Patterns of symptoms in functional dyspepsia: role of Helicobacter pylori infection and delayed gastric emptying

Accuracy of urea breath test in Helicobacter pylori infection: Meta-analysis

AIM: To quantitatively summarize and appraise the available evidence of urea breath test (UBT) use to diagnose Helicobacter pylori (H. pylori) infection in patients with dyspepsia and provide pooled diagnostic accuracy measures.

METHODS: We searched MEDLINE, EMBASE, Cochrane library and other databases for studies addressing the value of UBT in the diagnosis of H. pylori infection. We included cross-sectional studies that evaluated the diagnostic accuracy of UBT in adult patients with dyspeptic symptoms. Risk of bias was assessed using QUADAS (Quality Assessment of Diagnostic Accuracy Studies)-2 tool. Diagnostic accuracy measures were pooled using the random-effects model. Subgroup analysis was conducted by UBT type (¹³C vs¹⁴C) and by measurement technique (Infrared spectrometry vs Isotope Ratio Mass Spectrometry).

RESULTS: Out of 1380 studies identified, only 23 met the eligibility criteria. Fourteen studies (61%) evaluated ¹³C UBT and 9 studies (39%) evaluated ¹⁴C UBT. There was significant variation in the type of reference standard tests used across studies.Pooled sensitivity was 0.96 (95%CI: 0.95-0.97) andpooled specificity was 0.93 (95%CI: 0.91-0.94). Likelihood ratio for a positive test was 12 and for a negative test was 0.05 with an area under thecurve of 0.985. Meta-analyses were associated with a significant statistical heterogeneity that remained unexplained after subgroup analysis. The included studies had a moderate risk of bias.

CONCLUSION: UBT has high diagnostic accuracy for detecting H. pylori infection in patients with dyspepsia. The reliability of diagnostic meta-analytic estimates however is limited by significant heterogeneity.

Impact of coexisting irritable bowel syndrome on symptoms and pathophysiological mechanisms in functional dyspepsia

Epidemiological studies suggest considerable overlap between functional dyspepsia (FD) and irritable bowel syndrome (IBS).

AIM

The aim of the present study was to investigate whether coexisting IBS is also associated with symptom pattern or pathophysiology in FD.

METHODS

In 309 consecutive FD patients (207 women, age 42 +/- 0.8 yr), questionnaires were used to assess the dyspepsia symptom pattern and the Rome II criteria for IBS. The overall symptom severity was calculated adding the severity score (0-3, 0 = absent, 3 = severe) of eight dyspepsia symptoms. All patients underwent Helicobacter pylori testing, gastric barostat to determine sensitivity to distention and accommodation to a meal, and gastric emptying breath test.

RESULTS

Fifty-four percent of the patients had FD alone, whereas 46% had FD + IBS. FD + IBS patients were more likely to be female (75%vs 60%, p < 0.01) and to have a greater weight loss (5.4 +/- 0.6 vs 3.5 +/- 0.4 kg, p < 0.05). Coexisting IBS did not increase the risk of having any of the dyspeptic symptoms but the overall symptom severity was significantly higher in FD + IBS (12.4 +/- 0.4 vs 9.8 +/- 0.3, p < 0.01). FD + IBS patients had a lower threshold for first perception (2.9 +/- 0.3 vs 3.8 +/- 0.3 mmHg, p < 0.05) and for discomfort (7.9 +/- 0.4 vs 9.5 +/- 0.5 mmHg, p < 0.05) and a greater prevalence of hypersensitivity to gastric distention (44%vs 28%, p < 0.05). Gastric emptying, accommodation to a meal, and prevalence of H. pylori infection did not differ in the two groups.

CONCLUSION

About half of the FD patients fulfill the Rome II criteria for IBS. FD + IBS is more prevalent in female patients and is associated with a higher weight loss, with greater overall symptom severity, and with hypersensitivity to distention.

