General practitioners' approach to dyspepsia. Survey of consultation frequencies, treatment, and investigations

Implementation and evaluation of early gastroscopy for patients with dyspepsia and warning signs in Primary Care

INTRODUCTION

Dyspepsia is a common disorder in both Primary (PC) and Specialised Care (SC). Gastroscopy is recommended at the start of the study if there are warning signs, although it is not always available in PC.

OBJECTIVES AND METHODS

We developed a pilot project establishing an early gastroscopy programme for patients with dyspepsia and warning signs in PC, subsequently extending it to the entire healthcare area. The aim was to evaluate the requirements, impact and opinion of this service at the PC level. Demographic, symptomatic and endoscopic variables on the patients referred to SC from the pilot centre were recorded. A satisfaction survey was conducted among the PC physicians.

RESULTS

The one-year pilot study and the first year of implementation of the programme were evaluated. A total of 355 patients were included (median age 56.4 years; IQR 45.5-64.3); 61.2% (56.1-66.3%) were women. The waiting time for examination was 1.5 weeks (IQR 1.5-2.5). Gastroscopy was correctly indicated in 82.7% (78.4-86.3%) of patients. The median number of requests per month was 1.1 per 10,000 adults (range 0.8-1.6). Monthly referrals to SC clinics from the pilot centre fell by 11 subjects (95% CI 5.9-16) with respect to the previous median of 58 (IQR 48-64.5). Almost all those polled (98.4%) considered the programme useful in routine practice.

CONCLUSIONS

The availability of an early gastroscopy programme in PC for patients with dyspepsia and warning signs reduced the number of referrals to SC.

Endosonography For Right-sided and Acute Upper Intestinal Misery: the EFRAIM study: A prospective, randomized, controlled, blinded study

BACKGROUND

Acute upper abdominal pain is a frequent symptom leading to hospital admission.

OBJECTIVE

To determine whether a primary intra- and extraluminal diagnostic approach enabled by endoscopic ultrasound is as effective as a conventional diagnostic algorithm of transabdominal ultrasound followed by oesophagogastroduodenoscopy.

METHODS

A total of 240 patients who presented with acute right-sided and/or upper abdominal pain were prospectively recruited. Exclusion criteria were chronic pain, malignancy, prior abdominal surgery, bleeding, peritonitis, and elevated liver enzymes or lipase as defined 3-times higher than upper reference value. All patients underwent first transabdominal ultrasound and were then randomized (1 : 1) to either endoscopy followed by endoscopic ultrasound or vice versa. Patients and respective examiners were blinded to prior findings.

RESULTS

A total of 223 patients were included. Endoscopic ultrasound provided a higher diagnostic yield than the combination of transabdominal ultrasound and endoscopy (62.3 vs. 50.7%; p = 0.001). For mucosal/intraluminal lesions, we observed a very good agreement between both endoscopic modalities (kappa 0.89). The agreement for pancreatic and biliary causes was good between both ultrasound modalities (kappa 0.66).

CONCLUSIONS

Due to its high diagnostic yield, endoscopic ultrasound as a primary diagnostic modality appears to be a valuable option in patients with acute upper abdominal pain.

Impact of route to diagnosis on treatment intent and 1-year survival in patients diagnosed with oesophagogastric cancer in England: a prospective cohort study

OBJECTIVE

To investigate the relationship between the route to diagnosis, patient characteristics, treatment intent and 1 -year survival among patients with oesophagogastric (O-G) cancer.

SETTING

Cohort study in 142 English NHS trusts and 30 cancer networks.

PARTICIPANTS

Patients diagnosed with O-G cancer between October 2007 and June 2009.

DESIGN

Prospective cohort study. Route to diagnosis defined as general practitioner (GP) referral-urgent (suspected cancer) or non-urgent, hospital consultant referral, or after an emergency admission. Logistic regression was used to estimate associations and adjust for differences in casemix.

MAIN OUTCOME MEASURES

Proportion of patients diagnosed by route of diagnosis; proportion of patients selected for curative treatment; 1-year survival.

RESULTS

Among 14 102 cancer patients, 66.3% were diagnosed after a GP referral, 16.4% after an emergency admission and 17.4% after a hospital consultant referral. Of the 9351 GP referrals, 68.8% were urgent. Compared to urgent GP referrals, a markedly lower proportion of patients diagnosed after emergency admission had a curative treatment plan (36% vs 16%; adjusted OR=0.62, 95% CI 0.52 to 0.74) and a lower proportion survived 1 year (43% vs 27%; OR 0.78; 95% CI 0.68 to 0.89). Urgency of GP referral did not affect treatment intent or survival. Routes to diagnosis varied across cancer networks, with the adjusted proportion of patients diagnosed after emergency admission ranging from 8.7 to 32.3%.

CONCLUSIONS

Outcomes for cancer patients are worse if diagnosed after emergency admission. Primary care and hospital services should work together to reduce rates of diagnosis after emergency admission and the variation across cancer networks.

Effectiveness and safety of levosulpiride in the treatment of dysmotility-like functional dyspepsia

The objective of this study was to assess the effectiveness and safety of levosulpiride in patients with dysmotility-like functional dyspepsia including nonerosive reflux esophagitis in conditions of daily practice. The study was conducted as a prospective, open-label, multicenter design in 342 patients with dysmotility-like functional dyspepsia (n=279) and nonerosive reflux disease (n=63), who received levosulpiride 25 mg 3 times daily orally for 4 weeks. Individual symptoms (pain/discomfort, fullness, bloating, early satiety, pyrosis, regurgitation, and nausea/vomiting) and a global symptom score were assessed at 15, 30, and 60 days after starting treatment. Adverse events also were recorded. There were 151 men and 191 women (mean age 38.8 years) who referred dyspeptic symptoms for a mean of 10.2 (10.7) months. A total of 66.4% patients were treated with 75 mg/day levosulpiride and 33.6% with 50 mg/day. At the 15-day visit, a decrease greater than 50% in the global symptom score was observed. The frequency and intensity of individual symptoms showed a statistically significant decrease (p<0.001) at all visits compared with baseline. At the 30-day visit, all symptoms had almost disappeared, a trend that was maintained until the last visit. Treatment with levosulpiride was well tolerated and only 40 adverse events were recorded (galactorrhea 26.7%, somnolence 17.8%, fatigue 11.1%, headache 11.5%) and no patient had to abandon the study due to side effects. In conclusion, levosulpiride is an effective and safe drug in the treatment of dysmotility-like functional dyspepsia and non-erosive reflux disease.

The management of patients with new onset of upper gastro-intestinal symptoms in primary care

BACKGROUND

Data dealing with dyspepsia management in general practice are lacking, and most of the studies investigated a subset of patients with suspected peptic ulcer disease either with or without previous complaints.

AIMS

To evaluate the one-year management of patients presenting new onset upper abdominal symptoms without alarming features.

METHODS

275 patients were enrolled by 63 Italian general practitioners.

