A quantitative analysis of symptoms of non-ulcer dyspepsia as related to age, pathology, and Helicobacter infection

Treatment of acid-related diseases in the elderly with emphasis on the use of proton pump inhibitors

Proton pump inhibitors (PPIs) have revolutionised the treatment of acid-related disorders, and they have also made it possible to define the spectrum of acid inhibition required for optimal treatment in each disorder. Five PPIs are now available: the older drugs, omeprazole, lansoprazole and pantoprazole, and the two newest, rabeprazole and esomeprazole. These agents have predominantly been developed in the younger adult population, and data for the elderly population are limited. Subtle differences have emerged between the old and the new PPIs in their pharmacokinetic, pharmacodynamic and efficacy profiles. The degree of clinical relevance of these differences in the adult population is in question. However, according to this review, based on the available data for the elderly and by inference from the adult population, the differences are highly relevant in the elderly population. Studies of the pharmacokinetics of older PPIs demonstrated considerable variation in drug clearance that was reflected in a wide range of efficacy related to acid suppression with standard dosages. The newer PPIs offer several advantages over older agents, particularly in terms of rapid, profound and consistent acid inhibition. Consistent acid inhibition is particularly important in the elderly since clinical response is often difficult to judge in this patient group. An individual's cytochrome P450 (CYP) 2C19 genotype predicts the degree of acid suppression and consequently the clinical efficacy of the PPIs. The older PPIs are predominantly metabolised by CYP2C19, with this being of more importance for omeprazole and lansoprazole than pantoprazole. The hepatic metabolism of rabeprazole is predominantly by nonenzymatic reactions and minimally by CYP-mediated reactions, which therefore confers an advantage over older PPIs in that genetic polymorphisms for CYP2C19 do not significantly influence rabeprazole clearance, clinical efficacy or potential for drug interactions. The metabolism of esomeprazole involves CYP2C19 but to a lesser extent than its predecessor omeprazole. Furthermore, esomeprazole has a more rapid onset of action and less variation in clearance rates than omeprazole. Drug clearance decreases with age independently of CYP2C19 status, exaggerating some of the differences between the PPIs and increasing the risk of drug interactions.

Dyspeptic symptoms in middle-aged to old adults: the role of Helicobacter pylori infection, and various demographic and lifestyle factors

OBJECTIVES

To evaluate the role of factors supposed to interfere with the gastric mucosa like Helicobacter pylori, smoking and analgesics in symptom generation in a population-based sample of middle-aged to old.

SUBJECTS

A total of 288 subjects aged 50-85 (mean 65 +/- 7.2) attending a General Science-orientated Continuing Education Programme at the University of Ulm.

METHODS

Helicobacter pylori infection was determined by the 13C-urea breath test. Demographic data, gastrointestinal symptoms and factors supposed to be involved in symptom generation were collected by a standardized questionnaire. The association between various demographic and lifestyle factors with a gastrointestinal symptom score was quantified by odds ratios (ORs) using multiple logistic regression.

RESULTS

Use of nonsteroidal anti-inflammatory drugs (OR=1.2; 95% CI=0.7-2.1) was no risk factor for abdominal symptoms, whereas female sex (OR= 1.6; 95% CI=0.9-2.9) and current smoking (OR= 3.7; 95% CI=0.9-15.4) were associated with a high symptom score. Age 70 years and over was significantly associated with a lower symptom score (OR=0.4; 95% CI=0.2-0.9). However, H. pylori infection was a risk factor for a high symptom score in that age group (OR=4.3; 95% CI=1.2-14.8), whereas no such association (and even a tendency to reduced symptom levels in infected subjects) was observed in younger age groups.

CONCLUSION

The role of H. pylori infection in symptoms may vary by age. The loss of symptoms in the elderly may delay detection of gastroduodenal pathology and appropriate treatment in older adults.

Helicobacter pylori eradication and standardized 3-month omeprazole therapy in functional dyspepsia

OBJECTIVES

The role of Helicobacter pylori in functional dyspepsia remains unclear. This study evaluated the long term consequences for symptoms and quality of life in patients with H. pylori-positive functional dyspepsia after H. pylori eradication therapy with a standardized 3-month omeprazole treatment.

METHODS

A total of 151 H. pylori-positive patients with functional dyspepsia were randomized to receive either eradication therapy or placebo-antibiotics. The initial medication was administered in a double-blinded fashion. In addition, to standardize acid suppression, every patient received omeprazole therapy for the first 3-month period. Dyspeptic symptoms were evaluated by a questionnaire every 3 months, and quality of life was measured by a validated RAND 36-item health survey 1.0 questionnaire at the beginning of the study and after 12 months of follow-up. As the main outcome measure, the scores of patients who had received H. pylori eradication therapy and omeprazole were compared with those who received placebo and omeprazole during the 12 months of follow-up.

RESULTS

A total of 136 patients completed the 1-yr follow-up. In all, 77 patients received eradication therapy and 74 patients remained as controls. After 12 months, the mean reduction in the dyspepsia score was 28.8% in patients with H. pylori eradication therapy and 21.7% in the control group. The reduction of dyspepsia was significant (p < 0.0001) in both groups compared to baseline value, but no statistically significant differences in changes of dyspeptic symptoms or in quality of life were demonstrated between the H. pylori eradication therapy group and controls after 1 yr. In both patient groups, regurgitation (p < 0.001) and heartburn (p < 0.01) revealed relapse after cessation of 3-month omeprazole treatment.

CONCLUSIONS

No clear differences in symptoms or in quality of life were found between patients treated with H. pylori eradication therapy and omeprazole compared with patients receiving placebo and omeprazole after 1 yr. Regardless of H. pylori status, omeprazole treatment reduced heartburn and regurgitation. The placebo effect on the symptoms of functional dyspepsia and on quality of life was marked.

