Pathophysiology and treatment of functional dyspepsia

The role of psychotherapeutic approaches in treatment of functional dyspepsia, systematic review, and meta-analysis

Background

Functional dyspepsia is a common functional gastrointestinal disorder that is often challenging to treat. Psychotherapeutic interventions have been proposed as an alternative or adjunctive approach to conventional treatments, but their efficacy remains unclear.

Objective

This systematic review and meta-analysis aimed to evaluate the efficacy of psychotherapeutic interventions in the treatment of functional dyspepsia.

Methods

A comprehensive search of electronic databases was conducted, from inception to March 2023, for randomized controlled trials (RCTs) that evaluated the effects of psychotherapeutic interventions on patients with functional dyspepsia. The primary outcome measures were gastrointestinal symptoms, quality of life, depression, and anxiety. Data were extracted and analyzed using Review Manager 5.3 software. The risk of bias of the included studies was assessed using the Cochrane Risk of Bias tool.

Results

Sixteen RCTs comprising 1550 patients with functional dyspepsia were included in the meta-analysis. The types of psychotherapeutic interventions used in the included studies were cognitive-behavioral therapy (CBT), hypnotherapy, and mindfulness-based stress reduction (MBSR). The control groups were usual care, placebo, supportive therapy, or no treatment. The meta-analysis showed that psychotherapeutic interventions had a significant effect on reducing gastrointestinal symptoms,depression and anxiety in patients with functional dyspepsia. However, no significant improvement was observed in the quality-of-life scores of patients who received psychotherapeutic interventions compared to those in the control group.

Conclusion

Psychotherapeutic interventions, such as CBT, hypnotherapy, and MBSR, could be a useful adjunct to conventional treatments for functional dyspepsia, as they were found to significantly reduce gastrointestinal symptoms and anxiety in patients. However, further studies are needed to assess the long-term effects and generalizability of these interventions.

Differences in Duodenal Mast Cell and Eosinophil Counts Between Patients With Functional Dyspepsia and Healthy People

BACKGROUND Functional dyspepsia is a common, troubling, and usually chronic disorder. Although the merit of using pathological assays has not been confirmed, medications affecting eosinophils may result in some improvements. Disseminated distribution of mast cells may also be an essential factor. Given the probable associations and lack of evidenced-based data, this study was conducted to comparatively investigate the number of eosinophils and mast cells in the duodenum in functional dyspepsia patients and healthy controls. METHODS In this case-control study, 150 consecutive subjects in Kerman, Iran, were enrolled in 2015 and 2016; the subjects consisted of 100 patients with functional dyspepsia and 50 asymptomatic healthy controls. Samples from the two groups were compared for the number of eosinophils, mast cells, and Helicobacter pylori presence by grasp biopsy. RESULTS The mean number of mast cells significantly differed between the groups (P = 0.001), but the eosinophil count was similar (p > 0.05). Female gender, no opioid use, and H. pylori may increase mast cell count (p < 0.05). CONCLUSION Overall, the mast cell count was significantly different between people with functional dyspepsia and people without it, but the eosinophil count in the two groups was similar.

The effect of prucalopride on gastric sensorimotor function and satiation in healthy volunteers

BACKGROUND

Gastric motor function alterations have been implicated in the pathogenesis of functional dyspepsia with postprandial distress syndrome (PDS). Prucalopride, a 5-TH4 agonist, is known to stimulate gastrointestinal motility. We aimed to evaluate the effect of prucalopride on gastric sensorimotor function in healthy subjects (HV).

METHODS

Barostat and intragastric pressure (IGP) measurements were performed in 17 HV (59% females, age 29.4 ± 2.7 y) after treatment with placebo or prucalopride (2 mg) (single-blind cross-over). Isobaric stepwise distensions and gastric sensations were assessed to determine gastric compliance and sensitivity. Gastric accommodation (GA) with the barostat was quantified before and after ingestion of 200 ml of a nutrient drink (ND). GA measured by IGP was quantified as the drop of IGP from baseline during the intragastric infusion of ND until maximal satiation (60 ml/min).

KEY RESULTS

Prucalopride did not affect barostat assessed gastric compliance or sensitivity. No differences were observed in GA after prucalopride. During the barostat study, 10 min after the meal, 7 HVs reported significantly higher ratings for nausea after prucalopride (p < 0.001), and vomiting was induced in 4 of the HVs. A positive correlation was observed between the delta mean perception of nausea with the delta mean increase of intra-balloon volume before and after meal ingestion (r = 0.37, p = 0.03). During IGP measurements, no effect on nutrient tolerance was observed and increased cramp severity scores were observed which were associated with a significant increase of distal IGP (r = 0.78, p < 0.0001).

CONCLUSIONS & INFERENCES

Prucalopride does not enhances gastric accommodation but it might increase sensitivity to gastric distention. Furthermore, the increase in sensitivity seems to be related to an increase in nausea with distension. Clinicaltrials.gov: NCT04429802.

A mathematical model of food intake

The metabolic, hormonal and psychological determinants of the feeding behavior in humans are numerous and complex. A plausible model of the initiation, continuation and cessation of meals taking into account the most relevant such determinants would be very useful in simulating food intake over hours to days, thus providing input into existing models of nutrient absorption and metabolism. In the present work, a meal model is proposed, incorporating stomach distension, glycemic variations, ghrelin dynamics, cultural habits and influences on the initiation and continuation of meals, reflecting a combination of hedonic and appetite components. Given a set of parameter values (portraying a single subject), the timing and size of meals are stochastic. The model parameters are calibrated so as to reflect established medical knowledge on data of food intake from the National Health and Nutrition Examination Survey (NHANES) database during years 2015 and 2016.

Effect of Artemisia rupestris L. Extract on Gastrointestinal Hormones and Brain-Gut Peptides in Functional Dyspepsia Rats

Artemisia rupestris L. is the perennial herb of rupestris belonging to Artemisia (Compositae), which is wildly distributed in Xinjiang (China), middle Asia, and Europe. It is known to have anti-inflammatory, hepatoprotective, immune function regulation, and gastrointestinal function regulation effects. AR is used to treat digestive diseases, but the effects of AR on antifunctional dyspepsia (FD) activity have not yet been reported. In this study, we aimed to investigate the therapeutic effects of Artemisia rupestris L. extract (ARE) on gastrointestinal hormones and brain-gut peptide in functional dyspepsia (FD) rats. Sixty Sprague-Dawley rats were randomly divided into 6 groups. An FD rat model was established by irregular tail clamp stimulation for 14 days except the blank group. After FD rat models, the blank group and model group were given menstruum, and the medicated rats were given corresponding medicine for 14 days. The general observations, bodyweight, and food intake were observed, and the content of serum gastrin (GAS), plasma motilin (MTL), plasma vasoactive intestinal peptide (VIP), and plasma somatostatin (SS) by the enzyme-linked immunosorbent assay was observed. The content of plasma VIP and plasma SS in the ARE group was significantly lower than in the model group, and the content of serum GAS and plasma MTL was increased in the ARE group; the GAS expression of antrum and hypothalamus was increased in the ARE group, and SS expression of antrum and hypothalamus was decreased in the ARE group by immunohistochemical detection; the results of semiquantitative reverse transcription polymerase chain reaction (RT-PCR) indicate that ARE inhibits the mRNA expression of VIP. Our results suggest that ARE can recover gastrointestinal hormone levels and regulation of the peripheral and central nervous system and alter gut peptide levels, which confirm the therapeutic effect of ARE on functional dyspepsia.

Joint Hypermobility Syndrome in Patients With Functional Dyspepsia

INTRODUCTION:

The pathophysiology underlying functional dyspepsia (FD) is multifactorial and focuses on gastric sensorimotor dysfunction. Recent studies demonstrated that joint hypermobility syndrome (JHS) is strongly associated with unexplained dyspeptic symptoms in patients attending gastrointestinal clinics. We aimed to study the relationship between symptoms, gastric sensorimotor function, and JHS in FD patients.

METHODS:

Tertiary care FD patients who underwent a gastric barostat study and a gastric emptying breath test with 13C-octanoic acid were recruited for assessment of JHS. The presence of JHS was evaluated by a 2-phase interview and clinical examination that included major and minor criteria of the Brighton classification.