RESULTS

Referral to upper gastro-intestinal tract endoscopy resulted significantly higher in patients with predominant epigastric pain compared to subjects with non-painful symptoms or non-dominant symptoms. Amongst drug therapies, only prokinetics and antacids and anti-secretory therapies were prescribed differently amongst clinical subgroups. The rate and type of management and referrals resulted were not influenced by the age of patients or the use of anti-inflammatory drugs. The most frequent diagnosis at one-year follow-up was reflux oesophagitis. The absence of organic disease was less frequent in patients with dominant epigastric pain than non-painful or non-dominant symptoms.

CONCLUSION

The management of these patients in primary care in Italy is mainly determined by clinical presentation, independent of age. Any judgement about appropriateness of the treatment should consider not only conventional features such as age, but the more complex individual frameworks as well.

EUS compared with endoscopy plus transabdominal US in the initial diagnostic evaluation of patients with upper abdominal pain

BACKGROUND

Primary upper endoscopy (EGD) and transabdominal US (TUS) are often performed in patients with upper abdominal pain.

OBJECTIVE

Primary: Determine whether the combination of EGD and EUS was equivalent to EGD plus TUS in the diagnostic evaluation of upper abdominal pain. Secondary: Compare EUS versus TUS in detecting abdominal lesions, and compare EGD by using an oblique-viewing echoendoscope versus the standard, forward-viewing endoscope in detecting mucosal lesions.

DESIGN

Prospective, paired design.

SETTING

Six academic endoscopy centers.

PATIENTS

This study involved patients with upper abdominal pain referred for endoscopy.

INTERVENTION

All patients had EGD, EUS, and TUS. The EGD was done using both an oblique-viewing echoendoscope and the standard, forward-viewing endoscope (randomized order) by two separate endoscopists in a blinded fashion, followed by EUS. TUS was performed within 4 weeks of EGD/EUS, also in a blinded fashion.

FOLLOW-UP

telephone interviews and chart reviews.

MAIN OUTCOME MEASUREMENTS

Diagnose possible etiology of upper abdominal pain and detect clinically significant lesions.

RESULTS

A diagnosis of the etiology of upper abdominal pain was made in 66 of 172 patients (38%). The diagnostic rate was 42 of 66 patients (64%) for EGD plus EUS versus 41 of 66 patients (62%) for EGD plus TUS, which was statistically equivalent (McNemar test; P = .27). One hundred ninety-eight lesions were diagnosed with either EUS or TUS. EUS was superior to TUS for visualizing the pancreas (P < .0001) and for diagnosing chronic pancreatitis (P = .03). Two biliary stones were detected only by EUS. Two hundred fifty-one mucosal lesions were similarly diagnosed with EGD with either the standard, forward-viewing endoscope or the oblique-viewing echoendoscope (kappa = 0.48 [95% CI, .43-.54]). EGD with the standard, forward-viewing endoscope was preferred for biopsies.

LIMITATIONS

No cost analysis.

CONCLUSION

The combination of EGD with EUS is equivalent to EGD plus TUS for diagnosing a potential etiology of upper abdominal pain. EUS is superior to TUS for detecting chronic pancreatitis. EGD combined with EUS should be considered in the first-line diagnostic evaluation of patients with upper abdominal pain.

The role of protein digestibility and antacids on food allergy outcomes

Digestion assays with simulated gastric fluid have been introduced for characterization of food proteins to imitate the effect of stomach proteolysis on dietary compounds in vitro. By using these tests, dietary proteins can be categorized as digestion-resistant class 1 (true allergens triggering direct oral sensitization) or as labile class 2 allergens (nonsensitizing elicitors). Thus the results of these digestion assays mirror situations of intact gastric proteolysis. Alterations in the gastric milieu are frequently experienced during a lifetime either physiologically in the very young and the elderly or as a result of gastrointestinal pathologies. Additionally, acid-suppression medications are frequently used for treatment of dyspeptic disorders. By increasing the gastric pH, they interfere substantially with the digestive function of the stomach, leading to persistence of labile food protein during gastric transit. Indeed, both murine and human studies reveal that antiulcer medication increases the risk of food allergy induction. Gastric digestion substantially decreases the potential of food proteins to bind IgE, which increases the threshold dose of allergens required to elicit symptoms in patients with food allergy. Thus antiulcer agents impeding gastric protein digestion have a major effect on the sensitization and effector phase of food allergy.

Predictors and non-predictors of symptom relief in dyspepsia consultations in primary care

OBJECTIVE

We aimed to evaluate if the course of dyspepsia is influenced by medical consultation in primary care.

DESIGN, SETTING AND PATIENTS

Australian general practitioners (n = 27) recruited 157 dyspeptic patients, of whom 94 were eligible for follow-up. Dyspepsia, comorbidity, quality of life, emotional status, locus of control and consultation satisfaction were measured at baseline and follow-up (mean 3 months).

MAIN OUTCOME MEASURE

Response was defined as improvement of dyspepsia over time on the Nepean Dyspepsia Index score.

RESULTS

Dyspepsia improved in 82% (n = 77). There was no significant change in non-gastrointestinal symptoms. Half were worried or stressed by their symptoms, and 85% wanted reassurance, a need that (univariately) differentiated responders from non-responders (p = 0.02). Most patients seen in primary care with dyspepsia improved. If the doctor believed it was likely that the patient would follow their recommendations, the patient was nearly five times as likely to be a responder (OR 4.9, 95% CI 1.2-19.0). The only other significant predictor was acid suppression therapy (OR 3.5, 95% CI 1.1-10.9).

CONCLUSION

Most primary care visits for dyspepsia are followed by improvement, which may be predicted in part by indicators of patient compliance. Prescription of acid suppression therapy may also improve outcome in dyspepsia.

Reliability and validity of the Gastrointestinal Symptom Rating Scale (GSRS) and Quality of Life in Reflux and Dyspepsia (QOLRAD) questionnaire in dyspepsia: a six-country study

BACKGROUND

Symptoms of dyspepsia significantly disrupt patients' lives and reliable methods of assessing symptom status are important for patient management. The aim of the current study was to document the psychometric characteristics of the Gastrointestinal Symptom Rating Scale (GSRS) and the Quality of Life in Reflux and Dyspepsia questionnaire (QOLRAD) in Afrikaans, German, Hungarian, Italian, Polish and Spanish patients with dyspepsia.

METHODS

853 patients with symptoms of dyspepsia completed the GSRS, the QOLRAD, the 36-item Short-Form Health Survey (SF-36) and the Hospital Anxiety and Depression scale.

RESULTS

The internal consistency reliability of the GSRS was 0.43-0.87 and of the QOLRAD 0.79-0.95. Test-retest reliability of the GSRS was 0.36-0.75 and of the QOLRAD 0.41-0.82. GSRS Abdominal pain domain correlated significantly with all QOLRAD domains in most language versions, and with SF-36 Bodily pain in all versions. QOLRAD domains correlated significantly with the majority of SF-36 domains in most versions. Both questionnaires were able to differentiate between patients whose health status differed according to symptom frequency and severity.

