healthy individuals via wrist-mounted actigraphy over 7 days. Daily bowel pain logs (severity, distress; 10-point Likert) stool pattern (Bristol scale) and supporting symptoms (e.g. bloating, urgency; 5-point Likert) were kept. Validated measures, including the GI Symptom Rating Scale-IBS, Visceral Sensitivity Index, Pittsburgh Sleep Quality Index and the IBS-Quality of Life were collected. Mediation analysis explored the relationship between sleep, mood and bowel symptoms.

RESULTS

Fifty subjects (38.6 ± 1.0 years old, 44 female; 24 IBS and 26 healthy controls) completed sleep monitoring. IBS patients slept more hours per day (7.7 ± 0.2 vs. 7.1 ± 0.1, P = 0.008), but felt less well-rested. IBS patients demonstrated more waking episodes during sleep (waking episodes; 12.1 vs. 9.3, P < 0.001). Waking episodes predicted worse abdominal pain (P ≤ 0.01) and GI distress (P < 0.001), but not bowel pattern or accessory IBS symptoms (P > 0.3 for each). Waking episodes negatively correlated with general- and IBS-specific QOL in IBS (r = -0.58 and -0.52, P < 0.001 for each). Disturbed sleep effects on abdominal pain were partially explained by mood as an intermediate.

CONCLUSIONS

Sleep disturbances are more common in irritable bowel syndrome, and correlate with IBS-related pain, distress and poorer irritable bowel syndrome-related quality of life. Disturbed sleep effects extend beyond the bowel, leading to worse mood and greater somatic pain in patients with the irritable bowel syndrome.

The latent structure of the functional dyspepsia symptom complex: a taxometric analysis

OBJECTIVES

Rome III introduced a subdivision of functional dyspepsia (FD) into postprandial distress syndrome and epigastric pain syndrome, characterized by early satiation/postprandial fullness, and epigastric pain/burning, respectively. However, evidence on their degree of overlap is mixed. We aimed to investigate the latent structure of FD to test whether distinguishable symptom-based subgroups exist.

METHODS

Consecutive tertiary care Rome II FD patients completed the dyspepsia symptom severity scale. Confirmatory factor analysis (CFA) was used to compare the fit of a single factor model, a correlated three-factor model based on Rome III subgroups and a bifactor model consisting of a general FD factor and orthogonal subgroup factors. Taxometric analyses were subsequently used to investigate the latent structure of FD.

KEY RESULTS

Nine hundred and fifty-seven FD patients (71.1% women, age 41 ± 14.8) participated. In CFA, the bifactor model yielded a significantly better fit than the two other models (χ² difference tests both p < 0.001). All symptoms had significant loadings on both the general and the subgroup-specific factors (all p < 0.05). Somatization was associated with the general (r = 0.72, p < 0.01), but not the subgroup-specific factors (all r < 0.13, p > 0.05). Taxometric analyses supported a dimensional structure of FD (all CCFI<0.38).

CONCLUSIONS AND INFERENCES

We found a dimensional rather than categorical latent structure of the FD symptom complex in tertiary care. A combination of a general dyspepsia symptom reporting factor, which was associated with somatization, and symptom-specific factors reflecting the Rome III subdivision fitted the data best. This has implications for classification, pathophysiology, and treatment of FD.

Enhanced sympathetic nerve activity induced by neonatal colon inflammation induces gastric hypersensitivity and anxiety-like behavior in adult rats

Gastric hypersensitivity (GHS) and anxiety are prevalent in functional dyspepsia patients; their underlying mechanisms remain unknown largely because of lack of availability of live visceral tissues from human subjects. Recently, we demonstrated in a preclinical model that rats subjected to neonatal colon inflammation show increased basal plasma norepinephrine (NE), which contributes to GHS through the upregulation of nerve growth factor (NGF) expression in the gastric fundus. We tested the hypothesis that neonatal colon inflammation increases anxiety-like behavior and sympathetic nervous system activity, which upregulates the expression of NGF to induce GHS in adult life. Chemical sympathectomy, but not adrenalectomy, suppressed the elevated NGF expression in the fundus muscularis externa and GHS. The measurement of heart rate variability showed a significant increase in the low frequency-to-high frequency ratio in GHS vs. the control rats. Stimulus-evoked release of NE from the fundus muscularis externa strips was significantly greater in GHS than in the control rats. Tyrosine hydroxylase expression was increased in the celiac ganglia of the GHS vs. the control rats. We found an increase in trait but not stress-induced anxiety-like behavior in GHS rats in an elevated plus maze. We concluded that neonatal programming triggered by colon inflammation upregulates tyrosine hydroxylase in the celiac ganglia, which upregulates the release of NE in the gastric fundus muscularis externa. The increase of NE release from the sympathetic nerve terminals concentration dependently upregulates NGF, which proportionately increases the visceromotor response to gastric distention. Neonatal programming concurrently increases anxiety-like behavior in GHS rats.

Functional dyspepsia and dyspepsia associated with Helicobacter pylori infection: Do they have different clinical characteristics?

BACKGROUND

Helicobacter pylori causes motor, secretory, and inflammatory gastrointestinal disorders and therefore the term "functional" has been questioned when referring to dyspepsia associated with this bacterium. Patients with dyspepsia and Helicobacter pylori infection could have clinical characteristics that differentiate them a priori from those with true functional dyspepsia.

