Systematic review: Antacids, H2-receptor antagonists, prokinetics, bismuth and sucralfate therapy for non-ulcer dyspepsia

An overview of Ehlers Danlos syndrome and the link between postural orthostatic tachycardia syndrome and gastrointestinal symptoms with a focus on gastroparesis

There has been an increasingly reported association between Ehlers-Danlos syndrome (EDS), postural orthostatic tachycardia syndrome (POTS) and gastrointestinal disorders. EDS is a hereditary connective tissue disorder which may manifest as a spectrum of symptoms stemming from collagen defects. The prevalence of EDS is estimated to affect 1 in 5000 individuals which underscores its clinical significance. Notably the hypermobile form (hEDS) accounts for the majority of cases. POTS is characterized by orthostatic intolerance with an increase in heart rate on standing in the absence of hypotension. This condition predominantly affects women between 15 and 45 years of age. Gastrointestinal symptoms in the form of reflux, bloating and abdominal pain significant impact this population. Gastroparesis is a chronic disorder involving symptoms of delayed gastric emptying and may be closely associated with hEDS and POTS, and may be underreported. Autonomic dysfunction associated with hEDS has been proposed as the likely mechanism underlying POTS and gastrointestinal dysfunction though a clear pathophysiological process has not been established.

Ranitidine decreases human sperm motility and vitality and increases the activity of seminal creatine kinase

Ranitidine (brand name: Zantac), an acid reducer, belongs to histamine-2 receptor antagonists. Since 1981, even though several adverse effects of this drug were reported in the body, still, its effects on human sperm parameters have yet to be confirmed. In this work, we attempted to measure sperm motility, sperm vitality and activity of seminal creatine kinase in the ejaculated human semen (n = 31) in the presence of ranitidine at a range of concentrations (0.1, 0.3, 0.6, 0.9 and 1.2 μg/ml) compared with control (without ranitidine). Sperm motility was measured using the Makler counter, whilst sperm vitality was assessed using the Eosin test. Creatine kinase activity was measured using the kinetic spectrophotometric method. Sperm motility (total and progressive) as well as sperm vitality was significantly (p < .05) reduced in the presence of ranitidine in human semen, particularly at the higher tested concentrations (0.6-1.2 μg/ml) compared with the control. On the other hand, creatine kinase activity was significantly increased (p < .05) in the presence of ranitidine at 0.6, 0.9 and 1.2 μg/ml. In conclusion, ranitidine at 0.6-1.2 μg/ml reduced sperm motility and vitality, but increased the activity of creatine kinase in ejaculated human semen.

Chronic gastritis and functional dyspepsia. Unity and struggle of two opposites

The review article describes the epidemiology, clinical picture, pathogenesis, approaches to the diagnosis and treatment of chronic gastritis and functional dyspepsia. Chronic gastritis is an unreasonably common diagnosis in our clinical practice, which is diagnosed in patients with disturbing dyspeptic complaints. According to the agreement documents, chronic gastritis is primarily a morphological concept. Chronic gastritis has no pathognomonic clinical signs and should be diagnosed during the histological examination of the gastric mucosa. Functional dyspepsia is a diagnosis that reflects the presence of a certain symptom complex (pain  or burning sensation in  the  epigastrium, a  feeling of  fullness or early satiety) in  the  absence of  diseases that could explain the symptoms. Secondary dyspepsia is diagnosed in patients with organic diseases of the upper gastrointestinal tract, metabolic or systemic diseases that cause dyspeptic syndrome. In the process of examining a patient with disturbing dyspeptic complaints, it is advisable for the doctor to use the diagnosis “unspecified dyspepsia” – a preliminary diagnosis before laboratory and instrumental examination aimed at identifying the cause of the dyspeptic syndrome. Dyspepsia associated with H. pylori is diagnosed in patients with H. pylori infection. The diagnosis is revised over time and is competent if complaints have been relieved within 6 months after effective H. pylori eradication.

The main drugs for the treatment of patients with dyspeptic complaints are proton pump inhibitors and prokinetics. Omeprazole with domperidone sustained release (SR) in a fixed dose combination is characterized by optimal efficacy and a good safety profile in patients with both functional and secondary dyspepsia and ensures a high level of treatment adherence.

Is there still a role for sucralfate in the treatment of gastritis?

The endoscopic diagnosis of gastritis is usually made when a patient develops symptoms and undergoes an upper gastrointestinal endoscopy. There are often obvious aetiological causes such as smoking, alcohol Helicobacter pylori infection or drug treatment. Lifestyle changes can sometimes improve symptoms but often patients will be treated with a proton pump inhibitor. The stomach mucosa produces a protective mucous to prevent damage cause by gastric acid and exogenous agents can disrupt this layer. Repair of this protective layer can be enhanced by reduction in gastric acid secretion using H2 receptor antagonist or proton pump inhibitors or by cytoprotective drugs such as misoprostol, sucralfate, aluminium ions or bismuth subsalts. Sucralfate is a complex polymer which at a low pH changes its chemical configuration and binds to serum protein to form a protective layer protecting the mucosa against further injury. Cytoprotective drugs were the first line treatment for peptic disease including gastritis for many years but since the launch of cimetidine in 1976 and the subsequent launch of omeprazole in 1988, their use has slowly declined. First line treatment for patients with symptomatic gastritis after removal of potential causative factors is likely to be a proton pump inhibitor in 2019. This is despite the fact that there is some evidence that sucralfate is superior than a H2 receptor antagonist in the endoscopic healing rates in patients with gastritis. The logical treatment choice in patients with resistance symptoms is a combination of a proton pump inhibitor and sucralfate but evidence is lacking. Until such evidence is available In the meantime, we would suggest that there is a role for sucralfate in the treatment of intransigent gastritis and that mucosal protection should be considered even ahead of acid suppression given its favourable safety and toxicity profile.

Clinical Practice Guidelines for Functional Dyspepsia in Korea

Functional dyspepsia (FD) is a chronic upper gastrointestinal (GI) symptom complex that routine diagnostic work-up, such as endoscopy, blood laboratory analysis, or radiological examination, fails to identify a cause. It is highly prevalent in the World population, and its response to the various available therapeutic strategies is only modest because of the heterogenous nature of its pathogenesis. Therefore, FD represents a heavy medical burden for healthcare systems. We constituted a guideline development committee to review the existing guidelines on the management of functional dyspepsia. This committee drafted statements and conducted a systematic review and meta-analysis of various studies, guidelines, and randomized control trials. External review was also conducted by selected experts. These clinical practice guidelines for FD were developed based on evidence recently accumulated with the revised version of FD guidelines released in 2011 by the Korean Society of Neurogastroenterology and Motility. These guidelines apply to adults with chronic symptoms of FD and include the diagnostic role of endoscopy, Helicobacter pylori screening, and systematic review and meta-analyses of the various treatment options for FD (proton pump inhibitors, H.pylori eradication, and tricyclic antidepressants), especially according to the FD subtype. The purpose of these new guidelines is to aid the understanding, diagnosis, and treatment of FD, and the targets of the guidelines are clinicians, healthcare workers at the forefront of patient care, patients, and medical students. The guidelines will continue to be revised and updated periodically.