CONCLUSION

The psychometric characteristics of the different language versions of the GSRS and QOLRAD were found to be good, with acceptable reliability and validity. The GSRS and QOLRAD were found to be useful for evaluating dyspeptic symptoms and their impact on patients' daily lives in multinational clinical trials.

Redução da prevalência de úlcera duodenal: um estudo brasileiro (análise retrospectiva na última década: 1996-2005)

RACIONAL: A úlcera duodenal sempre representou uma doença muito prevalente entre as enfermidades digestivas, em qualquer parte do mundo. A prevalência média era de aproximadamente 10% da população mundial. A partir do início dos anos 90, a literatura, tanto européia como norte-americana, passou a demonstrar sua redução gradativa entre seus países. OBJETIVO: Demonstrar, através de análise retrospectiva, a prevalência anual da úlcera duodenal nos últimos 10 anos em um Serviço de Endoscopia Digestiva que é referência para o sistema público de saúde da cidade de Porto Alegre, municípios da Grande Porto Alegre e outras cidades vizinhas da mesma. Os dados analisados são de março de 1996 até dezembro de 2005. MÉTODOS: Estudo retrospectivo transversal, com análise documental de diagnósticos endoscópicos efetuados em endoscopia digestiva alta, no referido Serviço. Foi feita a análise retrospectiva de diagnósticos endoscópicos efetuados em 13.130 pacientes submetidos a endoscopia digestiva alta no período de março de 1996 a dezembro de 2005. A classificação de Sakita foi utilizada para o estádio do grau evolutivo da úlcera duodenal e foi considerado por ela acometido o paciente com a lesão no estágio A1, até o estágio S1, inclusive. Observou-se também a prevalência nos dois sexos, na raça, o percentual médio total nos 10 anos, além da prevalência anual. Para verificar se houve significância estatística dos resultados observados nos diferentes períodos, foi aplicado um teste de regressão linear ("linear regression model"). RESULTADOS: Observou-se decréscimo gradativo dos percentuais de prevalência da úlcera duodenal, ano após ano, iniciando-se em 1996 com 8,6% e se encerrando no final de 2005, com 3,3%. A exceção do período foi observada no ano de 2003 quando houve um acréscimo, comparando-se com o decréscimo gradativo dos 6 anos anteriores. Mas já, a partir do período seguinte (2004), a queda gradativa voltou a ser observada. O valor médio de queda anual, aplicando o teste de regressão linear, foi da ordem de 1,3% ao ano, no período analisado (10 anos). Este teste mostrou também significância estatística. A raça branca representou a maioria, com 78% dos pacientes, em relação a raça negra. O sexo masculino, em todos os períodos analisados, exceto em um (1997), foi o sexo mais acometido, com uma relação final masculino/feminino da ordem de 1.17/1.0. CONCLUSÕES: Observou-se então, neste estudo efetuado no Brasil, também uma redução da prevalência da úlcera duodenal, já apontada pela literatura em outros países. Estudos posteriores devem ser efetuados no sentido de apontar as razões desta importante observação.

Gastro-esophageal reflux disease symptoms are more common in general practice in Japan

AIM: To accurately assess the prevalence of GERD symptoms in general practice.

METHODS: 4139 consecutive patients (2025 men and 2114 women with a mean age of 43 years), who first attended the Outpatient Department of General Medicine and Emergency Care at Toho University Omori Hospital, were asked to respond to the F-scale questionnaire regardless of their chief complaints. The questionnaire is a self-report instrument, written in a simple and easy-to-understand language, containing 12 questions.

RESULTS: Of 4139 subjects, 1554 patients (37.6%) were identified as GERD according to their F-scale score (> 7). However, there were only 45 consultations (1.1%) for typical GERD symptoms. Although GERD symptoms are common in adults of all ages, the prevalence of GERD was highest in the 20-29 years age group and the age group 70-79 years had the lowest prevalence for both males and females.

CONCLUSION: Although there was a high rate indicating GERD in our primary care population, only 1.1% of outpatients attended our hospital with a chief complaint of GERD symptoms. Since about one-third of GERD patients are affected by atypical symptoms, general physicians need to be cautious about extrapolating these results to patients with a chief complaint other than typical GERD symptoms.

Cost-effectiveness analysis of two management strategies for dyspepsia

OBJECTIVES

To compare the cost-effectiveness of endoscopy and empirical proton pump inhibition (PPI) therapy for management of dyspepsia in primary care.

METHODS

A randomized controlled trial, including prospective collection of economic resource data, was conducted in general practice from June 2000 to August 2002, Aarhus County, Denmark. We randomly assigned 368 dyspeptic patients from thirty-two general practices to treatment with omeprazol 40 mg for 2 weeks (n=184) or endoscopy (n=184). The study adopted a societal perspective, and the year of costing was 2006.

OUTCOME MEASURES

days free of dyspeptic symptoms and proportion of patients with dyspepsia after 1 year based on patients' and general practitioners' (GPs) assessment. Costs were estimated from patient and GP questionnaires and from medical records.

RESULTS

The incremental cost-effectiveness (CE) ratio for 1 day free of dyspeptic symptoms using the endoscopy strategy was euro/day 154 compared with the PPI strategy. The incremental CE ratio for one person free of dyspeptic symptoms after 1 year using the endoscopy strategy was euro13,905 based on the patients' evaluation, and the incremental CE ratio for one person free of predominant symptoms after 1 year was euro5,990 according to the GPs' evaluation. The PPI strategy was both cheaper and more effective than the endoscopy strategy when reflux was the predominant symptom.

CONCLUSIONS

A strategy using empirical antisecretory PPI therapy should be recommended if the alternative is an endoscopy strategy for managing dyspeptic patients in general practice, especially if reflux was the predominant symptom.

Economic evaluation of empirical antisecretory therapy versus Helicobacter pylori test for management of dyspepsia: a randomized trial in primary care

OBJECTIVES

An economic evaluation was performed of empirical antisecretory therapy versus test for Helicobacter pylori in the management of dyspepsia patients presenting in primary care.

METHODS

A randomized trial in 106 general practices in the County of Funen, Denmark, was designed to include prospective collection of clinical outcome measures and resource utilization data. Dyspepsia patients (n = 722) presenting in general practice with more than 2 weeks of epigastric pain or discomfort were managed according to one of three initial management strategies: (i) empirical antisecretory therapy, (ii) testing for Helicobacter pylori, or (iii) empirical antisecretory therapy, followed by Helicobacter pylori testing if symptoms improved. Cost-effectiveness and incremental cost-effectiveness ratios of the strategies were determined.

RESULTS

The mean proportion of days without dyspeptic symptoms during the 1-year follow-up was 0.59 in the group treated with empirical antisecretory therapy, 0.57 in the H. pylori test-and-eradicate group, and 0.53 in the combination group. After 1 year, 23 percent, 26 percent, and 22 percent, respectively, were symptom-free. Applying the proportion of days without dyspeptic symptoms, the cost-effectiveness for empirical treatment, H. pylori test and the combination were 12,131 Danish kroner (DKK), 9,576 DKK, and 7,301 DKK, respectively. The incremental cost-effectiveness going from the combination strategy to empirical antisecretory treatment or H. pylori test alone was 54,783 DKK and 39,700 DKK per additional proportion of days without dyspeptic symptoms.

