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Masuy I, Van Oudenhove L, Tack J. Review article: treatment options for functional dyspepsia. Aliment Pharmacol Ther 2019; 49:1134-1172. [PMID: 30924176 DOI: 10.1111/apt.15191] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 12/03/2018] [Accepted: 01/23/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND Functional dyspepsia, consisting of epigastric pain syndrome and postprandial distress syndrome, is a prevalent functional gastrointestinal disorder. To date, only limited treatment options are available and conflicting results in terms of efficacy have been reported. Consequently, nonpharmacological treatment options are increasingly being explored for functional dyspepsia. AIM To provide an overview of current pharmacological and nonpharmacological treatment options for functional dyspepsia. METHODS A literature search was conducted on Pubmed and other sources to identify relevant studies. RESULTS Acid suppressive therapy reduced symptoms in 30%-70% of the patients, with higher benefit in epigastric pain syndrome and superior effectiveness for proton pump inhibitors compared to H2 -antagonists. Prokinetic agents, primarily used to treat postprandial distress syndrome, showed variable efficiency: 59%-81% responder rate for dopamine receptor antagonists, 32%-91% for serotonin-4-receptor agonists and 31%-80% for muscarinic receptor antagonists. H Pylori eradication, recommended in infected patients, was effective in 24%-82%. Refractory symptoms are addressed with neuromodulators. However, their efficacy in functional dyspepsia remains incompletely elucidated, available data showing symptom reduction in 27%-71% of the patients. Regarding herbal agents, peppermint oil reduced symptoms in 66%-91%, rikkunshito in 29%-34% and iberogast in 20%-95%. Lastly, acupuncture, cognitive behavioural therapy and hypnotherapy may help to provide symptom control, but research on their efficacy remains sparse. CONCLUSIONS None of the available therapies is effective in the majority of patients without being associated with major side effects. Developing new treatment options is challenging due to the heterogeneity of functional dyspepsia, the lack of readily identified target mechanisms and the poor association between pathophysiological disturbances and symptoms.
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Affiliation(s)
- Imke Masuy
- Translational Research Centre for Gastrointestinal Disorders, University of Leuven, Leuven, Belgium
| | - Lukas Van Oudenhove
- Translational Research Centre for Gastrointestinal Disorders, University of Leuven, Leuven, Belgium
| | - Jan Tack
- Translational Research Centre for Gastrointestinal Disorders, University of Leuven, Leuven, Belgium
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Jin M, Mo Y, Ye K, Chen M, Liu Y, He C. Efficacy of serotonin receptor agonists in the treatment of functional dyspepsia: a meta-analysis. Arch Med Sci 2019; 15:23-32. [PMID: 30697251 PMCID: PMC6348349 DOI: 10.5114/aoms.2017.69234] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 01/01/2017] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Functional dyspepsia (FD) is typically treated with serotonin receptor (5-HT) agonists such as cisapride, mosapride, tegaserod and tandospirone citrate. However, there are conflicting efficacy data, possibly due to significant heterogeneity between studies. In this meta-analysis, we analyzed the efficacy and safety data from studies evaluating the efficacy of serotonin receptor agonists in patients with FD. MATERIAL AND METHODS Relevant studies were selected from the Medline, Cochrane, EMBASE, and Google Scholar databases. The meta-analysis included 10 RCTs which evaluated the efficacy of serotonin receptor agonists in patients with FD (final total of 892 patients in the serotonin receptor agonist group, and 640 participants in the placebo group). The primary outcomes were the response rates and abdominal symptoms score. The Cochrane Collaboration's tool was used to assess risk. Sensitivity analysis was carried out using the leave-one-out approach. RESULTS Patients treated with serotonin receptor agonists had a significantly higher response rate compared to placebo-treated patients (pooled OR = 2.99; 95% CI: 1.15-7.77; p = 0.025). Patients treated with serotonin receptor agonists had a significant improvement in symptom scores compared to the placebo group (pooled standardized mean difference = -0.43; 95% CI: -0.83 to -0.04; p = 0.031). Sensitivity analysis indicated that the pooled estimates for abdominal symptom score might be affected by the Yeoh et al. (1997) study. CONCLUSIONS Serotonin receptor agonists had a significantly higher efficacy compared to placebo in the treatment of FD.
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Affiliation(s)
- Man Jin
- Department of Medicine, Hangzhou Seventh People’s Hospital, Zhejiang, China
| | - Yali Mo
- Department of Medicine, Hangzhou Seventh People’s Hospital, Zhejiang, China
| | - Kaisheng Ye
- Hangzhou Wengjingtang Combination of Chinese Traditional and Western Medicine Clinic, Zhejiang, China
| | - Mingxian Chen
- Department of Digestive Diseases, Chinese Traditional Medicine Research Institute of Zhejiang Province, China
| | - Yi Liu
- Department of Medicine, Hangzhou Seventh People’s Hospital, Zhejiang, China
| | - Cao He
- Department of Medicine, Hangzhou Seventh People’s Hospital, Zhejiang, China
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Henningsen P, Zipfel S, Sattel H, Creed F. Management of Functional Somatic Syndromes and Bodily Distress. PSYCHOTHERAPY AND PSYCHOSOMATICS 2018; 87:12-31. [PMID: 29306954 DOI: 10.1159/000484413] [Citation(s) in RCA: 164] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 10/17/2017] [Indexed: 12/18/2022]
Abstract
Functional somatic syndromes (FSS), like irritable bowel syndrome or fibromyalgia and other symptoms reflecting bodily distress, are common in practically all areas of medicine worldwide. Diagnostic and therapeutic approaches to these symptoms and syndromes vary substantially across and within medical specialties from biomedicine to psychiatry. Patients may become frustrated with the lack of effective treatment, doctors may experience these disorders as difficult to treat, and this type of health problem forms an important component of the global burden of disease. This review intends to develop a unifying perspective on the understanding and management of FSS and bodily distress. Firstly, we present the clinical problem and review current concepts for classification. Secondly, we propose an integrated etiological model which encompasses a wide range of biopsychosocial vulnerability and triggering factors and considers consecutive aggravating and maintaining factors. Thirdly, we systematically scrutinize the current evidence base in terms of an umbrella review of systematic reviews from 2007 to 2017 and give recommendations for treatment for all levels of care, concentrating on developments over the last 10 years. We conclude that activating, patient-involving, and centrally acting therapies appear to be more effective than passive ones that primarily act on peripheral physiology, and we recommend stepped care approaches that translate a truly biopsychosocial approach into actual management of the patient.
