[Diagnostic and therapeutic approach to dyspepsia and functional dyspepsia:what's new in 2019?]

Dyspepsia encompasses a set of symptoms that originate in the gastroduodenal region. It is characterized by pain or epigastric burning, early satiety and post-prandial fullness. According to the relationship of symptoms with meals, it is divided into epigastric pain syndrome and postprandial distress syndrome. However, in clinical practice, they frequently overlap. In recent years the paradigm of gastric physiological alterations has been changed and evidence supporting duodenal eosinophilia has increased, as a primary alteration that alters gastric physiology and can induce symptomatology. Every day there is more interest in the alteration of the microbiota. The treatment is based on the suppression of acid, neuromodulators, prokinetics, psychotherapy, alternative and complementary therapies. No treatment is effective in all patients.

Classification of pediatric functional gastrointestinal disorders related to abdominal pain using Rome III vs. Rome IV criterions

BACKGROUND

The primary purpose of this study was to compare Rome III and IV evaluation criteria for irritable bowel syndrome (IBS), functional dyspepsia (FD), and an overlap syndrome consisting of both IBS and FD by assessing the frequency of each diagnosis in a population of children with chronic abdominal pain. Frequencies of Rome IV FD subtypes of postprandial distress syndrome (PDS) and epigastric pain syndrome (EPS) were determined and FD/IBS overlap symptom associations were also assessed.

METHODS

We conducted a cross-sectional retrospective chart review of 106 pediatric patients who had completed standardized medical histories as part of their evaluation for chronic abdominal pain. The patients ranged from eight to 17 years of age and reported having abdominal pain at least weekly for 8 weeks. Patients whose evaluation revealed gastrointestinal disease were excluded. The patients' diagnoses were determined by a single pediatric gastroenterologist utilizing the specific criteria for Rome III and IV, respectively.

RESULTS

Patients were significantly more likely to be diagnosed with FD (84.9% vs. 52.8%), IBS (69.8% vs. 34%), and FD/IBS overlap (58.5% vs. 17.9%) by Rome IV criteria, as compared to Rome III criteria. With regard to Rome IV FD subtypes, 81.1% fulfilled criteria for PDS, 11.1% fulfilled criteria for EPS, 6.7% fulfilled criteria for both, and 1.1% did not fulfill criteria for either. Finally, we found an increased frequency of diarrhea and pain with eating in the overlap group compared to the non-overlap group of Rome III, while only an increased frequency of diarrhea was found in the overlap group compared to the non-overlap group of Rome IV.

CONCLUSIONS

Our data demonstrate that utilizing Rome IV criteria, as compared to Rome III, results in an increase in the diagnosis of FD, a two-fold increase in the diagnosis of IBS, and a three-fold increase in the diagnosis of FD/IBS overlap. Rome IV criteria appears to result in greater heterogeneity within diagnostic categories. It is important to determine whether Rome IV diagnoses are predictive of treatment response, and if so, whether assessing symptom variability within a diagnosis will enhance the ability to select patients for a particular treatment.

CHRONIC GASTRITIS AND FUNCTIONAL DYSPEPSIA: CURRENT ISSUES IN CLASSIFICATION, DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS IN THE CONTEXT OF THE KYOTO GLOBAL CONSENSUS

Set out the basic problems of classification, diagnostics and differential diagnostics of chronic gastritis and functional dyspepsia in the context of the Kyoto global consensus.

Clinical classification of subgroups according to the Rome III criteria cannot be used to distinguish the associated respective pathophysiology in Japanese patients with functional dyspepsia

OBJECTIVE

Patients who meet the Rome III criteria for functional dyspepsia (FD) are generally classified into the following two subgroups, those with postprandial distress syndrome (PDS) and those with epigastric pain syndrome (EPS), in order to treat the dyspeptic symptoms caused by the respective pathophysiological conditions. However, whether simple classification of FD can accurately distinguish the pathophysiological differences between PDS and EPS remains to be clarified because the pathophysiology of FD is characterized and complicated by various factors.

METHODS

After classifying FD patients who were not receiving medication at the initial visit, we assessed and compared the following pathophysiological factors between the PDS and EPS groups: (1) the gastric reservoir and emptying functions using a radioisotope method (n=75), (2) the autonomic nervous system (ANS) function using electrocardiography (n=45), (3) gastric mucosal atrophy and intestinal metaplasia using histological examinations (n=47), (4) endoscopic findings of the stomach, such as superficial changes, abnormal gastroesophageal flap valves (n=67) and (5) Helicobacter pylori infection (n=48).

RESULTS

The FD patients exhibited higher rates of an impaired reservoir function (49.3%), gastric emptying disorders (54.7%) and relative hyperactivity of the sympathetic nervous system (31.9%) than the control subjects. However, endoscopic and histological changes of the stomach were similar in both the FD patients and control subjects. In addition, no differences were observed in the above-mentioned factors between the PDS and EPS groups.

CONCLUSION

The simple classification of FD patients into two subgroups according to the Rome III criteria following diagnosis does not indicate any differences in the pathophysiology related to the respective dyspeptic symptoms of FD patients.

[Syndrome of functional dyspepsia and/or chronic gastritis?]

Definition and prevalence of syndrome of functional dyspepsia (SFD) are discussed along with the brief history of the problem, priority works of V.P. Obraztsov and other authors, current views of SFD etiology and pathogenesis with reference to the role of H. pylori infections. Clinical variants of SFD, their diagnostic criteria and principals of differential diagnostics are described. Special attention is given to the debatable relationship between CFD and chronic gastritis. Nosological and syndromal diagnostics, structure-function relationship, goals and methods of SFD treatment and other matters of dispute are considered.

Rome III subgroups of functional dyspepsia exhibit different characteristics of antral contractions measured by strain rate imaging - a pilot study

PURPOSE

Rome III defines two distinct entities of functional dyspepsia (FD), namely epigastric pain syndrome (EPS) and postprandial distress syndrome (PDS). We aimed at studying these subgroups of FD by simultaneously assessing antral strain, gastric accommodation and emptying and visceral hypersensitivity.

