Management guidelines for uninvestigated and functional dyspepsia in the Asia-Pacific region: First Asian Pacific Working Party on Functional Dyspepsia

Clinical Trial: Efficacy of Mosapride Controlled-release and Nortriptyline in Patients With Functional Dyspepsia: A Multicenter, Double-placebo, Double-blinded, Randomized Controlled, Parallel Clinical Study

Background/Aims

Prokinetic agents and neuromodulators are among the treatment options for functional dyspepsia (FD), but their comparative efficacy is unclear. We aimed to compare the efficacy of mosapride controlled-release (CR) and nortriptyline in patients with FD after 4 weeks of treatment.

Methods

Participants with FD were randomly assigned (1:1) to receive mosapride CR (mosapride CR 15 mg and nortriptyline placebo) or nortriptyline (mosapride CR placebo and nortriptyline 10 mg) in double-placebo, double-blinded, randomized controlled, parallel clinical study. The primary endpoint was defined as the proportion of patients with overall dyspepsia improvement after 4 weeks treatment. The secondary endpoints were changes in individual symptom scores, anxiety, depression, and quality of life.

Results

One hundred nine participants were recruited and assessed for eligibility, and 54 in the mosapride CR group and 50 in the nortriptyline group were included in the modified intention-to-treat protocol. The rate of overall dyspepsia improvement was similar between groups (53.7% vs 54.0%, P = 0.976). There was no difference in the efficacy of mosapride CR and nortriptyline in a subgroup analysis by FD subtype (59.3% vs 52.5% in postprandial distress syndrome, P = 0.615; 44.4% vs 40.0% in epigastric pain syndrome, P = > 0.999; 50.0% vs 59.1% in overlap, P = 0.565; respectively). Both treatments significantly improved anxiety, depression, and quality of life from baseline.

Conclusion

Mosapride CR and nortriptyline showed similar efficacy in patients with FD regardless of the subtype. Both treatments could be equally helpful for improving quality of life and psychological well-being while also relieving dyspepsia.

Value of age and alarm features for predicting upper gastrointestinal malignancy in patients with dyspepsia: an endoscopic database review of 4664 patients in Thailand

OBJECTIVE

Age and alarm features are commonly used as indicators for endoscopy in dyspeptic patients; however, the age cut-off and the predictive value of these parameters for identifying upper gastrointestinal (UGI) malignancies are uncertain.

DESIGN

Cross-sectional study.

SETTING

Data were extracted from the Gastrointestinal Endoscopy Centre of Siriraj Hospital, Thailand, during 2005-2011.

PARTICIPANTS

Consecutive patients underwent a first-time upper endoscopy for dyspepsia. Patients with previous surgery, suspected UGI malignancy by imaging, or indefinite biopsy results on prior examination were excluded.

MAIN OUTCOME MEASURES

Alarm features included dysphagia, unintentional weight loss, GI bleeding/anaemia, and persistent vomiting. The diagnostic performance of each alarm feature and different age cut-off values were evaluated.

RESULTS

A total of 4664 patients (mean age: 52.0±14.4 years, 66% female) were included. Alarm symptoms were presented in 21.6%. The prevalence of active Helicobacter pylori infection was 26.3%. Fifty-eight (1.2%) patients had UGI malignancy. The prevalence of malignancy significantly increased with increasing age (0.6% in patients aged <50 years, and 1.8% in patients aged >60 years (p<0.001)). Cancer was found in two patients aged <50 years who did not have alarm features. Patients with alarm features had a higher prevalence of malignancy (OR 22.3, 95% CI 10.5 to 47.4; p<0.001) than those without. The pooled sensitivity, specificity, positive predictive value and negative predictive value of alarm features for UGI malignancy were 87.0%, 79.1%, 4.7% and 99.8%, respectively. Among all age groups, persistent vomiting had a positive likelihood ratio (PLR) >10, while dysphagia and GI bleeding/anaemia had a PLR >10 in patients <50 years old.

CONCLUSION

Despite the overall limited value of age and alarm features, persistent vomiting, dysphagia, and GI bleeding/anaemia are strong predictors for malignancy in patients aged <50 years. Without these symptoms, cancer prevalence is negligible; thus, they are worthy guidance for endoscopic evaluation in this age group.

Endoscopic Findings in Patients With Uninvestigated Dyspepsia: A Retrospective Study From Qatar

Background and objective Dyspepsia is a common complaint encountered in general clinical practice. The prevalence of clinically significant endoscopy findings in dyspeptic subjects of various age groups and ethnicities in Qatar is not well studied. This study aimed to evaluate the prevalence of endoscopic findings in previously uninvestigated patients with dyspepsia. Patients and methods We retrospectively studied subjects older than 18 years of age who underwent endoscopy for dyspeptic complaints from January 2011 to December 2017. Subjects who already had peptic ulcer disease (PUD), those who underwent endoscopy for reasons other than dyspepsia, and those with incomplete data were excluded. Results A total of 824 subjects were reviewed for eligibility and 733 were included for analysis. The mean ±SD age of the study subjects was 42.7 ±13.5 years, and 59.5% of the subjects were male. Epigastric pain was the predominant symptom (79.2%) followed by heartburn (26.1%). Abnormal endoscopic findings were noted in 91.8% of subjects. Gastritis (65.5%) and oesophagitis (33.1%) were the most common findings observed. The overall prevalence of gastric ulcers was 4.6%, and it was higher in subjects who were more than 60 years of age (14.1%, p=0.001). Gastric carcinoma was seen in only four (0.54%) subjects. Conclusion Gastritis was the most common endoscopic finding observed followed by oesophagitis. The most common presenting symptoms were epigastric pain and heartburn. The prevalence of gastric ulcers was significantly high in patients above 60 years of age, and the incidence of gastric carcinoma was low in the study population.