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Affiliation(s)
- Peter Henningsen
- Department of Psychosomatic Medicine and Psychotherapy, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
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QIANG L, JIANG Y. Electroacupuncture for functional dyspepsia and the influence on serum Ghrelin, CGRP and GLP-1 levels. WORLD JOURNAL OF ACUPUNCTURE-MOXIBUSTION 2018. [DOI: 10.1016/j.wjam.2018.06.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Yang YJ, Bang CS, Baik GH, Park TY, Shin SP, Suk KT, Kim DJ. Prokinetics for the treatment of functional dyspepsia: Bayesian network meta-analysis. BMC Gastroenterol 2017; 17:83. [PMID: 28651565 PMCID: PMC5485548 DOI: 10.1186/s12876-017-0639-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Accepted: 06/20/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Controversies persist regarding the effect of prokinetics for the treatment of functional dyspepsia (FD). This study aimed to assess the comparative efficacy of prokinetic agents for the treatment of FD. METHODS Randomized controlled trials (RCTs) of prokinetics for the treatment of FD were identified from core databases. Symptom response rates were extracted and analyzed using odds ratios (ORs). A Bayesian network meta-analysis was performed using the Markov chain Monte Carlo method in WinBUGS and NetMetaXL. RESULTS In total, 25 RCTs, which included 4473 patients with FD who were treated with 6 different prokinetics or placebo, were identified and analyzed. Metoclopramide showed the best surface under the cumulative ranking curve (SUCRA) probability (92.5%), followed by trimebutine (74.5%) and mosapride (63.3%). However, the therapeutic efficacy of metoclopramide was not significantly different from that of trimebutine (OR:1.32, 95% credible interval: 0.27-6.06), mosapride (OR: 1.99, 95% credible interval: 0.87-4.72), or domperidone (OR: 2.04, 95% credible interval: 0.92-4.60). Metoclopramide showed better efficacy than itopride (OR: 2.79, 95% credible interval: 1.29-6.21) and acotiamide (OR: 3.07, 95% credible interval: 1.43-6.75). Domperidone (SUCRA probability 62.9%) showed better efficacy than itopride (OR: 1.37, 95% credible interval: 1.07-1.77) and acotiamide (OR: 1.51, 95% credible interval: 1.04-2.18). CONCLUSIONS Metoclopramide, trimebutine, mosapride, and domperidone showed better efficacy for the treatment of FD than itopride or acotiamide. Considering the adverse events related to metoclopramide or domperidone, the short-term use of these agents or the alternative use of trimebutine or mosapride could be recommended for the symptomatic relief of FD.
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Affiliation(s)
- Young Joo Yang
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon Sacred Heart Hospital, Sakju-ro 77, Chuncheon, Gangwon-do 24253 Republic of Korea
| | - Chang Seok Bang
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon Sacred Heart Hospital, Sakju-ro 77, Chuncheon, Gangwon-do 24253 Republic of Korea
| | - Gwang Ho Baik
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon Sacred Heart Hospital, Sakju-ro 77, Chuncheon, Gangwon-do 24253 Republic of Korea
| | - Tae Young Park
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon Sacred Heart Hospital, Sakju-ro 77, Chuncheon, Gangwon-do 24253 Republic of Korea
| | - Suk Pyo Shin
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon Sacred Heart Hospital, Sakju-ro 77, Chuncheon, Gangwon-do 24253 Republic of Korea
| | - Ki Tae Suk
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon Sacred Heart Hospital, Sakju-ro 77, Chuncheon, Gangwon-do 24253 Republic of Korea
| | - Dong Joon Kim
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon Sacred Heart Hospital, Sakju-ro 77, Chuncheon, Gangwon-do 24253 Republic of Korea
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Hashizume N, Yagi M, Ushijima K, Seki Y, Fukahori S, Muto M, Matsufuji H, Taguchi T. Pharmacotherapy for pediatric chronic intestinal pseudo-obstruction: Nationwide survey in Japan. Pediatr Int 2017; 59:467-472. [PMID: 27862707 DOI: 10.1111/ped.13201] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 10/27/2016] [Accepted: 11/08/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Chronic intestinal pseudo-obstruction (CIPO) is a rare disabling and life-threatening disorder characterized by severe impairment of gastrointestinal peristalsis. While a number of pharmacotherapeutics have been developed, only a few trials have been carried out for improvement of the pathological condition of CIPO patients. This report describes the results of a nationwide survey on the pharmacotherapy used in pediatric CIPO in Japan. METHODS In 2012, a nationwide survey was conducted to identify the clinical presentation of CIPO in Japan. Information was gathered on pharmacotherapy. Four categories were created for medicines used in pharmacotherapy: "probiotics", "Japanese herbal medicines (Kampo medicines)", "laxatives", and "prokinetics". RESULTS Ninety-two responses were collected from 47 facilities. Of the 62 patients who met the diagnostic criteria, 52 were treated with medications, while the remaining 10 were not. Thirty-four patients were given a total of 49 probiotics; 39 were treated with a total of 50 Kampo medicines; 20 were treated with a total of 28 laxatives; and 26 were given a total of 30 prokinetics, 70% of whom were treated specifically with mosapride. CONCLUSION Traditional Japanese medicines such as Kampo medicines and mosapride are often used to treat CIPO in Japan. Two combinations, that is, probiotics and Kampo medicines; and Kampo medicines and prokinetics, were often used for pediatric CIPO in Japan.