RESULTS:

A total of 62 FD patients (68% women, age 44 ± 1.8 years, and body mass index: 21.7 ± 0.7 kg/m²) accepted to participate in the study. JHS was diagnosed in 55% of FD patients. Assessed symptom profiles during the visit did not differ between the groups. Delayed gastric emptying was not significantly more common in JHS group compared with non-JHS group (JHS group 32% vs non-JHS group 16%, P = 0.31). Prevalence of hypersensitivity to distention (JHS group 24% vs non-JHS group 29%, P = 0.76) and impaired gastric accommodation (JHS group 38% vs non-JHS group 42%, P = 0.79) was similar in patients with or without JHS. No correlations were found between the Beighton hypermobility score and gastric compliance (r = 0.09).

DISCUSSION:

A large subset of this study cohort of tertiary care FD patients has coexisting JHS. We did not identify any specific differences in gastric sensorimotor function between patients with and without JHS. Further prospective research will be required to elucidate the relationship between JHS, a multisystemic disorder with widespread manifestations, and FD symptoms.

Feasibility, safety, and long-term efficacy of gastric peroral endoscopic myotomy (G-POEM) for postsurgical gastroparesis: a single-center and retrospective study of a prospective database

BACKGROUND

Postsurgical gastroparesis is recognized as a gastrointestinal dysfunction syndrome following foregut surgery. Gastric peroral endoscopic myotomy (G-POEM) is suggested as a minimally invasive therapy for gastroparesis. But the long-term efficacy and safety of G-POEM in treating postsurgical gastroparesis are rarely explored.

METHODS

The primary outcomes included the symptomatic improvement based on gastroparesis cardinal symptoms index (GCSI) and the improvement of gastric emptying. The secondary outcomes included the improvement of gastroesophageal reflux symptoms and complications of G-POEM.

RESULTS

The severity of postsurgical gastroparesis was not associated with the onset time and the course of the disease. G-POEM significantly reduced GCSI throughout the follow-up period (p < 0.0001). For different anastomotic site, a significant improvement of GCSI was found at 6 month post-G-POEM (F_4,165 = 74.18, p < 0.0001). Subscale analysis of GCSI showed that nausea/vomiting, post-prandial fullness/early satiety, and bloating were improved significantly at 6-month post-G-POEM (p < 0.0001, respectively). Half-emptying and whole-emptying time were significantly shortened in patients with different anastomotic site post-G-POEM (half-emptying time: F_3,174 = 65.44, p < 0.0001; whole-emptying time: F_3,174 = 54.85, p < 0.0001). The emptying of ioversol was obviously accelerated after G-POEM. GCSI wasn't related to pyloric length, pyloric diameter, and thickness of pyloric wall. GERDQ was also used to evaluate the clinical efficacy of G-POEM. For each time points, GERDQ didn't differ significantly in patients with different anastomotic site (F_4,104 = 0.8075, p = 0.5231). For patients with different anastomotic site, GERDQ was improved significantly at different time points (F_4,104 = 59.11, p < 0.0001). The higher the esophageal anastomotic site was, the faster G-POEM improved the symptoms of gastroesophageal reflux. No one required re-hospitalization for any complication.

CONCLUSION

G-POEM is a minimally invasive therapy with long-term effectiveness and safety in treating postsurgical gastroparesis.

Evaluation of Patients with Suspected Gastroparesis

There is substantial overlap between the symptoms of gastroparesis and a variety of alternative disorders. These conditions include rumination syndrome, drug-induced gastric emptying delay, cannabinoid hyperemesis syndrome, and eating disorders, which can be identified based on the history alone. The remaining patients require a diagnostic approach of physical examination, laboratory tests, evaluation with esophagogastroduodenoscopy or contrast radiography, and a test to measure gastric emptying. Symptomatic patients who have normal nutritional status and gastric emptying that is either normal or mildly delayed should be diagnosed with functional dyspepsia, whereas patients with moderate or severe gastric emptying delay are diagnosed with gastroparesis.

An Herbal Medicine, Yukgunja-Tang is more Effective in a Type of Functional Dyspepsia Categorized by Facial Shape Diagnosis: A Placebo-Controlled, Double-Blind, Randomized Trial

INTRODUCTION

Functional dyspepsia (FD) is a functional gastrointestinal disorder characterized by persistent upper dyspeptic symptoms without organic lesions. There is no standard therapy for FD. Yukgunja-tang (YGJT) is an herbal medicine used for treating upper gastrointestinal symptoms in Asia. Studies on the effect of YGJT on FD have been conducted. However, the results were inconsistent. In Hyungsang medicine, traditional Korean medicine, FD patients are classified into bladder body (BB) or gallbladder body (GB) subtypes by the shape and angle of their faces. Each subtype may have different characteristics, physiology, and pathology of the same disease. YGJT is more effective for patients with BB subtype. The three-dimensional facial shape diagnostic system (3-FSDS) was shown to be effective in diagnosing BB or GB subtypes. This study aimed to investigate the effect of YGJT on FD patients classified using the 3-FSDS.

MATERIALS AND METHODS

The current study was a placebo-controlled, double-blinded, randomized, two-center trial. Eligible patients were diagnosed with either BB or GB FD subtype using the 3-FSDS. Ninety-six participants (48 BB and 48 GB subtypes) were randomly allocated to treatment or control groups in a 2:1 ratio. YGJT or placebo was administered for eight weeks. The primary outcome was assessed using the total dyspepsia symptom scale (TDS), while the secondary outcomes were assessed using the single dyspepsia symptom scale (SDS), proportion of responders, visual analog scale, Nepean dyspepsia index, functional dyspepsia-related quality of life, and spleen qi deficiency questionnaire.

RESULTS AND DISCUSSION

The result of TDS showed the superior effect of YGJT on BB over GB subtype. The subgroup analysis of TDS and SDS scores showed the superior effect of YGJT over placebo. Other outcome variables did not show any significant differences between groups.

CONCLUSION

YGJT may be considered for FD patients diagnosed with BB subtype using 3-FSDS.

Enhanced Gastric Emptying Scintigraphy to Assess Fundic Accommodation Using Intragastric Meal Distribution and Antral Contractility

Gastric emptying scintigraphy (GES) as now commonly performed measures only total gastric emptying. Intragastric meal distribution (IMD) immediately after meal ingestion (t = 0 min) (IMD⁰) can assess fundic accommodation, and dynamic antral contraction scintigraphy (DACS) can assess antral motility. Our goals were to incorporate IMD and DACS into GES, compare IMD⁰ using gastric division into anatomic proximal and distal halves versus more physiologic separation of the antrum from the proximal stomach using DACS, and establish reference values. Methods: Healthy subjects (n = 20) underwent GES using a solid-liquid meal. DACS (1 frame/3 s) was performed for 20 min after each static imaging time. IMD⁰ was measured using both semiautomated software to divide the gastric long axis into anatomic halves and Fourier analysis to identify antral pixels with phasic contractions. Results: Using halving of the stomach, IMD⁰ averaged 0.75 ± 0.15 (SD). Using phasic contractions to define the antrum, mean IMD⁰ was 0.85 ± 0.14 (P = 0.004). Sustained antral contractions started at a mean of 11.24 ± 12.98 min after meal ingestion and originated in the gastric midbody with a starting location at 40.5% ± 10.8% from the distal to the proximal stomach along its long axis. Antral frequency and ejection fraction peaked 30 min after meal ingestion at 3.30 ± 0.71 contractions per minute and an ejection fraction of 30.3% ± 13.69%, when mean antral filling peaked at 36.7% ± 14%. Maximum antral contraction speed was 3.54 ± 0.90 mm/s at 60 min after meal ingestion. Gastric retention was 39.8% ± 12.8% at 2 h and 5.8% ± 6.0% at 4 h. Conclusion: Addition of DACS to GES permits physiologic characterization of both fundic accommodation and antral contractility to supplement routine GES.

Role of Gut Microbiota-Gut Hormone Axis in the Pathophysiology of Functional Gastrointestinal Disorders

Gut microbiota exert a pivotal influence on various functions including gastrointestinal (GI) motility, metabolism, nutrition, immunity, and the neuroendocrine system in the host. These effects are mediated by not only short-chain fatty acids produced by microbiota but also gut hormones and inflammatory signaling by enteroendocrine and immune cells under the influence of the microbiota. GI motility is orchestrated by the enteric nervous system and hormonal networks, and disturbance of GI motility plays an important role in the pathophysiology of functional gastrointestinal disorders (FGIDs). In this context, microbiota-associated mediators are considered to act on specific receptors, thus affecting the enteric nervous system and, subsequently, GI motility. Thus, the pathophysiology of FGIDs is based on alterations of the gut microbiota/gut hormone axis, which have crucial effects on GI motility.