[Functional Dyspepsia]

Dyspepsia is a common problem, and when dyspeptic symptoms develop within a short period of time, organic diseases such as gastroesophageal reflux disease, peptic ulcer diseases, pancreatoduodenal diseases, and gastrointestinal cancers should be suspected. Furthermore, functional dyspepsia (FD) should be considered if chronic or recurrent symptoms persist after eliminating underlying disease. FD is classified as epigastric pain syndrome (EPS) or postprandial distress syndrome (PDS), but these two conditions may overlap. Patients with the EPS subtype can be treated with proton pump inhibitors (PPIs), whereas patients with the PDS subtype may be managed primarily with prokinetics, and patients with EPS and PDS can be co-administered PPIs and prokinetics. Helicobacter pylori eradication therapy can be administered on a test-and-treat basis when PPIs and prokinetics are ineffective or to younger patients with chronic dyspepsia, and tricyclic antidepressants can be used as a secondary treatment because they are effective in patients with the EPS subtype. In addition, because the pathophysiology of FD is diverse, dietary education and stress management are required in addition to medical therapy, and should substantially aid treatment and long-term management. Here, we introduce and summarize recently published guidelines for the treatment of FD.

The clinical significance of disorders of the motor function of the esophagus, stomach and duodenum

The purpose of the review is to determine the relationship between the clinical symptoms of diseases and disorders of the motor function of the esophagus, stomach and duodenal bulb, to present modern methods of their diagnosis and pathogenetic principles of treatment of diseases. Depending on the pathogenesis, it is possible to distinguish secondary motility disorders resulting from organic lesions, and primary (functional) changes. The emergence of clinical symptoms is associated with impaired motor - evacuation function of the digestive tract, which can be divided into two large groups: changes in the peristaltic activity of the organ wall and the work of the sphincter apparatus. The basis of the regulation of motility of the esophagus, stomach and duodenum is the interaction of nervous and humoral factors, the central processing of impulses is carried out in the cerebral cortex. In case of violation of the coordinated action of inhibitory and excitatory regulation systems, pathological contractile activity occurs, which manifests itself as hypo - or hyper - motor dyskinesia. X-ray, ultrasound, high resolution manometry of the esophagus, pH-meter, scintigraphy, computed tomography, antroduodenal manometry and a number of others are used to diagnose disorders of the motor function of the digestive tract, which can determine the mechanism of the development of symptoms and prescribe pathogenetic treatment to the patient. Thus, the occurrence of clinical symptoms is associated with changes in the motor - evacuation function of the digestive tract due to a violation of the coordinating action of inhibitory and excitatory factors. The use of modern diagnostic methods for the study of motor function makes it possible to determine the mechanism for the development of clinical symptoms, which allows the patient to prescribe an effective pathogenetic treatment.

Clinical measurement of gastrointestinal motility and function: who, when and which test?

Symptoms related to abnormal gastrointestinal motility and function are common. Oropharyngeal and oesophageal dysphagia, heartburn, bloating, abdominal pain and alterations in bowel habits are among the most frequent reasons for seeking medical attention from internists or general practitioners and are also common reasons for referral to gastroenterologists and colorectal surgeons. However, the nonspecific nature of gastrointestinal symptoms, the absence of a definitive diagnosis on routine investigations (such as endoscopy, radiology or blood tests) and the lack of specific treatments make disease management challenging. Advances in technology have driven progress in the understanding of many of these conditions. This Review serves as an introduction to a series of Consensus Statements on the clinical measurements of gastrointestinal motility, function and sensitivity. A structured, evidence-based approach to the initial assessment and empirical treatment of patients presenting with gastrointestinal symptoms is discussed, followed by an outline of the contribution of modern physiological measurement on the management of patients in whom the cause of symptoms has not been identified with other tests. Discussions include the indications for and utility of high-resolution manometry, ambulatory pH-impedance monitoring, gastric emptying studies, breath tests and investigations of anorectal structure and function in day-to-day practice and clinical management.

Gastroprotectants in small animal veterinary practice - a review of the evidence. Part 1: cyto-protective drugs

Diverse drugs with presumed cytoprotective effect have been used therapeutically in small animal veterinary practice for various gastro-intestinal conditions such as oesophagitis, gastric ulceration, gastritis or chronic gastro-enteropathies. Their efficacy has been doubted in human medicine, raising similar questions in the veterinary field. The aim of this review was to assess the current evidence on the efficacy and safety of these drugs in dogs and cats. Through a systematic review of the literature, we identified 37 articles on the use of misoprostol, sucralfate and other gastroprotectants in dogs and cats. There was evidence to support use of misoprostol in the prevention of aspirin-induced gastroduodenal mucosal injury in dogs, and for use of sucralfate in the prevention of acid-induced oesophagitis in cats. However, the overall quality of evidence supporting the use of these drugs in small animal patients was poor. In contrast, there was evidence of important adverse effects, especially drug interaction and gastro-intestinal signs. We therefore recommend prescribing these drugs with caution until further well-conducted studies reveal a useful gastroprotectant effect.

Polymorphisms of 5-HTT LPR and GNβ3 825C>T and Response to Antidepressant Treatment in Functional Dyspepsia: A Study from The Functional Dyspepsia Treatment Trial

OBJECTIVES

The Functional Dyspepsia Treatment Trial reported that amitriptyline (AMI) was associated with adequate relief of functional dyspepsia (FD) symptoms, but the pharmacogenetics of antidepressant response in FD are not known. GNβ3 825C>T CC genotype has been previously linked to FD and TT genotype to antidepressant response in depression. The ss genotype of the 5-HTT LPR variant of the serotonin transporter gene (SLC6A4) has been linked to selective serotonin reuptake inhibitor (SSRI) response. We aimed to examine whether GNβ3 825C>T and 5-HTT LPR polymorphisms result in differential treatment effects in FD patients receiving antidepressant therapy.

METHODS

Participants were randomized to receive placebo, 50 mg AMI, or 10 mg escitalopram (ESC). The primary end point was adequate relief for ≥5 weeks of the last 10 weeks. Genotyping of GNβ3 825C>T and 5-HTT LPR was performed utilizing PCR-based methods.

