Does endoscopy have a positive impact on quality of life in dyspepsia?

Critical appraisal of international guidelines for the management of Helicobacter pylori infection in case of dyspepsia

BACKGROUND

Affecting between 20% and 90% of the world's population depending on the geo-socio-economic conditions, Helicobacter pylori (Hp) infection requires an adapted management because of the medico-economic stakes it generates. Also responsible for dyspepsia, the management of Hp infection differs in this context between international guidelines.

OBJECTIVES

The primary outcome of the study was assessing the quality of current guidelines for HP eradication in dyspepsia. The secondary was defining the best therapeutic strategy for patients consulting with dyspepsia in the outpatient setting.

METHODS

Clinical practice guidelines (CPG) published between January 2000 and May 2021 were retrieved from various databases (PubMed; Guidelines International Network; websites of scientific societies that issued the guidelines). Their quality was assessed using the AGREE II evaluation grid. To provide decision support for healthcare practitioners, particularly in primary care, a summary of the main points of interest for management was made for each guideline.

RESULTS

Fourteen guidelines were included. Only four (28.6%) could be validated according to AGREE II? Most of the non-validated guidelines had low ratings in the "Rigour of development" and "Applicability" domains with means of 40% [8%-71%] and 14% [0%-25%], respectively. Three out of four validated guidelines (75%) advocated a "test and treat" strategy for dyspepsia based on the national prevalence of Hp. Gastroscopy was the 1st line examination method in case of warning signs or high risk of gastric cancer. Triple therapy (Proton pomp inhibitor, amoxicillin, and clarithromycin) was favored for Hp eradication but required a study of the sensitivity to clarithromycin in the validated guidelines. Antibiotic resistance also had an impact on treatment duration.

CONCLUSIONS

Many guidelines were of poor quality, providing few decision-making tools for practical use. Conversely, those of good quality had established a management strategy addressing the current problems associated with the emergence of antibiotic-resistant strains.

Gastroscopy in younger patients: an analysis of referrals and pathologies

BACKGROUND AND AIM

Diagnostic guidelines for the investigation of dyspepsia for patients <50 years have been implemented. However, it is unsure whether these guidelines are used appropriately. We aimed to investigate the adherence to the national guidelines of uninvestigated dyspepsia and to examine the prevalence of upper gastrointestinal pathology in patients 18-50 years. We also aimed to detect any possible risk factors for pathology in esophagogastroduodenoscopy referrals and to evaluate differences between referrals from the hospital and primary health care.

METHOD

This is a retrospective review of medical records including patients who underwent esophagogastroduodenoscopy between January 2019 and April 2020 (n = 1809). Odds ratios (OR), positive predictive values (PPV), negative predictive values (NPV), chi-square and Mann-Whitney U-tests were applied.

RESULTS

In total 1708 patients were included, of whom 43.6% (n = 744) had a pathologic finding. Age group 41-50 years showed the highest prevalence with an OR 1.34 [95% confidence interval (CI), 1.07-1.69]. Helicobacter pylori testing was performed in 21.1% (n = 167) of patients with dyspepsia lacking alarm symptoms (n = 791). PPV and OR were generally low for a pathologic esophagogastroduodenoscopy. The absence of alarm symptoms showed a high NPV for significant pathology (98.7-99.6%). Significant pathology was almost exclusively found in hospital-based referrals.

CONCLUSIONS

Esophagogastroduodenoscopy is widely performed in young adults, often without significant findings. Adherence to the national guidelines was poor. No referral factors were associated with a significant risk for a pathologic finding. Esophagogastroduodenoscopy based on primary healthcare referrals demonstrated almost exclusively benign pathology. Significant pathology was only found via hospital-based referrals.

Effect of moderate aerobic exercises on symptoms of functional dyspepsia

BACKGROUND

Functional dyspepsia (FD) is a commonly encountered entity worldwide and is difficult to treat. Most of the treatment modalities have low-quality evidence for use, except for proton pump inhibitors. Aerobic exercise has been shown to improve the symptoms, but its direct effect on symptoms has never been studied. The objective was to study the effects of moderate aerobic exercise on symptoms of FD and to compare the effect of conventional treatment alone vs. exercise plus conventional treatment.

METHODS

Out of 112 patients, 72 were randomly divided into controls (conventional treatment; n=36) and experimental (aerobic exercise for 30 min per session, 5 times a week for 6 weeks with conventional treatment; n=36) groups. Both the groups were assessed on day 1 and at the end of 6 weeks, using Glasgow Dyspepsia Severity Score (GDSS), Depression Anxiety Stress Scales-42 (DASS-42), and visual analogue scale (VAS).

RESULTS

Pre-treatment GDSS, DASS-42, and VAS in the experimental group were significantly different as compared to the post-treatment scores (p=0.00019, p=0.0002, p=0.00019, respectively). Even in the control group, pre- and post-treatment GDSS, DASS-42, and VAS scores were significantly different (p=0.00019, p=0.0002, p=0.00019, respectively). However, on the head-to-head comparison of the 2 groups, scores at the end of 6 weeks were significantly different (p< 0.05), in favor of the experimental group.

CONCLUSION

Aerobic exercise as an auxiliary therapy to conventional treatment has better outcomes in the functional well-being of dyspepsia.

Prevalence of Non-Celiac Gluten Sensitivity in Patients with Refractory Functional Dyspepsia: a Randomized Double-blind Placebo Controlled Trial

Refractory functional dyspepsia (RFD) is characterized by symptoms persistence in spite of medical treatment or H. pylori eradication. No study has yet investigated the presence of gluten-dependent RFD as a clinical presentation of Non-Celiac Gluten Sensitivity (NCGS). Patients with RFD, in whom celiac disease, wheat allergy and H. pylori infection had been ruled out, followed a six weeks long gluten-free diet (GFD). Symptoms were evaluated by means of visual analogue scales; patients with ≥30% improvement in at least one of the reported symptoms after GFD underwent a double-blind placebo controlled gluten challenge. Subjects were randomly divided in two groups and symptoms were evaluated after the gluten/placebo challenge. GFD responders were further followed on for 3 months to evaluate the relationship between symptoms and gluten consumption. Out of 77 patients with RFD, 50 (65%) did not respond to GFD; 27 (35%) cases showed gastrointestinal symptoms improvement while on GFD; after blind gluten ingestion, symptoms recurred in 5 cases (6.4% of patients with RFD, 18% of GFD responders) suggesting the presence of NCGS. Furthermore, such extra-intestinal symptoms as fatigue and weakness (P = 0.000), musculo-skeletal pain (P = 0.000) and headache (P = 0.002) improved in NCGS patients on GFD. Because of the high prevalence of NCGS among patients with RFD, a diagnostic/therapeutic roadmap evaluating the effect of GFD in patients with RFD seems a reasonable (and simple) approach.

Appropriateness of American Society for Gastrointestinal Endoscopy Guidelines for Upper Gastrointestinal Endoscopy: A Prospective Analytical Study

Introduction

Extensive use of upper gastrointestinal endoscopy (UGE) with the advent of open access centers has resulted in inappropriate endoscopies. Our study aimed to evaluate the appropriateness of American Society for Gastrointestinal Endoscopy (ASGE) guidelines for UGE and to assess the diagnostic yield of endoscopy in a tertiary care center in South India.

Methods

The study was conducted as a prospective analytical study. Indications for endoscopy were classified as “ASGE appropriate” and “ASGE inappropriate”. The significance of association of ASGE guidelines and other categorical variables with endoscopic findings were assessed.

Results

ASGE appropriate indications and inappropriate indications accounted for 85.9% and 14.1% of endoscopies, respectively. The most common appropriate indication was persistent dyspepsia despite adequate proton-pump inhibitor (PPI) therapy (28.1%) and the only inappropriate indication for endoscopy was isolated dyspepsia without adequate PPI therapy (14.1%). The diagnostic yield of endoscopy for appropriate indications was 69.5% and for inappropriate indications was 55.1%, the difference was statistically significant (P= 0.003; OR-1.857). The sensitivity and specificity of ASGE guidelines was 88.5% and 19.5%, respectively.

Conclusion

According to our study, ASGE guidelines may be considered as appropriate guidelines for UGE in our population and these guidelines were followed 85.9% of the times in referring patients for the same. However, the high diagnostic yield even in inappropriate endoscopies indicates the necessity of further studies that might identify other relevant indications for endoscopy, thus avoiding misutilization of resources without missing out on relevant cases.

Factors associated with health-related quality of life in patients with functional dyspepsia

BACKGROUND

Health-related quality of life (HRQoL) assessment is important for patients with functional dyspepsia. However, no studies have assessed factors associated with HRQoL reduction in such patients in an Asian population. This study aimed to determine the contribution of clinical, psychosocial, and demographic factors to HRQoL in affected patients in Indonesia.