MATERIALS AND METHODS

Strain during antral contractions was assessed by ultrasound strain rate imaging in 15 controls and 19 FD patients (8 EPS patients and 11 PDS patients). Gastric accommodation and emptying were assessed using B-mode ultrasonography. Symptoms were assessed by visual analogue scale (VAS).

RESULTS

During fasting, antral strain in EPS patients (mean±SEM) was 61.4 ± 6.4 %, significantly higher than in controls (47.5 ± 3.3 %; p = 0.042) and in PDS patients (28.6 ± 1.7 %; p = 0.001). PDS patients had lower strain than controls (p < 0.001). Postprandially, EPS patients had higher strain than both controls and PDS patients (p < 0.01) but no difference was found between controls and PDS patients. Compared with controls, PDS patients had significantly larger fasting proximal area than controls (14.9 ± 1.6 cm2 vs. 7.8 ± 0.2 cm2; p < 0.001), whereas EPS patients did not differ (12.1 ± 1.9 cm2; p = 0.057). Gastric emptying fraction (1 - proximal area at 40 min postprandially/area at 1 min postprandial × 100) at 40 min postprandially in EPS patients 46.4 ± 6.6 % was lower than in controls (62.9 ± 1.3 %; p = 0.032), but higher than PDS patients (27.4 ± 5.3 %; p = 0.018).

CONCLUSION

Anterior radial strain measured by ultrasound strain rate imaging may discriminate between subgroups of FD and healthy controls. This study supports the Rome III classification of FD into EPS and PDS groups.

[Classification basis and train of thought of functional dyspepsia in disease menu of acupuncture]

OBJECTIVE

To explore the classification basis of functional dyspepsia in disease menu of acupuncture, and to provide regular analyzing process for classification of other diseases.

METHODS

Taking the control group as the classification basis, and the 5-level literature classification of evidence based medicine as the estimation basis, literatures which complied with the inclusion criteria were examined according to the sequence from high level to low. Evidences of low levels were given up if support can be acquired from documents of high level.

RESULTS

Acupuncture is approved to be effective for intervention on functional dyspepsia. Compared to the international accepted medicines such as Cisapride and Motilium, regular acupuncture has better therapeutic effects and less side effects in improving the gastro-power and relieving discomfort sensations.

CONCLUSION

Functional dyspepsia pertains to grade I of disease menu of acupuncture.

Pathophysiological concepts of functional dyspepsia and irritable bowel syndrome future pharmacotherapy

The functional gastrointestinal diseases (FGIDs) are often noticed disturbances. Functional dyspepsia (FD) is the most frequent FGID of the upper part of the gastrointestinal tract while irritable bowel syndrome (IBS) occurs in the lower gastrointestinal part. Both clinical entities are characterized by rich symptomatology and the pattern of the diagnostic guidelines. Recognition and the classification of FGIDs are difficult, consisting in exclusion of all possible organic disorders and subordinating on the predominant symptom basis to most appropriate class, acording to Rome III classification. The present FGIDs pharmacotherapy is limited mostly to the symptomatical treatment and it is based on medicines conventionally used in various gastrointestinal organic illnesses (antisecretory, gastroprotective agents, antidiarrhoeal and laxative drugs). Some of them which seem to diminish visceral hypersensitivity acting via serotonin receptors are also used, including 5-HT4 agonists and 5-HT3 antagonists. Many investigations over the new causal acting medicines last at present, which would be able to abolish the main pathophysiological FD and IBS mechanisms: visceral hypersensitivity and both myoelectrical and dysmotility phenomena. Thus, new pharmacological agents influencing opioid, purinergic, NMDA, CCK-A, or NK receptors are studied. The article is the mini-review, representing classification and the outline of the FGIDs pathogenesis, the present concepts of their pharmacological treatment and the future perspectives of pharmacoherapy with the use of new, interfering into key pathomechanisms drugs.

Effect and cost-effectiveness of step-up versus step-down treatment with antacids, H2-receptor antagonists, and proton pump inhibitors in patients with new onset dyspepsia (DIAMOND study): a primary-care-based randomised controlled trial

BACKGROUND

Substantial physician workload and high costs are associated with the treatment of dyspepsia in primary health care. Despite the availability of consensus statements and guidelines, the most cost-effective empirical strategy for initial management of the condition remains to be determined. We compared step-up and step-down treatment strategies for initial management of patients with new onset dyspepsia in primary care.

METHODS

Patients aged 18 years and older who consulted with their family doctor for new onset dyspepsia in the Netherlands were eligible for enrolment in this double-blind, randomised controlled trial. Between October, 2003, and January, 2006, 664 patients were randomly assigned to receive stepwise treatment with antacid, H(2)-receptor antagonist, and proton pump inhibitor (step-up; n=341), or these drugs in the reverse order (step-down; n=323), by use of a computer-generated sequence with blocks of six. Each step lasted 4 weeks and treatment only continued with the next step if symptoms persisted or relapsed within 4 weeks. Primary outcomes were symptom relief and cost-effectiveness of initial management at 6 months. Analysis was by intention to treat (ITT); the ITT population consisted of all patients with data for the primary outcome at 6 months. This trial is registered with ClinicalTrials.gov, number NCT00247715.

FINDINGS

332 patients in the step-up, and 313 in the step-down group reached an endpoint with sufficient data for evaluation; the main reason for dropout was loss to follow-up. Treatment success after 6 months was achieved in 238 (72%) patients in the step-up group and 219 (70%) patients in the step-down group (odds ratio 0.92, 95% CI 0.7-1.3). The average medical costs were lower for patients in the step-up group than for those in the step-down group (euro228 vs euro245; p=0.0008), which was mainly because of costs of medication. One or more adverse drug events were reported by 94 (28%) patients in the step-up and 93 (29%) patients in the step-down group. All were minor events, including (other) dyspeptic symptoms, diarrhoea, constipation, and bad/dry taste.

INTERPRETATION

Although treatment success with either step-up or step-down treatment is similar, the step-up strategy is more cost effective at 6 months for initial treatment of patients with new onset dyspeptic symptoms in primary care.