RESULTS

GNβ3 825C>T and 5-HTT LPR genotype data were available for 256 (88%) and 246 (84%) patients, respectively. Both polymorphisms were in Hardy-Weinberg equilibrium. In tests for differential treatment, neither 5-HTT LPR nor GNβ3 825C>T genotype influenced response to therapy (P=0.89 and P=0.54, respectively). Although there was a tendency for a more favorable response to ESC in the SS/LS genotype compared to the LL genotype groups (40% vs. 31% reporting adequate relief of FD symptoms) among those in the ESC treatment arm, this was not significant (P=0.43).

CONCLUSIONS

GNβ3 825C>T and 5-HTT LPR genetic variants do not alter treatment response to tricyclic and SSRI antidepressants in FD.

Mexican consensus on dyspepsia

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

[Duodenal ulcers, gastric ulcers and Helicobacter pylori]

The mortality in elderly patients over the age of 80 years with peptic ulcers in the case of complications, such as bleeding and perforation is higher than in the general population. Duodenal ulcers are associated with Helicobacter pylori infections in 90% of cases and in 70% of gastric ulcers. The treatment of elderly patients is often difficult due to multimorbidity and polypharmacy and necessitates a geriatric approach. Ulcers are often caused by medication with nonsteroidal anti-inflammatory drugs (NSAIDs) and acetylsalicylic acid. Despite the fact that progress in therapy has improved the prevalence and prognosis, the treatment of elderly patients with ulcers is complex.

Efficacy and tolerability of levosulipride, domperidone and metoclopramide in patients with non-ulcer functional dyspepsia: a comparative analysis

OBJECTIVE

This is a prospective, randomized study designed to demonstrate the efficacy of three study drugs (Levosulpiride, Domperidone and Metoclopramide) in Functional Dyspepsia. Subject recruitment was done from medicine outpatient department of the teaching hospital from June 2013 to November 2013.

MATERIALS AND METHODS

The data collection was performed by the Short-Form Leeds Dyspepsia Questionnaire (SF-LDQ) question instrument for assessing the dyspeptic symptoms of functional dyspepsia in patients enrolled in the study were assessed at base line (Prior to initiation of therapy) and at the next 4 weeks on a 5-point scale.

RESULT

Among 120 patients 113 patients completed this study in three groups (G-1 Levosulpiride 40 patients, G-2 Domperidone 35 patients and G-3 Metoclopramide 38 patients) were followed up. Female gender was dominated (75), occupation wise most of patients belong to laborer (49) class. Highly significant improvement in symptoms scale was noticed in G-1 Levosulpiride 40 patients' group.

CONCLUSION

Functional Gastrointestinal disorders are not serious ailments but have a key impact on quality of life. overall dyspeptic symptom relief rates were significantly high in the Levosulpiride group (p<0.004) as compare to Domperidone and Metoclopramide groups. A proper understanding of disease process by health care personnel and by sufferer is obligatory to enhance the quality of life and daunting the self/over the counter medication in this condition.

Prevalence of dyspepsia and its associated factors among the adult population in southeast of iran in 2010

Background:

Dyspepsia is a common disorder that can present many clinical dilemmas in patient management. Although not usually life-threatening, its symptoms such as abdominal pain, heartburn, early satiety and postprandial fullness can have a significant negative impact on patients' quality of life.

Objectives:

The aim of this study was to determine the prevalence of dyspepsia and its associated factors among the adult population in Kerman in 2010.

Patients and Methods:

This cross-sectional study was performed on 2210 patients with the mean age of 43.4 years in Kerman, a city in southeast of Iran. Demographic factors, lifestyle data and gastrointestinal symptoms were collected for each patient.

Results:

The prevalence of dyspepsia was 16.1% (95% confidence interval: 14.3-18.1). The prevalence in patients with abdominal obesity (7.3%) was lower in comparison with those with low physical activity (13.8%). Out of other psycho-behavioral risk factors, anxiety after controlling for other variables increased the risk of functional dyspepsia more than 65 percent (P = 0. 004) and depressive disorders also increased that risk about 2.13 percent (P < 0.0001). Patients with dyspepsia symptoms were more likely to restrict their diet, take herbal medicine, use over-the-counter drugs and consult with physicians.

Conclusions:

Results of this study reveal the moderate prevalence of dyspepsia among the adult population in Kerman like in other parts of the country and this prevalence is associated with several demographic factors, lifestyle and health-seeking behaviors.

Functional dyspepsia: outcome of focus groups for the development of a questionnaire for symptom assessment in patients suffering from postprandial distress syndrome (PDS)

BACKGROUND

To date, no patient reported outcomes (PRO) instrument is available for evaluation of treatment efficacy in functional dyspepsia (FD)/postprandial distress syndrome (PDS). The aim of our study was to perform focus group interviews for the development of a new questionnaire for assessing symptom pattern and severity in PDS.

METHODS

Random ambulatory patients diagnosed with FD/PDS based on Rome III criteria and no predominant gastro-esophageal reflux disease (GERD) symptoms were invited to participate. Focus group sessions were organized where patients reported and discussed their symptoms, facilitated by an experienced physician. After reaching saturation of identified symptom items, questions for a pilot PRO instrument were drafted and evaluated in cognitive interviews for relevance, clarity, and consistency.

KEY RESULTS

Of 225 screened patients, 26 patients were diagnosed with PDS without overlapping GERD as single final diagnosis. Fifteen of these (87% female, 48 ± 3.2 years) participated in one of three focus groups. All (100%) confirmed experiencing symptoms that were triggered or aggravated by ingestion of a meal, corresponding to early satiation (100%), and postprandial fullness (100%). In addition reported gastroduodenal symptoms were nausea (40%, postprandial in all, interprandial in 20%), upper abdominal bloating (33%), excessive belching (27%), and vomiting (13%). Epigastric pain and burning were present in respectively 20% and 13%. Non-gastroduodenal symptoms that patients reported included heartburn (33%, but mostly sporadic), weight loss (93%, on average 5.0 ± 1.7 kg), and fatigue (67%). Questions evaluating these symptoms were validated in 15 cognitive interviews.

CONCLUSIONS & INFERENCES

This focus group study confirms symptoms corresponding to postprandial fullness and early satiation as the key items for developing a PRO for PDS.

Effects of the New Prokinetic Agent DA-9701 Formulated With Corydalis Tuber and Pharbitis Seed in Patients With Minimal Change Esophagitis: A Bicenter, Randomized, Double Blind, Placebo-controlled Study

BACKGROUND/AIMS

DA-9701 (Motilitone) is a new prokinetic agent formulated with Corydalis Tuber and Pharbitis Seed. We assessed the efficacy of DA-9701 in symptomatic patients with minimal change esophagitis.

METHODS

Patients with minimal change esophagitis presenting with reflux or dyspeptic symptoms were randomly assigned to receive either DA-9701 30 mg or placebo t.i.d. (means 3 times a day). After 4 weeks of treatment, the primary efficacy end point determined by changes of the Nepean dyspepsia index questionnaire-Korean version (NDI-K) symptom scores, was analyzed.