METHODS

In a cross-sectional study, we recruited 124 patients in a tertiary hospital with functional dyspepsia according to Rome III criteria. HRQoL was measured using the Medical Outcomes Study Short-Form 36 (SF-36) physical component summary (PCS) and mental component summary (MCS) and compared with 2009 United States population norms. The factors investigated were age, gender, symptom severity, education level, employment status, anxiety, depression, and ethnicity. Factors associated with reduced HRQoL were identified using linear regression analysis.

RESULTS

All domains of HRQoL except vitality were impaired in patients with functional dyspepsia. The mean PCS was 42.3 (SD = 8.4); and the mean MCS was 47.8 (SD = 10). Increasing age (p = 0.002), female gender (p = 0.006), low-to-mid education level (p = 0.015) and greater symptom severity (p < 0.001) were significantly associated with impaired PCS (R2 = 0.36). Female gender (p = 0.047), greater symptom severity (p = 0.002), anxiety (p = 0.001), and depression (p = 0.002 were all significantly associated with an impaired MCS (R2 = 0.41). There were no significant associations between HRQoL and with ethnic group (Javanese/non-Javanese) or employment status.

CONCLUSIONS

There was significant HRQoL impairment in these patients with functional dyspepsia in Indonesia. Anxiety, depression, increasing age, female gender, greater symptom severity, and low-to-mid education level were significant factors associated with low HRQoL.  TRIAL REGISTRATION: ClinicalTrials.gov NCT03321383 . Registered 18 October 2017 retrospectively registered.

Factors associated with health-related quality of life in patients with functional dyspepsia

BACKGROUND

Health-related quality of life (HRQoL) assessment is important for patients with functional dyspepsia. However, no studies have assessed factors associated with HRQoL reduction in such patients in an Asian population. This study aimed to determine the contribution of clinical, psychosocial, and demographic factors to HRQoL in affected patients in Indonesia.

METHODS

In a cross-sectional study, we recruited 124 patients in a tertiary hospital with functional dyspepsia according to Rome III criteria. HRQoL was measured using the Medical Outcomes Study Short-Form 36 (SF-36) physical component summary (PCS) and mental component summary (MCS) and compared with 2009 United States population norms. The factors investigated were age, gender, symptom severity, education level, employment status, anxiety, depression, and ethnicity. Factors associated with reduced HRQoL were identified using linear regression analysis.

RESULTS

All domains of HRQoL except vitality were impaired in patients with functional dyspepsia. The mean PCS was 42.3 (SD = 8.4); and the mean MCS was 47.8 (SD = 10). Increasing age (p = 0.002), female gender (p = 0.006), low-to-mid education level (p = 0.015) and greater symptom severity (p < 0.001) were significantly associated with impaired PCS (R² = 0.36). Female gender (p = 0.047), greater symptom severity (p = 0.002), anxiety (p = 0.001), and depression (p = 0.002 were all significantly associated with an impaired MCS (R² = 0.41). There were no significant associations between HRQoL and with ethnic group (Javanese/non-Javanese) or employment status.

CONCLUSIONS

There was significant HRQoL impairment in these patients with functional dyspepsia in Indonesia. Anxiety, depression, increasing age, female gender, greater symptom severity, and low-to-mid education level were significant factors associated with low HRQoL.  TRIAL REGISTRATION: ClinicalTrials.gov NCT03321383 . Registered 18 October 2017 retrospectively registered.

The diagnostic yield of open-access endoscopy of the upper gastrointestinal tract in the Netherlands

BACKGROUND AND STUDY AIMS

Since the introduction of open-access esophago-gastroduodenoscopy (OAE) there is an increase in the total number of performed OAEs whilst the frequency of clinical relevant findings has decreased. The aim of this study was to assess the appropriate use and the diagnostic yield of OAE in the Netherlands and to determine which patient variables are able to predict a malignant finding.

PATIENTS AND METHODS

A retrospective chart review of all referrals for diagnostic OAE between October 2012 and October 2016 at the Northwest Clinics was performed. The indications were recorded from the referral letter and were classified as "appropriate" or "inappropriate" according to the NHG guideline. Logistic regression was used to detect significant predictive variables for a malignancy.

RESULTS

A total of 2006 patients were included, of whom 59.6 % had an 'appropriate' referral indication. The diagnostic yield of finding a clinical relevant finding was significantly higher for OAEs with an "appropriate" referral indication. Independent risk factors for malignancy were alarm symptoms, age and male gender with a combined AUC of 0.868.

CONCLUSIONS

Only 3.8 % of the malignancies would be missed by strict adherence to the guideline. This indicates that the open-access system in the Netherlands works well. Further improvement of the system can be achieved by only accepting appropriate indications for OAE and by treating patients under the age of 40 without OAE. We showed that a risk-prediction model based on the variables age, alarm symptoms and male gender is a good predictor of malignant finding.

Appropriateness of Indications of Upper Gastrointestinal Endoscopy and its Association With Positive Finding

INTRODUCTION

Upper Gastrointestinal Endoscopy is a frequently advised investigation for upper abdominal symptoms. Studies have questioned the appropriateness of indications for upper gastrointestinal endoscopy and have shown that inappropriate indications range from 5% to 49%. The unnecessary upper gastrointestinal endoscopy expose patients to the risk. The number of upper gastrointestinal endoscopy is rising in our region and we assume so is the number of unnecessary upper gastrointestinal endoscopy. With an aim to find out the appropriateness of the indications of upper gastrointestinal endoscopy and compare its association with positive findings, we conducted a cross-sectional descriptive study.

METHODS

All patients undergoing diagnostic upper gastrointestinal endoscopy during study period were included in the study. Appropriateness of indications for upper gastrointestinal endoscopy was defined as per American Society for Gastrointestinal Endoscopy criteria as "appropriate" and "inappropriate". Upper gastrointestinal endoscopy findings were classified as "significant" and "insignificant" based on endoscopy findings. The extent of this association between appropriateness of indications and upper gastrointestinal endoscopy findings was expressed as the odds ratio of finding a relevant diagnosis in patients with an ''appropriate'' indication compared with those with an 'inappropriate'' indication.

RESULTS

Seventy-nine patients were included in the study. Fifty- two (65.8%) of the indications were considered appropriate as per American Society for Gastrointestinal Endoscopy guidelines. Thirty-three (63.5%) of the appropriate indications has clinically significant finding as compared to seven (25.9%) of inappropriate indication with an odds ratio of 4.962 (95% CI:1.773 - 13.890, P=0.002) which is statistically significant.

CONCLUSIONS

Appropriate indications have significantly higher rates of clinically significant findings. Use of guidelines may decrease the number of unnecessary procedures.

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.

Equal efficacy of endoscopic and surgical cystogastrostomy for pancreatic pseudocyst drainage in a randomized trial

BACKGROUND & AIMS

Although surgery is the standard technique for drainage of pancreatic pseudocysts, use of endoscopic methods is increasing. We performed a single-center, open-label, randomized trial to compare endoscopic and surgical cystogastrostomy for pancreatic pseudocyst drainage.

METHODS

Patients with pancreatic pseudocysts underwent endoscopic (n = 20) or surgical cystogastrostomy (n = 20). The primary end point was pseudocyst recurrence after a 24-month follow-up period. Secondary end points were treatment success or failure, complications, re-interventions, length of hospital stay, physical and mental health scores, and total costs.

RESULTS

At the end of the follow-up period, none of the patients who received endoscopic therapy had a pseudocyst recurrence, compared with 1 patient treated surgically. There were no differences in treatment successes, complications, or re-interventions between the groups. However, the length of hospital stay was shorter for patients who underwent endoscopic cystogastrostomy (median, 2 days, vs 6 days in the surgery group; P < .001). Although there were no differences in physical component scores and mental health component scores (MCS) between groups at baseline on the Medical Outcomes Study 36-Item Short-Form General Survey questionnaire, longitudinal analysis showed significantly better physical component scores (P = .019) and mental health component scores (P = .025) for the endoscopy treatment group. The total mean cost was lower for patients managed by endoscopy than surgery ($7011 vs $15,052; P = .003).

CONCLUSIONS

In a randomized trial comparing endoscopic and surgical cystogastrostomy for pancreatic pseudocyst drainage, none of the patients in the endoscopy group had pseudocyst recurrence during the follow-up period, therefore there is no evidence that surgical cystogastrostomy is superior. However, endoscopic treatment was associated with shorter hospital stays, better physical and mental health of patients, and lower cost.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00826501.