Helicobacter pylori eradication in patients with non-ulcer dyspepsia

Epidemiological and pathophysiological studies, as well as clinical trials, attempting to identify a relationship between Helicobacter pylori infection and non-ulcer dyspepsia (NUD), or a subset of NUD, have produced inconsistent and confusing results. While it is possible that H. pylori eradication may be beneficial for symptom relief in a small proportion of patients, routine H. pylori testing and treatment in documented NUD is not currently widely accepted. Despite the lack of convincing evidence, the European Helicobacter pylori Study Group, an Asian Pacific Consensus Meeting, the American Digestive Health Foundation and the American Gastroenterology Association have all recommended considering H. pylori eradication in patients with NUD on a patient-by-patient basis. Recently, large prospective, randomised, double-blind, controlled clinical trials applying highly effective antimicrobial therapy have been conducted with 12 months follow-up. Although these well-designed studies have reached differing conclusions, the results have been largely negative. H. pylori eradication therapy in NUD will fail to relieve symptoms in most patients in the long term.

Dyspepsia and Helicobacter pylori infection: Analysis of 200 Kuwaiti patients referred for endoscopy

BACKGROUND

Dyspepsia is a very common symptom, and is the reason for most referrals for esophagogastroduodenoscopy (EGD). Peptic ulcer disease (PUD), gastroesophageal reflux and gastric cancer account for a minority of such patients. However, the majority have no significant endoscopic abnormalities (non-ulcer dyspepsia). Recently, infection with Helicobacter pylori (HP) has been implicated in the pathogenesis of PUD and gastric cancer. Since HP can be diagnosed by noninvasive techniques, it has been suggested that endoscopy should be restricted to HP-positive patients who do not respond to empirical therapy with antimicrobials. The aim of this study was to establish the prevalence of HP among Kuwaiti dyspeptic patients referred for endoscopy and to determine whether demographic and clinical screening, or the presence of HP, can help distinguish groups of patients with significant gastroduodenal pathology from those with non-ulcer dyspepsia.

PATIENTS AND METHODS

Two hundred randomly selected Kuwaiti patients referred for endoscopy were evaluated prospectively. A detailed personal interview was conducted to establish the demographic and clinical profile of each patient and a diagnostic EGD was performed after the interview. Finally, antral mucosal biopsies were taken to determine the presence of HP. The pre-coded data were analyzed.

RESULTS

The main endoscopic findings were normal (32%), non-erosive antral gastritis (26%), duodenitis (17.5%), duodenal ulcer (11.5%), deformed bulb (4%), esophagitis (7%), and erosive gastritis (2%). The demographic and clinical characteristics of patients did not correlate with endoscopic findings. The overall prevalence of HP infection was 88.5%. There were no statistically significant differences in the prevalence of HP among patients with various endoscopic findings.

CONCLUSION

HP infection is common in Kuwaiti dyspeptic patients referred for endoscopy, irrespective of their demographic and clinical features or the underlying cause of dyspepsia. Noninvasive methods to detect HP are not valid alternatives to endoscopy in the work-up of dyspeptic patients.

Helicobacter pylori colonization does not influence the symptomatic response to prokinetic agents in patients with functional dyspepsia

Functional dyspepsia (FD) is very common, but the pathogenesis of Helicobacter pylori leading to FD is still debated. The aim of this study was first to evaluate the impact of H. pylori colonization on the efficacy of Paspertase (a metoclopramide plus exogenous enzymes regimen for FD patients) and, second, to compare the prevalence of H. pylori infection in FD patients with the general population. Seventy-four consecutive FD patients were enrolled undergoing Paspertase treatment. The symptomatic response was evaluated according to 1-4 scales of six main dyspeptic symptoms (i.e. epigastric pain/discomfort, early satiety, heartburn, nausea/vomiting, abdominal fullness/bloating, and belching). Nine hundred and seventy healthy subjects undergoing a paid physical check-up were included to study the status of H. pylori colonization. The demographic data and basal symptom scores between 43 H. pylori-positive and 31 H. pylori-negative patients were not significantly different. Total and individual symptom scores improved significantly after 4 weeks of Paspertase therapy (P < 0.05), irrespective of H. pylori infection. The prevalences of H. pylori were very similar in FD patients and the general population (58.1 vs 58.0%, NS). In conclusion, these observations suggest that H. pylori colonization is not significant in FD patients of Taiwan while a short-term prokinetic medication is effective for these patients, irrespective of H. pylori status.

Helicobacter pylori and abdominal symptoms: a population-based study among preschool children in southern Germany

OBJECTIVE

To determine the relation of Helicobacter pylori infection with gastrointestinal symptoms in a healthy population-based sample of children.

DESIGN

Population-based cross-sectional study of preschool children.

SETTING

Screening examination for school fitness by physicians of the Public Health Service in Ulm, a city with 100 000 inhabitants in southern Germany.

PARTICIPANTS

One thousand two hundred one preschool children.

MAIN OUTCOME MEASURES

Infection status was determined by 13C-urea breath test. Information on gastrointestinal symptoms was collected from children's parents by a standardized questionnaire and integrated into a symptom score. Results. Nine hundred forty-five children participated in the study (response rate, 79%). Overall, 127 children (13.4%) were infected. H pylori infection was not positively related to specific gastrointestinal symptomatology. Infected children had even fewer symptoms when compared with uninfected children.

CONCLUSIONS

Our results indicate that H pylori infection in children is mostly asymptomatic and not associated with specific gastrointestinal symptoms.