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Affiliation(s)
- Naoki Hashizume
- Department of Pediatric Surgery, Kurume University School of Medicine, Kurume, Japan
| | - Minoru Yagi
- Department of Pediatric Surgery, Kurume University School of Medicine, Kurume, Japan.,Japanese Study Group of Allied Disorders of Hirschsprung's Disease, Japan
| | - Kosuke Ushijima
- Department of Pediatrics, Kurume University Medical Center, Kurume, Japan.,Japanese Study Group of Allied Disorders of Hirschsprung's Disease, Japan
| | - Yoshitaka Seki
- Department of Pediatrics and Child Health, Kurume University School of Medicine, Kurume, Japan.,Japanese Study Group of Allied Disorders of Hirschsprung's Disease, Japan
| | - Suguru Fukahori
- Department of Pediatric Surgery, Kurume University School of Medicine, Kurume, Japan.,Japanese Study Group of Allied Disorders of Hirschsprung's Disease, Japan
| | - Mitsuru Muto
- Department of Pediatric Surgery, Graduate School of Medical and Dental Sciences Kagoshima University, Kagoshima, Japan.,Japanese Study Group of Allied Disorders of Hirschsprung's Disease, Japan
| | - Hiroshi Matsufuji
- Department of Pediatric Surgery, St Luke's International Hospital, Tokyo, Japan.,Japanese Study Group of Allied Disorders of Hirschsprung's Disease, Japan
| | - Tomoaki Taguchi
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Japanese Study Group of Allied Disorders of Hirschsprung's Disease, Japan
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Bang CS, Kim JH, Baik GH, Kim HS, Park SH, Kim EJ, Kim JB, Suk KT, Yoon JH, Kim YS, Kim DJ. Mosapride treatment for functional dyspepsia: a meta-analysis. J Gastroenterol Hepatol 2015; 30:28-42. [PMID: 25041564 DOI: 10.1111/jgh.12662] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/24/2014] [Indexed: 01/12/2023]
Abstract
BACKGROUND AND AIM The aim of this study was to assess the therapeutic effect of mosapride in patients with functional dyspepsia (FD). METHODS Randomized controlled trials (RCTs) of mosapride for the treatment of FD performed between 2002 and 2013 were identified from databases. Symptom response rates were extracted and analyzed using risk ratios (RRs). A random effect model was applied based on Higgins I(2) tests. Publication bias was evaluated using a funnel plot, Egger's test, trim and fill, and the rank correlation test. RESULTS In total, 13 RCTs, which included 1091 mosapride-treated patients and 1129 control patients (on placebo or other drugs), were identified and analyzed. Overall, mosapride showed an RR of 0.999 (95% confidence interval [CI]: 0.869-1.150, P = 0.992) for improving global efficacy or symptom-based scores. In a sensitivity analysis of the high-quality RCTs, mosapride showed an RR of 1.114 (95% CI: 1.011-1.227, P = 0.029). However, in the studies using the Rome III criteria for the diagnosis of FD, mosapride showed an RR of 0.906 (95% CI: 0.807-1.016, P = 0.092). In the studies having funding source, mosapride showed an RR of 1.131 (95% CI: 1.028-1.244, P = 0.012), whereas an RR of 0.966 (95% CI: 0.896-1.042, P = 0.367) was observed in the studies without funding source. Publication bias was not detected. CONCLUSION In this analysis, we could not find a significant effect of mosapride on FD. Inconsistent diagnostic criteria for FD and different assessment outcomes are causes of heterogeneity. Further studies using common validated outcomes or questionnaires and high-quality RCTs will elucidate the real effect of this medication on FD.
