Reassessment of functional dyspepsia: A topic review

Evaluation of the Safety and Efficacy of a Multienzyme Complex in Patients with Functional Dyspepsia: A Randomized, Double-Blind, Placebo-Controlled Study

Functional dyspepsia (FD) is a highly prevalent disorder having nonspecific symptoms and varied pathophysiology. Its treatment remains a challenge as therapeutic options are limited, unsatisfactory, and elusive. Thus, safety and efficacy of DigeZyme^®, a proprietary multienzyme complex (MEC), was evaluated as a dietary supplement in FD patients. In this randomized, double-blind, placebo-controlled, parallel-group study, 40 patients were randomly assigned (1:1 ratio) to receive either MEC (50 mg, TID; n = 20) or placebo (n = 20) for 60 days. Reports of adverse or serious adverse events (AEs), abnormal results of vital signs, abnormal findings during physical examination, and abnormal laboratory investigations were monitored closely. Efficacy measures were change in Short-Form Leeds Dyspepsia Questionnaire (SF-LDQ), Nepean Dyspepsia Index-Short Form (NDI-SF), Visual Analog Scale (VAS), Clinical Global Impression Severity Rating Scale (CGI-S), and Glasgow Dyspepsia Severity Score (GDSS) at baseline and follow-up visits on day 15, 30, and 60. Supplementation with MEC was associated with statistically significant differences (P value ranging from .0401 to .0033) in all efficacy parameters compared with placebo. The between-group comparison also revealed that MEC supplement had a significantly greater effect (P < .001) versus placebo. No investigation product-related AEs were reported. There were no clinically significant abnormalities in physical findings and no statistically significant changes in biochemical and hematological parameters, vital signs, body weight, and body mass index observed between the two groups at baseline and follow-up visits. MEC supplementation represents an effective and safe alternative to manage dyspepsia symptoms in FD patients.

Overlap between functional GI disorders and other functional syndromes: what are the underlying mechanisms?

BACKGROUND

Irritable bowel syndrome and other gastrointestinal (GI) and non-GI disorders such as functional dyspepsia, fibromyalgia, temporomandibular joint disorder, interstitial cystitis/painful bladder syndrome, and chronic fatigue syndrome are known as functional pain syndromes. They commonly coexist within the same individual. The pathophysiologic mechanisms of these disorders are not well understood, but it has been hypothesized that they share a common pathogenesis.

PURPOSE

The objective of this review is to discuss the proposed pathophysiologic mechanisms, which have been similarly studied in these conditions. These mechanisms include enhanced pain perception, altered regional brain activation, infectious etiologies, dysregulations in immune and neuroendocrine function, and genetic susceptibility. Studies suggest that these functional disorders are multifactorial, but factors which increase the vulnerability of developing these conditions are shared.

Investigating functional dyspepsia in Asia

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

Abnormal resting brain activity in patients with functional dyspepsia is related to symptom severity

BACKGROUND & AIMS

Abnormal processing of visceral sensation at the level of the central nervous system is believed to be involved in functional dyspepsia. However, compared with studies of stimulation-related changes in brain activity, few studies have focused on resting brain activity, which also is important in pathogenesis. We mapped changes in resting brain glucometabolism of patients with functional dyspepsia, compared with healthy subjects, and attempted to correlate abnormal brain activity with symptom severity.

METHODS

We performed fluorodeoxyglucose positron emission tomography-computed tomography on 40 patients with functional dyspepsia and 20 healthy subjects who were in resting states. The symptom index of dyspepsia and the Nepean dyspepsia index were used to determine symptom severity. The positron emission tomography-computed tomography data were analyzed using statistical parametric mapping software.

RESULTS

Compared with healthy subjects, patients with functional dyspepsia had higher levels of glycometabolism in the bilateral insula, anterior cingulate cortex (ACC), middle cingulate cortex (MCC), cerebellum, thalamus, prefrontal cortex, precentral gyrus, postcentral gyrus, middle temporal gyrus, superior temporal gyrus, putamen, right parahippocampal gyrus, claustrum, and left precuneus (P < .001). The signal increase in the ACC, insula, thalamus, MCC, and cerebellum was correlated with symptom index of dyspepsia scores and Nepean dyspepsia index scores (P < .01). The glycometabolism in ACC, insula, thalamus, MCC, and cerebellum of patients with more severe functional dyspepsia was significantly higher than that of patients with less severe functional dyspepsia (P < .005).

CONCLUSIONS

In patients with functional dyspepsia, resting cerebral glycometabolism differs significantly from that of healthy subjects. The ACC, insula, thalamus, MCC, and cerebellum might be the key regions that determine the severity of symptoms.

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.

Upper gastrointestinal symptoms, psychosocial co-morbidity and health care seeking in general practice: population based case control study

BACKGROUND

The pathophysiology of upper gastrointestinal (GI) symptoms is still poorly understood. Psychological symptoms were found to be more common in patients with functional gastrointestinal complaints, but it is debated whether they are primarily linked to GI symptoms or rather represent motivations for health-care seeking. Purpose of our study was to compare co-morbidity, in particular psychological and social problems, between patients with and without upper GI symptoms. In addition, we investigated whether the prevalence of psychological and social problems is part of a broader pattern of illness related health care use.

METHODS

Population based case control study based on the second Dutch National Survey of general practice (conducted in 2001). Cases (adults visiting their primary care physician (PCP) with upper GI symptoms) and controls (individuals not having any of these complaints), matched for gender, age, PCP-practice and ethnicity were compared. Main outcome measures were contact frequency, prevalence of somatic as well as psychosocial diagnoses, prescription rate of (psycho)pharmacological agents, and referral rates. Data were analyzed using odds ratios, the Chi square test as well as multivariable logistic regression analysis.

RESULTS

Data from 13,389 patients with upper GI symptoms and 13,389 control patients were analyzed. Patients with upper GI symptoms visited their PCP twice as frequently as controls (8.6 vs 4.4 times/year). Patients with upper GI symptoms presented not only more psychological and social problems, but also more other health problems to their PCP (odds ratios (ORs) ranging from 1.37 to 3.45). Patients with upper GI symptoms more frequently used drugs of any ATC-class (ORs ranging from 1.39 to 2.90), including psychotropic agents. The observed differences were less pronounced when we adjusted for non-attending control patients. In multivariate regression analysis, contact frequency and not psychological or social co-morbidity was strongest associated with patients suffering from upper GI symptoms.

CONCLUSION

Patients with upper GI symptoms visit their PCP more frequently for problems of any organ system, including psychosocial problems. The relationship between upper GI symptoms and psychological problems is equivocal and may reflect increased health care demands in general.