Appropriateness and diagnostic yield of upper gastrointestinal endoscopy in an open-access endoscopy system

BACKGROUND/AIM

Open access endoscopy (OAE) decreases the waiting time for patients and clinical burden to gastroenterologist; however, the appropriateness of referrals for endoscopy and thus the diagnostic yield of these endoscopies has become an important issue. The aim of this study was to determine the appropriateness of upper gastrointestinal (GI) endoscopy requests in an OAE system.

PATIENTS AND METHODS

A retrospective chart review of all consecutive patients who underwent an upper gastroscopy in the year 2008 was performed and was defined as appropriate or inappropriate according to the American Society for Gastrointestinal Endoscopy (ASGE) guidelines. Endoscopic findings were recorded and classified as positive or negative. Referrals were categorized as being from a gastroenterologist, internist, surgeon, primary care physicians or others, and on an inpatient or out-patient basis.

RESULTS

A total of 505 consecutive patients were included. The mean age was 45.3 (standard deviation 18.1), 259 (51%) of them were males. 31% of the referrals were thought to be inappropriate. Referrals from primary care physicians were inappropriate in 47% of patients while only 19.5% of gastroenterologists referrals were considered inappropriate. Nearly, 37.8% of the out-patient referrals were inappropriate compared to only 7.8% for inpatients. Abnormal findings were found in 78.5% and 78% of patients referred by gastroenterologists and surgeons respectively while in those referred by primary care physicians it was (49.7%). Inpatients referred for endoscopy had abnormal findings in (81.7%) while in out-patients it was (66.6%). The most common appropriate indications in order of frequency were "upper abdominal distress that persisted despite an appropriate trial of therapy "(78.9%),''persistent vomiting of unknown cause "(19.2%), upper GI bleeding or unexplained iron deficiency anemia (7.6%). The sensitivity and specificity of the ASGE guidelines in our study population was 70.3% and 35% respectively.

CONCLUSION

A large proportion of patients referred for endoscopy through our open-access endoscopy unit are considered inappropriate, with significant differences among specialties. These results suggest that if proper education of practitioners was implemented, a better utilization would be expected.

Large-scale randomized clinical study on functional dyspepsia treatment with mosapride or teprenone: Japan Mosapride Mega-Study (JMMS)

BACKGROUND AND AIM

Functional dyspepsia (FD) is a common condition seen in primary gastroenterology practice. The present study was conducted to compare the clinical effectiveness of mosapride and teprenone in patients with FD.

METHODS

Prospective clinical comparative study with random allocation of open labeled medications was performed as a multicenter trial in Japan. 1042 patients presenting symptoms of FD, either with gastric stasis (GSS) and/or epigastric pain (EPS), were enrolled. After initial endoscopic evaluation, medication either with mosapride 5 mg tid or teprenone 50 mg tid was started. Severity and frequency of GSS and EPS, health-related quality of life (HR-QOL) by the SF-36 Japanese version, and patients' compliance to medication was evaluated.

RESULTS

Organic lesions were found in 90 patients (9%) in the 1027 patients examined by endoscopy. Among those without any specific lesions detected by endoscopy, gastrointestinal symptoms were resolved within one week after the endoscopy in 264 (28%) patients before initiating medication. 618 patients who remained symptomatic were randomized to medication either with mosapride (n = 311) or teprenone (n = 307). Two-week treatment with mosapride significantly improved GSS and EPS, while teprenone tended to improve only GSS. Mosapride also improved HR-QOL. 91% of patients treated with mosapride favored their medication, while only 52% of patients treated with teprenone favored their medication.

CONCLUSIONS

Endoscopic evaluation at patients' presentation was effective to find active lesions and to improve FD symptoms. Mosapride was more favorably accepted than teprenone by the patients with sufficient safety and efficacy.

A nine-year audit of open-access upper gastrointestinal endoscopic procedures: results and experience of a single centre

BACKGROUND

The appropriateness and safety of open-access endoscopy are very important issues as its use continues to increase.

OBJECTIVE

To present a review of a nine-year experience with open-access upper gastrointestinal endoscopy with respect to indications, diagnostic efficacy, safety and diseases diagnosed.

METHODS

A retrospective, observational case series of all patients who underwent open-access endoscopy between January 2000 and December 2008 was conducted. Indications were classified as appropriate or not appropriate according to American Society of Gastrointestinal Endoscopy (ASGE) guidelines. Endoscopic diagnoses were based on widely accepted criteria. Major complication rates were assessed.

RESULTS

A total of 20,620 patients with a mean age of 58 years were assessed, of whom 11,589 (56.2%) were women and 9031 (43.8%) were men. Adherence to ASGE indications led to statistically significant, clinically relevant findings. The most common indications in patients older than age 45 years of age were dyspepsia (28.5%) and anemia (19.7%) in the ASGE-appropriate group, and dyspepsia in patients younger than 45 years of age without therapy trial (6.6%) in the nonappropriate group. Of the examinations, 38.57% were normal. Hiatal hernia and nonerosive gastritis were the most common findings. Important diagnoses such as malignancies and duodenal ulcers would have been missed if endoscopies were performed only according to appropriateness. There were only two major complications and no mortalities.

CONCLUSIONS

Open-access upper gastrointestinal endoscopy is a safe and effective system. More relevant findings were found when adhering to the ASGE guidelines. However, using these guidelines as the sole determining factor in whether to perform an endoscopy is not advisable because many clinically relevant diagnoses may be overlooked.

WITHDRAWN: 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.

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

Twenty one randomised controlled trials were included in the systematic review. Eighteen trials compared antisecretory dual or triple therapy with placebo antibiotics +/- antisecretory therapy, and evaluated dyspepsia at 3-12 months. Seventeen of these trials gave results as dichotomous outcomes evaluating 3566 patients and there was no significant heterogeneity between the studies. There was a 10% relative risk reduction in the H pylori eradication group (95% CI = 6% to 14%) compared to placebo. The number needed to treat to cure one case of dyspepsia = 14 (95% CI = 10 to 25). 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.

Risk factors for impaired health-related quality of life in functional dyspepsia

BACKGROUND

The influence of patient characteristics on HRQoL in functional dyspepsia is poorly understood.

AIM

To determine the contribution of gastric sensorimotor function, psychosocial factors & 'somatization' to HRQoL in functional dyspepsia.

METHODS

In 259 tertiary care functional dyspepsia patients, we studied gastric sensorimotor function with barostat. We measured psychosocial factors and 'somatization' using self-report questionnaires. HRQoL was assessed using the SF-36 physical and mental composite scores (PCS, MCS). Bivariate associations between gastric sensorimotor function, psychosocial factors and 'somatization' on the one hand and PCS and MCS on the other were estimated. Variables significantly associated with PCS or MCS in bivariate analysis were entered into hierarchical multiple linear regression models.

RESULTS

Mean PCS was 40.1 ± 9.5; mean MCS was 45.1 ± 10.8. 'Somatization' (P < 0.0001) and chronic fatigue (P = 0.002) were significantly associated with impaired PCS (R² = 0.52, P < 0.0001). The effects of abuse history and depression were 'mediated' by 'somatization'. Trait anxiety (P = 0.02), alexithymia (P = 0.06), depression (P = 0.06), positive affect (P < 0.0001), negative affect (P = 0.002) and generalised anxiety disorder (P = 0.01) were significantly associated with impaired MCS (R² = 0.67, P < 0.0001).

CONCLUSIONS

'Somatization' is the most important risk factor for impaired physical HRQoL in functional dyspepsia; it 'mediates' the effect of abuse history and depression. Mental HRQoL is mainly explained by psychosocial factors.

Presentation and survival of operable esophageal cancer in patients 55 years of age and below

BACKGROUND

The increased incidence of esophageal cancer, especially in the younger age group, should encourage early diagnosis. The perceived rarity and poor prognostic outcome of esophageal cancer in this group is based on retrospective studies. The goal of this study was to review the presentation and survival of young patients with esophageal cancer.

METHODS

This study was conducted from 2000 to 2007 in a specialized esophagogastric center. All patients who had esophageal cancer operations were included. Variables collected included ages, duration of symptoms, presenting symptoms, tumor characteristics, and follow-up data.