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Affiliation(s)
- Chang Seok Bang
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon
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Stein B, Everhart KK, Lacy BE. Treatment of functional dyspepsia and gastroparesis. ACTA ACUST UNITED AC 2014; 12:385-97. [PMID: 25169218 DOI: 10.1007/s11938-014-0028-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OPINION STATEMENT Functional dyspepsia (FD) and gastroparesis (GP) are the two most prevalent gastric neuromuscular disorders. These disorders are frequently confused, have more similarities than differences, and can be thought of as two ends of a continuous spectrum of gastric neuromuscular disorders (Fig. 1). FD is currently defined by the Rome III criteria; it is now subdivided into a pain-predominant subtype (epigastric pain syndrome) and a meal-associated subtype (post-prandial distress syndrome). GP is defined by symptoms in conjunction with delayed gastric emptying in the absence of mechanical obstruction. Symptoms for both FD and GP are similar and include epigastric pain or discomfort, early satiety, bloating, and post-prandial nausea. Vomiting can occur with either diagnosis; it is typically more common in GP. A patient suspected of having either FD or GP should undergo upper endoscopy. In suspected FD, upper endoscopy is required to exclude an alternative organic cause for the patient's symptoms; however, most (70 %) patients with dyspeptic symptoms will have FD rather than an organic disorder. In suspected GP, upper endoscopy is required to rule out a mechanical obstruction. A 4-hour solid-phase gastric emptying scan is recommended to confirm the diagnosis of GP; its utility is unclear in patients with FD, as it may not change treatment. Once the diagnosis of FD or GP is made, treatment should focus on the predominant symptom. This is especially true in patients with GP, as accelerating gastric emptying with the use of prokinetics may not necessarily translate into an improvement in symptoms. Unfortunately, no medication is currently approved for the treatment of FD and, thus, technically, all treatment options remain off-label, including medications for visceral pain (e.g., tricyclic antidepressants) and nausea. This review focuses on treatment options for FD and GP with an emphasis on new advances in the field over the last several years.
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Affiliation(s)
- Benjamin Stein
- Division of Gastroenterology & Hepatology, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH, 03756, USA,
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Sebastián-Domingo JJ. La medicina integrativa en el manejo de la dispepsia funcional. Papel del preparado herbal STW5. GASTROENTEROLOGIA Y HEPATOLOGIA 2014; 37:256-61. [DOI: 10.1016/j.gastrohep.2013.10.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Revised: 09/30/2013] [Accepted: 10/08/2013] [Indexed: 02/07/2023]
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Wee EWL. Evidence-based approach to dyspepsia: from Helicobacter pylori to functional disease. Postgrad Med 2013; 125:169-80. [PMID: 23933904 DOI: 10.3810/pgm.2013.07.2688] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Patients with dyspepsia may present with associated complaints of abdominal pain, bloating, fullness, acid reflux, and epigastric tenderness on examination. The evaluation of patients with dyspepsia includes taking a comprehensive history and performing a physical examination. Although taking a patient history has its limitations in making an accurate diagnosis, it is useful in guiding the selection of subsequent diagnostic tests. Differential diagnoses of dyspepsia are best addressed using an anatomical approach. Patients with chronic dyspepsia lasting > 1 month should be evaluated for the presence of alarm features. Alarm features mandate an upper gastrointestinal endoscopy examination, as these may be suggestive of a malignancy. In patients without alarm features, a Helicobacter pylori test-and-treat strategy is cost-effective if the prevalence of H. pylori infection is high. Tests for H. pylori infection can be divided into non-invasive and minimally invasive tests. Many different antibiotic combination therapies (eg, triple therapy, quadruple therapy, levofloxacin-based therapy, sequential therapy, concomitant therapy, and probiotics with eradication therapy) are now available for the eradication of H. pylori infection. In patients who are symptomatic without an organic pathology, functional dyspepsia and other causes of abdominal pain need to be considered. Functional dyspepsia is best managed using a multifaceted approach by establishing a good physician-patient relationship, dietary and lifestyle interventions, medical therapy, psychotherapy, and the use of psychotropic medications. This review rationalizes the current-day recommendations for the evaluation and management of patients with dyspepsia in a clinical setting.
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Affiliation(s)
- Eric W L Wee
- Division of Gastroenterology, Department of General Medicine, Khoo Teck Puat Hospital, Singapore.
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Gisbert JP, Calvet X, Ferrándiz J, Mascort J, Alonso-Coello P, Marzo M. [Clinical practice guideline on the management of patients with dyspepsia. Update 2012]. Aten Primaria 2012; 44:727.e1-727.e38. [PMID: 23036729 PMCID: PMC7025630 DOI: 10.1016/j.aprim.2012.05.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Accepted: 05/30/2012] [Indexed: 12/13/2022] Open
Abstract
The aim of the Clinical Practice Guideline (CPG) on the Management of Patients with Dyspepsia is to generate recommendations on the optimal approach to dyspepsia in the primary care and specialized outpatient setting. The main objective of this CPG is to help to optimize the diagnostic process, identifying patients with a low risk of a serious organic disease (mainly tumoral), who could be safely managed without the need for invasive diagnostic tests and/or referral to a specialist. The importance of this aim lies in the need to accurately diagnose patients with esophagogastric cancer and correctly treat peptic ulcer while, at the same time, reduce negative endoscopies in order to appropriately use the available healthcare resources. This CPG reviews the initial strategies that can be used in patients with uninvestigated dyspepsia and evaluates the possible decision to begin empirical therapy or to investigate the existence of a lesion that could explain the symptoms. This CPG also discusses functional dyspepsia, which encompasses all patients with dyspepsia with no demonstrable cause on endoscopy. Recommendations for the diagnosis and treatment of peptic ulcer and Helicobacter pylori infection are also made. To classify the scientific evidence and strengthen the recommendations, the GRADE (Grading of Recommendations Assessment, Development and Evaluation Working Group) system has been used (http://www.gradeworkinggroup.org/).