RESULTS

Forty-two and 39 patients were assigned to the treatment and control groups, respectively. After 4 weeks, NDI-K symptom scores were reduced from 35.4 to 13.5 (P < 0.001) and from 43.0 to 27.7 (P < 0.001) in the treatment and the control groups, respectively. However, changes in the symptom scores did not differ between the 2 groups (P = 0.741). Although the quality of life scores were significantly improved after 4 weeks in both groups, changes in the quality of life score between the baseline value and that at 4 weeks did not differ between the 2 groups. The reflux symptom score was significantly improved in the treatment group compared to the placebo group in patients aged 65 years or older (P = 0.035).

CONCLUSIONS

Although NDI-K symptom scores and quality of life scores were improved after 4 weeks of treatment compared with baseline values in patients with minimal change esophagitis, DA-9701 did not improve the symptom scores or quality of life scores compared with the placebo.

Categorization of upper gastrointestinal symptoms is useful in predicting background factors and studying effects and usages of digestive drugs

BACKGROUND

There have been very few reports assessing the relationship between various upper gastrointestinal (GI) symptoms or evaluating each individual upper GI symptom separately.

METHODS

Based on the answers to Frequency Scale for the Symptoms of GERD from a large-scale population of healthy adults in Japan, a hierarchical cluster analysis was performed to categorize the typical 12 upper GI symptoms. The associations between the 12 symptoms and 13 background factors were systematically analyzed among the 18,097 digestive drug-free subjects, 364 proton-pump inhibitor (PPI) users, and 528 histamine H₂-receptor antagonist (H₂RA) users.

RESULTS

The derived relationship between the 12 upper GI symptoms suggests the five symptom categories: heartburn (2), dyspepsia (4), acid regurgitation (3), pharyngo-upper esophageal discomfort (2), and fullness while eating (1). Among the digestive drug-free subjects, inadequate sleep, weight gain in adulthood, NSAID use, meals immediately prior to sleep, and frequent skipping of breakfast showed significant positive association with most upper GI symptoms. Compared to the digestive drug-free subjects, significantly associated factors for PPI and H₂RA users are respectively different in "4 of 5" and "5 of 5" symptoms in heartburn and acid regurgitation categories, "1 of 2" and "1 of 2" symptoms in pharyngo-upper esophageal discomfort category, and "0 of 5" and "3 of 5" symptoms in dyspepsia and fullness while eating categories. These differences between digestive drug-free subjects and gastric acid suppressant users seem to correlate with our experiences in clinical situations: heartburn and acid regurgitation category symptoms are effectively controlled with PPI and H₂RA whereas other category symptoms are not.

CONCLUSIONS

The 12 upper GI symptoms can be classified into five categories, which are statistically associated with various background factors. The differences of associated factors between digestive drug-free subjects and digestive drug users may be useful in studying the drug effects upon diverse upper GI symptoms.

Randomised clinical trial: rabeprazole improves symptoms in patients with functional dyspepsia in Japan

BACKGROUND

The efficacy of proton pump inhibitors (PPIs) for treating functional dyspepsia (FD) is not well established.

AIM

This study, named the SAMURAI study, aimed to assess the efficacy and dose-response relationship of rabeprazole in Japanese patients with FD in a multicentre, double-blinded, randomised, placebo-controlled trial.

METHODS

Investigated FD was diagnosed using the Rome III criteria. Subjects who did not respond to 1 week of single-blind placebo treatment in a run-in period were randomly assigned to 8 weeks of double-blind treatment with rabeprazole 10 mg, 20 mg, 40 mg or placebo, once daily. Dyspeptic symptoms were assessed by a dyspepsia symptom questionnaire (7-point Likert scale) and symptom diary.

RESULTS

Of 392 subjects entered into the run-in period, 338 were randomly assigned. Although there was no significant difference between placebo and rabeprazole groups in complete symptom relief for four major dyspeptic symptoms, the satisfactory symptom relief of rabeprazole 20 mg was significantly higher than placebo according to the dyspepsia symptom questionnaire (45.3% vs. 28.2%, P = 0.027) and the symptom diary assessment (48.7% vs. 30.0%, P = 0.016). The efficacy was not influenced by syndrome type or Helicobacter pylori status. No statistically significant differences in the incidence of adverse events were seen among treatment groups.

CONCLUSIONS

Rabeprazole 20 mg once daily but not 10 or 40 mg significantly provides satisfactory symptom relief for functional dyspepsia (ClinicalTrials.gov, Number NCT01089543).

Helicobacter pylori infection in functional dyspepsia

Functional dyspepsia is the most common reason for patients to experience chronic epigastric pain or discomfort. The causes of functional dyspepsia are multifactorial but Helicobacter pylori infection is one likely candidate. Infection with this bacterial pathogen clearly results in chronic mucosal inflammation in the stomach and duodenum, which, in turn, might lead to abnormalities in gastroduodenal motility and sensitivity. Chronic gastritis might also affect a variety of endocrine functions of the stomach including the production of the gastrointestinal hormones and neurotransmitters somatostatin, gastrin and ghrelin. Although these abnormalities might generate symptoms in some patients with functional dyspepsia, the clinical evidence needs to be critically evaluated before this hypothesis can be confirmed. A Cochrane review reported that eradication of H. pylori in these patients had a small but statistically significant long-term effect on symptom relief when compared with placebo, lasting at least 12 months after 1 week of eradication therapy. The efficacy of eradication therapy was seen in all symptom subtypes of functional dyspepsia, but was more marked in Asian than Western patients. This evidence has led to alterations in most of the major guidelines throughout the world, which now recommend H. pylori eradication in patients with functional dyspepsia if they test positive for this bacterium.

Dyspepsia

PURPOSE OF REVIEW

A variety of organic diseases can cause dyspepsia, but most patients with epigastric pain have functional dyspepsia. As dyspepsia is common and usually has a benign cause, it is not possible to fully investigate everyone with epigastric pain. Current recommendations suggest that young patients without alarm symptoms can be treated empirically with Helicobacter pylori test and treat and proton pump inhibitor therapy can be offered to those who are negative or remain symptomatic despite treatment for their H. pylori. Patients who remain symptomatic with this strategy may be investigated with endoscopy, but most will have functional dyspepsia.

RECENT FINDINGS

There are a large number of trials for prokinetic therapy in functional dyspepsia, but treatment efficacy is uncertain, as there is evidence of publication bias. There are very limited data for the effectiveness of tricyclic antidepressants in functional dyspepsia. There has been recent interest in the observation that patients with functional dyspepsia have increased eosinophils in the duodenum and this may be accompanied by other subtle manifestations of upregulated mucosal immunity. It is possible that this is being driven by a dietary substance or by a change in the upper gut microbiome.