Validation of the oesophageal hypervigilance and anxiety scale for chronic oesophageal disease

BACKGROUND

Oesophageal hypervigilance and anxiety can drive symptom experience in chronic oesophageal conditions, including gastro-oesophageal reflux disease, achalasia and functional oesophageal disorders. To date, no validated self-report measure exists to evaluate oesophageal hypervigilance and anxiety.

AIMS

This study aims to develop a brief and reliable questionnaire assessing these constructs, the oesophageal hypervigilance and anxiety scale (EHAS).

METHODS

Questions for the EHAS were drawn from 4 existing validated measures that assessed hypervigilance and anxiety adapted for the oesophagus. Patients who previously underwent high-resolution manometry testing at a university-based oesophageal motility clinic were retrospectively identified. Patients were included in the analysis if they completed the EHAS as well as questionnaires assessing symptom severity and health-related quality of life at the time of the high-resolution manometry.

RESULTS

Nine hundred and eighty-two patients aged 18-85 completed the study. The EHAS demonstrates excellent internal consistency (α = 0.93) and split-half reliability (Guttman = 0.87). Inter-item correlations indicated multicollinearity was not achieved; thus, no items were removed from the original 15-item scale. Principal components factor analysis revealed two subscales measuring symptom-specific anxiety and symptom-specific hypervigilance. Construct validity for total and subscale scores was supported by positive correlations with symptom severity and negative correlations with health-related quality of life.

CONCLUSIONS

The EHAS is a 15-item scale assessing oesophageal hypervigilance and symptom-specfic anxiety. The EHAS could be useful in evaluating the role of these constructs in several oesophageal conditions in which hypersensitivity, hypervigilance and anxiety may contribute to symptoms and impact treatment outcomes.

The prevalence and sociodemographic determinants of uninvestigated dyspepsia in the Czech Republic: a multicentre prospective study accomplished 10 years after the first study from the same geographical areas

OBJECTIVE

The epidemiology of uninvestigated dyspepsia was studied in the Czech Republic for the first time in 2001. The aim of the current multicenter prospective study was to evaluate dyspepsia using the same methods in a representative sample of general unselected population from the same geographical areas 10 years later.

PARTICIPANTS AND METHODS

A total of 38 147 individuals comprised the general population for a random two-step selection process. A total of 1836 participants (863 males and 973 females; aged 5-98 years) took part in the questionnaire-based study. Helicobacter pylori status was investigated in all participants by means of C-urea breath test.

RESULTS

The overall prevalence of dyspepsia was 2.6% among children and adolescents aged 5-17 years and 16.0% among adults aged 18-98 years. We did not detect any statistically significant sex differences in the prevalence of total dyspepsia or its subtypes. Overall, 2.4% of H. pylori-negative children and adolescents aged less than 18 years reported dyspepsia, and 16.8% of H. pylori-negative adults reported it. Among H. pylori-positive children and adolescents and adults, dyspepsia was present in 8.3 and 15.8%, respectively. Type A dyspepsia (as the only long-lasting symptom) was statistically significantly associated with H. pylori status among children and adolescents. Among adults aged 18 years or older, we noted a lower prevalence of dyspepsia in adults with elementary education compared with university education. Current use of antibiotics was associated with an increased prevalence of dyspepsia in adults.

CONCLUSION

Despite the substantial decrease of H. pylori infection in the Czech Republic over the past 10 years, the prevalence and sociodemographic determinants of uninvestigated dyspepsia did not change significantly.

Association of Psychological Characteristics and Functional Dyspepsia Treatment Outcome: A Case-Control Study

This study was to investigate the association of psychological characteristics and functional dyspepsia treatment outcome. 109 patients who met the criteria for FD were enrolled. Eysenck Personality Questionnaire (EPQ), Symptom Checklist 90 (SCL90), and the Pittsburgh Sleep Quality Index (PSQI) were used to measure personality, psychological symptoms, and sleep quality in our patients. Leeds Dyspepsia Questionnaire (LDQ) was used to assess dyspeptic symptoms at baseline and after eight weeks of treatment. The LDQ scores change after therapy, and the degraded rate of LDQ was used to assess the prognosis of patients. Logistic regression model was used to assess the effect of the personality, psychological symptoms, and sleep quality on the prognosis of patients. Our result revealed that poor sleep quality (OR = 7.68, 95% CI 1.83–32.25) and bad marriage status (OR = 1.22, 95% CI 1.10–1.36) had the negative effect on the prognosis of FD, while extroversion in personality traits (OR = 0.86, 95% CI 0.76–0.96) had positive effect on the prognosis of FD. We should pay attention to the sleep quality, the personality, and the marriage status of FD patients; psychological intervention may have benefit in refractory FD.

Effect of DA-9701 on the Normal Motility and Clonidine-induced Hypomotility of the Gastric Antrum in Rats

Background/Aims

DA-9701 is a novel prokinetic agent. In the present study, we investigated the effect of DA-9701 on the motility of the gastric antrum in the normal and clonidine-induced hypomotility in an in vivo animal model.

Methods

A strain gauge force transducer was sutured on the gastric antrum to measure the contractile activity in rats. A total of 28 rats were subclassified into the 4 groups: (1) the placebo group, (2) the DA-9701 group, (3) the placebo group in the clonidine-pretreated rats, and (4) the DA-9701 group in the clonidine-pretreated rats. After the basal recording, either placebo (3% [w/v] hydroxypropylmethyl cellulose) or DA-9701 was administered. Contractile signals were measured after the administration and after a meal. In the clonidine-pretreated rats, either placebo or DA-9701 was administered. Contractile signals were measured after the administration and after a meal.

Results

Oral administration of DA-9701 did not significantly alter the motility index of the gastric antrum in the preprandial and postprandial periods, compared with the placebo group. The administration of clonidine decreased the motility index of the gastric antrum in the preprandial and postprandial periods, compared with the administration of placebo. This reduction of the antral motility by the administration of clonidine was not observed in the clonidine-pretreated DA-9701 group. The percentage of the motility index in the postprandial period was significantly greater in the clonidine-pretreated DA-9701 group, compared with the clonidine-pretreated placebo group.

Conclusions

DA-9701 improves the hypomotility of the gastric antrum induced by clonidine, suggesting its gastroprokinetic effect in the pathologic condition.

Abdominal migraine in children: association between gastric motility parameters and clinical characteristics

Background

Approximately 0.2–1 % of children suffers from abdominal migraine (AM). Pathophysiology of AM has not been adequately studied. This study evaluated gastric motility in children with AM.

Methods

Seventeen children (6 boys), within an age range of 4–15 years, referred to a tertiary care paediatric unit, North Colombo Teaching Hospital Ragama, Sri Lanka, from 2007 to 2012, were screened. Those fulfilling Rome III criteria for AM were recruited after obtaining parental consent. None had clinical or laboratory evidence of organic disorders. Twenty healthy children (8 boys), with an age range of 4–14 years, were recruited as controls. Liquid gastric emptying rate (GE) and antral motility parameters were assessed using an ultrasound method.

Results

Average GE (41.6 % vs. 66.2 %, in controls), amplitude of antral contractions (A) (57.9 % vs. 89.0 %) and antral motility index (MI) (5.0 vs. 8.3) were lower and fasting antral area (1.8 cm² vs. 0.6 cm²) was higher in children with AM (p < 0.01). No significant difference in the frequency of antral contractions (F) (8.8/3 min vs. 9.3/3 min, p = 0.08) was found between the two groups. Scores obtained for severity of abdominal pain had a negative correlation with A (r = −0.55, p = 0.03). Average duration of abdominal pain episodes correlated with GE (r = −0.58, p = 0.02). Negative correlations were observed between duration of AM and A (r = −0.55), F (r = −0.52), and MI (r = −0.57) (p < 0.05).

Conclusions

GE and antral motility parameters were significantly lower in children with AM. A significant correlation was found between symptoms and gastric motility. These findings suggest a possible role of abnormal gastric motility in the pathogenesis of AM.

Ghrelin enhancer, rikkunshito, improves postprandial gastric motor dysfunction in an experimental stress model

BACKGROUND

Functional dyspepsia (FD) is one of the most common disorders of gastrointestinal (GI) diseases. However, no curable treatment is available for FD because the detailed mechanism of GI dysfunction in stressed conditions remains unclear. We aimed to clarify the association between endogenous acylated ghrelin signaling and gastric motor dysfunction and explore the possibility of a drug with ghrelin signal-enhancing action for FD treatment.