RESULTS

In total, 365 esophagectomies were performed for cancer, of which 76 patients were younger than aged 55 years (20.8%) and 289 were older than aged 55 years. In patients younger than aged 55 years, 15 patients had symptoms for 6 months or more, 54 had dysphagia, 35 had weight loss compared with 220 and 175 respectively of patients older than aged 55 years. On histopathology, 48 had T3 tumors (63.2%), 17 had T2 (22.4%), and 10 had T1 (13.2%) for patients younger than aged 55 years compared with 141 had T3 (48.7%), 85 had T2 (29.4%), and 55 had T1 (19%) for patients older than aged 55 years. These differences in tumor stage at presentation between groups were significant (p < 0.05 with 3DF). In-hospital mortality was 0 for the group younger than aged 55 years and 5 for those older than aged 55 years. Average follow-up was 35 (minimum, 15) months. Thirty patients had locoregional recurrence in the first group and 110 in the latter group. Survival at 1 year after surgery was 79.6%, at 2 years 65.1%, and at 5 years 42.3% compared with 78.4, 60.6, and 45.9%, respectively, for the group older than aged 55 years, but this was not significant using log-rank (p = 0.99).

CONCLUSIONS

A significant proportion (20.8%) of patients presenting with operable esophageal cancer was younger than aged 55 years. Almost two-thirds of those presenting younger than aged 55 years had T3 stage tumors, which was significantly different than those older than aged 55 years. Despite more advanced tumor stage at presentation, the prognosis of esophageal cancer for patients younger than aged 55 years is similar to those older than aged 55 years (log-rank = 0.99).

Rate and yield of repeat upper endoscopy in patients with dyspepsia

AIM: To determine the rate and yield of repeat esophagogastroduodenoscopy (EGD) for dyspepsia in clinical practice, whether second opinions drive its use, and whether it is performed at the expense of colorectal cancer screening.

METHODS: We performed a retrospective cohort study of all patients who underwent repeat EGD for dyspepsia from 1996 to 2006 at the University of California, San Francisco endoscopy service.

RESULTS: Of 24 780 EGDs, 5460 (22%) were performed for dyspepsia in 4873 patients. Of these, 451 patients (9.3%) underwent repeat EGD for dyspepsia at a median 1.7 (interquartile range, 0.8-3.1) years after initial EGD. Significant findings possibly related to dyspepsia were more likely at initial (29%) vs repeat EGD (18%) [odds ratio (OR), 1.45; 95% confidence interval (CI): 1.20-1.75, P < 0.0001], and at repeat EGD if the initial EGD had reported such findings (26%) than if it had not (14%) (OR, 1.32; 95% CI: 1.08-1.62, P = 0.0015). The same endoscopist performed the repeat and initial EGD in 77% of cases. Of patients aged 50 years or older, 286/311 (92%) underwent lower endoscopy.

CONCLUSION: Repeat EGD for dyspepsia occurred at a low but substantial rate, with lower yield than initial EGD. Optimizing endoscopy use remains a public health priority.

Effectiveness of nurse delivered endoscopy: findings from randomised multi-institution nurse endoscopy trial (MINuET)

OBJECTIVE

To compare the clinical effectiveness of doctors and nurses in undertaking upper and lower gastrointestinal endoscopy.

DESIGN

Pragmatic trial with Zelen's randomisation before consent to minimise distortion of existing practice.

SETTING

23 hospitals in the United Kingdom. In six hospitals, nurses undertook both upper and lower gastrointestinal endoscopy, yielding a total of 29 centres.

PARTICIPANTS

67 doctors and 30 nurses. Of 4964 potentially eligible patients, we randomised 4128 (83%) and recruited 1888 (38%) from July 2002 to June 2003.

INTERVENTIONS

Diagnostic upper gastrointestinal endoscopy and flexible sigmoidoscopy, undertaken with or without sedation, with the standard preparation, techniques, and protocols of participating hospitals. After referral for either procedure, patients were randomised between doctors and nurses.

MAIN OUTCOME MEASURES

Gastrointestinal symptom rating questionnaire (primary outcome), gastrointestinal endoscopy satisfaction questionnaire and state-trait anxiety inventory (all analysed by intention to treat); immediate and delayed complications; quality of examination and corresponding report; patients' preferences for operator; and new diagnoses at one year (all analysed according to who carried out the procedure).

RESULTS

There was no significant difference between groups in outcome at one day, one month, or one year after endoscopy, except that patients were more satisfied with nurses after one day. Nurses were also more thorough than doctors in examining the stomach and oesophagus. While quality of life scores were slightly better in patients the doctor group, this was not statistically significant.

CONCLUSIONS

Diagnostic endoscopy can be undertaken safely and effectively by nurses.

TRIAL REGISTRATION

International standard RCT 82765705.

An international comparison of the burden of illness in patients with dyspepsia

BACKGROUND/AIMS

This study investigates the symptoms and the impact of symptoms on health-related quality of life (HRQL) in patients consulting with dyspepsia.

METHODS

Consecutive patients with a diagnosis of dyspepsia were recruited from primary and secondary care in Germany, Hungary, Italy, Poland, South Africa and Spain. Investigators assessed symptom frequency and severity, and subjects completed the following questionnaires: the Gastrointestinal Symptom Rating Scale (GSRS), the Quality of Life in Reflux and Dyspepsia (QOLRAD) questionnaire, the Hospital Anxiety and Depression (HAD) scale and the Short Form 36 (SF-36).

RESULTS

853 dyspepsia patients were included. Mean GSRS scores showed that patients were most troubled by abdominal pain and indigestion. QOLRAD scores indicated that symptoms caused emotional distress, food/drink problems and reduced vitality, with a lesser effect on sleep and physical functioning. Mean SF-36 scores were lower than mean normative values for all domains, indicating that patients had a worse HRQL than the normal population, particularly for Bodily Pain, Role Physical and Role Emotional. Of patients in each country, 18-43% were anxious and 11-21% were depressed.

CONCLUSIONS

Patients with dyspepsia have reduced HRQL because their symptoms - particularly abdominal pain and indigestion - cause emotional distress, problems with food and drink, and impaired vitality.

Prevalence of gastrointestinal symptoms in patients with chronic obstructive pulmonary disease

BACKGROUND

Symptoms of gastro-oesophageal reflux disease (GERD) have previously been shown to be of importance in patients with asthma. Limited data, however, exist on the prevalence of GERD in patients with chronic obstructive pulmonary disease (COPD), and information about the occurrence of the total burden of gastrointestinal (GI) symptoms in these patients is lacking.

METHODS

A total of 113 patients with COPD completed four self-administered questionnaires: the Gastrointestinal Symptom-Rating Scale (GSRS), ROME II modular questionnaires (criteria for irritable bowel syndrome), the Psychological General Well-Being index (PGWB), and the Hospital Anxiety and Depression scale. Eighty-two patients with chronic renal failure (CRF) and 2000 healthy individuals from the general Swedish population served as controls.

RESULTS

The total GSRS score in patients with COPD was 2.12 (1.92-2.28) which was significantly higher than the score from the general population of 1.96 (1.81-2.12). No significant difference between COPD and CRF patients was, however, observed, in any of the GSRS dimensions. Patients in the COPD group had lower total PGWB scores compared both with CRF patients 90 (78-104) vs. 98 (83-113) (P<0.05) and with the general population 103 (102-104) (P<0.001). A negative correlation between the GSRS and PGWB scores (r=-0.49; P<0.001) was observed in patients with COPD. Sixteen (14%) of the patients with COPD fulfilled the Rome II criteria for irritable bowel syndrome.

CONCLUSION

The prevalence of GI symptoms is higher in patients with COPD than in healthy individuals, but not higher than in CRF patients. The GI symptoms are associated with impairments in psychological well-being, and they require diagnostic workups to explore different treatment options in these patients.

Reliability and validity of the Gastrointestinal Symptom Rating Scale (GSRS) and Quality of Life in Reflux and Dyspepsia (QOLRAD) questionnaire in dyspepsia: a six-country study

BACKGROUND

Symptoms of dyspepsia significantly disrupt patients' lives and reliable methods of assessing symptom status are important for patient management. The aim of the current study was to document the psychometric characteristics of the Gastrointestinal Symptom Rating Scale (GSRS) and the Quality of Life in Reflux and Dyspepsia questionnaire (QOLRAD) in Afrikaans, German, Hungarian, Italian, Polish and Spanish patients with dyspepsia.

METHODS

853 patients with symptoms of dyspepsia completed the GSRS, the QOLRAD, the 36-item Short-Form Health Survey (SF-36) and the Hospital Anxiety and Depression scale.

RESULTS

The internal consistency reliability of the GSRS was 0.43-0.87 and of the QOLRAD 0.79-0.95. Test-retest reliability of the GSRS was 0.36-0.75 and of the QOLRAD 0.41-0.82. GSRS Abdominal pain domain correlated significantly with all QOLRAD domains in most language versions, and with SF-36 Bodily pain in all versions. QOLRAD domains correlated significantly with the majority of SF-36 domains in most versions. Both questionnaires were able to differentiate between patients whose health status differed according to symptom frequency and severity.