The clinical overlap between functional dyspepsia and irritable bowel syndrome based on Rome III criteria

BACKGROUND

Epidemiological studies suggest considerable overlap between functional dyspepsia (FD) and irritable bowel syndrome (IBS). To date, no surveys have been performed to investigate the clinical overlap between these two disorders using Rome III criteria. Our aim was to investigate the prevalence and risk factors for the overlap of FD and IBS based on Rome III criteria in a large clinical sample.

METHODS

Consecutive patients at the general gastroenterology outpatient clinic were requested to complete a self-report questionnaire. FD and IBS were defined by Rome III criteria.

RESULTS

Questionnaires were returned by 3014 patients (52.8% female, 89% response rate). FD-IBS overlap was observed in 5.0% of the patients, while 15.2% and 10.9% of the patients were classified as FD alone and IBS alone, respectively. Compared with non-IBS patients, the odds ratio of having FD among IBS patients was 2.09 (95% CI: 1.68-2.59). Patients with FD-IBS overlap had higher severity scores for the postprandial fullness symptom (2.35 +/- 1.49 vs. 1.72 +/- 1.59, P < 0.001) and overall FD symptom (6.65 +/- 2.88 vs. 5.82 +/- 2.76, P = 0.002) than those with FD alone. The only independent risk factor for FD-IBS overlap vs. FD alone was the presence of postprandial fullness symptom (OR 2.67, 95% CI: 1.34-5.31).

CONCLUSION

Clinical overlap of FD and IBS according to Rome III criteria is very common. One risk factor for FD-IBS overlap is the presence of postprandial fullness symptom. This study provides clues for future pathophysiological studies of FD and IBS.

Functional dyspepsia: past, present, and future

Functional dyspepsia (FD) is a highly prevalent gastrointestinal disorder characterized by symptoms originating from the gastroduodenal region in the absence of underlying organic disease that readily explains the symptoms. The Rome II consensus, which defined FD as the presence of unexplained pain or discomfort in the epigastrium, had a number of drawbacks, including an unjustified focus on pain, inclusion of a large number of nonspecific symptoms, and an unclear position on overlap with gastroesophageal reflux disease (GERD) and irritable bowel syndrome (IBS). The Rome III consensus redefined FD as the presence of epigastric pain or burning, postprandial fullness or early satiation in the absence of underlying organic disease. Frequent overlap with GERD and IBS is acknowledged but does not exclude a diagnosis of FD. A subgroup classification into postprandial distress syndrome and epigastric pain syndrome was proposed. Ongoing studies will clarify the impact of this subdivision on clinical management and treatment outcomes.

[Common gastrointestinal syndromes (2): dyspepsia or upper digestive tract syndrome related to food (I)]

We expose, this time, our ideas and findings on the definition, the classification and the cardinal symptoms of the dyspeptic syndrome.

[Functional dyspepsia: the past, the present and the Rome III classification]

The author summarizes the historical development of our knowledge about functional dyspepsia and overviews the so-called "road to Rome" process. Between 1988 and 2006, expert committees developed using the Delphi method subsequent classifications of functional gastrointestinal disorders (Rome I-III). The Rome III classification reassessed the diagnostic criteria for functional dyspepsia and distinguished new subgroups as the postprandial distress and epigastric pain syndrome. The rationale for the proposed new classification was based on the inadequacy of prior approaches such as the predominant symptom, the results of factor analyses in tertiary care and in the general population, clinical experience and new observations in the peer-reviewed literature. Epidemiologic data suggest that dyspeptic symptoms date back to the 1730s and their prevalence increased markedly subsequently, remaining the commonest diagnosis even in the endoscopic era. The current worldwide prevalence of functional dyspepsia is 7-45%, with large geographic variations. The role of Helicobacter pylori and Salmonella infection as etiologic factors is discussed. Amongst the pathophysiological features, the recent data on the role of phenotypic changes of acid secretion, alterations of fundic accommodation and antro-duodenal motility and gastric emptying, gastric hypersensitivity and hormonal disturbances are presented, but all these abnormalities are present only in a small part of the patients. The possible role of the polymorphism of alpha-adrenoceptor gene was also raised. The treatment of functional dyspepsia led to equivocal results and the high rate of placebo response makes difficult any interpretation. According to the recent meta-analyses, proton pump inhibitors and H 2 -histamine receptor blockers are superior to placebo. In spite of good results, cisapride was withdrawn in 2004. Eradication of Helicobacter pylori can induce sustained remission in a small but significant minority of patients. However, it might prevent further development of peptic ulcer and gastric carcinoma and from public health view, eradication of the infection must be performed by using a test-and-treat or test-and-scope strategy and the benefits and risks of this approach must be discussed with the patient. Each of the above treatments achieves transient symptomatic improvement only and follow-up of dyspeptic patients for 5-7 years showed the benign, but recurrent nature of the disease in 50% of the cases. The aim of the Rome III classification is the identification of pathophysiological changes associated with the new subgroups of functional dyspepsia which will permit their targeted pharmacologic treatment leading to better and cost-efficient results.

The validity of a symptom diary in ratings of dyspepsia measured against a detailed interview: do patients and clinicians agree in their assessment of symptoms?

BACKGROUND

Patients' self-assessment of symptoms is central in drug treatment trials of functional dyspepsia. The validity of such ratings is important.

AIM

To validate a diary for monitoring severity and duration of dyspepsia.

METHOD

We compared the diary-cards with two clinicians' ratings of the patient's open-ended responses to the same questions administered by interview. Agreements were evaluated by estimation of the overall agreement and weighted kappa values (Kw).

RESULTS

Forty-six patients were evaluated. The Kw between the two clinicians rating severity and duration of symptoms were 0.59 and 0.86, respectively. Overall agreement between patients' diary rating and clinicians' consensus rating of severity were 52%, and a moderate agreement with Kw of 0.49 was found. For duration of symptoms the overall agreement and Kw were 67% and 0.59, respectively. Qualitative data revealed useful insight in the possible causes of suboptimal agreement between patients and clinicians.