METHODS

Solid gastric emptying (GE) and plasma acylated ghrelin levels were evaluated in an urocortin1 (UCN1) -induced stress model. To clarify the role of acylated ghrelin on GI dysfunction in the model, exogenous acylated ghrelin, an endogenous ghrelin enhancer, rikkunshito, or an α2 -adrenergic receptor (AR) antagonist was administered. Postprandial motor function was investigated using a strain gauge force transducer in a free-moving condition.

KEY RESULTS

Exogenous acylated ghrelin supplementation restored UCN1-induced delayed GE. Alpha2 -AR antagonist and rikkunshito inhibited the reduction in plasma acylated ghrelin and GE in the stress model. The action of rikkunshito on delayed GE was blocked by co-administration of the ghrelin receptor antagonist. UCN1 decreased the amplitude of contraction in the antrum while increasing it in the duodenum. The motility index of the antrum but not the duodenum was significantly reduced by UCN1 treatment, which was improved by acylated ghrelin or rikkunshito.

CONCLUSIONS & INFERENCES

The UCN1-induced gastric motility dysfunction was mediated by abnormal acylated ghrelin dynamics. Supplementation of exogenous acylated ghrelin or enhancement of endogenous acylated ghrelin secretion by rikkunshito may be effective in treating functional GI disorders.

Rome III functional dyspepsia subdivision in PDS and EPS: recognizing postprandial symptoms reduces overlap

BACKGROUND

The Rome III consensus proposed to subdivide functional dyspepsia (FD) into two groups: meal-related dyspepsia or postprandial distress syndrome (PDS), and meal-unrelated dyspepsia or epigastric pain syndrome (EPS). However, in clinical practice, overlap between both has been reported to be as high as 50%, thereby hampering clinical applicability. Although EPS is referred to as meal-unrelated dyspepsia, relationship of symptoms to meal ingestion in this category is not formally addressed in the Rome III criteria. The aim of our study was to investigate whether taking into account the relationship of epigastric pain and nausea to meal ingestion may help to improve separation between EPS and PDS.

METHODS

Consecutive ambulatory tertiary-care patients with epigastric symptoms filled out Rome III gastro-duodenal questionnaires with supplementary questions. Those fulfilling Rome III FD criteria and a negative endoscopy were identified and subdivided into 'pure' PDS patients (i.e., meeting criteria for PDS without EPS symptoms), 'pure' EPS (i.e., meeting criteria for EPS without PDS symptoms), and overlapping PDS-EPS (i.e., symptoms of both PDS and EPS).

KEY RESULTS

Out of 1029 patients coming to endoscopy, 199 patients (73% females, 45.9 ± 1.0 years, BMI: 23.7 ± 0.35) fulfilled Rome III FD diagnostic criteria, and could be subdivided into pure PDS (69% females, 49 ± 2 years, BMI: 24.2 ± 0.61), pure EPS (59% females, 47.4 ± 2 years, BMI: 23.2 ± 0.97) and overlapping PDS-EPS (64% females, age 43 ± 5 years, BMI: 26 ± 0.46). Compared with pure EPS patients, the overlap PDS-EPS patients were characterized by a higher occurrence of postprandial epigastric pain (70% vs 31%, p < 0.0001), while the occurrence of epigastric pain in between meals was borderline (48% vs 38%, p = 0.05). In addition, the overlap PDS-EPS patients reported a higher occurrence of postprandial nausea (23% vs 0%, p < 0.0001), and bloating (79% vs 28%, p = 0.0001). When postprandial epigastric pain and postprandial nausea were considered as PDS symptoms, the 'adapted' subdivision identified 48% pure PDS, 16% pure EPS, and 36% overlapping PDS-EPS patients.

CONCLUSIONS & INFERENCES

EPS and PDS symptoms frequently coexist in FD patients, with postprandial symptoms substantially contributing to the overlap. A more rigorous linking of postprandially occurring symptoms to PDS, regardless of their qualitative nature, may improve the separation between PDS and EPS.

Central nervous system control of gastrointestinal motility and secretion and modulation of gastrointestinal functions

Although the gastrointestinal (GI) tract possesses intrinsic neural plexuses that allow a significant degree of autonomy over GI functions, the central nervous system (CNS) provides extrinsic neural inputs that regulate, modulate, and control these functions. While the intestines are capable of functioning in the absence of extrinsic inputs, the stomach and esophagus are much more dependent upon extrinsic neural inputs, particularly from parasympathetic and sympathetic pathways. The sympathetic nervous system exerts a predominantly inhibitory effect upon GI muscle and provides a tonic inhibitory influence over mucosal secretion while, at the same time, regulates GI blood flow via neurally mediated vasoconstriction. The parasympathetic nervous system, in contrast, exerts both excitatory and inhibitory control over gastric and intestinal tone and motility. Although GI functions are controlled by the autonomic nervous system and occur, by and large, independently of conscious perception, it is clear that the higher CNS centers influence homeostatic control as well as cognitive and behavioral functions. This review will describe the basic neural circuitry of extrinsic inputs to the GI tract as well as the major CNS nuclei that innervate and modulate the activity of these pathways. The role of CNS-centered reflexes in the regulation of GI functions will be discussed as will modulation of these reflexes under both physiological and pathophysiological conditions. Finally, future directions within the field will be discussed in terms of important questions that remain to be resolved and advances in technology that may help provide these answers.

Attenuation of stress-induced gastrointestinal motility disorder by gentiopicroside, from Gentiana macrophylla Pall

AIM

The current study was designed to explore the mechanism of the prokinetic activity of Gentiopicroside (Ge), from Gentiana macrophylla Pall which is widely used to strengthen gastric motility in clinic.

METHODS

Gastrointestinal motility disorder rats were induced by stress stimulation and the rats were treated with Ge. The functions of gastric emptying and intestinal propelling were measured after blood was obtained to assay the levels of plasmatic motilin (MTL), vasoactive intestinal peptide (VIP), somatostatin (SST), gastrin (GAS), neurotensin (NT) and substance of P (SP). The expressions of MTL receptor (MTLR), VIP receptor 2 (VIPR2) and SST receptor 2 (SSTR2) were measured also. In addition, an isolated guinea pig ileum was applied to evaluate the influences of Ge on M-R, H1-R, 5-HT4-R and D-R in vitro.

RESULTS

Ge increased gastric emptying and intestinal propelling obviously. It also decreased the level of SST and increased GAS in plasma significantly. Moreover, it promoted the expressions of MTLR in gastric antrum, duodenum, jejunum and ileum, and restrained the expression of VIPR2 in duodenum. Piboserod and loratadine had no obvious restrain to Ge' exciting ileum effect and Ge also didn't affect dopamine paralyzing ileum. However, Ge failed to improve the hypofunction of guinea pigs ileums pre-treated with atropine sulfate.

CONCLUSION

The mechanisms of Ge' prokinetic effect were associated with modulating the levels of SST and GAS in plasma, raising the expressions of MTLR in gastric antrum, duodenum, ileum and jejunum, reducing the expression of VIPR2 in duodenum and activating M-R.

Combination of symptoms, syndrome and disease: Treatment of refractory diabetic gastroparesis

AIM: To assess effect of combination of symptoms, syndrome and disease on treatment of diabetic gastroparesis with severe nausea and vomiting.

METHODS: Professor Tong Xiaolin’s clinical electronic medical records of patients who were treated between January 1, 2006 and October 1, 2012 were used as a database. Patients who met the inclusion criteria were enrolled. General information (name, sex and age), symptoms and blood glucose levels were obtained from the clinic electronic medical record, which was supplemented by a telephone interview. The patient-rated Gastroparesis Cardinal Symptom Index (GCSI) was used to evaluate the severity of the symptoms of gastroparesis. The effects of the treatment were assessed by the change in the severity of the symptoms of gastroparesis and the change in blood glucose between the baseline levels and the post-treatment levels at 1, 2, 4, 8 and 12 wk.

RESULTS: Forty-five patients had a mean GCSI nausea and vomiting severity score of 4.21 ± 0.67 and a total GCSI score of 2.77 ± 0.63 before treatment. There was a significant improvement in the nausea and vomiting score at every return visit compared with the baseline score (1 wk: 3.02 ± 1.04 vs 4.18 ± 0.71, P < 0.001; 2 wk: 2.32 ± 1.25 vs 4.16 ± 0.73, P < 0.001; 4 wk: 2.12 ± 1.26 vs 4.12 ± 0.73, P < 0.001; 8 wk: 1.79 ± 1.09 vs 4.24 ± 0.77, P < 0.001; 12 wk: 0.69 ± 0.92 vs 4.25 ± 0.70, P < 0.001). Twenty-five of the 45 patients had complete resolution of vomiting during the observation period (mean time to resolution was 37.9 ± 27.3 d). The postprandial fullness and early satiety subscale, bloating subscale and total GCSI scores were also improved. Finally, the blood glucose levels improved after treatment, although the change was not significant.