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.

Effectiveness of management strategies for uninvestigated dyspepsia: systematic review and network meta-analysis

OBJECTIVE

To determine the effectiveness of management strategies for uninvestigated dyspepsia.

DESIGN

Systematic review and network meta-analysis.

DATA SOURCES

Medline, Embase, Embase Classic, the Cochrane Central Register of Controlled Trials, and clinicaltrials.gov from inception to September 2019, with no language restrictions. Conference proceedings between 2001 and 2019.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials that assessed the effectiveness of management strategies for uninvestigated dyspepsia in adult participants (age ≥18 years). Strategies of interest were prompt endoscopy; test for Helicobacter pylori and perform endoscopy in participants who test positive; test for H pylori and eradication treatment in those who test positive ("test and treat"); empirical acid suppression; or symptom based management. Trials reported dichotomous assessment of symptom status at final follow-up (≥12 months).

RESULTS

The review identified 15 eligible randomised controlled trials that comprised 6162 adult participants. Data were pooled using a random effects model. Strategies were ranked according to P score, which is the mean extent of certainty that one management strategy is better than another, averaged over all competing strategies. "Test and treat" ranked first (relative risk of remaining symptomatic 0.89, 95% confidence interval 0.78 to 1.02, P score 0.79) and prompt endoscopy ranked second, but performed similarly (0.90, 0.80 to 1.02, P score 0.71). However, no strategy was significantly less effective than "test and treat." Participants assigned to "test and treat" were significantly less likely to receive endoscopy (relative risk v prompt endoscopy 0.23, 95% confidence interval 0.17 to 0.31, P score 0.98) than all other strategies, except symptom based management (relative risk v symptom based management 0.60, 0.30 to 1.18). Dissatisfaction with management was significantly lower with prompt endoscopy (P score 0.95) than with "test and treat" (relative risk v "test and treat" 0.67, 0.46 to 0.98), and empirical acid suppression (relative risk v empirical acid suppression 0.58, 0.37 to 0.91). Upper gastrointestinal cancer rates were low in all trials. Results remained stable in sensitivity analyses, with minimal inconsistencies between direct and indirect results. Risk of bias of individual trials was high; blinding was not possible because of the pragmatic trial design.

CONCLUSIONS

"Test and treat" was ranked first, although it performed similarly to prompt endoscopy and was not superior to any of the other strategies. "Test and treat" led to fewer endoscopies than all other approaches, except symptom based management. However, participants showed a preference for prompt endoscopy as a management strategy for their symptoms.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number CRD42019132528.

Therapy of gastroesophageal reflux disease and functional dyspepsia overlaps with symptoms after usual-dose proton pump inhibitor: Acotiamide plus usual-dose proton pump inhibitor versus double-dose proton pump inhibitor

BACKGROUND AND AIM

Gastroesophageal reflux disease (GERD) and functional dyspepsia (FD) often coexist or overlap. In this study, the efficacy of acotiamide in combination with a standard dose of rabeprazole for GERD and FD was compared with that of a double dose of rabeprazole.

METHODS

Patients with overlap between GERD and FD experiencing heartburn and epigastric fullness symptoms after standard-dose proton pump inhibitor (PPI) for ≥ 8 weeks were randomized into two groups and received either acotiamide 300 mg/day + rabeprazole 10 mg/day or rabeprazole 20 mg/day for 4 weeks. Efficacy was assessed by reductions in symptom scores using the Izumo scale questionnaire and modified F-scale questionnaire.

RESULTS

As the primary endpoint, three upper gastrointestinal symptoms (heartburn, epigastralgia, and epigastric fullness) were reduced by ≥ 50% in 40.8% and 46.9% of patients in the combination and PPI double-dose groups, respectively, with no significant difference between the two groups. Essentially similar results were obtained for the modified F-scale questionnaire. No serious adverse events were noted.

CONCLUSIONS

Acotiamide 300 mg/day in combination with rabeprazole 10 mg/day or rabeprazole 20 mg/day relieved symptoms in patients with overlap between GERD and FD experiencing heartburn and epigastric fullness symptoms after standard-dose PPI for ≥ 8 weeks, and the efficacies did not differ between the two treatments. The combination therapy may be an alternative option for persistent symptoms in these patients.

Evidence-based clinical practice guidelines for functional dyspepsia

General interest in functional gastrointestinal disorders is increasing among Japanese doctors as well as patients. This increase can be attributed to a number of factors, including recent increased interest in quality of life and advances in our understanding of the pathophysiology of gastrointestinal disease. Japan recently became the world's first country to list "functional dyspepsia" as a disease name for national insurance billing purposes. However, recognition and understanding of functional dyspepsia (FD) remain poor, and no standard treatment strategy has yet been established. Accordingly, the Japanese Society of Gastroenterology (JSGE) developed an evidence-based clinical practice guideline for FD, consisting of five sections: concept, definition, and epidemiology; pathophysiology; diagnosis; treatment; and prognosis and complications. This article summarizes the Japanese guideline, with particular focus on the treatment section. Once a patient is diagnosed with FD, the doctor should carefully explain the pathophysiology and benign nature of this condition, establish a good doctor-patient relationship, and then provide advice for daily living (diet and lifestyle modifications, explanations, and reassurance). The proposed pharmacological treatment is divided into two steps: initial treatment including an acid inhibitory drug (H2RA or PPI) or prokinetics, (strong recommendation); second-line treatment including anxiolytics, antidepressants, and Japanese traditional medicine (weak recommendation). H. pylori eradication, strongly recommended with a high evidence level, is positioned separately from other treatment flows. Conditions that do not respond to these treatment regimens are regarded as refractory FD. Patients will be further examined for other organic disorders or will be referred to specialists using other approaches such as psychosomatic treatment.