CONCLUSION

The psychometric characteristics of the different language versions of the GSRS and QOLRAD were found to be good, with acceptable reliability and validity. The GSRS and QOLRAD were found to be useful for evaluating dyspeptic symptoms and their impact on patients' daily lives in multinational clinical trials.

Clinical trial: knowledge of negative Helicobacter pylori status reduces subsequent dyspepsia-related resource use

BACKGROUND

Screening for Helicobacter pylori reduces dyspepsia and dyspepsia-related costs in positive individuals.

AIMS

To assess effect of knowledge of H. pylori status on healthcare-seeking in negative individuals.

METHODS

H. pylori-negative subjects in a community screening programme were randomized to placebo triple therapy or informed of their negative H. pylori status. Dyspepsia-related resource data were extracted from primary care records at 2 years, and National Health Service reference costs were applied to calculate the total cost per subject. Proportions of individuals incurring any cost were compared using a relative risk (RR) and 95% confidence interval (CI). Differences in costs were compared using an independent sample t-test.

RESULTS

A total of 1353 H. pylori-negative individuals were randomized to placebo whilst 1355 were informed of their infection status. In the placebo arm, 212 (16%) subsequently incurred any dyspepsia-related cost compared to 172 (13%) informed of their infection status (RR of incurring cost = 0.81; 95% CI: 0.67-0.97). Those informed of their infection status incurred lower costs (mean saving per individual = pound 11.02; 95% CI: - pound 3.52 to 25.56).

CONCLUSIONS

H. pylori-negative individuals informed of infection status sought health care for dyspepsia less often than those who were unaware. Population screening may reduce dyspepsia-related costs in uninfected, as well as infected individuals.

Dispepsia funcional e depressão como fator associado

OBJETIVO: Avaliar a associação entre depressão e dispepsia funcional. PACIENTES E MÉTODOS: Estudo transversal onde foram avaliados 348 pacientes com diagnóstico de dispepsia no Ambulatório de Gastroenterologia do Hospital Universitário de Pelotas, RS, cidade de médio porte do sul do Brasil, durante o período de 1 ano (de março de 2001 a março de 2002). Após o diagnóstico de dispepsia avaliou-se a presença de depressão, tanto em pacientes com dispepsia funcional, quanto naqueles com dispepsia orgânica. Utilizou-se a análise univariada para descrição das freqüências das variáveis de interesse e da análise bivariada, com o teste qui-quadrado, para comparação entre proporções das variáveis categóricas. A técnica da regressão logística foi utilizada para estabelecer a chance dos pacientes com depressão apresentarem dispepsia funcional e para controlar o efeito das variáveis intervenientes sobre a variável de desfecho RESULTADOS: Evidenciaram maior prevalência de deprimidos entre os pacientes com dispepsia funcional (30,4%) em relação àqueles com dispepsia orgânica (11,2%). As mulheres apresentaram maior chance de dispepsia funcional (OR: 1,74, IC 95%, 1,05-2,89) e, em relação à idade, os intervalos entre 31 e 50 anos (OR: 0,28 IC 95%, 0,13-0,54) e de 51 a 60 anos (OR: 0,41, IC 95%, 0,17-0,96) mostraram efeito protetor, ou seja, indivíduos nessas faixas etárias têm menor risco de apresentar dispepsia funcional. Após a análise multivariada, pacientes deprimidos apresentaram chance três vezes maior de co-morbidade com dispepsia funcional do que pacientes não-deprimidos (OR 3,13; IC 95%; 1,71-5,74).

Effect of rabeprazole and omeprazole on the onset of gastro-oesophageal reflux disease symptom relief during the first seven days of treatment

OBJECTIVE

Gastro-oesophageal reflux disease (GORD) symptoms have a significant impact on patients' well-being. Onset of symptom relief is therefore an important consideration in GORD treatment. The primary objective was to compare the efficacy of rabeprazole (20 mg) and omeprazole (20 mg) regarding onset of heartburn control during the first 7 days of treatment in patients with erosive oesophagitis. Secondary objectives included maintenance of sustained heartburn control, control of other GORD symptoms (e.g. acid regurgitation, epigastric pain, dysphagia), effect on quality of life, patient satisfaction with treatment, and adverse events.

MATERIAL AND METHODS

In this multicentre, randomized, parallel-group, double-blind, comparative study, performed in Europe and Iceland, patients with endoscopically confirmed erosive oesophagitis were randomized to receive once-daily treatment with rabeprazole 20 mg (n=358) or omeprazole 20 mg (n=359) for 7 days. Symptoms were recorded (scored on a 5-point Likert scale) twice daily by the patients on their diary cards.

RESULTS

Median time to reach heartburn control was 1.5 days for both the rabeprazole and omeprazole groups (p<0.43). The results were similar between treatments for other study parameters. Both treatments were well tolerated.

CONCLUSIONS

Unlike previous studies, no significant differences were found between treatments with rabeprazole (20 mg) and omeprazole (20 mg) in this study. Further studies are needed to evaluate the potential benefit of fast-acting proton-pump inhibitors, such as rabeprazole, with respect to onset of symptom control in erosive GORD.

Evaluation of a gastrointestinal symptoms questionnaire

Questionnaires are widely used instruments to monitor gastrointestinal (GI) symptoms. However, few of these questionnaires have been formally evaluated. We sought to evaluate our GI symptoms questionnaire in terms of clarity and reproducibility. Primary care patients referred for open access Helicobacter pylori urea breath testing reported GI symptoms (type+severity) and demographic information by written questionnaire. In an interview, patients gave a personal description of the meaning of the GI symptoms on the questionnaire. Patients' descriptions of GI symptoms were compared with current definitions. Symptom severity scores were compared before and after, interview versus questionnaire. Of the 45 patients included, 19 (42%) described all symptoms correctly, whereas 17 (38%) described one symptom incorrectly. None of the patients made more than three mistakes. Regurgitation was the most common incorrectly described symptom (16 patients [36%]), whereas the other individual symptoms were well explained. Symptom severities before the interview, after the interview and reported by questionnaire (mean value+/-SEM) were 2.1 +/- 0.2, 2.1 +/- 0.2, and 1.5 +/- 0.2 points on a 7-point Likert scale (0-6), respectively. Mean severity reported by interview (95% CI) was 1.4 (1.3-1.5) times higher than reported by questionnaire (P < .05). In conclusion, the GI symptom questionnaire is understandable and has good reproducibility for measuring the presence of GI symptoms, although symptom severity is consistently rated higher when reported by interview.

Esomeprazole 40 mg once a day in patients with functional dyspepsia: the randomized, placebo-controlled "ENTER" trial

OBJECTIVE

The etiologies of functional dyspepsia (FD) are unclear, but in some studies, treatment with a proton pump inhibitor has been beneficial. The objective of this study was to evaluate the efficacy of esomeprazole 40 mg once a day compared to placebo in achieving symptom relief in primary care patients with FD.

METHODS

This was a randomized, placebo-controlled trial in adult FD patients, who had at least moderate severity of symptoms, defined as a score of > or =4 on a 7-point Global Overall Symptom (GOS) scale. Patients were excluded if they had predominant symptoms of heartburn or regurgitation; after a normal baseline endoscopy, patients were randomized to esomeprazole 40 mg once daily or placebo for 8 wk. The primary outcome measure was symptom relief (GOS < or =2) at 8 wk.

RESULTS

Of the 502 enrolled patients, 224 were randomized. The main reasons for exclusion were abnormal endoscopic findings, especially esophagitis. A significantly greater proportion of patients in the esomeprazole group achieved symptom relief at 4 but not at 8 wk compared to placebo: 4 wk esomeprazole 50.5% versus placebo 32.2%, p= 0.009; 8 wk esomeprazole 55.1% versus placebo 46.1%, p= 0.16. A similar relationship at 4 and 8 wk was seen for symptom resolution (GOS = 1) and improvement (DeltaGOS > or =2).

CONCLUSION

For the primary outcome measure of symptom relief at 8 wk, there was no statistically significant difference between esomeprazole 40 mg once a day and placebo. However, at 4 wk, esomeprazole was significantly more effective than placebo for symptom relief. The difference in therapeutic gain between 4 and 8 wk was largely due to a higher placebo response rate at 8 wk.

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.

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

Twenty one randomised controlled trials were included in the systematic review. Eighteen trials compared antisecretory dual or triple therapy with placebo antibiotics +/- antisecretory therapy, and evaluated dyspepsia at 3-12 months. Seventeen of these trials gave results as dichotomous outcomes evaluating 3566 patients and there was no significant heterogeneity between the studies. There was a 10% relative risk reduction in the H pylori eradication group (95% CI = 6% to 14%) compared to placebo. The number needed to treat to cure one case of dyspepsia = 14 (95% CI = 10 to 25). 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.