SUMMARY

The initial management of dyspepsia is well established, but how to manage those who do not respond is a challenge. Future studies evaluating diet and altering the gut microbiome may give clinicians more therapeutic options.

Therapeutic strategies for the treatment of dyspepsia

IMPORTANCE OF THE FIELD

Dyspeptic symptoms are highly prevalent in the population and represent a major burden for healthcare systems. The ROME III criteria address and define two separate entities of functional dyspepsia: epigastric pain syndrome and postprandial distress syndrome. The etiology of dyspeptic symptoms is heterogeneous, underlying mechanisms are poorly understood and symptomatic improvement after drug therapy is often incomplete.

AREAS COVERED IN THIS REVIEW

This review of the literature included Medline data being published in the field of functional dyspepsia and different therapies.

WHAT THE READER WILL GAIN

The reader will gain a current, unbiased understanding of the pathophysiological mechanisms underlying functional dyspepsia and of the therapeutic regimens based on randomized, controlled trials and on the meta-analyses that have been published on different therapeutic agents.

TAKE HOME MESSAGE

Before starting medical treatment, a careful physical examination should exclude 'alarm symptoms'. Laboratory data, ultrasound and endoscopy are recommended in patients older than 45 - 55 years (depending on the guidelines being used). In areas with a high prevalence of Helicobacter pylori, the initial strategy includes 'test and treat' for H. pylori in addition to empiric acid suppressive therapy. Many studies have focused on the role of gastrointestinal dysmotility and hypersensitivity for dyspepsia with inconclusive results. Further therapeutic medical strategies include prokinetics, herbal preparations and psycho-/neurotopic drugs as well as additional psycho- or hypnotherapy.

Functional dyspepsia

Dyspepsia is a common term used for a heterogeneous group of abdominal symptoms. Functional dyspepsia (FD) is the focus of this review. The 2006 Rome III criteria defined FD and its subgroups, postprandial distress syndrome (PDS) and epigastric pain syndrome (EPS). FD is a very common condition with a high prevalence throughout the world, adversely affecting the quality of life of patients. The pathophysiology of FD has been under investigation during the past two decades. Multiple mechanisms such as abnormal gastric emptying, visceral hypersensitivity, impaired gastric accommodation, and central nervous system factors are likely involved. Several tests are available for the assessment of various physiologic functions possibly involved in the pathogenesis of FD, and some of these could be used in clinical practice, helping to understand the abnormalities underlining patients' complaints. Currently, the possibilities of pharmacological therapy for FD are still limited, however, experience of using prokinetics, tricyclic antidepressants, selective serotonin-reuptake inhibitors (SSRIs), proton-pump inhibitors (PPIs), and several alternative techniques has been accumulated. The different combinations of alterations in physiologic gastrointestinal and central nervous system functions result in the very heterogeneous nature of FD so combined approaches to these patients could be beneficial in challenging cases.

[Efficacy and tolerability of cinitapride in the treatment of functional dyspepsia and delayed gastric emptying]

INTRODUCTION AND OBJECTIVE

Functional dyspepsia is a highly common disorder. The physiopathological mechanisms of this entity are not yet completely known and prokinetic drugs seem to be useful. The aim of this study was to evaluate the prokinetic effect of cinitapride in patients with dysmotility-like dyspepsia and delayed gastric emptying.

METHODS

Nineteen patients were randomized to receive 1mg of an oral solution of cinitapride t.i.d or placebo for 4 weeks in two consecutive periods, following a crossover and double-blind design. The main variable was the mean change from baseline after 4 weeks of treatment in gastric-emptying half-time after a liquid test meal, measured by real-time ultrasonography.

RESULTS

At the end of treatment, the mean gastric-emptying half-time decreased with both treatments, with no statistically significant differences between them (ANOVA, p=0.8720). This decrease was greater for cinitapride than for placebo (ANOVA, p=0.0169) in patients with mild-to-moderate delayed gastric emptying. In this group of patients, cinitapride was also superior to placebo in the percentage AUC of the antral area and the percentage of days free of nausea. Cinitapride was well tolerated, with a safety profile comparable to that of placebo.

CONCLUSIONS

Oral cinitapride is safe and effective in improving gastric emptying and symptoms in patients with dysmotility-like dyspepsia and mild-to-moderate delayed gastric emptying.

Review article: gastroparesis

BACKGROUND

Gastroparesis is a chronic disorder caused by stomach pump failure and characterized by profound nausea, vomiting and epigastric pain. Most often, the cause is unapparent and of the known associations, diabetes is the most common. Diagnosis is usually made using an isotope-labelled test meal. Treatment is incremental and includes education, dietary support, prokinetic and antiemetic agents. There are novel approaches including gastric neurostimulation.

AIM

To review current concepts of gastric motor function, aetiology, investigation and treatment of gastroparesis.

METHODS

A systematic web-based review of the literature was undertaken using a lexicon of terms associated with gastroparesis.

RESULTS

There are few controlled studies of this condition. Little is known about causation or underlying nerve, muscle or pacemaker pathology. Idiopathic gastroparesis occurs most commonly in women and gastric emptying is often abnormal in diabetes. Isotopic gastric scintigraphy remains the gold standard investigation, but alternative tests are being developed. Treatment is multimodal and includes education, and nutritional support. There are no adequately powered controlled trials to support a particular drug regimen. In intractable gastroparesis, gastric neurostimulation appears to offer benefit.

CONCLUSION

Despite a significant progress in the past decade, further controlled trials are required into the therapeutic options available for treating this intriguing condition.

Current treatments in functional dyspepsia

By nature of the definition of functional dyspepsia (FD), organic causes have to be ruled out before therapy can be directed. However, in uninvestigated dyspepsia in the absence of alarm features, Helicobacter pylori "test and treat" or an empiric trial of acid suppression therapy for 4 to 8 weeks is reasonable. If alarm symptoms or signs are present, or if the dyspepsia symptoms first occur in those aged greater than 55 years, prompt esophagogastroduodenoscopy is mandatory to exclude serious disease and positively diagnose FD. Empiric acid suppression with H(2)-receptor antagonists or proton-pump inhibitors is superior to placebo in treatment of FD, but those patients with meal-related symptoms are least likely to respond. Helicobacter pylori eradication in FD benefits a minority of cases but is worthwhile, as response may be maintained. There is increasing evidence that some prokinetics may be superior to placebo in treatment of FD, but probably only a minority respond; those with meal-related symptoms may have the best response. Antidepressant therapy may have a place in management of difficult cases, but adequate randomized controlled trials are unavailable.