CONCLUSIONS

Empirical antisecretory therapy confers a small insignificant benefit but costs more than strategies based on test for H. pylori and is probably not a cost-effective strategy for the management of dyspepsia in primary care.

Impact of Helicobacter pylori on the management of dyspepsia in primary care

BACKGROUND

It is unclear what impact Helicobacter pylori infection has had on the management of dyspepsia in primary care and to what extent published guidelines on H. pylori are implemented in routine clinical practice.

AIM

To assess the impact of H. pylori infection on the management of dyspepsia in primary care.

METHODS

Patients referred by primary care doctors to an open-access 13-carbon urea breath test service over a 2-year period for their first urea breath test were included in the study. Individual breath results were linked with data on prescribing obtained from the General Medical Services prescription database.

RESULTS

Of 805 patients, 374 (47%) had a positive urea breath test and 431 (54%) a negative urea breath test. Of positive urea breath test patients, only 245 (64%) were prescribed eradication therapy in the 3 months after the breath test and only 43% were referred back for re-testing. In the year after the urea breath test, there was a significant fall in prescribing of antisecretory therapy which was greatest in the patients who received H. pylori therapy (P < 0.001).

CONCLUSIONS

There appears to be under and inappropriate treatment of H. pylori infection in primary care, and a low rate of re-testing after eradication, indicating that current guidelines are not well implemented in practice.

Complicated and uncomplicated peptic ulcers in a Danish county 1993-2002: a population-based cohort study

Peptic ulcer epidemiology changes as the proportion of Helicobacter pylori infected people decreases, use of nonsteroidal anti-inflammatory drugs (NSAID) increases, and the proportion of elderly persons increases.

OBJECTIVES

To describe incidence and prognosis of uncomplicated and complicated peptic ulcer patients in Funen County 1993-2002.

METHODS

Data on endoscopies, gastric and duodenal operations, and related peptic ulcer diagnoses were extracted from four population-based databases covering a period from 1974 to 2002. All citizens of Funen County (population 470,000) who between 1993 and 2002 had a peptic ulcer diagnosed for the first time were identified.

RESULTS

Between 1993 and 2002 the incidence of uncomplicated duodenal ulcer decreased from 0.55/1,000 person-years (95% CI 0.49-0.62) to 0.37 (0.31-0.43), uncomplicated gastric ulcer decreased from 0.56 (0.49-0.63) to 0.40 (0.34-0.46), and perforated ulcer decreased from 0.14 (0.11-0.18) to 0.08 (0.06-0.11). The incidence of bleeding peptic ulcer was stable with 0.55 (0.49-0.62) in 1993 and 0.57 (0.51-0.64) in 2002. The proportion of possible NSAID-related incident peptic ulcers increased from 320/827 (39%) in 1993 to 363/686 (53%) in 2002 (p < 0.01). A total of 3,233 patients with incident complicated peptic ulcer (9,927 person-years) and 4,421 patients with incident uncomplicated peptic ulcer (17,773 person-years) was followed for up to 10 yr. The first month following newly diagnosed complicated ulcer the standardized mortality rate was 37.1 (33.4-41.1) during the next 11 months it was 5.1 (4.6-5.6), and in the following years it was 2.6 (2.4-2.8). The corresponding figures for incident uncomplicated peptic ulcer was 11.6 (9.6-13.9), 4.0 (3.6-4.4), and 2.5 (2.3-2.7).

CONCLUSION

During the period, incidence of peptic ulcers decreased and an increasing proportion was related to NSAID. Mortality is high.

Prevalence of Helicobacter pylori infection, endoscopic gastric findings and dyspeptic symptoms among a young Japanese population born in the 1970s

BACKGROUND

With the prevalence of Helicobacter pylori (H. pylori) infection rapidly decreasing in Japan, endoscopic findings and dyspeptic symptoms need to be re-evaluated.

METHODS

In a health check-up program, endoscopy was performed on 530 young Japanese subjects (371 men and 159 women) born in the 1970s. Helicobacter pylori infection was evaluated using serology and a rapid urease test. Endoscopic gastritis was classified according to the Sydney classification system, in addition to nodular gastritis. Dyspeptic symptoms were also recorded before endoscopy.

RESULTS

Of the 530 subjects, 87 (16.4%) were H. pylori positive. Of the 443 H. pylori-negative subjects, 349 (78.8%) were considered to have endoscopically normal gastric mucosa. However, of the 87 H. pylori-positive subjects, only 19 (21.8%) tested normal (P < 0.001). The prevalence of several types of gastritis was significantly higher in H. pylori-positive subjects compared with H. pylori-negative subjects: atrophic gastritis (37.9% vs 1.1%, P < 0.001), flat erosive gastritis (29.9% vs 7.2%, P < 0.001), rugal hyperplastic gastritis (12.6% vs 0.0%, P < 0.001), and nodular gastritis (13.8% vs 0.0%, P < 0.001). Other types of gastritis were not related to H. pylori status. The prevalence of subjects with dyspeptic symptoms was significantly higher in H. pylori-positive subjects compared with H. pylori-negative ones (28.7% vs 6.5%, P < 0.001).

CONCLUSION

It is suggested that in consideration of its recent low prevalence and the slow increase in its infection, the prevalence of H. pylori-related gastritis will gradually decrease in Japan. Further studies will be required to ascertain if there is a need for H. pylori eradication in this young population.

Dyspepsia consulters and patterns of management: a population-based study

BACKGROUND

Although dyspepsia is common, management patterns in the United States are unknown.

AIM

To determine the pattern of dyspepsia evaluation and treatment over 20 years in a population-based cohort, and test the hypothesis that the management was influenced by dyspepsia subgroup and gender.

METHODS

The validated Bowel Disease Questionnaire was mailed to a random sample of Olmsted County, Minnesota residents (1988-1990). Of the 835 survey respondents, 213 subjects were identified as having dyspepsia according to Rome I Criteria. The medical chart of each dyspeptic subject who had not denied research authorization (n = 206) was reviewed to identify all episodes of care for dyspepsia symptoms 10 years before and 10 years after the date the Bowel Disease Questionnaire was completed. Of these 206 subjects (mean age 47 years, 48% female), 34% had ulcer-like dyspepsia, 32% had dysmotility-like dyspepsia, and 37% had reflux-like dyspepsia.