CONCLUSIONS

We found a moderate to good agreement between patient and observer ratings, indicating that patients to a reasonable extent interpret severity and duration of dyspeptic symptoms in the same way as do investigators. A ceiling effect of the duration scale indicates suboptimal response categories, which should be adjusted before further use.

Do distinct dyspepsia subgroups exist in the community? A population-based study

BACKGROUND

The heterogeneity of the dyspepsia symptom complex is well known. Several attempts to classify dyspepsia into subgroups have been proposed as a basis for diagnosis and therapy, but data are conflicting. We postulated that dyspepsia comprises three distinct subsets, characterized by pain, early satiety, or nausea/vomiting. We aimed to identify these subsets of dyspepsia: "frequent upper abdominal pain (UAP),""early satiety (ES)," and "nausea/vomiting (NV)."

METHODS

A population-based, cross-sectional survey study was conducted by mailing a valid questionnaire to an age- and gender-stratified random sample of residents of Olmsted County, MN, aged 20-94 yr (response rate 55%). Dyspepsia and irritable bowel syndrome (IBS) prevalence were estimated by Rome II criteria; gastroesophageal reflux (GERD) by weekly or more frequent heartburn or acid regurgitation. Dyspepsia subgroups were categorized based on a priori defined symptoms.

RESULTS

The prevalence (95% CI) of dyspepsia was 15% (14, 17). Of 351 dyspeptic subjects, 51% (46, 56) reported UAP, 21% (16, 25) NV, and 47% (42, 52) ES. The overlap of the subgroups was significantly less than expected by chance. Among the three groups, the subjects were similar in age, educational level, IBS status, and overall symptom severity. A high somatic symptom checklist score and those with GERD were associated with greater odds for reporting combination symptoms compared with the upper abdominal pain subgroup of dyspepsia or the early satiety subgroup of dyspepsia, respectively.

CONCLUSION

Distinct subgroups of uninvestigated dyspepsia do exist in the general population, suggesting that separate evaluation and treatment strategies are needed.

Prevalência de dispepsia e fatores sociodemográficos

OBJETIVO: Medir a prevalência e distribuição de dispepsia e dispepsia freqüente por subtipos na população com 20 anos ou mais segundo características socioeconômicas e demográficas. MÉTODOS: Estudo transversal, de base populacional, com 3.934 indivíduos moradores na cidade de Pelotas (RS), entrevistados em seus domicílios, de outubro de 1999 a janeiro de 2000. Dispepsia foi definida como dor ou desconforto no andar superior do abdome e/ou náuseas no ano anterior à entrevista (conforme critérios Roma I e II). Dispepsia freqüente incluiu o registro de dispepsia mais de seis vezes e/ou náuseas, uma vez por mês ou mais. Esses desfechos foram analisados por idade, sexo, cor da pele, escolaridade, renda e estado civil. Os dados foram analisados por meio do teste qui-quadrado de Pearson de associação para variáveis categóricas e teste de tendência linear, quando aplicável. RESULTADOS: A prevalência de dispepsia foi de 44,4% e de dispepsia freqüente, 27,4%. A prevalência de dispepsia tipo refluxo, úlcera, dismotilidade e não especificada foi, respectivamente, 19,4%, 6,3%, 13,9% e 16,6%; para dispepsia freqüente foram 14,7%, 4,9%, 11,2% e 6,8%, respectivamente. As mulheres apresentaram cerca de 50% mais dispepsia freqüente. Indivíduos mais jovens e de menor renda apresentaram maiores prevalências de dispepsia e dispepsia freqüente. Análise de acordo com critérios de Roma II mostrou prevalências de 15,9% e 7,5% para dispepsia e dispepsia freqüente, respectivamente. CONCLUSÕES: A dispepsia constitui um problema prevalente na população estudada. A maioria dos indivíduos apresentaram mais de um subtipo de dispepsia.

Therapeutic strategies for functional dyspepsia and the introduction of the Rome III classification

Although placebo response rates in clinical trials for functional dyspepsia (FD) are more than 30%, a recent meta-analysis based on randomized controlled trials (RCTs) showed that antisecretory drugs were more or less superior to placebos. On the other hand, large-scale RCTs on the efficacy of treatment with prokinetics on FD are still needed. Indications for antibiotic eradication therapy for Helicobacter pylori-positive FD are still controversial, but there seems to be a small but significant therapeutic gain achieved with H. pylori eradication. Since preprandial and postprandial symptomatic disturbances are very important targets for FD treatment, ghrelin, a novel appetite-promoting gastrointestinal peptide that also promotes gastric motility or basal acid secretion can be expected to be a therapeutic target. In the recently published Rome III classification, FD is redefined for patients with symptoms thought to originate from the gastroduodenal region, specifically epigastric pain or burning, postprandial fullness, or early satiation, and it is divided into the subcategories postprandial distress syndrome and epigastric pain syndrome. These new criteria are of value in clinical practice, for epidemiological, pathophysiological, and clinical research, and for the development of new therapeutic strategies.

Epidemiology of functional dyspepsia: A global perspective

Dyspepsia refers to group of upper gastrointestinal symptoms that occur commonly in adults. Dyspepsia is known to result from organic causes, but the majority of patients suffer from non-ulcer or functional dyspepsia. Epidemiological data from population-based studies of various geographical locations have been reviewed, as they provide more realistic information. Population-based studies on true functional dyspepsia (FD) are few, due to the logistic difficulties of excluding structural disease in large numbers of people. Globally, the prevalence of uninvestigated dyspepsia (UD) varies between 7% - 45%, depending on definition used and geographical location, whilst the prevalence of FD has been noted to vary between 11% - 29.2%. Risk factors for FD have been shown to include females and underlying psychological disturbances, whilst environmental/ lifestyle habits such as poor socio-economic status, smoking, increased caffeine intake and ingestion of non-steroidal anti-inflammatory drugs appear to be more relevant to UD. It is clear that dyspepsia and FD in particular are common conditions globally, affecting most populations, regardless of location.

