Nonulcer dyspepsia: a look into the future

The frequency of the psychiatric symptoms in the patients with dyspepsia at a university hospital

OBJECTIVE

According to the psychiatric hypothesis, the symptoms of dyspepsia may be due to depression, anxiety or a somatization disorder. We investigated the frequency of psychiatric symptoms in patients undergoing endoscopic procedures with dyspepsia, either with or without pathological findings, and compared this with control subjects without dyspeptic symptoms.

METHODS

Ninety patients with dyspeptic symptoms and 90 control subjects participated in the study. Both the patients and the controls were asked to complete a questionnaire about socio-demographic characteristics, the Turkish version of the Spielberger State-Trait Anxiety Inventory (STAI) and the Symptom Check List-90 (SCL-90). In order for us to determine whether the criteria for any of the conditions listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) were met, the patients were asked to take part in the Structured Clinical Interview for DSM-IV disorders.

RESULTS

Of the participants, 47.8% had a psychiatric disorder according to DSM-IV criteria, somatoform disorder (44.2%) being the most common. While 42.2% patients were determined to have a pathological finding using endoscopic evaluation, 57.8% had no findings. Together with the somatization and obsessive-compulsive disorder subscale scores, the total SCL-90 score and the mean trait anxiety score were statistically significantly higher in participants with no pathological findings. There were trends for anxiety (13.2% vs. 7.7%) and mood (2.6% vs. 0.0%) disorders to be more frequent in patients with pathological findings, while somatoform disorder+depressive disorder (17.3% vs. 5.2%) was more frequent in patients with no findings, although the differences were not statistically significant (Z=0.7, P>.05). The scores of state-trait anxiety, somatization, obsession-compulsion, depression, anxiety, phobic anxiety and psychotism subscales, and the total SCL-90 score were statistically significantly higher in those participants without a pathological finding than in the controls.

CONCLUSIONS

Regarding the high frequency of psychiatric disorders in patients with dyspeptic symptoms, we think that such patients should be evaluated by two separate departments, gastroenterology and psychiatry.

Cholecystokinin hyperresponsiveness in functional dyspepsia

Functional dyspepsia (FD) is a common disorder of yet uncertain etiology. Dyspeptic symptoms are usually meal related and suggest an association to gastrointestinal (GI) sensorimotor dysfunction. Cholecystokinin (CCK) is an established brain-gut peptide that plays an important regulatory role in gastrointestinal function. It inhibits gastric motility and emptying via a capsaicin sensitive vagal pathway. The effects on emptying are via its action on the proximal stomach and pylorus. CCK is also involved in the regulation of food intake. It is released in the gut in response to a meal and acts via vagal afferents to induce satiety. Furthermore CCK has also been shown to be involved in the pathogenesis of panic disorder, anxiety and pain. Other neurotransmitters such as serotonin and noradrenaline may be implicated with CCK in the coordination of GI activity. In addition, intravenous administration of CCK has been observed to reproduce the symptoms in FD and this effect can be blocked both by atropine and loxiglumide (CCK-A antagonist). It is possible that an altered response to CCK may be responsible for the commonly observed gastric sensorimotor dysfunction, which may then be associated with the genesis of dyspeptic symptoms.

Central serotonergic and noradrenergic receptors in functional dyspepsia

Functional dyspepsia is a symptom complex characterised by upper abdominal discomfort or pain, early satiety, motor abnormalities, abdominal bloating and nausea in the absence of organic disease. The central nervous system plays an important role in the conducting and processing of visceral signals. Alterations in brain processing of pain, perception and affective responses may be key factors in the pathogenesis of functional dyspepsia. Central serotonergic and noradrenergic receptor systems are involved in the processing of motor, sensory and secretory activities of the gastrointestinal tract. Visceral hypersensitivity is currently regarded as the mechanism responsible for both motor alterations and abdominal pain in functional dyspepsia. Some studies suggest that there are alterations in central serotonergic and noradrenergic systems which may partially explain some of the symptoms of functional dyspepsia. Alterations in the autonomic nervous system may be implicated in the motor abnormalities and increases in visceral sensitivity in these patients. Noradrenaline is the main neurotransmitter in the sympathetic nervous system and again alterations in the functioning of this system may lead to changes in motor function. Functional dyspepsia causes considerable burden on the patient and society. The pathophysiology of functional dyspepsia is not fully understood but alterations in central processing by the serotonergic and noradrenergic systems may provide plausible explanations for at least some of the symptoms and offer possible treatment targets for the future.