RESULTS

Nearly half (n = 98, 48%) had episodes of care for dyspepsia symptoms over 20 years. Of these 98 subjects, 49% had upper gastrointestinal endoscopy, 4% motility studies and 12% were tested for Helicobacter pylori. At the first visit of the episode of care closest to Bowel Disease Questionnaire completion, 72% were seen in primary care, 16% in emergency medicine and 2% in gastroenterology. In addition, 13% were referred to gastroenterology clinic within this episode. During the study period, 70% were given an 'acid' diagnosis, 7% a 'motility' diagnosis and 54% a 'functional' diagnosis; 78% received acid suppression agents (28% proton pump inhibitors), 18% psychotropic agents and 7% prokinetic agents. No significant association was found between gender and test usage, specialty referral or type of treatment, although women were three times less likely to receive proton pump inhibitors (odds ratio 3.3, 95% CI: 1.2-9.1). Symptom severity, frequency and pattern were risk factors for health care seeking in dyspepsia.

CONCLUSIONS

Delivery of care for dyspepsia was similar among dyspepsia subgroups and in men and women.

Clinical value of ultrasound in the evaluation of dyspepsia in primary health care

OBJECTIVE

In general practice, upper abdominal ultrasound (US) is widely used in the evaluation of patients with dyspepsia. However, there is a dearth of published data on the role of US in the dyspepsia work-up. There are no data on the use of US as a follow-up study in functional dyspepsia. The aims of this study were to assess the role of US in evaluating dyspepsia, and to assess the long-term clinical relevance of minor findings revealed by US in patients with functional dyspepsia.

MATERIAL AND METHODS

Four hundred consecutive dyspeptic patients were recruited. At baseline, all patients underwent gastroscopy and US. Patients were divided into two groups: "endoscopy-negative patients" and "endoscopy-positive patients". "The endoscopy-negative" group included all cases in which the final diagnoses could not be settled after gastroscopy. US was repeated after 6-7 years in patients who had functional dyspepsia.

RESULTS

In the endoscopy-negative group, gallstones were detected in 21 patients, but this was considered to be a cause of symptoms in 9 patients. No malignant lesions were detected by US in the endoscopy-negative group. In the endoscopy-positive group, a malignant tumor in the kidney was suspected in 3 patients. Only one of these tumors turned out to be an incidental small carcinoma. Moreover, several minor findings were shown by US: usually these consisted of abnormal echogenicity of the liver. During the follow-up period, 6 patients developed gallstones. At the end of the follow-up period, two clinically significant findings were diagnosed: a small renal cancer and hydronephrosis.

CONCLUSIONS

This study shows that the wide, untargeted use of abdominal US in the evaluation of patients with dyspepsia following a gastroscopy is not necessary. Repeated US examination in cases of functional dyspepsia is not recommended, and rarely changes the diagnosis.

Clinical usefulness of serum pepsinogens I and II, gastrin-17 and anti-Helicobacterpylori antibodies in the management of dyspeptic patients in primary care

BACKGROUND

Several tests have been proposed for evaluating dyspeptic symptoms and their relationship to the underlying gastric disease. Serum pepsinogens and gastrin-17 are known to be useful biomarkers for the detection of gastric pathologies.

AIM

To evaluate the capability of screening dyspeptic patients in the primary care by analyses of serum pepsinogens I (sPGI) and II (sPGII), gastrin-17 (sG-17) and the IgG anti-Helicobacter pylori antibodies (IgG-Hp).

PATIENTS AND METHODS

Three hundred and sixty-two consecutive patients with dyspeptic symptoms (208 females, mean age 50.6 +/- 16 years, range 18-88 years) referred by general practitioners for upper gastrointestinal endoscopy were enrolled. A blood sample was taken from each subject for IgG-Hp, sPGI, sPGII and sG-17 analyses.

RESULTS

Two hundred and eighty-seven patients had a complete screening; of these, 132 resulted positive for Hp infection. Patients with atrophic chronic gastritis showed significantly lower serum pepsinogen I levels and sPGI/sPGII ratio than patients with non-atrophic chronic gastritis. Moreover, by calculating the values of sPGI by sG-17 and sG-17 by sPGII/sPGI, subjects with atrophic chronic gastritis could be distinguished from those with non-atrophic chronic gastritis and from those with normal mucosa, respectively. sG-17 levels were found to be a useful biomarker for the detection of antral atrophic gastritis, while the combination of sPGI, the sPGI/sPGII ratio and sG-17 was found effective in identifying corpus atrophy.

CONCLUSION

A panel composed of PGI, PGII, G-17 and IgG-Hp could be used as a first approach in the 'test and scope' and/or 'test and treat' strategy in the primary care management of dyspeptic patients.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

"Alarm symptoms" in dyspepsia. How does the general practitioner investigate?

OBJECTIVE

Alarm symptoms are present in 10% of patients consulting a general practitioner (GP) because of dyspepsia. The options for the GP are: perform "own" investigation, refer to a specialist or secondary care, or maintain watchful waiting.

DESIGN

Postal questionnaire to GPs obtaining information from the records of patients who had consulted earlier owing to dyspepsia and reported one or more alarm symptoms at the consultation.

SETTING

92 general practices throughout Denmark.

SUBJECTS

In 7240 consecutive consultations in 1991-1992 a total of 749 patients reported 881 alarm symptoms. Follow-up data 3 years later were obtained from 81%.

MAIN OUTCOME MEASURES

The management of alarm symptoms by GPs: "own" investigation, referral to specialist, or expectance; procedures used in "own" investigations, patient characteristics related to such decisions, and gastrointestinal diseases diagnosed by this management.

RESULTS

67% of the patients with alarm symptoms were investigated promptly (8% by referral to specialists) and 33% were left uninvestigated, with great variations between alarm symptoms. The single most preferred GP investigation was endoscopy. A gastrointestinal diagnosis was obtained in 35% of the patients; 3% of these were malignancies while 9% were peptic ulcers.

CONCLUSION

The decision on whether and how to investigate alarm symptoms is complex and relates to specific symptom, type of dyspepsia, age, gender and dwelling of the patient.

Diagnostic investigation rates and use of prescription and non-prescription medications amongst dyspeptics: a population-based study of 2300 Australians

BACKGROUND

: There is limited knowledge of the diagnostic investigation rates and use of prescription and non-prescription drugs amongst dyspeptics.

AIM

: To assess the investigation rates and use of prescription and non-prescription anti-ulcer medications amongst dyspeptics in the population.

METHODS

: A cross-sectional survey was performed of 2300 Australians.

RESULTS

: Of 748 dyspeptics, 422 (56%) had consulted a doctor regarding dyspepsia at some time in their life. Of the consulters, 64% had undergone investigations at some time: 37% an endoscopy, 54% a barium meal and 27% both. A diagnosis of peptic ulcer was reported by 31% of those investigated. The symptom profile of gastroscopy patients differed significantly from that of uninvestigated dyspeptics. Of the consulters, 36% had taken anti-ulcer prescription drugs in the last 3 months: Histamine-2 receptor antagonists (73% of prescriptions), proton pump inhibitors (17%), cytoprotectants (5%) and prokinetic drugs (5%). Antacids were taken by 30% of non-consulting dyspeptics, 44% of consulters not on prescription drugs and 58% of dyspeptics taking prescription drugs. Advancing age, but not gender, was associated with diagnostic investigation and prescription and non-prescription drug usage.

