Investigation and therapy in patients with different types of dyspepsia: a 3 year follow-up study from general practice

Predictors of long-term outcome of functional dyspepsia and duodenal ulcer after successful Helicobacter pylori eradication--a 7-year follow-up study

AIMS

To investigate the course of dyspeptic symptoms, predictors of symptom relief and use of antidyspeptic drugs in patients with duodenal ulcer disease and functional dyspepsia 6-7 years after successful Helicobacter pylori eradication.

PATIENTS AND METHODS

Patients with H. pylori-positive duodenal ulcer or functional dyspepsia, included in a prospective, randomized study from January 1996 to June 1997, and successfully treated with standard triple therapy, were eligible. After 6-7 years, case histories of 142 patients were retrieved and patients were interviewed by telephone. They were asked about the presence of dyspeptic symptoms and health care needs during the last week and over the last 6-7 years. Predictive factors of complete long-term relief of symptoms have been evaluated.

RESULTS

Of the 114 eligible patients, 104 (49 with duodenal ulcer and 55 with functional dyspepsia) were included in the study. The mean duration of follow up was 6.6+/-0.5 years. Complete relief of dyspeptic symptoms was reported, in this period, by 49.0% of duodenal ulcer patients and 36.4% of patients with functional dyspepsia (P=0.271). Persistence of symptoms within 3 months of H. pylori eradication and female sex were predictive of persistence of symptoms in the following 6-7 years, in patients with functional dyspepsia. In turn, approximately 50% of the patients with complete symptom remission, within 6 months of H. pylori eradication, later became symptomatic. Since the end of the H. pylori eradication trial, 26.9% of patients were still using or had used antidyspeptic drugs; patients with functional dyspepsia having used them more frequently than duodenal ulcer patients (36.4 vs. 16.3%; P=0.037).

CONCLUSION

In clinical practice, long-term symptomatic benefit, in duodenal ulcer patients, after H. pylori eradication, is similar to that in patients with functional dyspepsia. Early evaluation of symptoms after successful H. pylori eradication may be predictive of outcome in dyspeptic patients. Most symptomatic patients did not seek antidyspeptic drugs. Use of antisecretory medications was, however, greater in patients with functional dyspepsia than in duodenal ulcer patients.

Subtypes of functional dyspepsia

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

Classification of dyspepsia and response to treatment with proton-pump inhibitors

BACKGROUND

Lacking an objective 'gold standard' for diagnosing dyspepsia, several symptom-based classifications have been suggested.

AIM

To assess if response to proton-pump inhibitor treatment could provide useful information for current or future dyspepsia classification.

METHODS

Post hoc analyses of 829 patients treated with omeprazole or placebo in a randomized-controlled trial. The 'true' response to omeprazole (trial response minus placebo response) was assessed according to different classifications of dyspepsia and different symptoms.

RESULTS

Symptoms described with the words 'burning' or 'sour' and patients with reflux-like dyspepsia demonstrated high response to omeprazole treatment, whereas patients with abdominal pain or ulcer-like dyspepsia responded unpredictably to omeprazole. The response to omeprazole in patients with epigastic pain was related to the pattern of other dyspeptic symptoms. Patients with heartburn or regurgitation overlapped extensively with patients with epigastric pain.

CONCLUSION

The study demonstrated significant problems in the current classification of dyspepsia: 'the most bothersome symptom' was not independently related to the omeprazole effect and, in patients with abdominal pain, the response to omeprazole was dependent on the presence or absence of other dyspeptic symptoms. The overlap of symptoms indicates that heartburn and regurgitation should be recognized as symptoms of dyspepsia in primary care.

Empiric treatment with high and standard dose of omeprazole in general practice: two-week randomized placebo-controlled trial and 12-month follow-up of health-care consumption

OBJECTIVES

Patients with acid-related symptoms in general practice are often treated empirically with a standard dose of proton pump inhibitors (PPIs). The effect of higher doses is not known. The study compared the immediate symptom relieving as well as the long-term effect of standard and double dose of omeprazole in such patients.

METHODS

Consecutive patients with dyspeptic symptoms, normally treated by the general practitioner with PPIs or H2-blockers were randomized to treatment with omeprazole 40 mg, 20 mg, or placebo in the morning for 2 wk. Patients with alarm symptoms, IBS, and PPI-treated patients were excluded. Dyspeptic symptoms and Helicobacter pylori status were recorded. The study endpoint was complete relief of the dyspeptic symptoms, which initiated the consultation. Relapse rates and health-care consumption were recorded during 12-month observation.

RESULTS

Eight hundred and twenty-nine patients were randomized. Complete relief of the predominant symptom was obtained by 66%, 63%, and 35% in patients treated with omeprazole 40 mg, 20 mg, and placebo, respectively. No difference was found comparing H. pylori-positive and -negative patients. Relapse rates were high and health-care consumption during 12 months was related to the treatment outcome, but not to the omeprazole dose or the H. pylori status.

CONCLUSIONS

Compared to placebo, omeprazole 40 mg and 20 mg were equally and significantly better in relieving acid-related symptoms; the numbers needed-to-treat (NNT) were 3.2 (40 mg) and 3.7 (20 mg). Relief of the dyspeptic complaint was followed by significantly reduced health-care consumption during 12-month observation.