Helicobacter Pylori "Test-and-Treat" Strategy for Management of Dyspepsia: A Comprehensive Review

OBJECTIVES:

Deciding on whether the Helicobacter pylori test-and-treat strategy is an appropriate diagnostic–therapeutic approach for patients with dyspepsia invites a series of questions. The aim present article addresses the test-and-treat strategy and attempts to provide practical conclusions for the clinician who diagnoses and treats patients with dyspepsia.

METHODS:

Bibliographical searches were performed in MEDLINE using the keywords Helicobacter pylori, test-and-treat, and dyspepsia. We focused mainly on data from randomized controlled trials (RCTs), systematic reviews, meta-analyses, cost-effectiveness analyses, and decision analyses.

RESULTS:

Several prospective studies and decision analyses support the use of the test-and-treat strategy, although we must be cautious when extrapolating the results from one geographical area to another. Many factors determine whether this strategy is appropriate in each particular area. The test-and-treat strategy will cure most cases of underlying peptic ulcer disease, prevent most potential cases of gastroduodenal disease, and yield symptomatic benefit in a minority of patients with functional dyspepsia. Future studies should be able to stratify dyspeptic patients according to their likelihood of improving after treatment of infection by H. pylori.

CONCLUSIONS:

The test-and-treat strategy will cure most cases of underlying peptic ulcer disease and prevent most potential cases of gastroduodenal disease. In addition, a minority of infected patients with functional dyspepsia will gain symptomatic benefit. Several prospective studies and decision analyses support the use of the test-and-treat strategy. The test-and-treat strategy is being reinforced by the accumulating data that support the increasingly accepted idea that “the only good H. pylori is a dead H. pylori”.

[Guidelines for the treatment of functional dyspepsia]

Functional dyspepsia (FD) is defined as the presence of symptoms thought to originate in the gastroduodenal area, in the absence of any organic, systemic, or metabolic disease that is likely to explain the symptoms. Based on the available evidence and consensus opinion, thirteen consensus statements for the treatment of FD were developed using the modified Delphi approach. Proton pump inhibitor, prokinetics, and histamine 2 receptor antagonists are effective for the treatment of FD. Mucosal protecting agents, fundus relaxant, and drugs for visceral hypersensitivity can improve symptoms in FD. Antacids and antidepressants may help improving symptoms in FD. Comparing endoscopy with 'test and treat' of Helicobacter pylori, endoscopy may be more effective initial strategy for managing patients with FD in Korea given high incidence of gastric cancer and low cost of endoscopy. Helicobacter pylori eradication can be one of the therapeutic options for patients with FD. Psychotherapy is effective for those who have severe symptoms and refractoriness. Further studies are strongly needed to develop better treatment strategies for Korean patients with FD.

The value of Carlsson-dent questionnaire in diagnosis of gastroesophageal reflux disease in area with low prevalence of gastroesophageal reflux disease

Background/Aims

Symptom-based diagnosis for gastroesophageal reflux disease (GERD) has been accepted in the population with high prevalence. Carlsson-Dent questionnaire (CDQ) is a standardized symptom-based diagnosis tool for GERD. The value of this tool in the population with low prevalence is unknown. The aim of this study was to determine CDQ performance for diagnosis of GERD in Thai population with low prevalence versus endoscopy or 24 hour pH monitoring.

Methods

Patients with dyspepsia by Rome II criteria were recruited. All patients completed a Thai version of CDQ and underwent endoscopic examination. Those without esophagitis or peptic ulcer and positive CDQ score took pH monitoring.

Results

One hundred patients (68 female) with mean age ± SD of 45.6 ± 12.4 years were recruited. Six with Los Angeles grade A esophagitis had negative CDQ score. In 44 with positive CDQ score, 3 had Los Angeles grade B esophagitis and 41 had pH monitoring done with 8 having positive test. The GERD diagnosis by CDQ was confirmed in 11 of 44 patients (25%). CDQ detected 11 out of 17 GERD detected by endoscopy and pH monitoring and the sensitivity of CDQ was 64%.

Conclusions

CDQ diagnosed more GERD in Thai population with low prevalence compared with endoscopy and pH monitoring. This may be due to some patients with functional heartburn were picked up by CDQ and some patients with GERD were not detected by endoscopy and pH monitoring.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Clinical practice: diagnosis and evaluation of dyspepsia

The main issue regarding the approach to the patient with uninvestigated dyspepsia is whether the symptoms are the result of an important clinical illness, which then determines the appropriate management strategy for the treatment of the symptoms. An initial trial of empiric antisecretory drugs is recommended for those without Helicobacter pylori infection and no alarm symptoms, whereas H. pylori eradication is recommended for those with an active H. pylori infection. Treatment expectations for H. pylori infections should theoretically be similar to other common infectious diseases. In most regions, clarithromycin resistance has undermined traditional triple therapy so that it is no longer a suitable choice as an empiric therapy. Four drug therapies, such as sequential, concomitant, and bismuth-quadruple therapy are generally still acceptable choices as empiric therapies. Posteradication testing is highly recommended to provide early identification of otherwise unrecognized increasing antimicrobial resistance. However, despite the ability to successfully cure H. pylori infections, a symptomatic response can be expected in only a minority of those with dyspepsia not associated with ulcers (so called nonulcer dyspepsia). Overall, from the patients stand point, symptomatic relief is often difficult to achieve and physicians must rely on reassurance along with empiric and individualized care.