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Affiliation(s)
- Javier P. Gisbert
- Servicio de Aparato Digestivo, Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria Princesa (IP), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, España
| | - Xavier Calvet
- Corporació Universitària Parc Taulí, Departament de Medicina, Universitat Autònoma de Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, España
| | - Juan Ferrándiz
- Subdireccion de Calidad, Dirección General de Atención al Paciente, Servicio Madrileño de Salud, Madrid, España
| | - Juan Mascort
- CAP Florida Sud, Institut Català de la Salut, Departament de Ciències Clíniques, Campus Bellvitge, Facultat de Medicina, Universitat de Barcelona, L’Hospitalet de Llobregat, Barcelona, España
| | - Pablo Alonso-Coello
- Centro Cochrane Iberoamericano, Instituto de Investigaciones Biomédicas (IIB Sant Pau) Barcelona, España
| | - Mercè Marzo
- Unitat de suport a la recerca – IDIAP Jordi Gol, Direcció d’Atenció Primària Costa De Ponent, Institut Català de la Salut, Barcelona, España
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12
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[Clinical practice guideline on the management of patients with dyspepsia. Update 2012]. GASTROENTEROLOGIA Y HEPATOLOGIA 2012. [PMID: 23186826 DOI: 10.1016/j.gastrohep.2012.05.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The aim of the Clinical Practice Guideline (CPG) on the Management of Patients with Dyspepsia is to generate recommendations on the optimal approach to dyspepsia in the primary care and specialized outpatient setting. The main objective of this CPG is to help to optimize the diagnostic process, identifying patients with a low risk of a serious organic disease (mainly tumoral), who could be safely managed without the need for invasive diagnostic tests and/or referral to a specialist. The importance of this aim lies in the need to accurately diagnose patients with esophagogastric cancer and correctly treat peptic ulcer while, at the same time, reduce negative endoscopies in order to appropriately use the available healthcare resources.This CPG reviews the initial strategies that can be used in patients with uninvestigated dyspepsia and evaluates the possible decision to begin empirical therapy or to investigate the existence of a lesion that could explain the symptoms. This CPG also discusses functional dyspepsia, which encompasses all patients with dyspepsia with no demonstrable cause on endoscopy. Recommendations for the diagnosis and treatment of peptic ulcer and Helicobacter pylori infection are also made. To classify the scientific evidence and strengthen the recommendations, the GRADE (Grading of Recommendations Assessment, Development and Evaluation Working Group) system has been used (http://www.gradeworkinggroup.org/).
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Abstract
The nature and determinants of the placebo response are widely unknown, as are the underlying psychological and biological mechanisms. Placebo response rates in functional bowel disorders (functional dyspepsia, irritable bowel syndrome) trials are similar to those in nonintestinal pain conditions and are comparable with other organic gastrointestinal diseases (duodenal ulcer, inflammatory bowel diseases). In this narrative review, different methodologies (meta-analyses, reanalyses, and experimental setups) are discussed that have been applied to the study of the placebo response in functional dyspepsia and the irritable bowel syndrome.
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Poghosyan T, Gaujoux S, Chirica M, Munoz-Bongrand N, Sarfati E, Cattan P. Functional disorders and quality of life after esophagectomy and gastric tube reconstruction for cancer. J Visc Surg 2011; 148:e327-35. [PMID: 22019835 DOI: 10.1016/j.jviscsurg.2011.09.001] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Functional disorders such as delayed gastric emptying, dumping syndrome or duodeno-gastro-esophageal reflux occur in half of the patients who undergo esophagectomy and gastric tube reconstruction for cancer. The potential role for pyloroplasty in the prevention of functional disorders is still debated. Antireflux fundoplication during esophagectomy can apparently reduce the reflux but at the cost of increasing the complexity of the operation; it is not widely used. The treatment of functional disorders arising after esophagectomy and gastroplasty for cancer is based mainly on dietary measures. Proton pump inhibitors have well documented efficiency and should be given routinely to prevent reflux complications. Erythromycin may prevent delayed gastric emptying, but it should be used with caution in patients with cardiovascular disorders. In the event of anastomotic stricture, endoscopic dilatation is usually efficient. Problems related to gastrointestinal functional disorders after esophageal resection and gastric tube reconstruction do not significantly impair long-term quality of life, which is mainly influenced by tumor recurrence.
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Affiliation(s)
- T Poghosyan
- Service de chirurgie générale, digestive et endocrinienne, hôpital Saint-Louis, AP-HP, 1, avenue Claude-Vellefaux, 75010 Paris, France
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Miura S, Sugano K, Kinoshita Y, Fock KM, Goh KL, Gibson P. Diagnosis and treatment of functional gastrointestinal disorders in the Asia-Pacific region: a survey of current practices. J Gastroenterol Hepatol 2011; 26 Suppl 3:2-11. [PMID: 21443699 DOI: 10.1111/j.1440-1746.2011.06635.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIMS Functional gastrointestinal disorders (FGIDs), namely functional dyspepsia (FD) and irritable bowel syndrome (IBS) are common disorders important to public health in the Asia-Pacific region. Our objectives were to determine the current practices in diagnosis and management of these disorders in the Asia-Pacific region. METHODS Forty-three physicians and researchers in FGID who attended the first Asian Pacific Topic Conference at Tokyo in November 2010 were invited to answer a questionnaire. Twenty-three Japanese doctors and twenty doctors from other Asia-Pacific Societies answered the questionnaire, which consisted of 60 multiple-choice questions concerning physician's preferences in diagnosis and management of FGIDs. RESULTS Overall, there were similarities in diagnostic approach, such as differential diagnosis, exclusion of organic diseases, psychophysiological assessment, medical advice or medication with psychological drugs, not only among different Asia-Pacific region but also between FD and IBS. Several notable differences were seen. For example, general practitioners did not commonly use the term FD or diagnose FD by themselves, while the term IBS was widely used and frequently diagnosed. Sub-categorization was more common in IBS than FD. There was also a difference between Japan and other Asia-Pacific region; upper GI endoscopy and blood examination were more common in Japan, while eradication of Helicobacter pylori was more frequently done in other countries. Anti-secretory drugs for FD and mild laxatives or anti-diarrheal drug for IBS were frequently used, and prokinetics were used for all patients with FD or IBS. Interestingly, drugs developed in Japan and Chinese herbal medicines were more frequently prescribed in Japan. CONCLUSION Information obtained in this survey is useful for understanding the most common clinical approaches for FGIDs in the Asia-Pacific region.