The relationship between patient knowledge of hemoglobin levels and health-related quality of life

BACKGROUND

An anti-anemia drug may improve self-reported quality of life (QOL) partly because patients know their hemoglobin level is rising. In the absence of any published studies on this topic, the authors investigated the association between knowledge of hemoglobin levels and self-reported QOL.

METHODS

The study analyzed health-related QOL (HRQOL) data from five randomized clinical trials of erythropoietic therapy in patients with cancer-related anemia. Patients were asked whether they knew their hemoglobin level and, if so, to report its value. Patients (n=1007) were grouped into three categories depending on the extent and accuracy of hemoglobin level knowledge. HRQOL scale scores were compared between categories.

RESULTS

Only 23.2% of patients reported knowing their hemoglobin level at the end of the study; however, the value was accurate (within 1 g/dl) in 88.0% of these patients. On five of the 11 HRQOL scales studied, there was a significant association between knowledge of hemoglobin level and HRQOL score. However, the magnitude of the mean difference between those who knew vs. those who did not know their hemoglobin was generally below scale thresholds for minimally important differences.

CONCLUSIONS

Patient knowledge of hemoglobin level has a modest association with some aspects of self-reported HRQOL. The magnitude of this association, where it exists, would be unlikely to explain large group differences in HRQOL reports over time, even for patients who know their hemoglobin level.

Detailed characterization of epidemiology of uninvestigated dyspepsia and its impact on quality of life among African Americans as compared to Caucasians

BACKGROUND AND AIMS

We wished to study the prevalence as well as the sociodemographic characteristics and quality of life (QoL) of African American patients with uninvestigated dyspepsia (UD) among the population at large and compare it to the Caucasians.

METHODS

A total of 990 adults from nine different sites in the Jackson, Mississippi metropolitan area (670 African Americans and 320 Caucasians), completed self-administered questionnaires providing sociodemographic information, and details regarding bowel habits and associated symptoms for diagnosing the presence or absence of UD based on ROME II criteria. QoL was assessed by the SF-12 questionnaire.

RESULTS

Of the 990 participants 247 had UD, giving a total sample prevalence of 24.9% (African Americans = 24.3%, Caucasians = 26.2%). Adjusting for other risk factors in a reduced logistic regression model, we found female sex (OR 1.8; CI 1.2-2.6; p < 0.01), lower education (p < 0.01), and larger size of household (p = 0.01) to be important correlates of UD prevalence whereas the lower household income showed a trend toward statistical significance (p = 0.057). Using the adjusted odds ratio as an estimate of relative risk, Caucasians were 1.5 (95% CI = 11.1-2.1; p = 0.017) more likely than African Americans to have UD. In terms of an index for QoL on SF-12 (possible score = 1-44, with 44 being ideal), the adjusted mean score was significantly lower for adults with UD compared to non-UD adults (30.4 vs 35.0; p < 0.01). However, there was no difference in impairment of life in Caucasians versus African Americans (32.9 vs 32.5; p = 0.36).

CONCLUSIONS

UD occurs less frequently among African Americans. While UD affects QoL among both Caucasians and African Americans, the degree of impairment is similar.

Guidelines for the management of dyspepsia

Dyspepsia is a chronic or recurrent pain or discomfort centered in the upper abdomen; patients with predominant or frequent (more than once a week) heartburn or acid regurgitation, should be considered to have gastroesophageal reflux disease (GERD) until proven otherwise. Dyspeptic patients over 55 yr of age, or those with alarm features should undergo prompt esophagogastroduodenoscopy (EGD). In all other patients, there are two approximately equivalent options: (i) test and treat for Helicobacter pylori (H. pylori) using a validated noninvasive test and a trial of acid suppression if eradication is successful but symptoms do not resolve or (ii) an empiric trial of acid suppression with a proton pump inhibitor (PPI) for 4-8 wk. The test-and-treat option is preferable in populations with a moderate to high prevalence of H. pylori infection (> or =10%); empirical PPI is an initial option in low prevalence situations. If initial acid suppression fails after 2-4 wk, it is reasonable to consider changing drug class or dosing. If the patient fails to respond or relapses rapidly on stopping antisecretory therapy, then the test-and-treat strategy is best applied before consideration of referral for EGD. Prokinetics are not currently recommended as first-line therapy for uninvestigated dyspepsia. EGD is not mandatory in those who remain symptomatic as the yield is low; the decision to endoscope or not must be based on clinical judgement. In patients who do respond to initial therapy, stop treatment after 4-8 wk; if symptoms recur, another course of the same treatment is justified. The management of functional dyspepsia is challenging when initial antisecretory therapy and H. pylori eradication fails. There are very limited data to support the use of low-dose tricyclic antidepressants or psychological treatments in functional dyspepsia.

Heartburn-dominant, uninvestigated dyspepsia: a comparison of 'PPI-start' and 'H2-RA-start' management strategies in primary care--the CADET-HR Study

BACKGROUND

There are few data on empiric, stepped therapy for heartburn relief or subsequent relapse in primary care.

AIMS

To compare heartburn relief produced by a proton pump inhibitor-start or an H(2)-receptor antagonist-start with step-up therapy, as needed, followed by a treatment-free period to assess relapse.

METHODS

Heartburn-dominant uninvestigated dyspepsia patients from 46 primary care centres were randomized to one of two active treatment strategies: omeprazole 20 mg daily (proton pump inhibitor-start) or ranitidine 150 mg bid (H2-receptor antagonist-start) for the first 4-8 weeks, stepping up to omeprazole 40 or 20 mg daily, respectively, for 4-8 weeks for persistent symptoms. Daily diaries documented heartburn relief (score < or = 3/7 on < or = of 7 prior days) and relapse (score > or = 4 on > or = 2 of 7 prior days).

RESULTS

For 'proton pump inhibitor-start' (n = 196) vs. 'H2-receptor antagonist-start' (n = 194), respectively, heartburn relief occurred in 55.1% vs. 27.3% (P < 0.001) at 4 weeks and in 88.3% vs. 87.1% at 16 weeks. After therapy, 308 patients were heartburn-free (159 vs. 149); median times to relapse were 8 vs. 9 days and cumulative relapse rates were 78.6% vs. 75.8%, respectively.

CONCLUSIONS

An empiric 'proton pump inhibitor-start' strategy relieves heartburn more effectively than an 'H2-receptor antagonist-start' strategy up to 12 weeks but has no effect on subsequent relapse, which is rapid in most patients.

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.

Review article: epidemiology and quality of life in functional gastrointestinal disorders

The epidemiology and health-related quality of life associated with functional gastrointestinal disorders are reviewed, with particular emphasis on irritable bowel syndrome and functional dyspepsia. The literature supports the significant world-wide prevalence of functional gastrointestinal disorders, including irritable bowel syndrome (IBS), functional dyspepsia and chronic constipation. An increased female prevalence has been demonstrated in most studies in patients with IBS and chronic constipation, but not functional dyspepsia. The female to male ratio appears to be greater in the health care-seeking population than in community populations. However, some differences in the reported general prevalence and gender-related prevalence of functional gastrointestinal disorders may be due to cultural factors and study methodology. A significant health care burden is associated with IBS, with increased out-patient services, abdominal and pelvic surgeries, and gastrointestinal- and non-gastrointestinal-related physician visits and health care costs. Health-related quality of life is impacted significantly in patients with functional gastrointestinal disorders, such as functional dyspepsia and IBS, compared with the general healthy population, as well as patients with other chronic medical conditions, such as gastro-oesophageal reflux disease and asthma. Impaired health-related quality of life has been demonstrated, in particular, in patients with moderate to severe disease seen in referral settings. The health-related quality of life appears to improve in treatment responders, or correlates with symptom improvement, with at least some treatment modalities studied in functional gastrointestinal disorders, but further studies are needed. Predictors of health-related quality of life in patients with functional gastrointestinal disorders include psychosocial factors, such as early adverse life events, and symptoms related to visceral perception, e.g. pain and chronic stress. The presence of extra-intestinal symptoms appears to have a major if not greater impact on health care visits, excess health care costs and health-related quality of life in patients with functional gastrointestinal disorders.

Identifying response to acid suppressive therapy in functional dyspepsia using a random starting day trial--is gastro-oesophageal reflux important?

BACKGROUND

Single subject trials offer an alternative approach to identify and characterize responders to a specific treatment.

AIM

To test a new single subject trials design, called random starting day trial, to identify acid-related symptoms in dyspepsia.