Evaluation and management of dyspepsia

Dyspepsia is a common clinical problem seen by both primary care physicians and gastroenterologists. Initial evaluation should focus on the identification and treatment of potential causes of symptoms such as gastroesophageal reflux disease (GERD), peptic ulcer disease, and medication side effects but also on recognizing those at risk for more serious conditions such as gastric cancer. This manuscript discusses the evaluation and management of dyspepsia including the role of proton-pump inhibitors, treatment of Helicobacter pylori, and endoscopy. Finally, treatment of refractory functional dyspepsia is addressed.

Gastric carcinogenesis: Possible role of polymorphisms of GSTM1, GSTT1, and GSTP1 genes

OBJECTIVE

Although Helicobacter pylori infection is associated with gastric cancer (GC), only 1% of patients develop a malignancy, which suggests a role of host genetic factors. The aim of this study was to investigate the role of polymorphisms of GSTM1, GSTT1, and GSTP1 genes, which encode for carcinogen-detoxifying enzymes, in gastric mutagenesis.

MATERIAL AND METHODS

Genotyping of GSTT1 and GSTM1 was done using PCR, while PCR-RFLP (polymerase chain reaction-restriction fragment length polymorphism) was used for genotyping of GSTP1 in 76 patients with gastric neoplasm (GN), 67 with non-ulcer dyspepsia (NUD), 44 with peptic ulcer (PU), and 100 healthy controls (HC).

RESULTS

The study population included: GN (intestinal 40 (53%), diffuse 26 (34%), primary gastric lymphoma 8 (11%) and unclassified 2 (2%)), PU (duodenal ulcer (DU) 33 (75%), gastric ulcer (GU) 10 (23%), both PU and DU 1 (2%)). GSTT1 null genotype (GSTT1*0) was more common in patients with GN (30/76 (40%)) than in those with PU (5/44 (11%); p=0.001, odds ratio (OR) 5; 95% CI=1-4) and HC (23/100 (23%); p=0.02, OR 2; 95% CI=1-4). GSTT1*0 conferred a higher cancer risk for patients with DU (2/33 (6%), OR 10; 95% CI=2-45; p=0.00). GSTM1*0 and GSTP1 variant genotypes (ile/val and val/val) not alone but in combination with GSTT1*0 conferred a higher risk in PU patients (21 (28%) versus 5 (11%); OR 3; 95% CI=1-9; p=0.04). Both GSTM1*0 (16/26 (61%) versus 10/40 (25%); p=0.003, OR 5; 95% CI=2-14) and GSTT1*0 (12/26 (46%) versus 13/40 (33%); p=0.2, OR 2; 95% CI=0.6-5) were associated with a higher risk of diffuse tumor than of intestinal tumor.

CONCLUSIONS

GSTT1*0 alone and in combination with GSTM1*0 and GSTP1 variant genotypes is a risk factor for GN in the Indian population. Low GSTT1*0 in DU patients may play a protective role against GN. GSTM1*0 and GSTT1*0 are risk factors for diffuse GC.

Current guidelines for dyspepsia management

BACKGROUND

Dyspepsia is a global problem and the management of the condition remains a considerable burden on health care resources. Many countries have adopted evidence-based guidelines for the management of the condition, in an attempt to reduce health care expenditure. This article compares and contrasts dyspepsia management guidelines from several geographical regions.

METHODS

We obtained current guidelines from five regions and examined composition of guideline development groups, methodology involved, definition of dyspepsia utilized, and recommendations in terms of first-line approach, age cutoff for prompt upper gastrointestinal (GI) endoscopy, and subsequent role of endoscopy.

RESULTS

All guidelines carried out extensive reviews of the literature to inform their recommendations. The majority used a definition of dyspepsia in line with the Rome criteria. All agreed that alarm symptoms at any age warranted prompt endoscopy, and most recommended an age cutoff of between 50 and 55 years for endoscopy as an initial management strategy. In young patients without alarm symptoms, either 'test and treat' or empirical acid suppression were the initial management strategies of choice in all cases, with only one guideline recommending mandatory endoscopy in those whose symptoms failed to settle after this approach.

CONCLUSIONS

Despite varying composition of guideline development groups and the different geographical regions, the recommendation of all the guidelines were remarkably similar, reflecting the quality of research conducted by the GI community as a whole.

Tegaserod for dyspepsia and reflux symptoms in patients with chronic constipation: an exploratory open-label study

OBJECTIVE

To evaluate the potential role of tegaserod in the management of functional dyspepsia (FD) and gastroesophageal reflux disease (GERD) in patients with chronic constipation and to determine the possible efficacy of tegaserod on solid-phase gastric emptying and gastric hypersensitivity.