Role of Helicobacter pylori in functional dyspepsia

The aetiology of dyspepsia is unknown in the majority of patients. Helicobacter pylori (H pylori) is the cause in a subset of patients. A non invasive test to assess the presence of H pylori is recommended in the management of patients under the age of 50 presenting to a family practitioner with dyspepsia. A urea breath test or a stool antigen test are the most reliable non invasive tests. Eradication of H pylori will reduce the risk to the patient with dyspepsia of developing a peptic ulcer, reduce the complication rate if prescribed non-steroid anti-inflammatory drugs and later reduce the risk of gastric cancer. The recommended treatment for non ulcer dyspepsia associated with a H pylori infection should be a 10-d course of treatment with a PPI and two antibiotics. Treatment efficacy should be assessed four weeks after completing treatment with a urea breath test or a stool antigen test.

Functional dyspepsia and irritable bowel syndrome, are they different entities and does it matter

A high prevalence of overlap between functional dyspepsia and irritable bowel syndrome has been consistently and universally reported. Recent studies demonstrating shared common pathophysiological disturbances including delayed gastric emptying and visceral hypersensitivity involving more than one region, suggest that these patients have a generalised rather than regional, disorder of the gut. Furthermore, a study of the natural history of dyspepsia suggests that with time, a substantial proportion will evolve into IBS. The recognition of IBS in dyspeptic patients has potentially profound therapeutic importance. It could help to reduce the risk of unnecessary cholecystectomy in IBS patients. The ability to appreciate the extent of involvement could allow us to address the disturbances more comprehensively, and thereby achieve greater patient satisfaction with their treatment.

Subtypes of functional dyspepsia

Functional dyspepsia is a common clinical condition characterised by chronic or recurrent upper abdominal pain or discomfort commonly associated with a variety of associated gastrointestinal symptoms and a normal endoscopy. To standardise research-based approaches, an initial categorisation of into sub groups was agreed to, based on clusters of symptoms. However the early expectation that these subgroups would be associated with distinct pathophysiologies amenable to specific therapy has not been realised. A classification based on the most troublesome symptom has been suggested but the utility of this is also unclear. More recent data suggest that some of the pathophysiologic dysfunctions may be associated with specific symptoms and so provide a better tool for grouping patients. But this approach remains incomplete as current insights into the pathogenesis are still too limited for this to be satisfactory. In conclusion, no classification provides for an adequate treatment-based approach to the syndrome of functional dyspepsia. As a consequence treatment remains largely empiric.

Association of the predominant symptom with clinical characteristics and pathophysiological mechanisms in functional dyspepsia

BACKGROUND & AIMS

Functional dyspepsia (FD) is considered a heterogeneous disorder with different pathophysiological mechanisms contributing to the symptom pattern. The Rome II committee proposed that subdividing patients with FD into groups with predominant pain versus discomfort might identify subgroups with homogeneous pathophysiological and clinical properties. The aim of this study was to analyze the relationship of predominant pain or discomfort with pathophysiological mechanisms and to evaluate whether considering individual predominant symptoms yields better results.

METHODS

Consecutive FD patients (n = 720; 489 women; mean age, 41.3 +/- 0.6 years) filled out a dyspepsia questionnaire and identified a single most bothersome symptom. We analyzed the association of this predominant symptom with demographic, clinical, and pathophysiological features (Helicobacter pylori status, gastric emptying in 592 patients, and gastric sensitivity and accommodation testing in 332 patients).

RESULTS

According to Rome II criteria, 22% were pain predominant and 78% discomfort predominant. Patients with predominant pain had a higher prevalence of hypersensitivity (44% vs 25%) and delayed gastric emptying was observed less frequently in these patients (16% vs 26%), but there was major overlap. Detailed analysis showed that any of 8 dyspeptic symptoms could be predominant. Predominant early satiety or vomiting was associated with significantly higher prevalences of weight loss (89% and 75%, respectively) and of acute onset (61% and 60%, respectively). Impaired accommodation was found in 79% of patients with predominant early satiety. The highest prevalence of delayed emptying was found in predominant fullness (38%) and of hypersensitivity in predominant pain (44%).

CONCLUSIONS

Subdividing FD patient groups according to the predominant symptom does not reliably identify subgroups with a homogeneous underlying pathophysiological mechanism.

How useful are the Rome II criteria for identification of upper gastrointestinal disorders in general practice?

OBJECTIVE

The Rome II criteria are a classification of functional gastrointestinal disorders. It is not known whether they can be used as a diagnostic tool. This study evaluates the agreement between GPs and the Rome II criteria on the diagnosis of upper gastrointestinal disorders.

MATERIAL AND METHODS

Consecutive patients with abdominal complaints were included in this pragmatic cross-sectional study. All patients answered a questionnaire based on the Rome II criteria. The diagnoses based on these criteria were compared with the GPs' diagnoses.

RESULTS

A total of 549 consecutively selected patients were included in the study. The agreement between GPs and the Rome II criteria was 65%, kappa 0.34 (CI 0.27-0.41). The agreement was lower when dyspepsia and gastroesophageal reflux/functional heartburn were evaluated separately. The positive and negative predictive values of the Rome II criteria varied between 29-58% and 82-90%, respectively, in various groups of patients with confirmed diagnoses.

CONCLUSIONS

The GPs' diagnoses differed from those based entirely on the Rome II criteria. Strict adherence to the criteria will result in other diseases being disregarded. The diagnoses of upper gastrointestinal disorders should be based on all available information and the Rome II criteria used only as an additional aid to improve the precise classification of functional disorders.

An optimized experimental protocol based on neuro-evolutionary algorithms application to the classification of dyspeptic patients and to the prediction of the effectiveness of their treatment

OBJECTIVE

This paper aims to present a specific optimized experimental protocol (EP) for classification and/or prediction problems. The neuro-evolutionary algorithms on which it is based and its application with two selected real cases are described in detail. The first application addresses the problem of classifying the functional (FD) or organic (OD) forms of dyspepsia; the second relates to the problem of predicting the 6-month follow-up outcome of dyspeptic patients treated by helicobacter pylori (HP) eradication therapy.