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Affiliation(s)
- Soichiro Miura
- Department of Internal Medicine, National Defense Medical College, Saitama, Japan.
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Tominaga K, Kido T, Ochi M, Sadakane C, Mase A, Okazaki H, Yamagami H, Tanigawa T, Watanabe K, Watanabe T, Fujiwara Y, Oshitani N, Arakawa T. The Traditional Japanese Medicine Rikkunshito Promotes Gastric Emptying via the Antagonistic Action of the 5-HT(3) Receptor Pathway in Rats. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2011; 2011:248481. [PMID: 19861508 PMCID: PMC3095508 DOI: 10.1093/ecam/nep173] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/19/2009] [Accepted: 10/02/2009] [Indexed: 12/14/2022]
Abstract
The traditional Japanese medicine rikkunshito ameliorates the nitric oxide-associated delay in gastric emptying. Whether rikkunshito affects gastric motility associated with 5-hydroxytryptamine (serotonin: 5-HT) receptors or dopamine receptors is unknown. We examined the effects of rikkunshito on the delay in gastric emptying induced by 5-HT or dopamine using the phenol red method in male Wistar rats. 5-HT (0.01–1.0 mg kg−1, i.p.) dose dependently delayed gastric emptying, similar to the effect of the 5-HT3 receptor agonist 1-(3-chlorophenyl) biguanide (0.01–1.0 mg kg−1, i.p.). Dopamine also dose dependently delayed gastric emptying. The 5-HT3 receptor antagonist ondansetron (0.04–4.0 mg kg−1) and rikkunshito (125–500 mg kg−1) significantly suppressed the delay in gastric emptying caused by 5-HT or 1-(3-chlorophenyl) biguanide. Hesperidin (the most active ingredient in rikkunshito) suppressed the 5-HT-induced delayed gastric emptying in a dose-dependent manner, the maximum effect of which was similar to that of ondansetron (0.4 mg kg−1). The improvement obtained by rikkunshito or ondansetron in delaying gastric emptying was completely blocked by pretreatment with atropine. Rikkunshito appears to improve delay in gastric emptying via the antagonistic action of the 5-HT3 receptor pathway.
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Affiliation(s)
- K Tominaga
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka 545-8585, Japan
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Chen JH, Song GQ, Yin J, Sun Y, Chen JDZ. Gastric electrical stimulation reduces visceral sensitivity to gastric distention in healthy canines. Auton Neurosci 2010; 160:16-20. [PMID: 21126929 DOI: 10.1016/j.autneu.2010.10.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2010] [Revised: 10/12/2010] [Accepted: 10/28/2010] [Indexed: 12/27/2022]
Abstract
The aim of this study was to investigate the effects and mechanisms of gastric electrical stimulation (GES) on proximal stomach distention-induced visceral sensitivity. Isobaric gastric distention was performed using a barostat system in 8 normal and 6 vagotomized dogs and animal behaviors were noted and graded. The normal dogs were studied in 4 sessions: control (no GES), short pulse GES, long pulse GES, and dual-pulse GES, and the vagotomized dogs were studied in three sessions: control (no GES), long pulse GES and guanethidine. It was found that: 1) proximal stomach distention-induced behavioral changes were mediated by vagal and sympathetic pathways. The total behavior score (TBS) was 40.6 ± 7.4 in the controls, 15.3 ± 8.9 in vagotomized dogs (P=0.006 vs. control) and 8.8 ± 0.9 in the vagotomized dogs with guanethidine (P=0.04 vs. vagotomy). The behavioral changes were mediated via the vagal pathway at distention pressures below 20 mmHg, but mediated via both the vagal and sympathetic pathways at distention pressures equal to and above 20 mmHg. 2) GES with long pulses or dual pulses but not short pulses reduced the distention-induced behavioral score (P=0.003, P=0.006 and P=0.7, respectively) and the effects of GES of long pulses might be mediated via the vagal and sympathetic pathways. In conclusion, gastric distention-induced visceral sensitivity is mediated via the vagal pathway at low distention pressures but via both vagal and sympathetic pathways at high distention pressures. GES with long but not short pulses reduces distention-induced visceral sensitivity.