A second-order simulation model of the cost-effectiveness of managing dyspepsia in the United States

BACKGROUND

The "gold-standard'' evidence of effectiveness for a clinical practice guideline is the randomized controlled trial (RCT), although RCTs have a limited ability to explore potential management strategies for a chronic disease where these interact over time. Modeling can be used to fill this gap, and models have become increasingly complex, with both dynamic sampling and representation of second-order uncertainty to provide more precise estimates. However, both simulation modeling and probabilistic sensitivity analysis are rarely used together. The objective of this study was to explore uncertainty in controversial areas of the 2005 American Gastroenterology Association position statement on the management of dyspepsia.

METHODS

Individual sampling model, incorporating a second-order probabilistic sensitivity analysis.

POPULATION

US adult patients presenting in primary care with dyspepsia. Interventions compared: empirical acid suppression, test and treat for Helicobacter pylori, initial endoscopy, acid suppression then endoscopy, test and treat then proton pump inhibitor (PPI) then endoscopy.

OUTCOMES

Cost-effectiveness, quality-adjusted life years, and costs in US dollars from a societal perspective, measured over a 5-year period.

DATA SOURCES

mainly Cochrane meta-analyses.

RESULTS

Endoscopy was dominated at all ages by other strategies. PPI therapy was the most cost-effective strategy in 30-year-olds with a low prevalence of H. pylori. In 60-year-olds, H. pylori test and treat was the most cost-effective option.

CONCLUSIONS

Acid suppression alone was more cost-effective than either endoscopy or H. pylori test and treat in younger dyspepsia patients with a low prevalence of infection.

Standardized concept for the treatment of gastrointestinal dysmotility in critically ill patients--current status and future options

Inhibition of gastrointestinal motility is a major problem in critically ill patients. Motor stasis gives rise to subsequent complications including intolerance to enteral feeding, enhanced permeability of the atrophic intestinal mucosa and conditions as severe as systemic inflammatory response syndrome, sepsis and multiple organ failure. Although the diagnosis of motility disturbances in critically ill patients is difficult, the type and site of the disturbance are important to consider in the analysis of the condition and in the choice of therapeutic approach. The pharmacological treatment of impaired gastrointestinal motility is difficult to handle for the clinician, because the underlying mechanisms are complex and not fully understood and the availability of pharmacological treatment options is limited. In addition, there is a lack of controlled studies on which to build an evidence-based treatment concept for critically ill patients. Notwithstanding this situation, there has been remarkable progress in the understanding of the integrated regulation of gastrointestinal motility in health and disease. These advances, which largely relate to the organization of the enteric nervous system and its signaling mechanisms, enable the intensivist to develop a standardized concept for the use of prokinetic agents in the treatment of impaired gastrointestinal motility in critically ill patients.

The difficult patient with gastroparesis

Gastroparesis is often difficult to manage. First of all, exact criteria for making a diagnosis of gastroparesis have not been established, and merely finding delayed gastric emptying does not justify the label. Furthermore, the relationship between symptoms and gastric emptying rate is poor, and the number of therapies with proven efficacy is extremely limited. A number of technical investigations are helpful to establish the anatomy and motor function of the upper gastrointestinal tract. In most cases where gastroparesis can be presumed or established, prokinetic therapy will be tried. A number of agents are available, with variable efficacy and tolerance. Rarely, in case of debilitating refractory symptoms, experimental or invasive therapies can be tried such as injection of botulinum toxin, enteral feeding tube insertion, gastric electrical stimulation or surgery.

[H2 blockers and antacids in gastrointestinal diseases]

Kaum ein gastroenterologisches Krankheitsbild hat in den vergangenen 30 Jahren einen derartigen Wandel hinsichtlich der medikamentösen Therapie erfahren wie das Ulcusleiden.

Quality of life in patients with functional dyspepsia: Short- and long-term effect of Helicobacter pylori eradication with pantoprazole, amoxicillin, and clarithromycin or cisapride therapy: A prospective, parallel-group study

BACKGROUND

Quality of life (QOL) is impaired in functional dyspepsia (FD). Little is known about the effects of different therapies on the QOL profile in patients with this condition.

OBJECTIVES

The aims of this study were to measure baseline QOL in patients with FD and to assess changes in QOL over time associated with Helicobacter pylori eradication and prokinetic treatment. The primary and secondary end points were the improvement in QOL 6 weeks and 1 year after successful eradication of the infection or prokinetic therapy.

METHODS

This 1-year, single-center, prospective, open-label, controlled, parallel-group trial was conducted at the Department of Gastroenterology, Ferencvdros Health Centre, Budapest, Hungary. The Functional Digestive Disorder Quality of Life (FDDQoL) Questionnaire (MAPI Research Institute, Lyon, France) was translated and validated previously in Hungarian. Male and female subjects aged 20 to 60 years were enrolled and classified as H pylori positive (HP+), H pylori negative (HP-) with FD, or healthy (control group). The HP+ patients received pantoprazole 40 mg BID + amoxicillin 1000 mg BID + clarithromycin 500 mg BID for 7 days, followed by on-demand ranitidine (150-300 mg/d) for 1 year. The HP- patients received the prokinetic cisapride 10 mg TID for 1 month, followed by on-demand cisapride (10-20 mg/d) for 1 year. The FDDQoL questionnaire was completed by all 3 groups on enrollment, at 6 weeks, and 1 year.

RESULTS

A total of 101 HP+ patients, 98 HP- patients, and 123 healthy controls were included in the study (185 women, 137 men; mean age, 39.0 ears). The mean (SD) baseline QOL scores were significantly lower in the HP+ group (53.3 [9.6]; 95% CI, 54.4-58.2) and the HP- groups (50.0 [9.8]; 95% CI, 58.0-62.0) compared with that in healthy controls (76.2 [8.7]; 95% CI, 74.6-77.8) (both, P < 0.001). Analysis of the short-term domain scores found that the HP+ group had significantly decreased scores in 6 of 8 domains: daily activities (P = 0.005), anxiety level (P = 0.02), diet (P = 0.008), sleep (P < 0.001), discomfort (P = 0.004), and disease control (P = 0.02); the HP- group had significantly decreased scores in 5 of 8 domains: daily activities (P < 0.001), diet (P = 0.004), sleep (P = 0.005), discomfort (P < 0.001), and disease control (P = 0.02). Eradication of the infection was successful in 77/101 (76.2%) of the patients on intent-to-treat analysis and 77/94 (81.9%) on per-protocol analysis. Eradication was associated with an increase in mean (SD) QOL score to 70.8 (10.7) at 6 weeks (95% CI, 63.3-73.2; P < 0.001 vs baseline) and to 75.3 (9.3) at 1 year (95% CI, 73.2-77.5; P= 0.05 vs 6 weeks). In the HP- group, the QOL score increased to 73.3 (9.7) (95% CI, 71.3-75.4; P < 0.001 vs baseline) at 6 weeks of cisapride treatment and to 76.5 (8.5) at 1 year (95% CI, 74.5-78.4; P = 0.06 vs 6 weeks). Most of the impaired domain scores improved significantly after both treatments. The short-term effect size was 1.48 in HP+ and 1.35 in HP- patients. Adverse events (AEs) occurred in 22 (21.8%) patients in the HP+ group (nausea, 8 [7.9%] patients; diarrhea, 5 [5.0%]; loss of appetite, 5 [5.0%]; stomatitis, 5 [5.0%]; abdominal pain, 4 [4.0%]; bloating, 4 [4.0%]; headache, 4 [4.0%]; vomiting, 4 [4.0%]; constipation, 3 [3.0%]; and vaginitis, 3 [3.0%]). In HP- cases, AEs occurred in 9 (9.2%) patients (abdominal cramps, 7 [7.1%]; diarrhea, 4 [4.1%]; and nausea, 3 [3.1%]).