Role of cholecystokinin and central serotonergic receptors in functional dyspepsia

Symptoms of functional dyspepsia are characterized by upper abdominal discomfort or pain, early satiety, postprandial fullness, bloating, nausea and vomiting. It is a chronic disorder, with symptoms more than 3 mo per year, and no evidence of organic diseases. Dysfunctional motility, altered visceral sensation, and psychosocial factors have all been identified as major pathophysiological mechanisms. It is believed that these pathophysiological mechanisms interact to produce the observed symptoms. Dyspepsia has been categorized into three subgroups based on dominant symptoms. Dysmotility-like dyspepsia describes a subgroup of patients whose symptom complex is usually related to a gastric sensorimotor dysfunction. The brain-gut peptide cholecystokinin (CCK) and serotonin (5-HT) share certain physiological effects. Both have been shown to decrease gastric emptying and affect satiety. Furthermore the CCK induced anorexia depended on serotonergic functions probably acting via central pathways. We believe that abnormalities of central serotonergic receptors functioning together with a hyper responsiveness to CCK or their interactions may be responsible for the genesis of symptoms in functional dyspepsia (FD).

Identifying dyspepsia and irritable bowel syndrome: the value of pain or discomfort, and bowel habit descriptors

BACKGROUND

The utility of current diagnostic criteria for dyspepsia and irritable bowel syndrome (IBS) in clinical practice is largely unknown. We aimed to compare the diagnostic value of different definitions and questionnaires in a population.

METHODS

The Abdominal Symptom Questionnaire (ASQ) was mailed to a representative sample (n = 1506, 20-87 years old), and every fifth person (n = 302) concomitantly received the Bowel Disease Questionnaire (BDQ). The diagnostic agreement for dyspepsia and for IBS, defined in accordance with the Manning and the modified Rome criteria and a new simple definition, was analysed.

RESULTS

In the ASQ the agreement on the IBS status for the three IBS definitions was > or = 88%, and in the BDQ > or = 93%. Agreement for the three definitions on the two questionnaires was > or = 88% regardless of which definition of IBS was applied. Agreement between questionnaires was similar (88%) for dyspepsia. For both IBS and dyspepsia the kappa coefficients indicated moderate to substantial concordance. 'Pain or discomfort' did not cover all linguistic aspects of dyspepsia. Prevalence rates of dyspepsia were comparable in the ASQ and BSQ, whereas higher prevalences of IBS with the ASQ was related to the cutoff levels for reporting abdominal pain or discomfort.

CONCLUSION

It is possible to identify IBS more simply by self-report questionnaires.

Nonulcer dyspepsia: what it is and what it is not

Nonulcer dyspepsia is a description of persistent or recurrent upper abdominal pain or discomfort with no structural or biochemical explanation for the patient's symptoms. The exact cause of nonulcer dyspepsia is not known, but many myths have evolved regarding its etiology and treatment. The goal of this review is to evaluate the potential causes of nonulcer dyspepsia. By determining what it is and what it is not, we can be more selective in our approach to diagnosis and our choice of empiric therapies.

Predominant symptoms identify different subgroups in functional dyspepsia

OBJECTIVE

Dyspepsia is a common syndrome that often defies diagnosis. Whether the unexplained (or "functional") dyspepsia represents a homogeneous syndrome or includes different subgroups with specific clinical features has not been clarified. The aim of this study was to investigate the relationship between symptom severity, demographic features, and gastric dysmotility in a large series of patients with functional dyspepsia.

METHODS

Severity of individual digestive symptoms, demographic features, and scintigraphic gastric emptying of solids were evaluated in 483 patients with chronic unexplained dyspepsia.

