Relationship between antral distension and postprandial symptoms in functional dyspepsia

Duodenal nutrient exposure contributes to enhancing gastric accommodation

BACKGROUND

The gastric accommodation reflex consists of a relaxation which creates a reservoir for the ingested food before emptying to the duodenum occurs. The mechanisms that control gastric accommodation are not fully understood. This study aims to use intragastric pressure (IGP) measurement and pyloric balloon obstruction to determine the contribution of duodenal nutrient exposure to gastric accommodation and meal-induced satiation.

METHODS

Two conditions were tested in 11 healthy subjects (28.3 ± 3.2 years; 23.6 ± 0.7 kg/m² ; four females). IGP was measured during an intragastric nutrient drink (ND) infusion at a constant rate (60 mL/min) in the presence of a deflated (control) or inflated (pyloric obstruction) balloon placed into the pylorus. During the study, subjects filled out Likert scales for satiation scores and visual analogue scale for 9 epigastric symptoms (hunger, expected amount to eat, satiation, bloating, fullness, nausea, belching, gastric cramps, and pain) before and during ND infusion until maximal satiation.

KEY RESULTS

During pyloric obstruction, the IGP drop and the area above the IGP curve (AAC) were significantly smaller compared with the control condition (6.7 ± 1.0 mm Hg vs3.6 ± 0.8 mm Hg, P = .03 and 69.7 ± 13.5 mm Hg × min vs 20.1 ± 9.0 mm Hg × min, P = .001, respectively). Pyloric obstruction decreased nutrient tolerance compared with the control condition (787.9 ± 73.1 mL vs 970.9 ± 79.2 mL, respectively, P < .05). Pyloric obstruction increased symptoms of bloating (1.3 ± 0.4 vs 2.6 ± 0.6; P = .04), fullness (2.3 ± 0.5 vs 3.6 ± 0.3; P = .03), and nausea (0.4 ± 0.2 vs 1.3 ± 0.4; P = .04) compared to control.

CONCLUSION & INFERENCES

Duodenal nutrient exposure contributes to enhancing gastric accommodation. Preventing the passage of nutrients from the stomach to the duodenum inhibits gastric accommodation and increases meal-induced satiation, bloating, nausea, and fullness.

Gastric Emptying Scintigraphy: Beyond Numbers - An Observational Study to Differentiate between Various Etiologies and a Step toward Personalized Management

Aim:

Gastric emptying (GE) scintigraphy is commonly used as a standard diagnostic procedure for the assessment of functional dyspepsia (FD). Results of the study are often reported as either normal or delayed GE times. The aim of this study was to recognize various patterns of scintigraphy among both normal and abnormal emptying times.

Materials and Methods:

Fifty patients with suspected FD were included in the study. GE study was performed with a standardized vegetarian solid meal.

Results:

Out of 50 patients, 33 patients had deranged GE. Thirty patients had delayed GE. Three patients demonstrated gastric hurrying. Five different patterns were demonstrated in patients having similar emptying and retention times such as reduced fundus compliance, decreased fundic accommodation, antral dysmotility, gastric hurrying, and gastroesophageal reflux.

Conclusion:

According to our findings, it may be suggested that visual assessment of GE and identification of various pattern is a very important aspect of the GE study. It not only subcategorized patients but also decreases the number of “normal” studies. This finding may have an impact on patient management in the era of personalized medicine.

Histomorphological Spectrum of Duodenal Pathology in Functional Dyspepsia Patients

INTRODUCTION

Functional Dyspepsia (FD) is one of the most common causes of gastrointestinal symptoms aetiology of which is poorly understood.

AIM

To study duodenal histomorphological features and their relationship with Helicobacter pylori (H Pylori) infection in patients of FD.

MATERIALS AND METHODS

This case control study included 50 cases of FD patients selected according to Rome III criteria and 30 age and sex matched controls. These were subjected to oesophago-gastro-duodenoscopy, rapid urease test for detection of H. pylori on gastric antral biopsy and duodenal biopsy from second part of duodenum for histopathological evaluation by light microscopy. Ten antral urease positive cases of FD with highest Intraepithelial Lymphocyte Count (IEL) were subjected to Immunohistochemistry (IHC).

RESULTS

Duodenal inflammation was an invariable feature noted in FD. Morphological spectrum consisted of increased IEL in 72%, increased duodenal eosinophils in 92%, presence of focal villous atrophy in 16%, lymphoid aggregates, colonic metaplasia, and duodenal H. pylori infection in 4% each. Gastric H. pylori positivity was noted in 48% cases of FD. Increased duodenal IEL count and duodenal eosinophilia was noted in 75%, 87.5% such cases. Same was noted respectively, with 61.5% and 95.15% cases with gastric H. pylori negativity. In cases of FD, duodenal IEL and eosinophil count in lamina propria showed statistically significant rise when compared with control and had positive correlation with gastric H pylori infection. On IHC, increased expression of CD 8 was noted in duodenal IEL and lymphocytes in lamina propria as compared to CD4.

CONCLUSION

Our study provided some insight in pathogenesis of FD and role of H. pylori in its aetiology.