METHODS AND MATERIAL

The database built by the multicentre observational study, performed in Italy by the NUD-look Study Group, provided the material studied: a collection of data from 861 patients with previously uninvestigated dyspepsia, being referred for upper gastrointestinal endoscopy to 42 Italian Endoscopic Services. The proposed EP makes use of techniques based on advanced neuro-evolutionary systems (NESs) and is structured in phases and steps. The use of specific input selection (IS) and training and testing (T and T) techniques together with genetic doping (GenD) algorithm is described in detail, as well as the steps taken in the two benchmark and optimization protocol phases.

RESULTS

In terms of accuracy results, a value of 79.64% was achieved during optimization, with mean benchmark values of 64.90% for the linear discriminant analysis (LDA) and 68.15% for the multi layer perceptron (MLP), for the classification task. A value of 88.61% was achieved during optimization for the prediction task, with mean benchmark values of 49.32% for the LDA and 70.05% for the MLP.

CONCLUSIONS

The proposed EP has led to the construction of inductors that are viable and usable on medical data which is representative but highly not linear. In particular, for the classification problem, these new inductors may be effectively used on the basal examination data to support doctors in deciding whether to avoid endoscopic examinations; whereas, in the prediction problem, they may support doctors' decisions about the advisability of eradication therapy. In both cases the variables selected indicate the possibility of reducing the data collection effort and also of providing information that can be used for general investigations on symptom relevance.

Development and psychometric evaluation of the patient assessment of upper gastrointestinal symptom severity index (PAGI-SYM) in patients with upper gastrointestinal disorders

OBJECTIVE

Describe the development and evaluation of a new self-report instrument, the patient assessment of upper gastrointestinal disorders-symptom severity index (PAGI-SYM) in subjects with gastroesophageal reflux disease (GERD), dyspepsia, or gastroparesis.

METHODS

Recruited subjects with GERD (n=810), dyspepsia (n = 767), or gastroparesis (n = 169) from the US, France, Germany, Italy, the Netherlands, and Poland. Subjects completed the PAGI-SYM, SF-36, a disease-specific HRQL measure (PAGI-QOL), and disability day questions. Two-week reproducibility was evaluated in 277 stable subjects. We evaluated construct validity by correlating subscale scores with SF-36, PAGI-QOL, disability days, and global symptom severity scores.

RESULTS

The final 20-item PAGI-SYM has six subscales: heartburn/regurgitation, fullness/early satiety, nausea/vomiting, bloating, upper abdominal pain, and lower abdominal pain. Internal consistency reliability was good (alpha = 0.79-0.91); test-retest reliability was acceptable (Intraclass correlation coefficients alpha=0.60-0.82). PAGI-SYM subscale scores correlated significantly with SF-36 scores (all p < 0.0001), PAGI-QOL scores (all p < 0.0001), disability days (p < 0.0001), and global symptom severity (p < 0.0001). Mean PAGI-SYM scores varied significantly in groups defined by disability days (all p < 0.0001), where greater symptom severity was associated with more disability days.

CONCLUSIONS

Results suggest the PAGI-SYM, a brief symptom severity instrument, has good reliability and evidence supporting construct validity in subjects with GERD, dyspepsia, or gastroparesis.

Cross-cultural development and validation of a patient self-administered questionnaire to assess quality of life in upper gastrointestinal disorders: The PAGI-QOL�

OBJECTIVE

Summarize the Patient Assessment of Upper GastroIntestinal Disorders-Quality of Life (PAGI-QOL) development and provide results on its reliability and validity from the international psychometric validation in dyspepsia, GastroEsophageal Reflux Disease (GERD), and gastroparesis.

METHODS

Subjects completed the pilot PAGI-QOL at baseline and 8 weeks; and a subsample also at 2 weeks. Other assessments were: Patient Assessment of Upper Gastrointestinal Disorders-Symptom Severity Index, SF-36, number of disability days.

RESULTS

1736 patients completed the PAGI-QOL at baseline. The questionnaire was reduced, producing a 30-item final version covering five domains: Daily Activities, Clothing, Diet and Food Habits, Relationship (REL), and Psychological Well-Being and Distress. Internal consistency was excellent (Cronbach's alpha range: 0.83-0.96). Test-retest reproducibility was good: intraclass correlations coefficients were over 0.70 except for the REL scale (0.61). Concurrent validity between the PAGI-QOL total score and all SF-36 subscale scores was good with moderate (0.52) to strong (0.72) correlations. PAGI-QOL scores showed excellent discriminant properties: patients who had spent some days in bed, had missed some days at work, and were kept from usual activities had much lower PAGI-QOL scores than those who did not (p < 0.0001).

CONCLUSION

The PAGI-QOL is a valid and reliable instrument assessing quality of life in patients with dyspepsia, GERD, or gastroparesis.

Classification of dyspepsia and response to treatment with proton-pump inhibitors

BACKGROUND

Lacking an objective 'gold standard' for diagnosing dyspepsia, several symptom-based classifications have been suggested.

AIM

To assess if response to proton-pump inhibitor treatment could provide useful information for current or future dyspepsia classification.

METHODS

Post hoc analyses of 829 patients treated with omeprazole or placebo in a randomized-controlled trial. The 'true' response to omeprazole (trial response minus placebo response) was assessed according to different classifications of dyspepsia and different symptoms.

RESULTS

Symptoms described with the words 'burning' or 'sour' and patients with reflux-like dyspepsia demonstrated high response to omeprazole treatment, whereas patients with abdominal pain or ulcer-like dyspepsia responded unpredictably to omeprazole. The response to omeprazole in patients with epigastic pain was related to the pattern of other dyspeptic symptoms. Patients with heartburn or regurgitation overlapped extensively with patients with epigastric pain.

CONCLUSION

The study demonstrated significant problems in the current classification of dyspepsia: 'the most bothersome symptom' was not independently related to the omeprazole effect and, in patients with abdominal pain, the response to omeprazole was dependent on the presence or absence of other dyspeptic symptoms. The overlap of symptoms indicates that heartburn and regurgitation should be recognized as symptoms of dyspepsia in primary care.