CONCLUSIONS

: There are high rates of diagnostic investigation amongst dyspeptics who consult doctors. Many individuals with dyspepsia decide to self-medicate with antacids regardless of consulting or prescriptions, suggesting that current management is suboptimal.

A rational approach to uninvestigated dyspepsia in primary care: review of the literature

In this paper the rationale and limitations of the four most important approach strategies to dyspepsia in primary care (empiric treatment, prompt endoscopy, "test-and-scope", and "test-and-treat") are analysed. It is concluded that in the absence of alarm symptoms, a "test-and-treat" approach is currently the most rational approach provided that three conditions are met: (1) a highly accurate test should be used, (2) the prevalence of Helicobacter pylori in the population should not be too low, and (3) an effective anti-H pylori regimen should be prescribed taking sufficient time to instruct and motivate the patient.

Dyspeptic symptoms in primary care. An observational study in general practice

BACKGROUND AND AIMS

Dyspepsia frequently causes patients to consult a general practitioner, but is generally investigated in referral centres. This study describes features of dyspepsia and its relationship with demographic, clinical and socio-economic factors in patients seen by general practitioners in Italy.

PATIENTS AND METHODS

In Italy, 10 000 general practitioners were asked to recruit up to 10 consecutive dyspeptic patients during a 1-month period. Painful and non-painful dyspeptic symptoms, retrosternal pain/burning and visible abdominal distension were graded 0-3 by a validated questionnaire. Demographics and clinical features were also recorded.

RESULTS

During the test period, 43 446 patients were included (55% were men; 50% were over 45 years old; 49% were smokers; 45% had experienced symptoms for > or = 1 month; 28% had a history of peptic ulcer). Dyspepsia accounted for 8.3% (range 3-11%) of the consultations of a subset of participating doctors. Epigastric pain and fullness were reported in 84% and 79% of patients, respectively. Dyspeptic symptoms were moderate-severe (graded > or = 2) in 69% of patients. Predominant epigastric pain and predominant discomfort were reported in 21% and 25% of the cases, respectively. Male gender, smoking, nocturnal awakening, overlapping reflux symptoms and a history of peptic ulcer were more frequent in patients with predominant pain, while female gender and overlapping abdominal distension were more common in patients with predominant discomfort. Age, educational level and working status were not related to any symptom pattern. Young patients presenting for the first time with uncomplicated dyspepsia accounted for 10% of the dyspepsia workload.

CONCLUSIONS

Dyspepsia accounts for a relevant workload for general practitioners. A considerable overlap exists among digestive symptoms. The proportion of patients that can be empirically treated according to current guidelines may be lower than expected.

Helicobacter pylori and dyspepsia: physicians' attitudes, clinical practice, and prescribing habits

BACKGROUND

Consensus guidelines have been published on the management of Helicobacter pylori infection and it is assumed that these guidelines are adhered to in clinical practice.

AIM

To assess the changing attitudes of medical practitioners to H. pylori, and the impact of H. pylori infection on everyday clinical practice and prescribing patterns.

METHODS

Data for this review were gathered up to December 2000 from detailed review of medical journals, the biomedical database MEDLINE, and relevant abstracts.

RESULTS

Physician surveys show widespread acceptance of H. pylori as a causal agent in peptic ulcer disease. Gastroenterologists adopted H. pylori therapy for peptic ulcer earlier and more comprehensively than primary care physicians. Despite a low level of belief in H. pylori as a causal agent in non-ulcer dyspepsia and gastro-oesophageal reflux disease (GERD), H. pylori therapy is widely prescribed for these conditions. Proton pump inhibitor-based triple therapy is the eradication regimen of choice by all physician groups. In routine clinical practice, there appears to be significant under-treatment of peptic ulcer disease with H. pylori therapy, but extensive use for non-ulcer indications. Prescription of H. pylori treatment regimens of doubtful efficacy appears commonplace, and are more likely in primary care. Despite the advent of H. pylori therapy, the prescription of antisecretory therapy, particularly of proton pump inhibitors, continues to rise.

CONCLUSIONS

Publication of consensus guidelines per se is not enough to ensure optimal management of H. pylori infection. Innovative and ongoing educational measures are needed to encourage best practice in relation to H. pylori infection. These measures might be best directed at primary care, where the majority of dyspepsia is managed.

One-year prognosis of primary care dyspepsia: predictive value of symptom pattern, Helicobacter pylori and GP management

BACKGROUND AND AIMS

Dyspepsia is a highly prevalent, heterogeneous condition with a poorly defined clinical course in family practice. We observed its clinical outcome and identified prognostic factors.

PATIENTS

We studied 583 patients presenting to their general practitioner (GP) with a new episode of dyspeptic complaints.

METHODS

A validated dyspepsia severity score was used to observe deterioration of dyspepsia. Furthermore, the general health status and the patient's perception of no improvement were registered. As prognostic determinants, demographic characteristics, concomitant conditions, and management were studied. Univariate and multivariate analyses were performed.

RESULTS

A total of 518 (89%) patients completed the 1-year follow-up. Of these, 111 patients (22%, 95% CI 18% to 25%) had a negative change in their dyspepsia score after 1 year; 46 patients (9%, 95% CI 6% to 11%) noted impairment of general health; and 122 patients (24%, 95% CI 20% to 28%) regarded complaints as not improved. Frequent dyspepsia (>1 episode/year) and a history of peptic ulcer predicted deterioration of dyspepsia, while smoking and little psychological distress predicted impairment of general health. Eradication of Helicobacter pylori reduced the chance of patient's negative judgement for especially those with frequent dyspepsia.

CONCLUSION

One-quarter of the dyspepsia patients had an unfavourable 1-year prognosis, which was predictable because of frequent complaints and previously diagnosed ulcers. Psychological factors need to be identified, since they are related to general health improvement. The observed benefit of H. pylori eradication on perceived improvement of complaints may well be placebo effect.

The cost of gastro-oesophageal reflux disease, dyspepsia and peptic ulcer disease in Sweden

BACKGROUND AND OBJECTIVE

Dyspepsia, peptic ulcer disease (PUD) and gastro-oesophageal reflux disease (GORD) involve a substantial cost to Swedish society. There is a lack of up-to-date nationwide cost estimates after 1985. This study was conducted to present a comprehensive and updated cost analysis and study the change over time of the national cost of these disorders.

DESIGN AND SETTING

Primarily, data from National Swedish databases and secondly, data from databases from the County of Uppsala for 1997 were used for the calculations and estimations.

PERSPECTIVE

Swedish societal perspective.

RESULTS

The total cost to Swedish society of dyspepsia, PUD and GORD in 1997 was $US424 million, or $US63 per adult. Direct costs totalled $US258 million (61%) while indirect costs totalled $US166 million (39%). The highest proportions of costs were due to drugs and sick leave, these being 37 and 34%, respectively.

CONCLUSIONS

The cost of dyspepsia and GORD is substantial for patients, health providers and society. Since 1985, drug costs have increased substantially while the cost of sick leave has decreased.