CONCLUSION

In this study in patients with FD and healthy controls, eradication of H pylori infection in infected patients and cisapride treatment in uninfected patients reversed low QOL scores during the 1-year follow-up period.

Review article: current and emerging therapies for functional dyspepsia

Functional dyspepsia represents a heterogeneous group of gastrointestinal disorders marked by the presence of upper abdominal pain or discomfort. Although its precise definition has evolved over the last several decades, this disorder remains shrouded in controversy. The symptoms of functional dyspepsia may overlap with those of other functional bowel disorders including irritable bowel syndrome and non-erosive reflux disease. There may be coexistent psychological distress or disease complicating its presentation and response to therapy. Given the prevalence and chronicity of functional dyspepsia, it remains a great burden to society. Suspected physiological mechanisms underlying functional dyspepsia include altered motility, altered visceral sensation, inflammation, nervous system dysregulation and psychological distress. Yet the exact pathophysiological mechanisms that cause symptoms in an individual patient remain difficult to delineate. Numerous treatment modalities have been employed including dietary modifications, pharmacological agents directed at various targets within the gastrointestinal tract and central nervous system, psychological therapies and more recently, complementary and alternative treatments. Unfortunately, to date, all of these therapies have yielded only marginal results. A variety of emerging therapies are being developed for functional dyspepsia. Most of these therapies are intended to normalize pain perception and gastrointestinal motor and reflex function in this group of patients.

Treatment of functional dyspepsia

Functional dyspepsia (FD) is a common reason a patient presents with upper gastrointestinal symptoms for medical care. Although treatment of FD remains expensive, the agents are rarely used in a systematic manner; the majority of treatments are empirical and the results short lived once therapy is ceased. This is partly due to the lack of consistent pathophysiologic markers in FD, so therapy is symptom driven. This review appraises the best evidence on available interventions. A structured scheme for deciding on appropriate therapies is to consider the possible putative pathophysiologic mechanisms. Eradicating Helicobacter pylori, if present, is a first-line strategy. In patients who have symptoms suggesting excessive gastric acid secretion, particularly epigastric pain, antisecretory agents are recommended. Prokinetics may confer benefits on symptoms suggestive of upper gastrointestinal dysmotility, like fullness or early satiety. However, their use is limited due to availability issues. The expanding field of psychologic therapies provides a promising avenue of treatment. Complementary medicines are now widely use and their benefits have been suggested in recent controlled trials. Emerging treatments include cholecystokinin 1 blockers, opioid receptor agonists, and serotonergic agents, although their application in FD is in the preliminary stages.

Natural course of functional dyspepsia after Helicobacter pylori eradication: a seven-year survey

The role of Helicobacter pylori(Hp) in functional dyspepsia (FD) is controversial and previously published data do not help to clarify whether Hp eradication affects the natural course of FD. The aim of this study was to assess the clinical course of FD during a long follow-up period of 7 years in a homogeneous sample of Hp-eradicated patients. Among patients referred between 1991 and 1996, patients with FD and infected with Hp were enrolled. Patients were administered a structured symptom questionnaire and evaluated after Hp eradication at each 12-month time points. Patients were divided into three FD subgroups: predominantly ulcer-like, dismotility-like, and reflux-like symptom clusters. A composite symptom score ranging from 0 (no symptom) to 3 (severe symptoms) was assigned to each FD cluster. Of the 1685 screened patients, 405 had FD and 211 of them (52.1%) were also Hp-positive. During the follow-up, the amount of missing information varied from 10% to 17.5% within the first 6 years and was 30.8% at 7 years. The rates of improved patients ranged from 33% (reflux-like) to 34.9% (dismotility-like) to 47.3% (ulcer-like). However, only a proportion of 10%-50% of them was symptom-free after eradication and also at each 12-month evaluation, whereas the other patients became symptomatic at different times. FD symptoms slightly improve after Hp eradication over a long period of time but a large percentage of these improved patients may experience FD symptoms again, even after some years of well-being after Hp eradication.

Treatment of functional dyspepsia with antianxiety or antidepressive agents: systematic review

BACKGROUND

The pathophysiology of functional dyspepsia (FD) has not been elucidated precisely; accordingly, effective management of FD has not yet been found. Until now, treatment with antianxiety or antidepressive agents has been empirically applied; however, the efficacy of these treatments has not been established. We carried out this study to estimate the efficacy of these treatment approaches by systematically reviewing the literature concerning trials with agents that are efficacious against anxiety, neurosis, or depression.

METHODS

Articles were searched from the MEDLINE database up to October 2003, using the terms, "antianxiety agents", "antidepressants", and "dyspepsia", and from reference lists of published articles. Finally, studies in which the effectiveness of drugs was clearly stated were selected from the retrieved articles.

RESULTS

Thirteen articles, on 1717 patients, were selected from among 90 articles retrieved through our literature search. In 11 of the 13 studies, dyspeptic symptoms were improved significantly by treatment. Statistical analysis of 4 trials showed a significant benefit of treatment with antianxiety or antidepressive agents (pooled relative risk, 0.55; 95% confidence interval [CI], 0.36-0.85), although funnel plots were asymmetric.

CONCLUSIONS

Antianxiety or antidepressive agents may be effective in the treatment of FD patients, though further clinical trials are necessary.

The efficacy of proton pump inhibitors in nonulcer dyspepsia: a systematic review and economic analysis

BACKGROUND AND AIMS

The evidence that proton pump inhibitor (PPI) therapy affects symptoms of nonulcer dyspepsia is conflicting. We conducted a systematic review to evaluate whether PPI therapy had any effect in nonulcer dyspepsia and constructed a health economic model to assess the cost-effectiveness of this approach.

METHODS

Electronic searches were performed using the Cochrane Controlled Trials Register, MEDLINE, EMBASE, CINAHL, and SIGLE until September 2002. Dyspepsia outcomes were dichotomized into cured/improved versus same/worse. Results were incorporated into a Markov model comparing health service costs and benefits of PPI with antacid therapy over 1 year.