Functional dyspepsia: outcome of focus groups for the development of a questionnaire for symptom assessment in patients suffering from postprandial distress syndrome (PDS)

BACKGROUND

To date, no patient reported outcomes (PRO) instrument is available for evaluation of treatment efficacy in functional dyspepsia (FD)/postprandial distress syndrome (PDS). The aim of our study was to perform focus group interviews for the development of a new questionnaire for assessing symptom pattern and severity in PDS.

METHODS

Random ambulatory patients diagnosed with FD/PDS based on Rome III criteria and no predominant gastro-esophageal reflux disease (GERD) symptoms were invited to participate. Focus group sessions were organized where patients reported and discussed their symptoms, facilitated by an experienced physician. After reaching saturation of identified symptom items, questions for a pilot PRO instrument were drafted and evaluated in cognitive interviews for relevance, clarity, and consistency.

KEY RESULTS

Of 225 screened patients, 26 patients were diagnosed with PDS without overlapping GERD as single final diagnosis. Fifteen of these (87% female, 48 ± 3.2 years) participated in one of three focus groups. All (100%) confirmed experiencing symptoms that were triggered or aggravated by ingestion of a meal, corresponding to early satiation (100%), and postprandial fullness (100%). In addition reported gastroduodenal symptoms were nausea (40%, postprandial in all, interprandial in 20%), upper abdominal bloating (33%), excessive belching (27%), and vomiting (13%). Epigastric pain and burning were present in respectively 20% and 13%. Non-gastroduodenal symptoms that patients reported included heartburn (33%, but mostly sporadic), weight loss (93%, on average 5.0 ± 1.7 kg), and fatigue (67%). Questions evaluating these symptoms were validated in 15 cognitive interviews.

CONCLUSIONS & INFERENCES

This focus group study confirms symptoms corresponding to postprandial fullness and early satiation as the key items for developing a PRO for PDS.

Gastric emptying and antral motility parameters in children with functional dyspepsia: association with symptom severity

BACKGROUND AND AIMS

Functional dyspepsia (FD) is an important gastrointestinal problem with obscure etiology. Abnormal gastric motility is suggested as a possible pathophysiological mechanism for symptoms. The main objective of this study was to assess gastric motility in Sri Lankan children with FD.

METHODS

Forty-one children (19 [46.3%] males, age 4-14 years, mean 7.5 years, SD 2.6 years) referred to the Gastroenterology Research Laboratory, Faculty of Medicine, University of Kelaniya, from January 2007 to December 2011, were screened. Those fulfilling Rome III criteria for FD were recruited. None had clinical or laboratory evidence of organic disorders. Twenty healthy children were recruited as controls (eight [40%] males, age 4-14 years, mean 8.4 years, SD 3.0 years). Liquid gastric emptying rate (GE) and antral motility parameters were assessed using an ultrasound-based method.

RESULTS

Average GE (45.6% vs 66.2% in controls), amplitude of antral contractions (58.2% vs 89.0%) and antral motility index (5.1 vs 8.3) were lower and fasting antral area (1.5 cm(2) vs 0.6 cm(2)) was higher in patients with FD (P < 0.01). Frequency of antral contractions (8.8 vs 9.3) did not show a significant difference (P = 0.07). Scores obtained for severity of abdominal pain negatively correlated with GE (r = -0.35, P = 0.025). Children with FD, exposed to stressful events had higher fasting antral area (1.9 cm(2)) than those not exposed to stress (1.0 cm(2)) (P = 0.02).

CONCLUSIONS

GE and antral motility parameters were significantly impaired in children with FD compared with controls. GE negatively correlated with severity of symptoms. This study points to disturbances in gastric motility as an etiological factor for FD.

Duodenal intraepithelial T lymphocytes in patients with functional dyspepsia

AIM: To quantify the intraepithelial lymphocytes (IELs) and to document the membrane expression of CD4, CD8, TCRγδ and adhesion and/or activation-associated molecules (CD103, CD28, CD44, CD69, HLA-DR, CD95/Fas) in the duodenal mucosa of patients with functional dyspepsia (FD) in order to provide arguments for an immunological process in FD.

METHODS: Twenty-six FD patients according to Rome II criteria (20 were H pylori negative) were studied and compared to 12 healthy adults. IELs were isolated from five duodenal biopsy samples, then quantified by microscopy and flow cytometry while the membrane phenotypes were determined by cytofluorometry.

RESULTS: Duodenal histological examination was normal. In H pylori negative patients, the number of IELs was not different from that in healthy controls. Median percentage expression of CD4, CD8, or TCRγδ and CD103, CD44, CD28, CD69 on CD3+ IELs, among the adhesion/activation associated molecules tested, was not different from that in healthy controls. In contrast, the median percentage expression of CD95/Fas [22 (9-65) vs 45 (19-88), P = 0.03] and HLA-DR expressing CD3+ IELs [4 (0-30) vs 13 (4-42), P = 0.04] was significantly lower in the H pylori negative FD group than in healthy controls, respectively. The number of IELs was significantly greater in H pylori positive FD patients than in healthy controls [median ratiofor 100 enterocytes 27.5 (6.7-62.5) vs 10.8 (3-33.3), P = 0.02] due to a higher number of CD8+ CD3+ IELs.

CONCLUSION: In H pylori negative FD patients, the phenotypic characterization of IELs suggests that we cannot exclude a role of IELs in FD.