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Affiliation(s)
- Ji-Hong Chen
- Division of Gastroenterology, University of Texas Medical Branch, Galveston, United States
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Long-term tegaserod treatment for dysmotility-like functional dyspepsia: results of two identical 1-year cohort studies. Dig Dis Sci 2010; 55:684-97. [PMID: 19957035 DOI: 10.1007/s10620-009-1049-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2009] [Accepted: 10/28/2009] [Indexed: 12/30/2022]
Abstract
BACKGROUND Functional dyspepsia (FD) is a chronic disorder that adversely affects health-related quality of life (HRQoL). Published information on its long-term management is minimal and treatment options are limited. AIM The aim of this study was to evaluate safety, efficacy and HRQoL with tegaserod 6 mg twice daily over 1 year in women with FD who completed one of two 6-week, randomized, placebo-controlled, double-blind studies. METHODS About 780 patients received tegaserod 6 mg twice daily in two identical 1-year extension studies. Scheduled assessments included adverse events, the Short-Form Nepean Dyspepsia Index (SF-NDI), Work Productivity and Activity Impairment-Dyspepsia (WPAI-Dyspepsia) questionnaire, and patient perceptions of treatment efficacy. RESULTS Mean tegaserod treatment duration in the two studies was 236 and 222 days. Most adverse events occurred in the first 6 months, were similar to previous reports (commonly diarrhea), and were transient and well tolerated. SF-NDI, WPAI-Dyspepsia scores and perceived symptom relief improved from baseline over the 1-year evaluation. CONCLUSIONS The long-term safety profile of tegaserod in women with FD was consistent with that of short-term treatment and accompanied by improvements in HRQoL, work productivity and symptom relief. These long-term results add to the clinical experience with FD and support the potential value of a 5-HT(4) agonist in the management of FD.
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Ponce J, Mearin F, Ponce M, Balboa A, Zapardiel J. [Symptom profile in gastroesophageal reflux disease in untreated patients and those with persistent symptoms despite treatment]. GASTROENTEROLOGIA Y HEPATOLOGIA 2010; 33:271-9. [PMID: 20133018 DOI: 10.1016/j.gastrohep.2009.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2009] [Revised: 11/04/2009] [Accepted: 11/10/2009] [Indexed: 01/10/2023]
Abstract
AIM 1. To analyze the symptom profile of gastroesophageal reflux disease (GERD) with typical clinical manifestations (heartburn and/or regurgitation); 2. to compare untreated patients with those with persistent symptoms despite treatment; 3. to evaluate severity according to physicians' and patients' opinions; and 4. to determine the diagnostic and therapeutic approaches used. METHODS We performed a prospective, observational, cross-sectional study under conditions of standard clinical practice. RESULTS A total of 2356 patients were included. Dyspeptic symptoms were highly frequent (close to 90% in both groups) and supraesophageal symptoms were also common (50-60%). Patients with persistent symptoms despite treatment were older, and had more supraesophageal symptoms; in addition, the typical supraesophageal and dyspeptic symptoms of GERD were more severe in these patients. Severity evaluations by patients and doctors were concordant but patients considered severity to be greater. Older age was a risk factor for supraesophageal symptoms, female gender for dyspeptic symptoms and body mass index for greater severity of GERD symptoms. Endoscopy was requested in about 60% of the patients. Diet counseling was advised in most patients and postural recommendations were made in more than half. Proton pump inhibitors were prescribed in almost all patients, and were associated with prokinetics and/or antacids in many patients. CONCLUSIONS Dyspeptic symptoms should not be considered as independent of GERD, and typical and atypical symptoms are associated in 50% of patients. Gastroenterologists follow clinical practice guidelines fairly closely but diagnostic procedures seem to be overindicated.
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Affiliation(s)
- Julio Ponce
- Servicio de Medicina Digestiva, Hospital Universitario La Fe, Valencia, España.
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Hiyama T, Matsuo K, Urabe Y, Fukuhara T, Tanaka S, Yoshihara M, Haruma K, Chayama K. Meta-analysis used to identify factors associated with the effectiveness of proton pump inhibitors against non-erosive reflux disease. J Gastroenterol Hepatol 2009; 24:1326-32. [PMID: 19702900 DOI: 10.1111/j.1440-1746.2009.05879.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND A lack of published data remains on factors associated with the treatment response to proton pump inhibitors (PPI) in patients with non-erosive reflux disease (NERD). METHODS Studies on effectiveness of PPI in patients with NERD were identified using the MEDLINE database and manual searches of the available literature. Twenty publications that comprised a total of 22 study arms were eligible, and meta-analyses of these 22 study arms were carried out. RESULTS Overall improvement rate in patients with PPI was 68%. Univariate meta-regression analysis was used to explore the source of heterogeneity, P-value for males was 0.192, and in the presence of Helicobacter pylori (H. pylori) infection was 0.186, indicating that these factors are associated with treatment effectiveness. Thus, as the frequency of male and H. pylori-infected patients increased, the effectiveness of PPI against NERD improved. By multivariate meta-regression analysis, the P-value for male and H. pylori infection decreased further (P = 0.002 and P = 0.003, respectively), indicating little interaction between male sex and H. pylori infection. CONCLUSION These results suggest that H. pylori infection and patient sex may be associated with the effectiveness of PPI against patients with NERD. The reasons are still unclear, and further examinations are needed to clarify them.
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Affiliation(s)
- Toru Hiyama
- Health Service Center, Hiroshima University, Higashihiroshima, Japan.
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Qin F, Huang X, Ren P. Chinese herbal medicine modified xiaoyao san for functional dyspepsia: meta-analysis of randomized controlled trials. J Gastroenterol Hepatol 2009; 24:1320-5. [PMID: 19702899 DOI: 10.1111/j.1440-1746.2009.05934.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND To critically assess the evidence of modified xiaoyao san (MXS) for treating functional dyspepsia (FD). METHODS Systematic literature searches were carried out on the Medline database, CNKI database, Wanfang Data, VIP Information and the Cochrane Library. Reference lists located were checked for further relevant publications. Experts in the field and manufacturers of identified products were contacted for unpublished material. Studies were selected according to predefined inclusion and exclusion criteria. All randomized clinical trials of MXS for treating FD were included. Study selection, data extraction and validation were carried out by at least two reviewers with disagreements being settled by discussion. Weighted means and 95% confidence intervals were calculated and sensitivity analyses were carried out. RESULTS Thirty-three potentially relevant articles were retrieved for further evaluation. Fourteen were suitable for inclusion in the meta-analysis. There was evidence that MXS compared with prokinetic drugs reduced symptoms (odds ratio 3.26, 95% CI 2.24 to 4. 47). There was evidence that MXS + prokinetic drugs compared with prokinetic drugs reduced symptoms (odds ratio 4.32, 95% CI 2.64 to 7.08). CONCLUSION MXS appears to be more effective compared to prokinetic drugs in the treatment of FD and no serious side-effects were identified. However, the evidence remains weak due to publication bias and methodological flaws, which may amplify the therapeutic benefit of MXS.