RESULTS

Eight trials were identified that compared PPI therapy with placebo in 3293 patients. The relative risk of remaining dyspeptic with PPI therapy versus placebo was .86 (95% confidence interval, .78-.95; P = .003, random-effects model) with a number needed to treat of 9 (95% confidence interval, 5-25). There was statistically significant heterogeneity between trials (heterogeneity chi(2) = 30.05; df = 7; P < .001). The PPI strategy would cost an extra US dollar 278/month free from dyspepsia if the drug cost US dollar 90/month. If a generic price of US dollar 19.99 is used, then a PPI strategy costs an extra US dollar 57/month free from dyspepsia. A third-party payer would be 95% certain that PPI therapy would be cost-effective, provided they were willing to pay US dollar 94/month free from dyspepsia.

CONCLUSIONS

PPI therapy may be a cost-effective therapy in nonulcer dyspepsia, provided generic prices are used.

Functional dyspepsia

PURPOSE OF REVIEW

Functional dyspepsia is a common disorder, most of the time of unknown etiology and with variable pathophysiology. Therapy has been and still is largely empirical. Data from recent studies provide new clues for targeted therapy based on knowledge of etiology and pathophysiologic mechanisms.

RECENT FINDINGS

The role of Helicobacter pylori gastritis in the pathogenesis of functional dyspepsia has been defined: It is causative in a small minority of patients. Associations between (groups of) symptoms and pathophysiologic mechanisms have been established, but there is much overlap and interaction, and their relevance for the individual patient is uncertain, especially because of the variability of symptoms over time. Little progress has been made in pharmacotherapy of functional dyspepsia, but exploratory studies show interesting new options. Hypnotherapy seems a promising alternative.

SUMMARY

For the time being, diagnostic strategies for patients with suspected functional dyspepsia continue to be directed at excluding other disorders, in particular peptic ulcer disease and gastroesophageal reflux disease. In the presence of reflux symptoms, acid inhibitory therapy, preferably with a proton pump inhibitor, is a rational choice; otherwise, therapy is still empirical. Hypnotherapy is an option that could be seriously considered.

A systematic review of psychological therapies for nonulcer dyspepsia

OBJECTIVES

We conducted a systematic review to determine the effectiveness of psychological interventions including psychodrama, cognitive behavioral therapy, relaxation therapy, guided imagery, or hypnosis in the improvement of dyspepsia symptoms in patients with nonulcer dyspepsia (NUD).

DESIGN

Trials were identified through electronic searches of the Cochrane Controlled Trials Register (CCTR), MEDLINE, EMBASE, CINAHL, and PsycLIT, using appropriate subject headings and text words and searching bibliographies of retrieved articles. All randomized controlled trials (RCTs) or quasi-randomized studies were eligible.

RESULTS

The four eligible trials all used different psychological interventions including applied relaxation therapy, psychodynamic psychotherapy, cognitive therapy, and hypnotherapy. Trials did not present data in a form that could be synthesized. All reported an improvement in the dyspepsia symptom scores at the end of treatment and at 1 yr in the intervention arm compared with controls. All studies only achieved statistically significant results through adjusting for baseline differences between groups. This reflects the small sample sizes of the trials. There were also problems with assumptions made in the statistical analyses used to achieve statistical significance. The studies highlighted problems with recruitment and compliance.

CONCLUSIONS

There was insufficient evidence on the efficacy of psychological therapies in NUD. This emphasizes the need for appropriately powered well-designed trials in this area.

What the physician needs to know for correct management of gastro-oesophageal reflux disease and dyspepsia

Upper gastrointestinal symptoms are highly prevalent; usually those consulting have multiple symptoms, confounding management. Here, common clinically relevant management issues are considered based on the best available evidence. Regardless of the presenting symptoms, determine if there are any alarm features; these have a low positive predictive value for malignancy but all patients with them should be referred for prompt upper gastrointestinal endoscopy. Ask about medications; of most importance are the non-steroidal anti-inflammatory drugs (NSAIDs), both non-selective and COX-2 selective. Try to ascertain if the symptom pattern suggests gastro-oesophageal reflux disease (GERD) or not. Dominant heartburn, however, may be of limited value; if the background prevalence of GERD is 25% and the patient complains of dominant heartburn, then the likelihood that such a patient has GERD as identified by 24-h oesophageal pH testing is only just over 50%. If reflux disease is strongly suspected and there are no alarm features, give an empirical trial of a proton pump inhibitor (PPI). Symptoms cannot separate adequately functional from organic dyspepsia. Endoscopy in dyspepsia with no alarm features is more costly than an empirical management approach. H. pylori testing and treatment remains in most settings the preferable initial choice for managing dyspepsia without obvious GERD. However, a PPI trial may offer a similar outcome and may be preferable in low H. pylori prevalence areas; head-to-head management trials in primary care are lacking.

Systemic review: the prevalence and clinical course of functional dyspepsia

AIM

To examine the prevalence of functional dyspepsia in the general population, and to evaluate the natural history/clinical course of patients with functional dyspepsia.

METHODS

Full-length published manuscripts during 1980-2002 were included if: (i) participants had uninvestigated or functional dyspepsia; (ii) dyspepsia was defined; (iii) for prevalence, population-based samples were evaluated; (iv) for prognosis, the total number of the inception cohort and the total number of individuals available at the end of follow-up were reported.

RESULTS

Twenty-two studies (1976-2002) that examined the prevalence of dyspepsia fulfilled the inclusion and exclusion criteria; 17 studies examined more than 1000 participants, but only two studies provided information sufficient to calculate the prevalence of functional dyspepsia (11.5-14.7%). The prevalence of uninvestigated dyspepsia was in the range 10-40%. When the definition of dyspepsia was restricted to participants with upper abdominal pain, irrespective of the presence of heartburn or acid regurgitation, the prevalence rate estimate was 5-12%. Thirteen studies examined the clinical course of functional dyspepsia (seven retrospective and six prospective). Sample sizes were small (n = 35-209). A follow-up ascertainment of symptoms amongst individuals in the original cohorts was obtained in 92.5-98.2% of prospective studies and in 67.7-82.2% of retrospective studies. The follow-up duration was in the range 1.5-10 years for prospective studies and 5-27 years for retrospective studies; the median follow-up duration for all studies was approximately 5 years. A variable prognosis was reported. An outcome of symptom improvement or becoming asymptomatic was reported in at least one-half of patients in 10 of the 13 studies, and in at least two-thirds of patients in six of the 13 studies. Prognostic factors were inconsistent and, in general, poorly described.

CONCLUSIONS

Functional dyspepsia is prevalent world-wide, but the prognosis remains poorly defined. There is a need for population-based studies to examine the prevalence and clinical course of documented functional dyspepsia.