Responsiveness and interpretation of a symptom severity index specific to upper gastrointestinal disorders

BACKGROUND AND AIMS

Determining clinically meaningful change of patient-reported outcome measures is important for evaluating effectiveness of treatments for gastrointestinal (GI) diseases. This study evaluates responsiveness of the Patient Assessment of Gastrointestinal Disorders-Symptom Severity Index (PAGI-SYM) in gastroesophageal reflux disease (GERD) and dyspepsia.

METHODS

The PAGI-SYM was based on a review of the published literature and interviews with patients and clinicians. Items were developed to be linguistically and culturally appropriate for multicountry studies. The PAGI-SYM includes 6 subscales: heartburn/regurgitation, fullness/early satiety, nausea/vomiting, bloating, upper abdominal pain, and lower abdominal pain. Subjects with GERD (n = 810) or dyspepsia (n = 767) participated in this multicountry, observational study. All subjects completed the PAGI-SYM, a global symptom relief questionnaire, and a measure of patient-rated change in GI-related symptoms, the Overall Treatment Effect (OTE) scale. Responsiveness was evaluated at 8 weeks by comparing groups by disease, symptom relief, and OTE (improved, stable, and worsened).

RESULTS

Subjects reporting symptom relief reported significantly lower (better) PAGI-SYM scores than those reporting no symptom relief ( P < 0.0001 to P < 0.0005). Subjects with improvements in overall GI symptoms exhibited significant decreases in PAGI-SYM subscale scores compared with those who remained the same or worsened (all P values < 0.0001). Effect sizes ranged from 0.21-1.28, and standard errors of measurement ranged from 0.29-0.63, depending on subscale and disease sample.

CONCLUSIONS

The PAGI-SYM is a brief symptom severity instrument that measures common GI symptoms. Results suggest that the PAGI-SYM is responsive and sensitive to change in clinical status in subjects with GERD or dyspepsia.

[New considerations in the treatment of functional dyspepsia]

Functional dyspepsia is a clinical syndrome defined by chronic or recurrent pain or discomfort in the upper abdomen of unknown origin. Dyspepsia is a very common condition, with a high prevalence in the general population. The multifactorial pathogenesis of dyspeptic symptoms is poorly defined. However, several factors have been identified as relevant, including the role of gastric acid secretion, gastroduodenal dysmotility, visceral hypersensitivity and also the effects of stress and psychological factors. The role of Helicobacter pylori infection is more controversial, the infection plays only an irrelevant role in the pathophysiology of functional dyspepsia, nevertheless in a subgroups of patients eradication therapy is generally accepted as a preventive tool. The need for positive diagnosis is emphasized. The management of dyspeptic patients has a considerable impact on health services. As the costs of initial investigation are high, most patients receive empirical management (prescribing without a proven diagnosis), at least initially. Subgrouping of functional dyspepsia according to its predominant symptom into ulcer-like, dysmotility-like and non-specific dyspepsia has been attempted to tailor its treatment accordingly. This review aims to summarize the new aspects of pathophysiology, investigation and management strategies of functional dyspepsia.

[Functional dyspepsia: definition, classification, clinical and therapeutic management]

Dyspepsia is a very common syndrome characterized by pain and/or discomfort of the upper abdomen. Sometimes, an organic disease causes this syndrome (organic dyspepsia); more frequently, there are no known diseases (functional dyspepsia). These latter conditions are identified by exclusion. The pathogenesis of this syndrome is yet to be clarified. Currently, functional dyspepsia is classified in ulcer-like dyspepsia, dysmotility-like dyspepsia and nonspecific dyspepsia, in which symptoms do not clearly fit into any of the above categories. The current guidelines for the management of "uninvestigated dyspepsia" suggest testing for Helicobacter pylori infection and relative treatment if positive. A gastroscopy should be performed in case of persistence of symptoms to discriminate between the organic and functional forms. In the latter, to optimize patient management, it is necessary to find the exact subgroup. Antacids, H2-receptor antagonists and proton pump inhibitors have been demonstrated to be useful in ulcer-like dyspepsia. Prokinetic agents are more effective in the dysmotility-like dyspepsia. Further studies will be necessary to confirm the efficacy of emerging therapeutic strategies.

Comparative classification and grading of Helicobacter pylori gastritis in patients with gastric cancer and patients with functional dyspepsia

BACKGROUND

It has previously been shown that corpus-dominant grade and activity of Helicobacter pylori gastritis in combination with intestinal metaplasia in the antrum or corpus are risk markers for the development of stomach cancer. If one point is scored for each of these three parameters, a gastric cancer risk index is obtained that permits prediction of the risk of gastric cancer developing on the soil of H. pylori gastritis. The aim of the present study was to evaluate the accuracy of the gastric cancer risk index based on a large number of patients compared with dyspeptic controls.

METHODS

In 415 biopsied patients with gastric carcinoma, biopsy specimens taken from the antrum and corpus were investigated retrospectively. From this group of patients, 244 patients positive for H. pylori were compared with 244 sex- and age-matched H. pylori-infected patients with functional dyspepsia.

RESULTS

H. pylori gastritis was detected in 395 carcinoma patients (95.2%). The 244 sex- and age-matched patients significantly more frequently had corpus-dominant H. pylori gastritis (compared with NUD controls). The incidence of intestinal metaplasia was also significantly increased. For a gastric cancer risk index score of 3 points (i.e. corpus pronounced grade and activity of gastritis, and intestinal metaplasia in antrum or corpus), a sensitivity of 93% and a specificity of 85% for the presence of gastric carcinoma can be calculated.

CONCLUSION

Using the proposed risk index, the topographic grading of H. pylori gastritis in the antrum and corpus enables the diagnosis of a 'risk gastritis' to be made.

Development and validation of a patient-assessed gastroparesis symptom severity measure: the Gastroparesis Cardinal Symptom Index

BACKGROUND

Patient-based symptom assessments are necessary to evaluate the effectiveness of medical treatments for gastroparesis.

AIM

To summarize the development and measurement qualities of the Gastroparesis Cardinal Symptom Index (GCSI), a new measure of gastroparesis-related symptoms.