Prognostic significance of antrum-predominant gastritis in functional dyspepsia

BACKGROUND

The role of Helicobacter pylori infection in functional dyspepsia is still controversial, and subgroups of patients with functional dyspepsia who may benefit from H. pylori eradication should be identified. Patients with functional dyspepsia and antrum-predominant H. pylori-positive chronic gastritis, it has been argued, have fewer symptoms after eradication therapy. In the present study, we analysed the clinical significance of antrum-predominant gastritis on the long-term prognosis of functional dyspepsia.

METHODS

Consecutive unselected dyspeptic patients were investigated in primary care and the patients with functional dyspepsia were enrolled in this long-term follow-up study. Altogether 182 patients were recruited: 65 with normal histology of the stomach, 36 with antrum-predominant gastritis, 21 with corpus-predominant gastritis and 60 with pangastritis. Patients' medical histories were reviewed after 6 to 7 years, with total number and outcome of repeated investigations analysed. At the end of follow-up, all patients were invited for voluntary gastroscopy.

RESULTS

At the end of follow-up, the proportion of asymptomatic patients ranged from 21% (normal histology) to 26% (antrum-predominant gastritis). No statistically significant differences between groups appeared in regard to re-visits or to proportion of patients examined by sigmoideo- or colonoscopy during follow-up. Patients with antrum-predominant gastritis less often underwent upper endoscopy. Peptic ulcer was more frequent (P = 0.05) in patients with antrum gastritis than in other groups, but no other differences existed among any organic gastrointestinal findings. No significant differences between subgroups appeared among the 30% of patients using drugs for upper abdominal complaints during the previous year.

CONCLUSIONS

Functional dyspepsia has an excellent long-term prognosis. Antrum-predominant gastritis in functional dyspepsia seems to carry an increased risk for peptic ulcer, and for this group in particular, H. pylori eradication should be considered. This finding requires confirmation in future studies performed in primary care.

What is the long-term outcome of the different subgroups of functional dyspepsia?

BACKGROUND

Functional dyspepsia is often a long-lasting disorder that accounts for substantial healthcare costs. It has been classified into subgroups assuming that it can guide management of dyspepsia.

AIM

To evaluate the clinical significance of subgrouping functional dyspepsia in a long-term perspective study.

METHODS

Consecutive patients with dyspepsia identified by general practitioners were investigated. Those patients with functional dyspepsia (n=201) were enrolled in this study. Initially, patients were divided into five subgroups (ulcer-like, dysmotility-like, reflux-like, unspecified, and irritable bowel syndrome-like). Patients' medical histories were reviewed after 6-7 years, and the number and outcome of repeated investigations were analysed. At the end of follow-up, patients filled in a questionnaire similar to that at baseline, and were invited for gastroscopy.

RESULTS

Only 2% of patients developed peptic ulcer during follow-up, none of them were in the ulcer-like subgroup. When referrals to hospital and examinations during follow-up were registered, no statistically significant differences existed between subgroups. Patients with reflux-like dyspepsia made fewer revisits than others (P=0.02), but had used antidyspepsia drugs during the previous year more often (P=0.036). Stability of the subgroups over time was poor.

CONCLUSIONS

Functional dyspepsia is a long-lasting disorder with a very good prognosis. Subgroups of functional dyspepsia play only a minor role in prediction of the long-term outcome, and their usefulness in clinical practice is also hampered by subgroup instability over time.

Fluctuation in dyspepsia subgroups over time. A three-year follow-up of patients consulting general practice for dyspepsia

BACKGROUND

General practitioners base their treatment and investigation on the symptoms presented by the patients. Subgroups of dyspepsia have been defined in order to guide management.

AIM

To study prospectively changes over time in the presentation of dyspepsia according to different subtypes in a general practitioner population.

SUBJECTS

Patients consulting the general practitioner because of dyspeptic complaints.

METHODS

A random sample of general practitioner patients consulting with different dyspepsia subtypes (ulcer-like, reflux-like, dysmotility-like, uncharacteristic and relapsing dyspepsia) were studied three years after the initial consultation by postal questionnaires to the general practitioners (obtaining information from the patient records) and to the patients (obtaining self-reported symptoms during twelve months). The subtype of dyspepsia at baseline was compared to the subtype in the patient questionnaire.

RESULTS

Between 20 and 34% of the patients reported no dyspepsia after three years, with so significant difference between the subtypes. Changes from one subtype to another were common, ulcer-like and reflux-like often changed into dysmotility-like dyspepsia. Dysmotility-like dyspepsia was significantly more stable over time. Patients with more than one episode of dyspepsia changed subtype significantly less.

CONCLUSIONS

Most patients who presented with dyspepsia to the general practitioner still reported symptoms three years later. Few patients with dysmotility-like dyspepsia changed subtype over time, whereas changes from one subtype to another were common in other subtypes. This implies that dyspeptic patients could end up having dysmotility-like complaints possibly due to the lack of effective treatment for this condition, compared to the other dyspepsia subtypes.