METHODS

A total of 119 patients with functional dyspepsia entered a 12-day, double-blind random starting day trial. All patients started on placebo and switched to omeprazole 80 mg/day at a randomized and blinded day between day 5 and day 9, with active treatment continuing for the rest of the trial. Based on changes of a daily symptom score, response was defined as a sustained > or =50% reduction of symptoms within 3 days of active treatment.

RESULTS

Thirteen of 119 patients (11%) were classified as spontaneous responders because of complete symptom relief before switching to omeprazole. Of the remaining 106 patients, 15 (15.6%) were classified as responders. Five of six (83%) responders compared with 28 of 53 (53%) non-responders had pathological reflux. Multivariate testing identified symptoms suggestive of gastro-oesophageal reflux predictive of response.

CONCLUSIONS

The random starting day trial design could identify a subset of dyspeptic patients with a uniform symptomatic response to acid-suppressive therapy. Response seems to be associated with gastro-oesophageal reflux. The random starting day trial needs to be further validated to be considered as a reliable instrument in clinical research.

Long-term follow-up of empirical treatment or prompt endoscopy for patients with persistent dyspeptic symptoms?

BACKGROUND

There are concerns about the safety and possible high costs of ongoing proton pump inhibitor therapy of empirical management strategies for patients with persistent dyspeptic symptoms.

AIM

To compare the long-term results of two treatment strategies: empirical treatment followed by the Helicobacter pylori test and treat strategy (treat and test group) and prompt upper gastrointestinal endoscopy followed by directed medical treatment (endoscopy group).

METHODS

In this study we describe the long-term follow-up data from a previously published randomized clinical trial. At least 6 years after randomization all participating general practitioners and patients were asked to give information about medication use, diagnostic testing, symptoms and quality of life by questionnaire.

RESULTS

Information about a total of 77 out of the 80 patients initially included (96%) was retrieved. Overall, 16 patients from the treat and test group (41%) underwent 18 diagnostic investigations. The 34 patients (100%) from the endoscopy group underwent 38 investigations (P < 0.01). The number of patients of the treat and test group and endoscopy group using acid inhibition therapy was 15 (38%) and 19 (56%), respectively (P = 0.14). There were also no differences in symptom prevalence and quality of life between the groups.

CONCLUSIONS

Treat and test management for patients with dyspeptic symptoms is safe and does not lead to additional diagnostic testing or use of medication when compared to prompt endoscopy.

Health-related quality of life of patients with gastrointestinal symptoms

BACKGROUND

Little is known about the variation in health-related quality of life among patients with different presentations of gastrointestinal symptoms.

AIM

To study the association between health-related quality of life and presentations of gastrointestinal symptoms.

METHODS

Health-related quality of life and demographic information was obtained from 873 patients referred to the hospital for endoscopy, using a questionnaire.

RESULTS

A total of 436 patients (50%) reported predominantly upper gastrointestinal symptoms, 344 (39%) predominantly lower symptoms, and 93 (11%) patients reported both upper and lower symptoms. Patients with mild, moderate and severe symptoms, reported mean scores on a 100-point visual analogue scale (95% CI) of 90 (79-100), 75 (64-86) and 64 (53-76), respectively (P < 0.001). Mean visual analogue scale scores (95% CI) almost linearly declined from 81 (77-85) to 49 (46-52) for those with one to those with more than eight symptoms. Patients who reported upper gastrointestinal symptoms and in particular epigastric pain, bloating and vomiting had significantly impaired health status in comparison to patients without these symptoms (P < 0.05).

CONCLUSIONS

Severity of gastrointestinal symptoms is the most important factor in affecting health status, followed by the numbers and type of gastrointestinal symptoms.

Appropriateness and diagnostic yield of EGD: a prospective study in a large Asian hospital

BACKGROUND

The appropriateness has become an important issue as the use of EGD becomes more widespread. No study of the appropriateness of EGD has been performed in the Asia-Pacific region. This study examined the appropriateness of EGD in a large Asian hospital by using the American Society for Gastrointestinal Endoscopy 2000 guidelines. A secondary aim was to correlate appropriateness with the presence of positive findings at EGD.

METHODS

A cross-sectional study was conducted of consecutive diagnostic EGDs performed at a university-affiliated, teaching hospital, which has an open-access endoscopy system for doctors who work in the hospital. The main indication(s) for EGD was recorded and assessed as appropriate or inappropriate by using American Society for Gastrointestinal Endoscopy criteria. EGD findings were recorded and classified as positive or negative. Referrals were categorized as being from endoscopists, primary care physicians, and others.

RESULTS

Of 1076 referrals for EGD, 88.3% were deemed appropriate. The group with the highest rate of appropriate referral was endoscopists (90.2%), followed by primary care physicians (89.6%) and "others" (81.9%). The rate of appropriate referrals was significantly higher for endoscopists and primary care physicians compared with "others" (respectively, p=0.001 and p=0.022). The most common appropriate indication was "upper abdominal distress that persists despite an appropriate trial of therapy" (35.4%). The most common inappropriate indication was "dyspepsia in patients aged 45 years or below without adequate empirical medical treatment" (48.4%); 42.2% with an appropriate indication had positive findings compared with only 25.6% of those with inappropriate indications (p=0.006). On multivariate analysis, the following were identified as independent predictive factors for positive findings at EGD: male gender (p=0.005), age over 45 years (p=0.011), smoking (p=0.005), none/primary education (p<0.001), and secondary education (p=0.026).

CONCLUSIONS

The proportion of patients referred for open-access EGD with an appropriate indication(s) was high for all doctor groups in a large university-affiliated medical center in Asia. EGDs performed for appropriate indications had a higher yield of positive findings. Independent predictive factors of positive findings were male gender, age over 45 years, lower education level, and referral by an endoscopist.

Quality of life in patients with functional dyspepsia: a prospective 1-year follow-up study in Spanish patients

BACKGROUND AND AIMS

The natural history of functional dyspepsia is not well known. We prospectively assess the quality of life and severity of symptoms in a group of Spanish patients with functional dyspepsia.

PATIENTS AND METHODS

One hundred and twelve consecutive patients with functional dyspepsia, according to Rome II criteria, were prospectively followed up for 1 year. All patients completed symptom (Dyspepsia Questionnaire and the Gastrointestinal Symptoms Rating Scale) and quality of life [the Psychological General Well-Being (PGWB) Index and the General Health Questionnaire (GHQ)] questionnaires every 3 months. Only free antacid consumption was permitted during the study period.

RESULTS

The group was made up of 81 women and 31 men with a mean age of 45 +/- 17 years; 66% of patients were infected with Helicobacter pylori, and ulcer-like dyspepsia (53%) was the predominant subgroup. At baseline, quality of life scores were low (PGWB, 87.1 +/- 17.6 and GHQ, 20.6 +/- 11.8), but these values gradually improved during the year of follow-up (PGWB, 107.7 +/- 1.1 and GHQ, 8.9 +/- 0.4). Digestive symptoms also decreased. In the multivariate analysis, the anxiety score on the PGWB index (Wald, 5.2; P = 0.02) and smoking status (Wald, 4.3; P = 0.04) were predictors of end quality of life. At baseline, patients with a high level of anxiety had a very reduced quality of life, although their symptom scores were similar to other patients.

CONCLUSION

Quality of life is reduced in patients with functional dyspepsia. Some improvement in quality of life together with a decrease in the severity of symptom scores was seen during the 1 year of follow-up. We believe that both the reassurance of negative endoscopy and the scheduling of visits to the doctor favourably influence the quality of life.

Living with chronic heartburn: insights into its debilitating effects

Heartburn is a common, often disabling condition. Twenty percent of adults exhibit symptoms at least once weekly. Few obtain complete satisfactory relief of their symptoms without the simultaneous implementation of significant lifestyle modifications and appropriate pharmacologic intervention. Poor sleep and chronic symptoms impair the QoL in 25% to 30% of such cases. Nocturnal symptoms are more troublesome, more difficult to treat, and are often manifested by extraesophageal symptoms. Several patients, however, unknown to their physicians continue to experience heartburn, despite lifestyle changes and taking prescription drugs. Adequate acid suppression is currently essential to effective management of the condition.

Health-related quality of life in functional dyspepsia

BACKGROUND

We performed a systematic review of the literature to compare the health-related quality of life (HRQOL) of patients with functional dyspepsia with either healthy controls or those with other diseases.

METHODS

Full-length published manuscripts during 1980-2002 were included if (a) patients had functional dyspepsia, but not uninvestigated dyspepsia; and (b) HRQOL was measured using a validated generic or dyspepsia-specific instruments, but not global assessment alone.