METHODS

The GCSI was based on reviews of the medical literature, clinician interviews and patient focus groups. The measurement qualities (i.e. reliability, validity) of the GCSI were examined in 169 gastroparesis patients. Patients were recruited from seven clinical centres in the USA to participate in this observational study. Patients completed the GCSI, SF-36 Health Survey and disability day questions at a baseline visit and again after 8 weeks. Clinicians independently rated the severity of the patients' symptoms, and both clinicians and patients rated the change in gastroparesis-related symptoms over the 8-week study.

RESULTS

The GCSI consists of three sub-scales: post-prandial fullness/early satiety, nausea/vomiting and bloating. The internal consistency reliability was 0.84 and the test-re-test reliability was 0.76 for the GCSI total score. Significant relationships were observed between the clinician-assessed symptom severity and the GCSI total score, and significant associations were found between the GCSI scores and SF-36 physical and mental component summary scores and restricted activity and bed disability days. Patients with greater symptom severity, as rated by clinicians, reported greater symptom severity on the GCSI. The GCSI total scores were responsive to changes in overall gastroparesis symptoms as assessed by clinicians (P = 0.0002) and patients (P = 0.002).

CONCLUSION

The findings of this study indicate that the GCSI is a reliable and valid instrument for measuring the symptom severity in patients with gastroparesis.

Contribution of artificial neural networks to the classification and treatment of patients with uninvestigated dyspepsia

OBJECTIVES

To verify whether symptoms reported by patients with uninvestigated dyspepsia might be helpful in either classifying functional from organic dyspepsia (1st experiment), or recognising which Helicobacter pylori infected patients may benefit from eradication therapy (2nd experiment).

METHODS

We compared the performance of artificial neural networks and linear discriminant analysis in two experiments on a database including socio-demographic features, past medical history, alarming symptoms, and symptoms at presentation of 860 patients with uninvestigated dyspepsia enrolled in a large observational multi-centre Italian study.

RESULTS

In the 1st experiment, the best prediction for organic disease was given by the Sine Net model (specificity of 87.6% with 13 patients misclassified) and the best prediction for functional dyspepsia by the FF Bp model (sensitivity of 83.4% with 56 patients misclassified). The highest global accuracy of linear discriminant analysis was 65.1%, with 150 patients misclassified. In the 2nd experiment, the highest predictive performance was provided by the SelfDASn model: all infected patients who became symptom-free after successful eradicating treatment were correctly classified, whereas nine errors were made in forecasting patients who did not benefit from such a therapy. The highest global performance of linear discriminant analysis was 53.2%, with 37 patients misclassified.

CONCLUSIONS

In patients with uninvestigated dyspepsia, artificial neural networks might have potential for categorising those affected by either organic or functional dyspepsia, as well as for identifying all Helicobacter pylori infected dyspeptic patients who will benefit from eradication.

Diagnostic yield of upper endoscopy in Asian patients presenting with dyspepsia

BACKGROUND

The aim of this study was to determine the frequency of diagnosis of significant disease by EGD in Asian patients of various ages with simple dyspepsia.

METHODS

Database records of 10,488 consecutive patients undergoing EGD between 1992 and 1998 were analyzed. The frequency of significant upper GI disease (defined as esophagitis, peptic ulcer, and cancer) in patients presenting with simple dyspepsia was determined for various age groups.

RESULTS

For the indication simple dyspepsia, 5066 (48.3%) EGDs were performed. At 988 (19.5%) EGDs, significant disease was noted (peptic ulcer 14.9%, esophagitis 5.0%, stomach cancer 0.47%, esophageal cancer 0.06%). There was a positive correlation between disease frequency and increasing age. The cumulative percentages of significant disease by age group were as follows: 10.8% in patients less than 35 years of age, 11.9% for those less than 40 years old, 13.7% for patients less than 45 years of age, and 19.5% overall. The cumulative frequencies of gastric cancer by age group were as follows: 0.68 of 1000 EGDs in patients less than 35 years of age, 1.15 of 1000 EGDs in patients less than 45 years old, and 9.60 of 1000 EGDs in patients greater than 45 years of age.

CONCLUSION

The present study provides data to assist decision-making regarding the use of EGD in the patient population of Singapore. For patients with simple dyspepsia residing in Singapore, an age threshold of 45 years is reasonable inasmuch as gastric cancer is rarely found at endoscopy in younger patients. The age threshold for EGD for simple dyspepsia for Asians residing in other parts of the world would have to be determined based on the local prevalence of gastric cancer.

Empiric clustering of dyspepsia into symptom subgroups: a population-based study

BACKGROUND

Different definitions of dyspepsia are applied by researchers yet measurement of the influence of these on prevalence estimates is uncertain. Despite continued debate regarding dyspepsia subgroups, few studies have used a data-drive approach to assess the existence and relevance of symptom clusters. We aimed to address both these issues.

METHODS

A random population sample (n = 2300) identified in New South Wales. Prevalence estimates of dyspepsia were calculated by applying four standardized dyspepsia definitions. Principal components analyses, using firstly the presence/absence of symptoms and then secondly severity of symptoms, were undertaken to determine if symptom factors existed.

RESULTS

Prevalence estimates ranged from 11% to 36%. Similar prevalence rates for men and women were observed for all definitions except Rome II. Over one-third of respondents nominated heartburn or epigastric pain as their most bothersome symptom. However, 22% of respondents were unable to answer this question. The principal components analysis produced four symptom factors: a nausea factor, dysmotility-like dyspepsia (early satiety and fullness), ulcer-like (epigastric pain and bloating) and reflux-like (heartburn and acid regurgitation). However, the factors accounted for less than 50% of the variance. Similar factors were identified in men and women for dysmotility-like and reflux-like dyspepsia. Use of presence/absence or severity of symptoms made little difference to the symptom factors produced or the amount of variance explained.

CONCLUSIONS

The prevalence of dyspepsia depends on the definition applied. While there is some empirical evidence of symptom subgroups, they appear to be of little clinical utility.