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Affiliation(s)
- Feng Qin
- Laboratory of Ethnopharmacology and Institute of Integrated Traditional Chinese and Western Medicine, Xiangya Hospital, Central South University, Changsha, China
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Hiyama T, Yoshihara M, Tanaka S, Haruma K, Chayama K. Effectiveness of prokinetic agents against diseases external to the gastrointestinal tract. J Gastroenterol Hepatol 2009; 24:537-46. [PMID: 19220673 DOI: 10.1111/j.1440-1746.2009.05780.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Prokinetic agents are effective not only for disease of the gastrointestinal (GI) tract but also for those external to the GI tract such as the central nervous system, and the respiratory, urologic, and metabolic organs. This article reviews the effectiveness of prokinetic agents against diseases external to the GI tract. Studies were identified by computerized and manual searches of the available literature. A Medline search was performed (1975-July, 2008) using the following medical subject headings: prokinetic agent, metoclopramide, domperidone, trimebutine, cisapride, itopride, mosapride, tegaserod, and human. The identified diseases for which prokinetic agents may be effective are various: bronchial asthma, chronic cough, hiccup, spontaneous bacterial peritonitis, cholelithiasis, diabetes mellitus, acute migraine, Parkinson's disease, anorexia nervosa, Tourette's disorder, urologic sequelae of spinal cord injury and of radical hysterectomy for cervical cancer, laryngeal dysfunction and so on. These agents are also useful for prevention of aspiration pneumonia during anesthesia, and in tube-fed patients. Prokinetic agents should be a valuable addition to our currently limited pharmacological armamentarium not only for functional bowel disease, but also for diseases external to the GI tract.
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Affiliation(s)
- Toru Hiyama
- Health Service Center, Hiroshima University, 1-7-1 Kagamiyama, Higashihiroshima 739-8521, Japan.
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Zheng D, Xia B, Shi XY, Song M, Wu J, Wang P, Zhang H. Combined therapy of domperidone and compound digestive enzymes for functional dyspepsia: an analysis of 84 cases. Shijie Huaren Xiaohua Zazhi 2009; 17:336-339. [DOI: 10.11569/wcjd.v17.i3.336] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To study the efficacy and safety of combined therapy of domperidone and compound digestive enzymes for functional dyspepsia.
METHODS: Eighty-four patients with functional dyspepsia were randomly grouped into experimental group (n = 42) and the controls (n = 42). The patients in the control group were only given domperidone 10 mg 3 times per day 30 min before meals for 4 weeks. The patients in the experimental group were given 1 capsule of compound digestive enzyme 3 times a day 30 min after meals in addition to domperidone 10 mg 3 times per day for four weeks. The therapeutic efficacy and side effects were compared between the two groups by chi square test.
RESULTS: The general therapeutic efficacy in the experimental group was superior to the controls (85.7% vs 61.9%, P < 0.05). The symptoms of upper abdominal pain, abdominal distention, early satiety and stomach burn in the patients in the experimental group were more improved than in the control group. The experimental group had shown shorter onset time than the controls. No severe side-effects were found in the both groups.
CONCLUSION: Combined therapy of domperidone and compound digestive enzymes can more significantly improve general efficacy and symptoms in patients with functional dyspepsia than single use of motility medicine domperidone.
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Hiyama T, Yoshihara M, Tanaka S, Haruma K, Chayama K. Strategy for treatment of nonerosive reflux disease in Asia. World J Gastroenterol 2008; 14:3123-8. [PMID: 18506915 PMCID: PMC2712842 DOI: 10.3748/wjg.14.3123] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The paper is to review the clinical and pathophysiologic differences between of nonerosive reflux disease (NERD) and reflux esophagitis (RE), and to propose a treatment strategy for NERD, especially for patients in Asia. A Medline search was performed regarding the clinical and pathophysiologic differences between NERD and RE, and treatment of NERD and RE. The characteristics of NERD patients in Asia are as follows: (1) high proportion of female patients, (2) low frequency of hiatal hernia, (3) high frequency of H pylori infection, (4) severe glandular atrophy of the gastric mucosa, and (5) frequent resistance to proton pump inhibitor (PPI) therapy. In Asian NERD patients, exposure of the esophagus to acid is not increased, and esophageal motility is normal. These characteristics are similar to those of patients in Western countries. Our recommended first-choice treatment is administration of PPI in combination with a prokinetic agent. However, at present, because there is limited evidence regarding effective treatments for NERD, it is best to try several different treatment strategies to find the best treatment for each patient.
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Schmitt EC, Pigatto PD, Boneschi V, Bubola D, Finzi AF. Pyoderma gangrenosum treated with low-dose cyclosporin. Drugs 1993; 68:981-91. [PMID: 8457463 DOI: 10.2165/00003495-200868070-00007] [Citation(s) in RCA: 70] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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