CONCLUSION: Use of the combination of symptoms, syndrome and disease to treat diabetic gastroparesis with refractory nausea and vomiting may be a new treatment option.

Administration of exogenous acylated ghrelin or rikkunshito, an endogenous ghrelin enhancer, improves the decrease in postprandial gastric motility in an acute restraint stress mouse model

BACKGROUND

Physical or psychological stress causes functional disorders in the upper gastrointestinal tract. This study aims to elucidate the ameliorating effect of exogenous acylated ghrelin or rikkunshito, a Kampo medicine which acts as a ghrelin enhancer, on gastric dysfunction during acute restraint stress in mice.

METHODS

Fasted and postprandial motor function of the gastric antrum was wirelessly measured using a strain gauge force transducer and solid gastric emptying was detected in mice exposed to restraint stress. Plasma corticosterone and ghrelin levels were also measured. To clarify the role of ghrelin on gastrointestinal dysfunction in mice exposed to stress, exogenous acylated ghrelin or rikkunshito was administered, then the mice were subjected to restraint stress.

KEY RESULTS

Mice exposed to restraint stress for 60 min exhibited delayed gastric emptying and increased plasma corticosterone levels. Gastric motility was decreased in mice exposed to restraint stress in both fasting and postprandial states. Restraint stress did not cause any change in plasma acylated ghrelin levels, but it significantly increased the plasma des-acyl ghrelin levels. Administration of acylated ghrelin or rikkunshito improved the restraint stress-induced delayed gastric emptying and decreased antral motility. Ameliorating effects of rikkunshito on stress-induced gastric dysfunction were abolished by simultaneous administration of a ghrelin receptor antagonist.

CONCLUSIONS & INFERENCES

Plasma acylated/des-acyl ghrelin imbalance was observed in acute restraint stress. Supplementation of exogenous acylated ghrelin or enhancement of endogenous ghrelin signaling may be useful in the treatment of decreased gastric function caused by stress.

Altered intrinsic regional activity and corresponding brain pathways reflect the symptom severity of functional dyspepsia

BACKGROUND

Increasing evidence shows central abnormalities in functional dyspepsia (FD) patients, but whether the symptom severity is directly reflected in altered brain patterns remains unclear. The purpose of this study was to explore how FD affected the resting functional brain patterns for different degrees of symptom severity.

METHODS

Functional magnetic resonance imaging was carried out in 40 FD patients and 20 healthy controls. The resting-state brain changes in regional homogeneity (ReHo) and seed correlation analysis were investigated in patients relative to controls. To what degree the brain changes reflected the severity of the disease was assessed by a pattern classification technique.

KEY RESULTS

Altered ReHo values (p < 0.05, FDR corrected) were discovered in multiple brain areas in FD patients, and only the anterior cingulate cortex (ACC) and thalamus exhibited significant correlation with the severity of dyspepsia symptoms. Compared with controls, the neural signal changes of the thalamus were not found in the less severe FD patient group but in the relatively more severe group, while the ACC showed aberrations in both groups. Seed-based correlation analysis revealed ACC- and thalamus-related functional connectivity differences between FD patients and controls at a voxel-wise level, and the altered thalamic circuits provided the best performance in distinguishing FD patients with different levels of symptom severity.

CONCLUSIONS & INFERENCES

Our results indicated that the functional abnormalities of the ACC and thalamus may occur at different clinical courses in FD. This may help us better understand the progression of FD.

Dysfunctional endogenous pain modulation in patients with functional dyspepsia

BACKGROUND

Endogenous pain modulation (EPM) is central to the processing of sensory information. Visceral and somatic EPM are abnormal in irritable bowel syndrome, but have not been studied in functional dyspepsia (FD).

METHODS

Visceral EPM was assessed in 34 FD patients and 42 healthy controls. Gastric pain was induced with oral capsaicin and EPM was studied by adding heterotopic thermal foot stimulation or distraction by STROOP test. Somatic EPM was assessed using foot heat stimulation with heterotopic hand electrical stimulation.

KEY RESULTS

Endogenous pain modulation by distraction reduced mean gastric pain by 11.9 on the 0-100 visual analog scale (95% CI: 3.8-20.1) in controls (p = 0.006) and by 2.0 (-6.18 to 10.44) in FD (p = 0.6), with greater EPM in controls than in FD (difference -13.3 [-26.1 to -0.5]; p = 0.04). Endogenous pain modulation by heterotopic foot stimulation reduced gastric pain by 6.5 (-0.7 to 13.6) in controls (p = 0.07) and by 7.1 (-2.29 to 16.47) in FD (p = 0.1), with no significant difference in EPM between controls and FD (-2.0 [-14.5 to 10.5]; p = 0.75). In patients with prominent FD pain, greater pain correlated with decreased visceral EPM by distraction (r = 0.51, p = 0.04). Somatic EPM by heterotopic stimulation significantly decreased foot pain in controls (p = 0.004), but not in FD (p = 0.80).

CONCLUSIONS & INFERENCES

In FD, visceral pain modulation by distraction was dysfunctional compared to controls. Somatic pain modulation was also decreased in FD. These data and the correlation of abnormal pain modulation by distraction with clinical pain in pain-predominant FD suggest a potential pathophysiological significance of abnormal pain modulation in FD.

A traditional herbal formula, Hyangsa-Pyeongwi san (HPS), improves quality of life (QoL) of the patient with functional dyspepsia (FD): randomized double-blinded controlled trial

ETHNOPHARMACOLOGICAL RELEVANCE

Hyangaa-Pyeongwi san is the most well known description in Traditional Chinese Medicine for treating functional gastrointestinal disorders. Functional dyspepsia (FD) is a main concern of intimidating quality of life (QoL) in recent days. Although many medicines have been developed to improve FD symptoms as well as QoL, there are no potential drugs and treatments for FD. The aim of this study is to investigate the effects of Hyangaa-Pyeongwi san (HPS) on QoL of patients with FD.

METHODS

This study was designed as a randomized, double blinded, placebo controlled, and parallel group trial. Participants received either placebo or HPS (9.68g of HPS at once, three times daily) for 4-weeks, and the efficacy evaluations were performed by assessing the Nepean Dyspepsia Index (NDI) and functional dyspepsia-quality of life (FD-QoL) at 0-, 4- and 8-weeks.

RESULTS

Total of 170 patients participated and were randomly allocated into placebo or HPS groups. Total symptom score of NDI decreased after 4-weeks trial in both groups (p>0.05). HPS significantly improved QoL scores, especially in the area of 'interference and eat/drink' in NDI (p=0.0031) as well as 'liveliness status', 'role-functioning status', and total score in FD-QoL (p=0.026 for liveliness status and p=0.035 for role-functioning status). This significant improvement of FD-QoL had lasted for 4-weeks.

CONCLUSION

HPS treatment is markedly effective in improving QoL in patients with FD. Moreover, we observed that this improvement had lasted for 4 weeks after finishing the trial through the follow-up study.

Effect of acute auditory stress on gastric motor responses to a meal in healthy volunteers

BACKGROUND AND AIM

Stress is believed to play a role in the pathogenesis of functional gastrointestinal disorders. The aim of the present study was to investigate the effect of acute auditory stress on gastric motor responses to a meal in healthy subjects.

METHODS

A total of eight healthy volunteers (seven men and one woman; median age, 33.4 years [30-35 years]) who had no recurrent gastrointestinal symptoms participated in the prospective, randomized, crossover study. Gastric half-emptying time and meal-induced proximal gastric accommodation were measured using gastric scintigraphy under the auditory stress and control conditions in a randomized crossover design.

RESULTS

The gastric half-emptying time under the stress condition was significantly longer than that under the control condition (130.8 ± 16.6 vs. 105.0 ± 13.1 min; P = 0.005 by paired t-test). Under the stress and control conditions, the proximal gastric volume significantly increased after a meal (P < 0.001 by repeated measures analysis of variance). The degree of the postprandial increase in proximal gastric volume did not significantly differ between both conditions (P = 0.598 by tests of between-subjects effects using repeated measures analysis of variance). The severity scores of postprandial epigastric discomfort and fullness were significantly higher under the stress condition than under the control condition (P = 0.001 and P = 0.039, respectively, by paired t-test).