RESULTS

Two main subgroups were identified. The first was characterized by predominant epigastric pain, male gender (61%), and normal gastric emptying. The second subgroup was characterized by predominant nonpainful symptoms, female gender (60%), a high frequency of associated irritable bowel syndrome (30%), and delayed gastric emptying (42%). A third group included approximately one-third of patients who did not present with any predominant symptom, and was characterized by a high frequency of delayed gastric emptying (30%), overlapping irritable bowel syndrome (28%), and gastroesophageal reflux disease (41%).

CONCLUSIONS

Different subgroups exist among patients with functional dyspepsia seen in a referral center. They can be identified by the predominant symptom and are characterized by different demographic, clinical, and pathophysiological features.

Nonulcer Dyspepsia

Dyspepsia is a heterogeneous symptom complex with differing symptom presentations, underlying pathophysiology and available treatments. Patients older than 50 years and those who have "alarm" symptoms or signs (eg, weight loss, dysphagia, vomiting, anemia, or heme-positive stool) should undergo an initial endoscopic evaluation. Empiric treatment without diagnostic testing may be used in the initial approach to young patients without alarm symptoms. For patients presenting with uncomplicated dyspepsia, initial testing for H. pylori is appropriate. If present, H. pylori infection is generally treated and symptoms are followed. In patients who do not have H. pylori infection or do not respond to H. pylori treatment, initial treatment with an H(2) blocker or promotility agent is appropriate empiric therapy. In some patients, gastroesophageal reflux disease (GERD) presents atypically with primarily dyspeptic symptoms. In these patients, a trial of gastric acid suppressant may help implicate GERD. For patients with nonulcer dyspepsia (ie, dyspeptic symptoms with negative endoscopy), prokinetic therapy may be the most effective empiric treatment.

Clinical economics review: functional (non-ulcer) dyspepsia

Dyspepsia is common within the general population and it imposes a significant burden on health-care resources. Calculation of the economic implications of functional dyspepsia is constrained by the fact that it is only possible to make this diagnosis in a minority of individuals with the disorder, because many do not seek medical attention and investigation is not appropriate for all who do. Studies which attempt to assess the effectiveness or cost-effectiveness of therapy may be further constrained by the fact that there is now good evidence that many patients with dyspepsia seek medical attention not so much because of the severity of symptoms, but because they fear that the symptoms signal the presence of some serious underlying disease. In this situation, effective well-founded reassurance that no serious disease is present is an important outcome of medical intervention and one which should be included in an economic appraisal of dyspepsia management. For obvious reasons, it is sensible to compare the cost-effectiveness of various clinical management strategies applicable in dyspepsia. Decision-tree analyses are currently fashionable but suffer from the major defect that there is no theoretical basis from which patient satisfaction with treatment options can be assessed. It is suggested that for disorders such as functional dyspepsia, which are non-lethal and non-progressive, recommendations about acceptable clinical management strategies require that account be taken of patient satisfaction with the strategies being reviewed. Cost-effectiveness calculations which take no account of this aspect of outcome are of limited relevance to clinical practice.

Urea breath tests for the detection of Helicobacter pylori infection

BACKGROUND

Helicobacter pylori is recognized as an important human pathogen. The urea breath test, using either 13C or 14C, provides a noninvasive diagnostic method for the detection of active H. pylori infection.

METHODS

We review the data regarding the utility of the urea breath test in the diagnosis and follow-up of patients with suspected H. pylori infection.

RESULTS

Following its ingestion, labeled urea is hydrolyzed by H. pylori urease, producing ammonia and labeled CO2, which is absorbed and can be detected in expired breath. The urea breath test provides a semiquantitative assessment of the load of H. pylori and overcomes the problem of the sampling error due to the patchy distribution of the infection. 13C-urea breath test has an advantage over the 14C version, because the 13C isotope is a nonradioactive natural isotope; therefore, a user's license is unnecessary, making simple the handling and mailing of samples. The 13C-urea breath test is preferred in children and expectant mothers.

CONCLUSION

The high sensitivity, and specificity of the 13C-urea breath test are such that it can be considered a clinical gold standard against which other diagnostic methods can be validated. This test can be used as the sole method for evaluating the effectiveness of treatment of H. pylori infection.