METHOD

This was an exploratory open-label trial of tegaserod therapy for dyspepsia and reflux symptoms in patients with chronic constipation. The study cohort consisted of 90 patients randomized to three treatment groups for a study period of 4 weeks (tegaserod 6 mg, twice daily; esomeprazole 40 mg, once daily; tegaserod 6 mg, twice daily plus esomeprazole 40 mg, once daily). Twenty healthy volunteers provided control values. Clinical symptoms were evaluated by one of the investigators using a Gastrointestinal Symptom Rating Scale (GSRS). Solid-phase gastric emptying and colonic transit were measured by the radiopaque barium marker method, and the water load test (WLT) was used to evaluate gastric sensation and the function of proximal stomach. The proportions of patients with complete relief of epigastric pain /discomfort, epigastric fullness, early satiety and heartburn in the tegaserod group and the tegaserod plus esomeprazole group were compared with the esomeprazole group, respectively.

RESULTS

The mean global gastrointestinal (GI) scores of all three treatment groups reported using the GSRS showed the same trend, with decreasing scores over the 4-week study period indicating a reported decreasing severity of symptoms that was significantly different from baseline values. Patients in the tegaserod plus esomeprazole group reported the lowest global GI scores after 4 weeks, as expected. Solid-phase gastric emptying (GER) and colonic transit (CTT) increased significantly in the tegaserod 6 mg twice daily group compared with baseline. These parameters did not change in the esomeprazole group at week 4 compared with baseline. In terms of gastric sensation, in the tegaserod group, the proportions of patients with hypersensitivity of the first perception threshold did not change at week 2 or week 4 compared with baseline; however, in this group and in the tegaserod plus esomeprazole group, the proportions of patients with hypersensitivity of discomfort threshold decreased significantly at week 4 compared with baseline. In the esomeprazole group, there were no changes in the proportions of patients with hypersensitivity of the first perception threshold and discomfort threshold at week 2 or 4 compared with baseline. No severe adverse events were recorded, and the medications were in general well-tolerated.

CONCLUSION

Tegaserod is effective and safe at improving dyspepsia and reflux symptoms in patients with chronic constipation, and tegaserod plus esomeprazole is superior to esomeprazole alone in the resolution of epigastric pain/discomfort and heartburn.

Comparison between empirical prokinetics, Helicobacter test-and-treat and empirical endoscopy in primary-care patients presenting with dyspepsia: A one-year study

AIM: To investigate the optimal strategy to treat dyspeptic patients in primary care.

METHODS: Dyspeptic patients presenting to primary care outpatient clinics were randomly assigned to: (1) empirical endoscopy, (2) H pylori test-and-treat, and (3) empirical prokinetic treatment with cisapride. Early endoscopy was arranged if patients remained symptomatic after 2 wk. Symptom severity, quality-of-life (SF-36) as well as patient preference and satisfaction were assessed. All patients underwent endoscopy by wk 6. Patients were followed up for one year.

RESULTS: Two hundred and thirty four patients were recruited (163 female, mean age 49). 46% were H pylori positive. 26% of H pylori tested and 25% of empirical prokinetic patients showed no improvement at wk 2 follow-up and needed early endoscopy. 15% of patients receiving empirical cisapride responded well to treatment but peptic ulcer was the final diagnosis. Symptom resolution and quality-of-life were similar among the groups. Costs for the three strategies were HK$4343, $1771 and $1750 per patient. 66% of the patients preferred to have early endoscopy.

CONCLUSION: The three strategies are equally effective. Empirical prokinetic treatment was the least expensive but peptic ulcers may be missed with this treatment. The H pylori test-and-treat was the most cost-effective option.

Functional dyspepsia--a multicausal disease and its therapy

Functional dyspepsia is a common chronic disorder with non-specific upper abdominal symptoms which can not be explained by organic or biochemical abnormalities. The dyspeptic symptoms are very compromising and bothersome and result in a substantial reduction of quality of life. The substantial direct and indirect medical and economical costs induce a high socioeconomic interest in the pathogenesis and the treatment options of this disease. Over the past 30 years several theories about the etiology of the symptoms in functional dyspepsia patients have been put forward. These include disorders of gastrointestinal motility, acid secretion, visceral hypersensitivity, adaptation and accommodation, Hp-infection, mucosal inflammation and finally genetic predisposition. There is increasing evidence that functional dyspepsia is a multi-causal disorder, which leads to altered processing of afferent information from the gastrointestinal tract to the CNS. Autonomic hypersensitivity and altered central processing could be a common phenomenon whereas motility changes, inflammation or altered secretion could increase neural afferent inputs. Treatment of this complex disorder could and should involve these different levels of symptom generation. Thus different approaches with anti-secretory, spasmolytic, prokinetic and anti-inflammatory effects and most preferably reduction of visceral hypersensitivity seem logical. This could explain the variety of drugs which show a positive symptomatic response. This could also offer the conclusion, whether a combination of these drugs could be clinically superior which remains to be proven. And this could offer a logical approach for the use of substances with a multi-target action, e.g. STW 5.

The optimal age threshold for screening upper endoscopy for uninvestigated dyspepsia in Taiwan, an area with a higher prevalence of gastric cancer in young adults

BACKGROUND

It is estimated that 1% to 2% of patients with dyspepsia are associated with gastric cancer. To avoid missing gastric cancer, most guidelines recommend that patients over 45 years old should undergo EGD for uninvestigated dyspepsia. In Taiwan, however, the prevalence of gastric cancer in younger patients is higher than that of Western countries. The optimal age threshold for endoscopy in patients with uninvestigated dyspepsia in Taiwan remains controversial. Therefore, we aimed to determine an optimal age threshold for screening endoscopy in patients with uninvestigated dyspepsia to avoid missing gastric cancer in Taiwan.