AIMS

To determine whether there are clinical differences between patients with functional dyspepsia and Helicobacter pylori-associated dyspepsia that enable their a priori identification and to know the prevalence of Helicobacter pylori infection in patients with functional dyspepsia.

PATIENTS AND METHODS

A total of 578 patients with dyspepsia with no significant lesions detectable through endoscopy were divided into 2 groups according to the presence of Helicobacter pylori. The clinical characteristics, medical history, comorbidities, and use of health resources were compared between the two groups. A sub-analysis pairing the groups by age and sex in a 1:1 ratio was carried out to reduce bias.

RESULTS

A total of 336 patients infected with Helicobacter pylori were compared with 242 non-infected patients. The prevalence of infection in the patients with dyspeptic symptoms and no endoscopically detectable lesions was 58%. The initial analysis showed that the cases with dyspepsia and Helicobacter pylori infection were more frequently associated with overweight, obesity, high blood pressure, diabetes mellitus, and metabolic syndrome, but the paired analysis nullified all these differences.

CONCLUSIONS

The patients with dyspepsia infected with Helicobacter pylori had similar clinical characteristics to the non-infected patients and could not be differentiated a priori. The prevalence of Helicobacter pylori infection in patients with functional dyspepsia was 58% and increased with age.

Depression and Somatization Are Associated With Increased Postprandial Symptoms in Patients With Irritable Bowel Syndrome

BACKGROUND & AIMS

Patients with irritable bowel syndrome (IBS) have increased postprandial symptom responses and more psychosocial morbidities than healthy individuals. However, the relationship between psychosocial status and postprandial symptom responses in patients with IBS is unclear. We investigated this relationship in a prospective study of patients with IBS.

METHODS

A total of 193 IBS patients, diagnosed according to Rome II (n = 126) or Rome III (n = 67) criteria, consumed a standard breakfast (540 kcal: 36% fat, 15% proteins, 49% carbohydrates, and 8.9 g fiber). They completed visual analogue scales assessing the severity of 5 gastrointestinal symptoms (abdominal pain, bloating, nausea, gas, and fullness) before breakfast and every 30 minutes, up to 240 minutes after eating. All patients completed validated self-report questionnaires for their current levels of anxiety and depression; patients diagnosed based on Rome II criteria also completed a somatization questionnaire. The relationship between these variables and the course of gastrointestinal symptom scores over time was analyzed using linear mixed models, controlling for comorbid functional dyspepsia.

RESULTS

We observed a main effect of anxiety levels on fullness and bloating (P < .04), and of depression levels on abdominal pain (P = .007), reflecting a general upward shift of the entire symptom curve. Depression-by-time interactions were seen for nausea and gas (P < .03). Somatization levels had a main effect on all 5 symptoms (P < .0001), independent of anxiety and depression. We observed somatization-by-time interaction effects for bloating (P = .005), and nausea (P = .02), and a nonsignificant trend was found for pain (P = .054), reflecting a steeper early postprandial increase in symptoms among subjects with higher levels of somatization.

CONCLUSIONS

Based on a prospective study of patients with IBS, psychosocial morbidities are associated with increased levels of gastrointestinal symptoms in general. Depression and somatization levels are associated specifically with increased postprandial symptoms.

Efficacy and Safety of Acupuncture for the Treatment of Functional Dyspepsia: Meta-Analysis

OBJECTIVES

Functional dyspepsia (FD) is a common gastrointestinal disorder. Currently, no established optimal treatment is available. The aim of this study was to assess the efficacy of acupuncture in relieving symptoms and improving quality of life in patients with FD.

METHODS

PubMed, MEDLINE, Web of Science, Sino-Med, China National Knowledge Infrastructure, VIP databases, and Google Scholar engine were searched from inception through April 2014 to identify randomized controlled trials of acupuncture therapy that reported on overall FD symptoms or FD-related quality of life as a primary outcome. The Cochrane Collaboration's risk of bias tool, RevMan 5.0, and Stata 12.0 software were used for meta-analysis. Data were pooled to calculate relative risk (RRs) and 95% confidence intervals (CIs) of substantial improvement after treatment for dichotomous data and mean differences (SMDs) and 95% CIs for continuous data using random-effects models.

RESULTS

Twenty-four English- and Chinese-language articles describing randomized, placebo-controlled, clinical trials involving 3097 patients were included. Acupuncture significantly improved FD symptoms in studies reporting outcomes using dichotomous (RR, 1.19; 95% CI, 1.12-1.27; p < 0.001) and continuous (standardized MD [SMD], -0.78; 95% CI, -1.21 to -0.35; p = 0.0004) variables. Pooled analyses showed that acupuncture improved FD-related (weighted MD [WMD], 5.97; 95% CI, 3.14-8.80; p = 0.0002) and health-related (WMD, 6.83; 95% CI, 3.02-10.65; p = 0.004) quality of life, without serious adverse events. However, acupuncture failed to increase plasma motilin concentration (SMD, 0.67; 95% CI, -0.07 to 1.42; p = 0.08).

CONCLUSIONS

Acupuncture appears to be efficacious in relieving FD symptoms and improving quality of life.