Consultations and referrals for dyspepsia in general practice--a one year database survey

OBJECTIVE

Dyspepsia usually presents first in primary care. There are many reasons for referral including urgent problems (for example, haematemesis and melaena), treatment failure, or to exclude serious pathology. Referral will change the population characteristics of primary and secondary care dyspeptics. Many of the guidelines for primary care dyspepsia, however, are based on secondary care research on these referred patients. The aim of this study was to describe the prevalence of dyspepsia in general practice, the characteristics of patients presenting with dyspepsia in primary care, and the clinical and non-clinical determinants of referral in these patients.

DESIGN

Cross sectional survey of the consultation records of patients presenting with dyspepsia in primary care during a one year period.

METHODS

Dyspeptic patients who consulted their general practitioner (GP) in 1997 were selected on the basis of International Classification of Primary Care codes using a computer search among 20 sentinel practices affiliated with the Utrecht Network of General Practitioners. Cross tables and logistic regression analysis were carried out to reveal patient characteristics and determinants of referral.

RESULTS

The prevalence of dyspepsia presenting in primary care in 1997 was 3.4% (1740/48958). These patients were usually not referred during the first consultation. Men, elderly patients, and patients with a previous history of dyspepsia were referred to secondary care more frequently than other dyspeptic patients. Patients diagnosed with both irritable bowel syndrome and dyspepsia were at risk of being referred most.

CONCLUSION

Dyspepsia is a frequently occurring complaint in primary care and patients are usually treated by their GP. Besides clinically relevant reasons for referral, dyspeptic patients with irritable bowel syndrome seem to be more "at risk" of being referred to secondary care than other dyspeptic patients. The differences between primary and secondary care dyspeptic patients should be taken into account when interpreting research for guideline purposes. Further research is needed to clarify the background of the relation between irritable bowel syndrome and dyspepsia and its influence on referral.

Factors associated with consulting medical or non-medical practitioners for dyspepsia: an australian population-based study

BACKGROUND

Little is known about how many dyspeptics in the population consult medical and non-medical practitioners, or the factors associated with various consulting patterns.

METHODS

A cross-sectional survey of 748 Australians with dyspepsia investigated their age, sex, dyspepsia symptoms, medical and non-medical consultations, and health status on the SF-12.

RESULTS

Overall, 56% had ever consulted a medical practitioner for dyspepsia. Of these, 54% consulted within 6 months of first symptoms. Non-medical practitioners were consulted by 29%. Compared to dyspeptics in all, or most, other consulting groups, subjects who did not consult (37%, group NO) were characterized by fewer symptoms, better physical health, and younger age. Those who only consulted doctors (34%, group M) were older and had better mental, but poorer physical health. Those who only consulted non-medical practitioners (7%, group N) were younger and had better physical, but poorer mental health. Dyspeptics consulting both medical and non-medical practitioners (22%, group M + N), were older, more dissatisfied with medical care, had more symptoms and poorer physical and mental health. Timing of medical consultations was similar in groups M and M + N. Group M + N dyspeptics consulted similar types, but more non-medical practitioners than group N. No sex differences were found in consulting behaviour.

CONCLUSIONS

Many dyspeptics do not consult; they have fewer symptoms than consulters. Consultation with non-medical practitioners is common and is associated with poor mental health. Dyspeptics seeking advice from both medical and non-medical practitioners are less satisfied with their medical management than those who only consult doctors for their dyspepsia.

Dyspepsia workload in urban general practice and implications of the British Society of Gastroenterology Dyspepsia guidelines (1996)

AIM

To define the characteristics of patients consulting with active dyspeptic symptoms in urban general practice, and to consider the implications of applying the British Society of Gastroenterology Dyspepsia management guidelines.

DESIGN

Prospective observational study over a period of 12 months.

SETTING

Two multipartner, two-centre general practices in the City of Leeds (UK) with a combined target population of 11 011 registered patients.

SUBJECTS

A total of 340 patients consulting with active dyspeptic symptoms (52% male; mean age 53 years, range 16-89 years).

RESULTS

Of the practice population, 3% consulted with dyspepsia (first-time consulter: 19%; previous consulter not yet investigated: 30%; previously investigated: 51%). Of 168 undiagnosed patients, 43% had upper abdominal pain (dysmotility-like symptoms in 42%), 35% had reflux symptoms, 22% had mixed symptoms, 12% had 'alarm' symptoms and 18% had a history of NSAID use. Patients < 45 years old with simple dyspepsia accounted for 32% of undiagnosed cases. A fifth of the workload was in dealing with undiagnosed dyspeptics over 45 years old. One per cent of the population would require endoscopy if all undiagnosed cases either > 45 years or with complicated dyspepsia were investigated. Of 172 previously investigated patients, 29% had negative tests, 25% had 'minor' findings, and 45% had evidence of acid-peptic disease. Patients with duodenal ulcer disease accounted for 12% of the total workload.

CONCLUSIONS

A knowledge of the characteristics of patients consulting with dyspepsia in primary care should allow the adaptation of guidelines, to ensure advice is relevant to local case mix and compatible with local resources.

The health economic impact of upper gastrointestinal symptoms in the general population: results from the Domestic/International Gastroenterology Surveillance Study (DIGEST)

BACKGROUND

The Domestic/International Gastroenterology Surveillance Study (DIGEST) is the first large, multinational, population-based survey to assess the 3-month prevalence and economic/quality-of-life impact of upper gastrointestinal symptoms (UGIS).

METHODS

A total of 5581 subjects were interviewed in 10 countries (grouped into seven regions). Respondents were classified as having relevant or non-relevant upper gastrointestinal symptoms, and questioned about consumption of healthcare resources in terms of doctor consultations, prescribed and non-prescribed medications, hospital stays and investigations for both gastrointestinal and other health problems. The impact of symptoms in terms of time lost and reduced effectiveness at work or social activities was also recorded.

RESULTS AND CONCLUSIONS

Twenty-eight percent of the total sample was defined as having clinically relevant UGIS (UGIS of at least moderate severity and with a frequency of at least once per week in the previous 3 months). During the period studied, 20% of these subjects had consulted a family practitioner (16.2%) and/ or a specialist (6.3%), primarily for UGIS. Of those with clinically relevant UGIS, 49% had taken over-the-counter medication, and 27% prescription medication for gastrointestinal (GI) symptoms. Two percent reported a hospital stay and 27% reported days of reduced or no work, school or domestic productivity due to UGIS. Four percent of all study subjects underwent investigations for UGIS during this period. Variations between countries in these parameters may be due to differences in healthcare systems and cultural attitudes towards UGIS, influencing both the healthcare-seeking behaviour of subjects with UGIS and their management.

Quality of life in patients with upper gastrointestinal symptoms: results from the Domestic/International Gastroenterology Surveillance Study (DIGEST)

BACKGROUND

Our purpose was to evaluate the impact of upper gastrointestinal (GI) symptoms on quality of life (QoL), which was assessed using the Psychological General Well-Being Index (PGWBI) and the three-item Interference with Daily Life Index (IDLI).