METHODS

We reviewed the findings in all adult patients who underwent upper endoscopy because of uninvestigated dyspepsia at the National Taiwan University Hospital. In those patients with confirmed gastric cancer histology, further analysis was performed. Cumulative age frequency distributions for gastric cancer were calculated according to gender and to the presence or the absence of alarm features. The stages of gastric cancer also were analyzed according to the presence or the absence of alarm symptoms.

RESULTS

During the 5-year period, a total of 17,894 patients received upper endoscopy caused by uninvestigated dyspepsia. Gastric cancer was found in 225 (12.6 cases per 1000 EGDs) patients who presented with uninvestigated dyspepsia, 135 men and 90 women. Thirty-one (13.7%) and 17 (7.6%) patients were aged less than 45 and 40 years old, respectively. Among these 225 patients with gastric cancer, 114 (50.7%) patients did not have alarm symptoms (simple dyspepsia), whereas 111 (49.3%) had alarm symptoms. About 5.3% (12/225) of gastric cancer cases would have been missed if endoscopy had been omitted in patients without alarm symptoms and aged less than 45 years. The cumulative age relative frequencies of patients with gastric cancer who presented with simple dyspepsia were 1.8 (12/6720), 1.02 (5/4920), and 0.59 (2/3411) cases per 1000 EGDs for uninvestigated dyspepsia in patients aged less than 45, 40, and 35 years, respectively. When the frequencies of gastric cancer were stratified by age and gender, we found a trend of male predominance in older patients but not in younger patients. The cutoff age was 60 years old ( p < 0.05). Early gastric cancer was detected in 9.9% (11/111) and 26.3% (30/114) of patients with and without alarm symptoms, respectively (p = 0.002).

CONCLUSIONS

Gastric cancer is not uncommon in patients with dyspepsia aged less than 45 years in Taiwan. The age threshold of screening endoscopy for uninvestigated dyspepsia should be the same for both genders in view of comparable frequencies of gastric cancer in a young age population. Because more than 5% of gastric cancer cases would be missed in Taiwan if endoscopy was omitted in simple dyspeptic patients who were aged less than 45 years, we recommend that 40 years old might be an optimal age threshold for screening endoscopy for uninvestigated dyspepsia in Taiwan, in both men and women patients.

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.

Cost-effectiveness of routine endoscopic biopsies for Helicobacter pylori detection in patients with non-ulcer dyspepsia

BACKGROUND

The role of endoscopic biopsies in the detection of Helicobacter pylori in patients with nonulcer dyspepsia is poorly defined. This study assesses the cost-effectiveness of performing routine biopsies for the detection of H pylori at upper endoscopy in these patients.

METHODS

Clinical decision-making was modeled based on outcomes data from published articles and expert opinion. The target group was adults, less than 45 years of age, with nonulcer dyspepsia as defined by a normal endoscopy. Costs, expressed in Canadian dollars, were tabulated over a 1-year time horizon. The main outcome was relief of symptoms, defined as the absence of symptom persistence or recurrence over the 12 months. A strategy of performing a biopsy for the detection of H pylori with a rapid urease test during gastroscopy was compared with that of not performing a biopsy. In addition, as a secondary analysis, the cost-effectiveness of obtaining a biopsy specimen for histopathologic evaluation in patients after a negative rapid urease test was evaluated.

RESULTS

A strategy of endoscopy with biopsy and rapid urease testing costs 3940 dollars per additional symptom-free patient as compared with endoscopy without biopsy. This result was sensitive to the difference in symptomatic recurrence rate at 1 year between patients in whom H pylori was successfully and unsuccessfully eradicated, which in this analysis, was set at 9.9%. Only when the difference in symptomatic recurrence in patients with successful versus unsuccessful eradication fell to less than 4% was endoscopy with biopsy over 10,000 dollars per cured patient greater than endoscopy without biopsy. The conclusions were otherwise robust when varying the values of other variables across clinically relevant ranges. There was little additional benefit associated with histopathologic assessment of biopsy specimens in patients with a negative rapid urease test and the cost per additional cure was 25,529 dollars.

CONCLUSIONS

In adults with nonulcer dyspepsia under age 45 years undergoing endoscopy, routine procurement of a biopsy specimen for detection of H pylori was more costly yet more effective compared with not obtaining a specimen. The cost-effectiveness of a biopsy is dependent on the benefits of H pylori eradication in this patient population. The less likely a patient with nonulcer dyspepsia is to become asymptomatic after successful H pylori eradication, the more costly a strategy of routinely obtaining a specimen at endoscopy. The additional cost of sending a specimen for histopathologic analysis if the rapid urease test is negative does not appear warranted based on cost-effectiveness considerations.

Management of dyspepsia

Proper management of uninvestigated dyspepsia is a challenging task for any clinician. Efficient and cost-effective management of such patients requires careful history taking and awareness of the available options.

Anxiety but not depression determines health care-seeking behaviour in Chinese patients with dyspepsia and irritable bowel syndrome: a population-based study

AIMS

To study the prevalence of dyspepsia and irritable bowel syndrome and the effects of co-existing anxiety and depression on health care utilization by a population survey in Chinese.

METHODS

Ethnic Chinese households were invited to participate in a telephone survey using a validated bowel symptom questionnaire and the hospital anxiety and depression scale. Gastrointestinal symptoms were classified as dyspepsia and irritable bowel syndrome according to the Rome I criteria and gastro-oesophageal reflux disease by the presence of weekly heartburn or acid regurgitation. The anxiety and depression scores were compared between patients who sought medical attention and those who did not, using multiple logistic regression analysis.