CONCLUSIONS

Acute auditory stress delays gastric emptying and increases the severity of postprandial symptoms in the healthy subjects, suggesting the relevance of psychological stress to the pathophysiological mechanism of functional dyspepsia.

Efficacy of Gastrosis No.1 compound on functional dyspepsia of spleen and stomach deficiency-cold syndrome: a multi-center, double-blind, placebo-controlled clinical trial

OBJECTIVE

To assess the efficacy and safety of Gastrosis No.1 compound in the treatment of functional dyspepsia with Spleen (Pi) and Stomach (Wei) deficiency-cold syndrome.

METHODS

A randomized, double-blind, placebo-controlled trial was performed in 5 centers. Patients with functional dyspepsia (FD) of Spleen-deficiency and qi-stagnation syndrome (162 cases) were randomly assigned to groups given Chinese herbal medicine (CHM) Gastrosis No.1 compound or placebo in a 2:1 ratio. This trial included a 4-week treatment period and a 4-week follow-up period. The outcomes were the dyspepsia symptom scores (measured by total dyspepsia symptom scale and single dyspepsia symptom scale) and syndromes of traditional Chinese medicine score (measured by traditional Chinese medicine syndrome scale). The outcomes were noted at weeks 0, 4 and 8.

RESULTS

Compared with patients in the placebo group, patients in the CHM group showed significant improvement in the dyspepsia symptom scores as rated by patients and investigators (P <0.01), and also showed improvement in syndromes of traditional Chinese medicine score (P <0.01). No serious adverse event was reported. Safety tests obtained after 4 weeks of treatment showed no abnormal values.

CONCLUSION

CHM Gastrosis No.1 compound was effective and safe in the treatment of functional dyspepsia with Spleen and Stomach deficiency-cold syndrome.

Improvement of quality of life and symptoms after gastric electrical stimulation in children with functional dyspepsia

BACKGROUND

Our objective is to evaluate the effect of gastric electrical stimulation (GES) on symptoms and quality of life for pediatric patients with functional dyspepsia (FD).

METHODS

Twenty-four patients (16 female, median 15 years) were treated with GES for FD after a median of 24 months of symptoms (3 months-14 years). At baseline, 46% required tube feeds and 25% parenteral nutrition. Sixty percent had gastroparesis. The PedsQL GI Module (PedsQL) was completed for 18/24 both pre-/post-GES after a median of 8 months. Patients also completed the Symptom Monitor Worksheet (SMW) pre-/post-GES after a median of 6 months. Pre-/post-GES global health was also assessed.

KEY RESULTS

Significant improvements were seen in multiple areas of the PedsQL, including stomach pain/upset, food/drink limits, heartburn/reflux, gas/bloating, patient worry, medication tolerance, and constipation (P < 0.05). A decrease was found in combined symptom severity/frequency based on SMW (P < 0.01). Improvements were made in all categories, including vomiting, nausea, early satiety, bloating, fullness, epigastric pain, and burning (P < 0.01). Improvements in PedsQL/SMW scores remained when analysis was limited to normal or delayed gastric emptying (P < 0.05, P < 0.05). Thirteen percent needed tube feeds and 13% parenteral nutrition after GES. Sixty-five percent reported that their health was much improved after GES vs 15% the same or worse. Five patients experienced complications, primarily mild abdominal discomfort.

CONCLUSIONS & INFERENCES

In the largest series to date of pediatric patients who have undergone GES for FD, we found significant improvements in upper gastrointestinal symptoms, quality of life, and perception of global health. Patients were less dependent on tube feeding or parenteral nutrition.

Gastric emptying and antral motility parameters in children with functional dyspepsia: association with symptom severity

BACKGROUND AND AIMS

Functional dyspepsia (FD) is an important gastrointestinal problem with obscure etiology. Abnormal gastric motility is suggested as a possible pathophysiological mechanism for symptoms. The main objective of this study was to assess gastric motility in Sri Lankan children with FD.

METHODS

Forty-one children (19 [46.3%] males, age 4-14 years, mean 7.5 years, SD 2.6 years) referred to the Gastroenterology Research Laboratory, Faculty of Medicine, University of Kelaniya, from January 2007 to December 2011, were screened. Those fulfilling Rome III criteria for FD were recruited. None had clinical or laboratory evidence of organic disorders. Twenty healthy children were recruited as controls (eight [40%] males, age 4-14 years, mean 8.4 years, SD 3.0 years). Liquid gastric emptying rate (GE) and antral motility parameters were assessed using an ultrasound-based method.

RESULTS

Average GE (45.6% vs 66.2% in controls), amplitude of antral contractions (58.2% vs 89.0%) and antral motility index (5.1 vs 8.3) were lower and fasting antral area (1.5 cm(2) vs 0.6 cm(2)) was higher in patients with FD (P < 0.01). Frequency of antral contractions (8.8 vs 9.3) did not show a significant difference (P = 0.07). Scores obtained for severity of abdominal pain negatively correlated with GE (r = -0.35, P = 0.025). Children with FD, exposed to stressful events had higher fasting antral area (1.9 cm(2)) than those not exposed to stress (1.0 cm(2)) (P = 0.02).

CONCLUSIONS

GE and antral motility parameters were significantly impaired in children with FD compared with controls. GE negatively correlated with severity of symptoms. This study points to disturbances in gastric motility as an etiological factor for FD.

Whole-brain functional connectivity identification of functional dyspepsia

Recent neuroimaging studies have shown local brain aberrations in functional dyspepsia (FD) patients, yet little attention has been paid to the whole-brain resting-state functional network abnormalities. The purpose of this study was to investigate whether FD disrupts the patterns of whole-brain networks and the abnormal functional connectivity could reflect the severity of the disease. The dysfunctional interactions between brain regions at rest were investigated in FD patients as compared with 40 age- and gender- matched healthy controls. Multivariate pattern analysis was used to evaluate the discriminative power of our results for classifying patients from controls. In our findings, the abnormal brain functional connections were mainly situated within or across the limbic/paralimbic system, the prefrontal cortex, the tempo-parietal areas and the visual cortex. About 96% of the subjects among the original dataset were correctly classified by a leave one-out cross-validation approach, and 88% accuracy was also validated in a replication dataset. The classification features were significantly associated with the patients' dyspepsia symptoms, the self-rating depression scale and self-rating anxiety scale, but it was not correlated with duration of FD patients (p>0.05). Our results may indicate the effectiveness of the altered brain functional connections reflecting the disease pathophysiology underling FD. These dysfunctional connections may be the epiphenomena or causative agents of FD, which may be affected by clinical severity and its related emotional dimension of the disease rather than the clinical course.

Alterations of the default mode network in functional dyspepsia patients: a resting-state fmri study

BACKGROUND

Increasing brain imaging studies have emphasized the role of regional brain activity abnormalities in functional dyspepsia (FD) during the resting state. The goal of this study was to investigate the default mode network (DMN) in FD patients and healthy controls (HCs).

METHODS

Resting-state functional magnetic resonance imaging (fMRI) scanning was carried out on 49 patients and 39 HCs. Independent component analysis (ICA) was used to isolate the DMN in each subject. Group topography of the DMN was compared to study significant alteration in FD. A correlation analysis was then performed in the FD group to investigate the effects of symptom severity and the psychological factors on the DMN.

KEY RESULTS

Significant spatial differences with the DMN in FD patients, compared with HCs, were mainly found in the dorsomedial prefrontal cortex (dmPFC), ventromedial prefrontal cortex (vmPFC), orbitofrontal cortex (OFC), pregenual anterior cingulate cortex (pACC), thalamus, parahippocampal gyrus, precuneus, parietal cortex, and temporal pole. Meanwhile, Nepean Dyspepsia Index (NDI) scores were positively correlated with the pACC, and was negative correlated with the OFC. However, both the Self-Rating Anxiety Scale (SAS) and Self-Rating Depression Scale (SDS) scores were not correlated with any regions of interest showing differences between the FD patients and the HCs.

CONCLUSIONS & INFERENCES

These findings suggested that the DMN might indeed undergo dysfunctional changes due to the abnormal persistent activity in FD patients. To a certain extent, the changes in the DMN were related to the FD-related symptom severity.