RESULTS

Twelve studies were reviewed; six fulfilled the selection criteria. None examined HRQOL among samples of the general population. None used dyspepsia-specific HRQOL instruments. Three studies contained four comparisons of HRQOL between functional dyspepsia patients and controls; two studies examined HRQOL changes in response to therapy. Two studies demonstrated a significant reduction at least in some domains of HRQOL among patients with functional dyspepsia compared to controls, while one study was negative. In general, studies that reported a decline in HRQOL Short Form-36 (SF-36) showed that changes in the physical domain were similar to those on mental domain of the SF-36.

CONCLUSIONS

There is some evidence for a decrease in HRQOL in patients with moderate to severe functional dyspepsia who seek care for their symptoms; however, more studies are needed. A therapeutic response in functional dyspepsia-related pain or discomfort might result in a corresponding improvement in HRQOL.

Health-related anxiety and the effect of open-access endoscopy in US patients with dyspepsia

BACKGROUND

The role of endoscopy in dyspepsia is the subject of debate. The detection of lesions is infrequent, but patients may benefit from the knowledge that the examination is normal. We sought to determine the prevalence of health-related anxiety in dyspeptic patients referred for open-access endoscopy and to investigate the effect of endoscopy on health-related anxiety.

METHODS

Consecutive patients referred for open-access endoscopy from primary care were studied using a validated questionnaire for health-related anxiety before and after endoscopy, at 1 month and 6 months. Symptoms were assessed using a validated questionnaire at 1 and 6 months.

RESULTS

One hundred and nine patients were studied (69 women and 40 men; mean age, 49 +/- 15 years). Thirty-six of the 109 patients (33%) had high anxiety scores at baseline (mean score, 41 +/- 1), which decreased after endoscopy to 35 +/- 1 (P < 0.05). The changes persisted at 1 month (33 +/- 1) and 6 months (33 +/- 1). Endoscopic findings were as follows: normal examination, 120; erosive oesophagitis, 11 (Grade A); erosive duodenitis (all Helicobacter pylori-negative), 6. Scales for preoccupation with health and fear of illness and death showed significant improvement after endoscopy, and the effects were preserved for 6 months. Anxiety scores in our population were substantially higher than in a corresponding UK population.

CONCLUSIONS

Health-related anxiety is common in dyspeptic patients referred for endoscopy. Endoscopy decreases the preoccupation with health and fear of illness and death in patients with severe anxiety, and the effects persist for 6 months.

Impact of upper endoscopy on satisfaction in patients with previously uninvestigated dyspepsia

BACKGROUND

In patients with uninvestigated dyspepsia who undergo endoscopy, the presence of abnormal findings guides subsequent management. However, upper endoscopy is "negative" in the majority of these patients, and the value of endoscopy in these individuals has been questioned. This study evaluated the impact of endoscopy on patient satisfaction in patients with previously uninvestigated dyspepsia.

METHODS

The study was a secondary analysis of data obtained from a double-blind, randomized placebo-controlled trial, evaluating a 6-week course of omeprazole versus placebo in 140 patients with uninvestigated dyspepsia who were followed for up to 1 year. The setting was the primary care outpatient clinics at the Houston Veterans Affairs Hospital. Participants had to be 18 years of age or older with at least a 1-week history of dyspepsia (epigastric discomfort) without alarm features. Satisfaction was measured at each visit with the Severity of Dyspepsia Assessment, a validated, reliable dyspepsia-related health measure that has a satisfaction scale (scores 2-23; higher scores indicate greater satisfaction). Patients unresponsive to empiric therapy with placebo or omeprazole based on predefined criteria underwent endoscopy. Severity of Dyspepsia Assessment satisfaction scores were analyzed for 5 visits: 2 closest in time to, but before, the day of endoscopy (Times 1 and 2); immediately before endoscopy (Time 3); and the 2 visits closest in time after endoscopy (Times 4 and 5). After determining there was no difference in treatment failure rates between patients who received placebo or omeprazole, data from these groups were combined. The mean Severity of Dyspepsia Assessment satisfaction scores for Times 1 through 5 in all patients who underwent endoscopy were compared as well as for subgroups with positive and negative endoscopic findings with a repeated-measures analysis of variance.

RESULTS

Data on all 5 visits were available in 62 patients, 36 of whom had a negative endoscopy. For all patients the mean scores for Time 2 (8.5; 95% CI [7.4, 9.6]), and Time 3 (7.6; 95% CI [6.6, 8.6]) were significantly lower than those for Time 4 (13.7; 95% CI [12.2, 15.3]) and Time 5 (14.4; 95% CI [12.9, 15.9]). The mean score for Time 1 (11.1; 95% CI [9.5, 12.6]) was significantly lower than the mean score for Time 5. Similar significant improvements in satisfaction scores were observed in subgroups with negative and positive findings.

CONCLUSIONS

In patients with previously uninvestigated dyspepsia, endoscopy leads to improved patient satisfaction regardless of the endoscopic findings.

The impact of treatment for gastro-oesophageal reflux disease on health-related quality of life: a literature review

Gastro-oesophageal reflux disease (GORD) is common in the general population and is diagnosed based on patient-reported symptoms and clinical tests. Although clinical tests are available, significant percentages of patients report symptoms of heartburn and reflux despite negative endoscopies, and 24-hour pH tests are not often used by primary-care physicians in diagnosis. Consequently, patient-reported symptoms and health-related QOL (HR-QOL) are important in assessing treatment outcome. HR-QOL is significantly impaired in patients with GORD, and HR-QOL is associated with symptom severity and changes in GORD-related symptoms. The objective of this literature review is to examine the impact of pharmacological treatment on HR-QOL in patients with GORD. Generic and disease-specific HR-QOL measures have been used in clinical trials to evaluate the impact of GORD on patient functioning and well-being. The Psychological General Well-Being (PGWB) Index and the 36-Item Short-Form Health Survey (SF-36) have been used in several clinical trials of treatment for GORD and have consistently shown that HR-QOL improves with successful therapy. These trials have been conducted primarily with two pharmacological agents, omeprazole and ranitidine. On the Heartburn-specific Quality of Life questionnaire, patients treated with ranitidine reported better HR-QOL after treatment compared with placebo therapy. In two clinical trials where omeprazole and ranitidine were compared, patients treated with omeprazole reported significantly better HR-QOL (based on the PGWB Index) than those treated with ranitidine; however, 2 other trials did not detect significant differences between the treatments. Results from clinical trials using disease-specific measures (Gastrointestinal Quality of Life Index [GIQLI] and Heartburn-specific Quality of Life questionnaire) demonstrate similar findings, supporting the association between treatment-related symptom resolution and improvements in HR-QOL. The GIQLI was used in a trial comparing pantoprazole and ranitidine, where results favoured pantoprazole therapy. Several studies have demonstrated that resolution of GORD symptoms is associated with improvement in HR-QOL. Although there is evidence that treatment for GORD does improve symptoms and HR-QOL outcomes, further research is needed to more completely understand the value of medical therapy for GORD.

Helicobacter pylori test-and-treat intervention compared to usual care in primary care patients with suspected peptic ulcer disease in the United States

OBJECTIVES

[corrected] The Helicobacter pylori (H. pylori) "test-and-treat" strategy in uninvestigated dyspepsia is an effective alternative to prompt endoscopy. Our aims were to determine whether the combination of an educational session and availability of office-based H. pylori testing (test-and-treat intervention [TTI]) increases use of the test-and-treat strategy by primary care practitioners and whether it improves patient outcomes.

METHODS

We conducted a 1-yr prospective trial of patients with suspected peptic ulcer disease in six primary care centers, three with TTI and three designated as usual care controls (UCC).

RESULTS

H. pylori testing was performed in 81% of 54 TTI patients and in 49% of 39 UCC patients (p = 0.004). TTI and UCC patients had similar gastroenterology referral rates (24% vs 33%, p = 0.33), endoscopy or upper GI radiography rates (30% vs 31%, p = 0.91), and primary care visits per patient (3.1 +/- 2.8 vs 3.1 +/- 2.6, p = 0.92). TTI patients were less likely than UCC patients to receive repeated antisecretory medication prescriptions (35% vs 66%, p = 0.003). Symptomatic status at 1 yr and satisfaction with medical care did not differ between groups. Median (and interquartile range) annualized disease-related expenditures per patient were $454 ($162-932) for TTI and $576 ($327-1,435) for UCC patients (p = 0.17).

CONCLUSIONS

The combination of an educational session and availability of office-based H. pylori testing may increase acceptance of the test-and-treat strategy by primary care providers. It remains to be determined whether increased use of the test-and-treat strategy yields significant improvements in clinical and economic outcomes compared to usual care.