RESULTS

One thousand, six hundred and forty-nine subjects completed the interview (response rate, 62%). The population prevalences of dyspepsia, irritable bowel syndrome and gastro-oesophageal reflux disease were 18.4%, 4.1% and 4.8%, respectively. Dyspepsia and irritable bowel syndrome were associated with anxiety, depression, medical consultation, sick leave and adverse effects on social life. The degree of anxiety was an independent factor associated with health care-seeking behaviour in both dyspeptics (P = 0.003) and irritable bowel syndrome patients (P = 0.036).

CONCLUSIONS

Irritable bowel syndrome and dyspepsia are associated with anxiety, depression, significant social morbidity, health care utilization and days off work. Anxiety is an independent factor in determining health care utilization in patients with dyspepsia and irritable bowel syndrome.

Do NSAIDs cause dyspepsia? A meta-analysis evaluating alternative dyspepsia definitions

OBJECTIVE

Nonsteroidal anti-inflammatory drugs (NSAIDs) may be associated with dyspepsia, but the relationship is obscured by variations in the terminology used to report GI symptoms. Using alternative definitions, we assessed the relationship between NSAID use and dyspepsia.

METHODS

We searched MEDLINE, EMBASE, HEALTHSTAR, and BIOSIS databases (1966-1997) and New Drug Application reviews, identifying randomized, placebo-controlled trials (5 days or more duration) of any NSAID, reporting original data on GI complications. Based upon reported terms describing upper GI symptoms, we derived three definitions: strict, using terms synonymous with epigastric pain/discomfort; loose, (containing the strict definition plus terms for heartburn, nausea, bloating, anorexia, and vomiting); and a loose definition without heartburn terms (the loose-less-heartburn definition). Using each definition, we performed a random-effects model meta-analysis of the relationship between NSAID exposure and dyspepsia.

RESULTS

Fifty-five published and 37 unpublished controlled NSAID trials met our inclusion criteria. The mean duration of the trials was 33.2 days (SD 40 days). Application of the strict definition resulted in a pooled risk ratio of dyspepsia for NSAIDs compared with placebo of 1.36 (95% CI = 1.11-1.67). For the loose definition, the pooled risk ratio was 1.13 (95% CI = 0.98-1.32). The loose-less-heartburn definition yielded a pooled risk ratio of 1.19 (95% CI = 1.03-1.39). In the placebo-treated control groups, the percent of patients reporting dyspepsia ranged from 2.3% (strict definition) to 4.2% (loose and loose-less-heartburn definitions).

CONCLUSIONS

Using the strict definition, based solely on epigastric pain-related symptoms, NSAIDs increased the risk of dyspepsia by 36% (p < 0.05). These findings may be useful in creating a standardized definition of NSAID-related dyspepsia.

The Hong Kong index of dyspepsia: a validated symptom severity questionnaire for patients with dyspepsia

AIM

Locally validated symptom questionnaires are essential instruments in dyspepsia research. A symptom score for Chinese dyspeptics was developed. Multiple aspects of validity and reliability were assessed.

METHODS

Sixty-five patients with endoscopy-negative dyspepsia and 65 healthy controls were presented with a list of 24 previously determined common abdominal symptoms and asked to rate the severity in a five point Likert scale. Comprehensibility and relevance of symptoms were assessed. The questionnaire was administered 3 h later to assess for reproducibility. A locally validated Short Form-36 quality-of-life questionnaire was also administered. Cisapride 5 mg thrice daily was prescribed to dyspeptic patients but not to the controls. The dyspepsia symptom and SF-36 questionnaires were repeated after 3 weeks for patients under treatment. Global change in symptoms and the need for further medical care were assessed. Concept, content, construct and criterion validity, consistency and reproducibility of the dyspepsia symptom questionnaire were assessed.

RESULTS

All items were considered comprehensible by more than 90% of subjects. Relevance of individual symptoms to dyspeptic patients ranged from 10.8-76.9%. Twelve items were selected by logistic regression to account for most of the differences between control and dyspeptic patients. Test-retest reproducibility and internal consistency were good with the intraclass correlation coefficient of 0.89 and Cronbach's alpha coefficient of 0.90. A cut-off score of equal to or greater than 16 was determined to discriminate between controls and dyspeptic patients. The dyspepsia score correlated negatively with all domains of the SF-36 quality of life scale except physical functioning. The dyspepsia questionnaire also discriminated between patients who reported a subjective improvement in symptoms and those who reported no change or worsening.

CONCLUSIONS

The dyspepsia symptom index was easy to understand, internally consistent and reproducible. It predicted global symptom change, and the symptom severity scores correlated negatively with quality of life.

Therapeutic options in nonulcer dyspepsia

Dyspepsia, defined as pain or discomfort centered in the upper abdomen, affects an estimated 25% of the U.S. population each year; accounts for up to 5% of all visits to primary care physicians, and generates over $1.3 billion in prescription drug costs annually. In the majority of patients evaluated, no clear cause of symptoms can be identified, and the condition is termed functional or nonulcer dyspepsia (NUD). The pathophysiology of NUD remains unclear, but disturbances in gastrointestinal motility or sensation are often found. Clinically, NUD can be subdivided into dysmotility-like (in which discomfort, fullness, bloating, early satiety, or nausea [but not pain] predominate) or ulcer-like (in which epigastric pain is predominant). In ulcer-like NUD, antisecretory therapy is useful, but in dysmotility-like NUD, acid suppression is not superior to placebo. Cisapride accelerates gastric emptying and enhances gastric accommodation but probably does not blunt perception. Although cisapride relieves symptoms of dyspepsia without the adverse central nervous system effects often associated with metoclopramide, its cardiac toxicity has led to disuse. Antidepressants are of uncertain efficacy but are widely used. New prokinetics and other enteric neuromodulating agents are being tested in NUD and are likely to find an important place in clinical practice in the future.