Efficacy of modified ban xia xie xin decoction on functional dyspepsia of cold and heat in complexity syndrome: a randomized controlled trial

Background. Chinese herbal medicine (CHM) has been used in China and elsewhere to treat patients with functional dyspepsia (FD). However, controlled studies supporting the efficacy of such treatment are lacking. Objective. To assess the efficacy and safety of modified Ban xia xie xin decoction in patients with FD of cold and heat in complexity syndrome. Methods. We performed a randomized, double-blind, placebo-controlled trial involving patients from five centers. Patients with FD of cold and heat in complexity syndrome (n = 101) were randomly assigned to groups given either CHM modified Ban Xia Xie Xin decoction or placebo in a 2 : 1 ratio. Herbal or placebo granules were dissolved in 300 mL of boiled water cooled to 70°C. Patients in both groups were administered 150 mL (50°C) twice daily. The trial included a 4-week treatment period and a 4-week followup period. The primary outcomes were dyspepsia symptom scores, measured by the total dyspepsia symptom scale and the single dyspepsia symptom scale at weeks 0, 1, 2, 3, 4, and 8. Results. Compared with patients in the placebo group, patients in the CHM group showed significant improvements according to the total and single dyspepsia symptom scores obtained from patients (P < 0.01) and investigators (P < 0.01). Conclusions. CHM modified Ban Xia Xie Xin decoction appears to offer symptomatic improvement in patients with FD of cold and heat in complexity syndrome. Trial Registration. Chinese Clinical Trial Registry (ChiCTR): ChiCTR-TRC-10001074.

Efficacy of modified LiuJunZi decoction on functional dyspepsia of spleen-deficiency and qi-stagnation syndrome: a randomized controlled trial

BACKGROUND

Chinese herbal medicine (CHM) has been used in China and some other countries for the treatment of patients with functional dyspepsia (FD). However, controlled studies supporting the efficacy of such treatments in patients with FD are lacking. In this trial, we aimed to assess the efficacy and safety of modified LiuJunZi decoction in patients with FD of spleen-deficiency and qi-stagnation syndrome.

METHODS

We performed a randomized, double-blind, placebo-controlled trial with patients from five centers. Patients with FD of spleen-deficiency and qi-stagnation syndrome (n = 160) were randomly assigned to groups given CHM modified LiuJunZi decoction or placebo in a 2:1 ratio. Herbal or placebo granules were dissolved in 300 ml of boiled water cooled to 70°C. Patients in both groups were administered 150 ml (50°C) twice daily. The trial included a 4-week treatment period and a 4-week follow-up period. The primary outcomes were dyspepsia symptom scores, measured by the total dyspepsia symptom scale and the single dyspepsia symptom scale at weeks 0, 1, 2, 3, 4 and 8. The secondary outcome was the change of radiopaque barium markers emptied from the stomach between week 0 and week 4 of treatment.

RESULTS

Compared with patients in the placebo group, patients in the CHM group showed significant improvements according to the scores of total dyspepsia symptoms and single dyspepsia symptoms obtained from patients (P < 0.01) and investigators (P < 0.01). They also showed an improvement in the number of radiopaque barium markers emptied from the stomach (P < 0.05).

CONCLUSIONS

CHM modified LiuJunZi decoction appears to offer symptomatic improvement in patients with FD of spleen-deficiency and qi-stagnation syndrome.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR): http://ChiCTR-TRC-10001074.

Visceral and somatic sensory function in functional dyspepsia

BACKGROUND

Visceral hypersensitivity is one of the proposed underlying mechanisms in functional dyspepsia (FD). It is not clear whether visceral hypersensitivity in FD is a manifestation of a central sensitization also encompassing somatic sensitization. Transient receptor potential vanilloid-1 (TRPV(1)) pathways are involved in gastric mechanosensory physiology and the TRPV(1) receptor agonist, capsaicin, has been used as a chemical stimulant.

METHODS

In this double-blind, randomized study we evaluated both visceral and somatic sensory function in 34 FD patients and 42 healthy controls using quantitative sensory testing. Visceral pain sensitivity was assessed using a validated gastric pain model with oral capsaicin capsule titration and somatic pain sensitivity was determined by foot heat and hand electric stimulation.

KEY RESULTS

The median capsaicin dose required to attain moderate pain was 0.5mg in FD and 1mg in controls (P = 0.03). At these doses, mean pain intensities on a 0-100 visual analog scale were greater for FD than controls [56.9 (95% confidence intervals, 52.2-61.5) vs 45.1 (41.6-48.6), resp.] (P = 0.005). Overall, mean somatic sensory and pain thresholds were similar in FD and control groups, but in a subgroup of FD pain hypersensitivity was seen on the hand and on the foot at different stimulation thresholds.

CONCLUSIONS & INFERENCES

A majority of patients with FD have visceral chemo-hypersensitivity involving TRPV(1) pathways. A substantial subgroup also has somatic hypersensitivity as evidence of central sensitization.

A Study on the Efficacy of Proton Pump Inhibitors in Helicobacter pylori-Negative Primary Care Patients with Dyspepsia in Japan

Background/Aims

There have been few studies on the efficacy of proton pump inhibitors and the doses required to treat dyspeptic symptoms observed in clinical practice. The aim of this study was to compare the efficacy of different doses of omeprazole and different administration methods in Helicobacter pylori-negative, dyspeptic patients.

Methods

Patients with chronic upper abdominal symptoms within the previous 3 months were randomly divided into three groups: a daily, omeprazole 20 mg treatment group (OPZ20, n=61); a daily, omeprazole 10 mg treatment group (OPZ10, n=72); and an on-demand omeprazole 20 mg treatment group (on-demand, n=62). After 4 weeks of administration of the drug, symptom improvement rates were evaluated based on the Overall Global Severity score.

Results

The rates of symptom improvement after 4 weeks of treatment were 65.6% (40/61) in the OPZ20 group, 47.2% (34/72) in the OPZ10 group, and 50.0% (31/62) in the on-demand group. The OPZ20 group exhibited a significantly higher improvement rate (p=0.034) than the OPZ10 group. The OPZ20 group had significant improvements in regurgitation, postprandial fullness, vomiting, and bloating compared with the OPZ10 group.

Conclusions

Daily treatment with 20 mg of omeprazole was efficient in treating upper abdominal symptoms. Trial registration: ClinicalTrials.gov, number UMIN000002621.

Efficacy of rebamipide for low-dose aspirin-related gastrointestinal symptoms

Gastrointestinal symptoms are a problematic issue for patients who take low-dose aspirin for long time. We conducted a pilot study to investigate the efficacy of combination therapy with proton pump inhibitor and rebamipide. This was a prospective, randomized, double-blind, placebo-controlled cross-over study. All the subjects received aspirin 100 mg and omeprazole 20 mg. The subjects were divided into two groups and received either rebamipide 300 mg or placebo, which was prescribed for 4 weeks. The subjects were instructed to record their gastrointestinal symptom rating scale before the study and 1 and 4 weeks after beginning the protocol. These scores of the groups were compared before and after the treatment to evaluate the severity of their symptoms and the number of symptom items present in each group. For the subjects receiving rebamipide, the total prevalence of lower gastrointestinal symptoms was significantly different from the placebo group (p=0.0093) at week 4. No troublesome symptoms were observed in the rebamipide group. Inconclusion, the administration of rebamipide prevented the occurrence of troublesome symptoms, especially lower gastrointestinal symptoms, in patients taking aspirin and omeprazole. Rebamipide is a candidate drug for combination therapy with proton pump inhibitors to prevent low-dose aspirin-induced gastrointestinal symptoms.

Efficacy of rebamipide for low-dose aspirin-related gastrointestinal symptoms

Gastrointestinal symptoms are a problematic issue for patients who take low-dose aspirin for long time. We conducted a pilot study to investigate the efficacy of combination therapy with proton pump inhibitor and rebamipide. This was a prospective, randomized, double-blind, placebo-controlled cross-over study. All the subjects received aspirin 100 mg and omeprazole 20 mg. The subjects were divided into two groups and received either rebamipide 300 mg or placebo, which was prescribed for 4 weeks. The subjects were instructed to record their gastrointestinal symptom rating scale before the study and 1 and 4 weeks after beginning the protocol. These scores of the groups were compared before and after the treatment to evaluate the severity of their symptoms and the number of symptom items present in each group. For the subjects receiving rebamipide, the total prevalence of lower gastrointestinal symptoms was significantly different from the placebo group (p=0.0093) at week 4. No troublesome symptoms were observed in the rebamipide group. Inconclusion, the administration of rebamipide prevented the occurrence of troublesome symptoms, especially lower gastrointestinal symptoms, in patients taking aspirin and omeprazole. Rebamipide is a candidate drug for combination therapy with proton pump inhibitors to prevent low-dose aspirin-induced gastrointestinal symptoms.