Diet, food intake, and disturbed physiology in the pathogenesis of symptoms in functional dyspepsia

Functional dyspepsia (FD) remains a relatively poorly characterized gastrointestinal disorder of unknown etiology that is frequently difficult to manage. A systematic review of the literature relating to food intake and FD is summarized here. Many patients with FD report symptoms after meal ingestion, including fullness, bloating, epigastric pain, nausea, and vomiting, and this has been interpreted as indicative of an underlying "motor disorder of the stomach or small intestine." Such hypotheses are, however, still largely unsubstantiated, and the data that do exist are inconclusive, particularly as few studies have directly examined the temporal relationships between dyspeptic symptoms, meal ingestion, and disordered gastric motility. Moreover, studies attempting to relate symptoms to specific disturbances in gastric motor function have, in most cases, not evaluated symptoms concurrently with the function test, and/or have used suboptimal symptom scoring to quantify symptoms. Furthermore, the term "early satiety" has been used loosely as a symptom, rather than a quantitative measure of food intake. Currently, the most widely accepted mechanism underlying FD is visceral hypersensitivity, which may contribute to both enhanced motor and symptomatic responses to food ingestion. However, the possible contribution of food and dietary habits to the induction and/or exacerbation of dyspeptic symptoms represents a relatively new area-despite frequent reports by patients that their symptoms are often related to food ingestion; this association has not been formally assessed. Dietary assessments have frequently implicated fatty foods in symptom induction, and these findings are supported by laboratory-based studies, particularly the demonstration that FD patients more often experience symptoms after intraduodenal infusions of fat, than glucose. Further studies into the potential role of dietary factors in the induction of dyspeptic symptom are required to establish whether dietary therapies have any place in the management of FD.

Symptoms associated with impaired gastric emptying of solids and liquids in functional dyspepsia

OBJECTIVE

The relationship between functional dyspepsia and delayed gastric emptying of solids or liquids is still unclear. The aim of the present study was to investigate in dyspeptic patients the prevalence of delayed gastric emptying for solids or for liquids and to investigate the relationship to the dyspepsia symptom pattern.

METHODS

In 392 and 330 patients with functional dyspepsia, the solid and liquid gastric emptying, respectively, was measured using breath tests, and the severity of eight dyspeptic symptoms was scored.

RESULTS

Gastric emptying of solids and liquids were delayed in 23% and 35% of the patients. Multivariate analysis showed that the presence of vomiting and postprandial fullness was associated with delayed solid emptying (OR 2.65, 95% CI = 1.62-4.35 and OR 3.08, 95% CI = 1.28-9.16, respectively). Postprandial fullness was also associated with the risk of delayed liquid emptying when symptom was present (OR 3.5, 95% CI = 1.57-8.68), relevant or severe (OR 2.504, 95% CI = 1.41-4.65), and severe (OR 2.214, 95% CI = 1.34-3.67). Severe early satiety was associated with the risk of delayed liquid emptying (OR 1.902, 95% CI = 1.90-3.30).

CONCLUSIONS

A subset of dyspeptic patients has delayed gastric emptying of solids or of liquids. Delayed gastric emptying of solids was constantly associated with postprandial fullness and with vomiting. Delayed emptying for liquids was also associated with postprandial fullness and with severe early satiety.

Dyspeptic symptoms and gastric emptying in the irritable bowel syndrome

OBJECTIVES

Irritable bowel syndrome (IBS) and dyspepsia often overlap. Delayed gastric emptying has been reported in IBS patients, although conflicting results exist. Whether overlapping dyspepsia correlates with gastric emptying abnormalities in IBS patients has not been clarified. This study aimed to evaluate gastric emptying of solids and its relationship with dyspeptic symptoms in IBS patients.

METHODS

A total of 146 IBS outpatients seen in a referral center were evaluated for dyspeptic symptoms using a validated questionnaire. Gastric emptying of solids was evaluated scintigraphically in all patients and in 50 healthy controls.