Review article: the initial management of uninvestigated dyspepsia in younger patients-the value of symptom-guided strategies should be reconsidered

Several major management guidelines on dyspepsia (upper abdominal pain or discomfort) recommend an initial 'test-and-treat' policy (non-invasive Helicobacter pylori testing with eradication therapy if positive) in uninvestigated patients less than about 45 years old. However, the evidence that this is the optimal strategy is limited. Data from the few available randomized controlled trials provide evidence that this policy improves symptomatology more than a 'test-and-endoscope' approach (in which only H. pylori-positive patients undergo early endoscopy) in those with upper abdominal pain. The balance of cost-effectiveness data from clinical studies and decision analyses indicates that both 'test-and-treat' and empirical anti-secretory therapy approaches are more cost-effective than the 'test-and-endoscope' strategy. Therefore, given concerns about the safety of widespread H. pylori eradication, initial empirical anti-secretory therapy may be a cost-effective alternative to the 'test-and-treat' policy in some younger dyspeptic patients. The effectiveness of such an empirical approach might well be improved by symptom-guided therapy and there is growing evidence that the predominant dyspeptic symptom may provide this guide. The diagnostic, therapeutic and economic utility of this approach merits further clinical investigation.

Management of uninvestigated and functional dyspepsia: a Working Party report for the World Congresses of Gastroenterology 1998

BACKGROUND

The management of dyspepsia is controversial.

METHODS

An international Working Party was convened in 1998 to review management strategies for dyspepsia and functional dyspepsia, based on a review of the literature and best clinical practice.

RESULTS

Dyspepsia, defined as pain or discomfort centred in the upper abdomen, can be managed with reassurance and over-the-counter therapy if its duration is less than 4 weeks on initial presentation. For patients with chronic symptoms, clinical evaluation depends on alarm features including patient age. The age cut off selected should depend on the age specific incidence when gastric cancer begins to increase, but in Western nations 50 years is generally an acceptable age threshold. In younger patients without alarm features, Helicobacter pylori test and treatment is the approach recommended because of its value in eliminating the peptic ulcer disease diathesis. If, after eradication of H. pylori, symptoms either are not relieved or rapidly recur, then an empirical trial of therapy is recommended. Similarly, in H. pylori-negative patients without alarm features, an empirical trial (with antisecretory or prokinetic therapy depending on the predominant symptom) for up to 8 weeks is recommended. If drugs fail, endoscopy should be considered because of its reassurance value although the yield will be low. In older patients or those with alarm features, prompt endoscopy is recommended. If endoscopy is non-diagnostic, gastric biopsies are recommended to document H. pylori status unless already known. While treatment of H. pylori is unlikely to relieve the symptoms of functional dyspepsia, the long-term benefits probably outweigh the risks and treatment can be considered on a case-by-case basis. In H. pylori-negative patients with documented functional dyspepsia, antisecretory or prokinetic therapy, depending on the predominant symptom, is reasonable, assuming reassurance and explanation are insufficient, unless patients have already failed this approach. Other treatment options include antidepressants, antispasmodics, visceral analgesics such as serotonin type 3 receptor antagonists, and behavioural or psychotherapy although these are all of uncertain efficacy. Long-term drug treatment in functional dyspepsia should be avoided; intermittent short courses of treatment as needed is preferred.

CONCLUSION

The management of dyspepsia recommended is based on current best evidence but must be tailored to local factors such as practice setting, the background prevalence of H. pylori and structural disease, and costs.

Metronidazole- and clarithromycin-resistant Helicobacter pylori in dyspeptic patients in western Sydney as determined by testing multiple isolates from different gastric sites

It is unknown whether antibiotic susceptibility testing of antral isolates alone is representative of Helicobacter pylori susceptibility. We aimed to determine: (i) the prevalence of metronidazole- and clarithromycin-resistant strains in infected dyspeptic patients; and (ii) whether there is consistency in the susceptibility to metronidazole and clarithromycin among isolates cultured from different gastric sites. Antral, body and fundus biopsies were taken from 242 consecutive patients and cultured on blood agar under micro-aerophilic conditions for 5-7 days. Isolates from 66 patients (13 had one, 15 had two and 38 had three isolates) were tested for susceptibility to metronidazole and clarithromycin using previously validated disc diffusion tests. Of the 66 patients, 42 (64%) had strains resistant to metronidazole while four (6.1%) had clarithromycin-resistant strains. The prevalence of metronidazole resistance was not significantly different between men and women (65% vs 60%) or across different age groups. In five (9.4%) of the 53 patients with multiple isolates, discrepant results for metronidazole susceptibility were observed: susceptible antral and body isolates but resistant fundus isolates in two cases and susceptible antral isolates but resistant body and fundus isolates in the others. Clarithromycin susceptibilities were consistent among the isolates cultured from different gastric sites in all patients. It is concluded that metronidazole-resistant strains of H. pylori are common while clarithromycin-resistant strains are rare. Metronidazole susceptibility testing of antral isolates does not appear to be representative of isolates from the body and fundus in a subset of patients.