Investigating functional dyspepsia in Asia

The diagnosis of functional dyspepsia (FD) is challenging since it depends largely on symptoms which are often heterogeneous and overlapping. This is particularly so in Asia with many different cultures and languages. Symptom-based diagnosis of FD based on Rome III criteria has not been fully validated and it may not be suitable in some Asian populations. Clinicians often assume that investigations in FD are not rewarding and physiological tests are often not available unless in the research setting. Investigation of alarm features and role of Helicobacter pylori in FD remain controversial but experts agreed that both should be tested. Physiological tests including gastric accommodation and chemical hypersensitivity tests are underutilized in Asia and available studies were few. While experts do not recommend routine clinical use of gastric accommodation tests but they agree that these tests can be advocated if clinically indicated. Empiric therapeutic trial is not currently a diagnostic option. The pathogenesis of FD is still poorly understood and there is a substantial placebo response. As a conclusion, a diagnosis of FD is challenging especially so in the context of Asia and despite the limitations of available physiological tests experts agreed that these tests can be advocated if and when clinically indicated.

Effects of DA-9701, a novel prokinetic agent, on gastric accommodation in conscious dogs

BACKGROUND AND AIM

DA-9701, a novel prokinetic agent formulated with Pharbitis Semen and Corydalis Tuber, has strong prokinetic effects, and enhances gastric compliance in conscious dogs. In this study, the effects of DA-9701 on gastric accommodation were studied in conscious dogs.

METHODS

Beagle dogs with an implanted gastric cannula in the stomach were used in this study. After an overnight fast, the dogs received DA-9701 orally, or served as a positive control that received sumatriptan or a negative control before ingestion of a meal. The basal and postprandial gastric volumes were monitored at a constant operating pressure using an electronic barostat. To investigate the long-lasting effects on increased postprandial gastric volume, the area under the volume versus time curve (AUC) was calculated.

RESULTS

DA-9701 significantly increased the basal gastric volume compared to the negative controls (P < 0.05); the effects were comparable to sumatriptan. DA-9701 and sumatriptan significantly increased gastric accommodation compared to the negative control (P < 0.05). In the negative control, the gastric volume reached the maximal volume 40 min after the meal, and then gradually decreased. However, with DA-9701, the increased gastric volume remained significantly elevated for 60 min postprandially (P < 0.05). DA-9701 significantly increased the value of AUC compared to the negative control; this was observed during both the early and late postprandial phases (P < 0.05).

CONCLUSIONS

A novel prokinetic agent, DA-9701, improved gastric accommodation by increasing the postprandial gastric volume; these effects persisted for 60 min after a meal.

Oxytocin-immunoreactive innervation of identified neurons in the rat dorsal vagal complex

BACKGROUND

Oxytocin (OXT) has been implicated in reproduction and social interactions and in the control of digestion and blood pressure. OXT-immunoreactive axons occur in the dorsal vagal complex (DVC; nucleus tractus solitarius, NTS, dorsal motor nucleus of the vagus, DMV, and area postrema, AP), which contains neurons that regulate autonomic homeostasis. The aim of the present work is to provide a systematic investigation of the OXT-immunoreactive innervation of dorsal motor nucleus of the vagus (DMV) neurons involved in the control of gastrointestinal (GI) function.

METHODS

We studied DMV neurons identified by (i) prior injection of retrograde tracers in the stomach, ileum, or cervical vagus or (ii) induction of c-fos expression by glucoprivation with 2-deoxyglucose. Another subgroup of DMV neurons was identified electrophysiologically by stimulation of the cervical vagus and then juxtacellularly labeled with biotinamide. We used two- or three-color immunoperoxidase labeling for studies at the light microscopic level.

KEY RESULTS

Close appositions from OXT-immunoreactive varicosities were found on the cell bodies, dendrites, and axons of DMV neurons that projected to the GI tract and that responded to 2-deoxyglucose and juxtacellularly labeled DMV neurons. Double staining for OXT and choline acetyltransferase revealed that OXT innervation was heavier in the caudal and lateral DMV than in other regions. OXT-immunoreactive varicosities also closely apposed a small subset of tyrosine hydroxylase-immunoreactive NTS and DMV neurons.

CONCLUSIONS & INFERENCES

Our results provide the first anatomical evidence for direct OXT-immunoreactive innervation of GI-related neurons in the DMV.

Nutritional therapy for the management of diabetic gastroparesis: clinical review

Diabetic gastroparesis (DGP), or slow emptying of the stomach, is a well-established complication of diabetes mellitus and is typically considered to occur in individuals with long-standing type 1 and type 2 diabetes mellitus. Clinical consequences of DGP include induction of gastrointestinal (GI) symptoms (early satiety, abdominal distension, reflux, stomach spasm, postprandial nausea, vomiting), alteration in drug absorption, and destabilization of glycemic control (due to mismatched postprandial glycemic and insulin peaks). Effective nutritional management not only helps in alleviating the symptoms, but also in facilitating better glycemic control. Although there have been no evidence-based guidelines pertaining to the nutrition care process of the DGP, the current dietary recommendations are based on expert opinions or observational studies. The dietary management of gastroparesis needs to be tailored according to the severity of malnutrition and kind of upper GI symptom by changing the volume, consistency, frequency, fiber, fat, and carbohydrates in the meal. Small frequent meals, using more liquid calories, reducing high fat or high fiber, consuming bezoar forming foods, and adjusting meal carbohydrates based on medications or insulin helps in improving the upper GI symptoms and glycemic control. Enteral nutrition can be an option for patients who fail to stabilize their weight loss, or for those who cannot gain weight with oral feedings, while total parenteral nutrition is rarely necessary for the patient with gastroparesis.

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.

Thermal care of functional dyspepsia based on bicarbonate-sulphate-calcium water: a sequential clinical trial

Drug treatment of functional dyspepsia is often unsatisfactory. We assessed the efficacy of a bicarbonate-sulphate-calcium thermal water cycle of 12 days, in patients with functional dyspepsia. Patients with functional dyspepsia were sent by their general practitioners to 12 days of treatment with thermal water, 200–400 ml in the morning, at temperature of 33°C (91.4 F) and were evaluated on a strict intention to treat basis. Four efficacy endpoints were analyzed as follows: (i) reduction of the global symptoms score, (ii) reduction of intensity to a level not interfering with everyday activities, (iii) specific efficacy on ulcer-like or dysmotility-like dyspepsia and (iv) esophageal or abdominal-associated symptoms. Statistical significance was reached for all three primary outcomes after the first 29 consecutive patients. Thermal water reduced the global symptom score, reduced intensity of symptoms to a level not interfering with everyday activity, but was unable to completely suppress all symptoms. A parallel effect emerged for ulcer-like and dyspepsia-like subgroups. The effect on heartburn and abdominal symptoms was not significant, suggesting a specific effect of the water on the gastric and duodenal wall. The Roma II criteria identify a natural kind of dyspepsia that improves with thermal water. Ulcer-like and dysmotility-like are not therapeutically distinguishable subgroups. Patients with dominant esophageal or abdominal symptoms should receive a different therapy. Sequential methods are very effective for the evaluation of traditional care practices and should be considered preliminary and integrative to randomized controlled trials in this context.

Plasticity of vagal brainstem circuits in the control of gastrointestinal function

The afferent vagus transmits sensory information from the gastrointestinal (GI) tract and other viscera to the brainstem via a glutamatergic synapse at the level of the nucleus of the solitary tract (NTS). Second order NTS neurons integrate this sensory information with inputs from other CNS regions that regulate autonomic functions and homeostasis. Glutamatergic and GABAergic neurons are responsible for conveying the integrated response to other nuclei, including the adjacent dorsal motor nucleus of the vagus (DMV). The preganglionic neurons in the DMV are the source of the parasympathetic motor response back to the GI tract. The glutamatergic synapse between the NTS and DMV is unlikely to be tonically active in regulating gastric motility and tone although almost all neurotransmitters tested so far modulate transmission at this synapse. In contrast, the tonic inhibitory GABAergic input from the NTS to the DMV appears to be critical in setting the tone of gastric motility and, under basal conditions, is unaffected by many neurotransmitters or neurohormones. This review is based, in part, on a presentation by Dr Browning at the 2009 ISAN meeting in Sydney, Australia and discusses how neurohormones and macronutrients modulate glutamatergic transmission to NTS neurons and GABAergic transmission to DMV neurons in relation to sensory information that is received from the GI tract. These neurohormones and macronutrients appear to exert efficient "on-demand" control of the motor output from the DMV in response to ever-changing demands required to maintain homeostasis.