METHODS

The Domestic/International Gastroenterology Surveillance Study (DIGEST) was conducted among 5581 respondents (mean age 44 years) from 10 countries (seven European countries plus Canada, USA and Japan).

RESULTS

Approximately 25% of the respondents reported conditions such as hypertension, asthma or diabetes, and a mean of 46.4% reported at least one GI symptom. The most frequent symptoms were heartburn, diarrhoea and postprandial fullness. Approximately 10-20% of the respondents reporting individual symptoms experienced these several times a week. Symptoms were considered as severe or interfering 'quite a lot' with daily activities by at least 7.3% and 4.8% of respondents, respectively. PGWBI scores varied from 71.82 (Italy) to 79.43 (Switzerland) and daily activity scores from 88.62 (USA) to 97.78 (Switzerland). Female gender, medical conditions and presence of GI symptoms were associated with significantly impaired wellbeing and daily life. PGWBI and IDLI scores were lower among respondents with relevant upper GI symptoms than non-upper GI symptoms. Among upper GI symptom groups, subjects with ulcer-like symptoms had lower scores than patients with GERD-like or dysmotility-like symptoms. PGWBI and IDLI scores were found to discriminate between respondents reporting different symptom frequencies and severities.

CONCLUSIONS

Results from the DIGEST demonstrate on a large scale the importance of GI symptoms in daily life and their influence on QoL.

Management of Helicobacter pylori-related gastrointestinal diseases by general practitioners in Italy

AIMS

To investigate the diagnostic approach to and management of Helicobacter pylori infection at primary care level in Italy 2 years after the Maastricht consensus report.

METHODS

A total of 100 randomly selected general practitioners (GPs) answered a 12-item multiple-choice questionnaire, personally delivered and collected by non-medical staff.

RESULTS

In 25% of cases, GPs preferred a prompt referral of dyspeptic patients to the specialist. The favourite diagnostic test for H. pylori infection was gastroscopy with biopsies (55%), followed by standard and office-based serology (24% and 18%, respectively), and 13C urea breath test (5%). H. pylori-eradication was prescribed in patients with peptic ulcer, reflux oesophagitis and functional dyspepsia by 64%, 43% and 66% of GPs, respectively. Only 7% of GPs adopted a test-and-treat approach. Proton pump inhibitor-based triple therapies were used by almost all physicians. In peptic ulcer disease, most of GPs re-tested patients in order to confirm H. pylori eradication (50% by gastroscopy with biopsies and 30% by serology only 2 months after therapy).

CONCLUSIONS

Uncertainty seems to persist among Italian GPs concerning the indications for H. pylori treatment, the use of diagnostic tests, and patient follow-up. In contrast, no doubts exist regarding the first choice eradication regimens. This survey suggests that further efforts should be made to spread scientific knowledge and guidelines on H. pylori diagnosis and management in primary care in Italy.

Helicobacter pylori treatment instead of maintenance therapy for peptic ulcer disease: the effectiveness of case-finding in general practice

BACKGROUND

Maintenance therapy with acid-inhibiting medication is common in general practice. Since the eradication of Helicobacter pylori has become the treatment of choice for peptic ulcer disease, H. pylori treatment could replace maintenance therapy in patients with an ulcer history.

AIM

To determine the effectiveness of a full peptic ulcer disease history case-finding strategy, together with subsequent H. pylori testing and treatment, in discontinuing maintenance therapy.

METHOD

Patients were included from seven general practices, who had been using acid-inhibiting medication for more than 3 months in the period May 1996-May 1997. Patients with a history of proven peptic ulcer disease were tested, and treated with proton pump inhibitor-triple therapy if positive. Maintenance therapy was discontinued and restart within 12 months was monitored.

RESULTS

Long-term acid suppression was used by 2.8% of the practice-populations. A peptic ulcer disease history was found in 18% of the patients, 73% of whom were offered the 'H. pylori test and treat' alternative. The majority responded: 92% of the H. pylori-infected patients were treated, 78% of whom successfully discontinued long-term medication.

CONCLUSION

Implementing an 'H. pylori test and treat' strategy enabled one-third of the patients with a peptic ulcer disease history to stop maintenance therapy successfully. The strategy contributes to reduction of long-term drug use, but compliance needs improvement.

Self medication and health habits in the management of upper gastrointestinal symptoms

Upper gastrointestinal symptoms are a common complaint among the general population but only a small proportion of sufferers seek medical advice. The aim of this study was to examine what kind of perceptions persons using self medication have about the causes of their gastrointestinal symptoms, whether they have made any health-related lifestyle changes, and whether visits to a physician are related to lifestyle changes. A pharmacy-based survey was done in 10 pharmacies in the Helsinki area in 1995. The questionnaire was completed by 292 customers. The response rate was 53%. Respondents in a population-based health interview survey (n = 10,410) were used as a comparison group for poor health-behavior (consumption of tobacco, alcohol, coffee). The most common perceived causes of gastrointestinal symptoms were poor diet, coffee, and stress. Ignorance about possible causes of symptoms was especially common among less educated respondents and among those persons who had never visited a physician due to their symptoms. Respondents were significantly more often smokers and they had attempted to reduce their coffee and alcohol consumption more often than the general population. Those who had visited a physician during past year, less often had poor health-behavior and they had better knowledge about the possible causes of their symptoms. They had also made lifestyle changes more often, but after adjustment for background characteristics, physician visits were positively correlated only with coffee reduction. Counseling about healthy lifestyles, especially about smoking, should be increased in physician consultations and in pharmacies for all patients and customers having gastrointestinal problems.

Self-medication of dyspepsia: how appropriate is it?

BACKGROUND

The scope of self-medication is increasing in many countries, and drugs for dyspepsia are a popular group for deregulative activities. This study investigated what kind of upper gastrointestinal symptoms people self-medicate and how appropriate this self-medication is.

METHODS

An anonymous questionnaire was give to 50 consecutive customers buying antacids, alginates, or sucralfates in 10 pharmacies in the capital area in Finland in 1995. In half of the pharmacies the questionnaire was returned by mail, and in the other half the questionnaire was filled out at the pharmacy. The response rate was 53% (n = 292).

RESULTS

The commonest reasons for self-medication were heartburn (88%), gastrointestinal pain (31%), and acid regurgitation (32%). Seventy-five per cent of respondents had used dyspepsia drugs for more than a year. The commonest way to self-medicate was to interchange regular and occasional use. Knowledge about the proper use of dyspepsia drugs was poor, and 6% of respondents had symptoms contraindicating self-medication but had not visited a physician during the past year. Patients more than 60 years old were especially at risk of potential inappropriate use.

CONCLUSIONS

Over-the-counter (OTC) drugs for dyspepsia are likely to be used improperly. A physician's advice on the use of OTC dyspepsia drugs, in addition to detailed printed information about drug action and proper administration, would be important means to guarantee appropriate use of these drugs.