RESULTS

Overlapping dyspepsia was diagnosed in 96 (66%) IBS patients. On average, gastric emptying rates were lower in IBS patients (mean +/- SEM, 33% +/- 1%/h) compared with controls (40% +/- 2%/h; p < 0.01). Specifically, gastric emptying was delayed in IBS patients with overlapping dyspepsia (31% +/- 1%/h; p < 0.01), whereas IBS patients without dyspeptic complaints showed gastric emptying rates (37% +/- 2%/h) that were similar to those of healthy controls (40% +/- 2%/h). Relevant postprandial fullness (OR = 4.7, 95% CI = 1.8-12.5) and relevant nausea (OR = 3.3, 95% CI 1.2-9.3) were independently associated with delayed gastric emptying.

CONCLUSIONS

IBS patients without overlapping dyspepsia have normal gastric emptying of solids. A significant association exists in IBS patients between delayed gastric emptying and overlapping relevant postprandial fullness and nausea.

Prevalence of functional dyspepsia and its relationship with Helicobacter pylori infection in a Japanese population

AIM

To investigate the prevalence of functional dyspepsia and Helicobacter pylori infection and their relationship in a Japanese population.

METHODS

Two thousand five hundred people who visited Shimane Institute of Health Science for their annual medical check-up from September 1998 to August 1999 were prospectively enrolled in the study. After routine medical examination, including an upper gastrointestinal study and an ultrasonographic examination, all subjects were asked standard questions to check for the presence of any symptoms that suggested dyspepsia. Helicobacter pylori infection was determined by using a serum IgG antibody concentration with an ELISA.

RESULTS

Of the 2,500 persons investigated, 2,263 showed no abnormal finding in any medical examination. The presence or absence of symptoms and H. pylori infection was investigated in these 2,263 cases. Of these, 201 people (8.9%) experienced nausea, fullness and/or early satiety and were diagnosed as having dysmotility-like dyspepsia, while 118 people (5.2%) experienced pain localized to the epigastrium and were diagnosed as having ulcer-like dyspepsia. The frequency of these symptoms had a tendency to decline with age, although this was not statistically significant. In contrast, the rate of H. pylori infection increased with age. There was no significant relationship between H. pylori infection and any type of functional dyspepsia.

CONCLUSIONS

Helicobacter pylori infection does not influence the prevalence of the dysmotility-like and ulcer-like dyspeptic symptoms.

The association between Helicobacter pylori infection and functional dyspepsia in patients with irritable bowel syndrome

OBJECTIVE

Irritable bowel syndrome (IBS) is associated with an exaggerated response to a variety of physiological and nonphysiological gastrointestinal stimuli. Many patients with IBS also have functional dyspepsia. Our aim was to examine the hypothesis that Helicobacter pylori (H. pylori) infection may predispose IBS patients to functional dyspepsia.

METHODS

In 69 IBS patients, dyspeptic symptoms, H. pylori status, and sociodemographic and psychological variables (perceived stress, trait anxiety, and depression) were assessed. Sociodemographic and psychological variables were also evaluated in 52 control subjects.

RESULTS

Mean scores for perceived stress (17.1 +/- 6.0 vs 14.9 +/- 6.0, p = 0.05), trait anxiety (45.6 +/- 9.1 vs 41.1 +/- 7.8, p = 0.004) and depression (9.9 +/- 8.4 vs 5.0 +/- 5.5, p = 0.0002) were higher in IBS patients than in controls. In all, 33 of the 69 patients (47.8%) had H. pylori infection, and this was associated with relevant symptoms of epigastric pain (odds ratio [OR] = 6.77, 95% confidence interval [CI] 1.89-24.3) and postprandial upper abdominal fullness (OR = 4.23, 95% CI 1.38-13.2). H. pylori infection and female gender were independent predictors of the presence of relevant dyspepsia (OR = 8.31, 95% CI 2.35-29.5 and 6.06, 95% CI 1.71-21.5, respectively). Symptom intensity was associated with the level of perceived stress (total relevant symptom number > or =3 vs <3, OR = 1.16 per point on a 40-point perceived stress scale, 95% CI 1.01-1.34).

CONCLUSIONS

In IBS patients, the presence of dyspepsia is associated with H. pylori infection, female gender, and perceived stress.