Helicobacter pylori infection and the development of gastric cancer

BACKGROUND

Although many studies have found an association between Helicobacter pylori infection and the development of gastric cancer, many aspects of this relation remain uncertain.

METHODS

We prospectively studied 1526 Japanese patients who had duodenal ulcers, gastric ulcers, gastric hyperplasia, or nonulcer dyspepsia at the time of enrollment; 1246 had H. pylori infection and 280 did not. The mean follow-up was 7.8 years (range, 1.0 to 10.6). Patients underwent endoscopy with biopsy at enrollment and then between one and three years after enrollment. H. pylori infection was assessed by histologic examination, serologic testing, and rapid urease tests and was defined by a positive result on any of these tests.

RESULTS

Gastric cancers developed in 36 (2.9 percent) of the infected and none of the uninfected patients. There were 23 intestinal-type and 13 diffuse-type cancers. Among the patients with H. pylori infection, those with severe gastric atrophy, corpus-predominant gastritis, and intestinal metaplasia were at significantly higher risk for gastric cancer. We detected gastric cancers in 21 (4.7 percent) of the 445 patients with nonulcer dyspepsia, 10 (3.4 percent) of the 297 with gastric ulcers, 5 (2.2 percent) of the 229 with gastric hyperplastic polyps, and none of the 275 with duodenal ulcers.

CONCLUSIONS

Gastric cancer develops in persons infected with H. pylori but not in uninfected persons. Those with histologic findings of severe gastric atrophy, corpus-predominant gastritis, or intestinal metaplasia are at increased risk. Persons with H. pylori infection and nonulcer dyspepsia, gastric ulcers, or gastric hyperplastic polyps are also at risk, but those with duodenal ulcers are not.

Symptoms associated with impaired gastric emptying of solids and liquids in functional dyspepsia

OBJECTIVE

The relationship between functional dyspepsia and delayed gastric emptying of solids or liquids is still unclear. The aim of the present study was to investigate in dyspeptic patients the prevalence of delayed gastric emptying for solids or for liquids and to investigate the relationship to the dyspepsia symptom pattern.

METHODS

In 392 and 330 patients with functional dyspepsia, the solid and liquid gastric emptying, respectively, was measured using breath tests, and the severity of eight dyspeptic symptoms was scored.

RESULTS

Gastric emptying of solids and liquids were delayed in 23% and 35% of the patients. Multivariate analysis showed that the presence of vomiting and postprandial fullness was associated with delayed solid emptying (OR 2.65, 95% CI = 1.62-4.35 and OR 3.08, 95% CI = 1.28-9.16, respectively). Postprandial fullness was also associated with the risk of delayed liquid emptying when symptom was present (OR 3.5, 95% CI = 1.57-8.68), relevant or severe (OR 2.504, 95% CI = 1.41-4.65), and severe (OR 2.214, 95% CI = 1.34-3.67). Severe early satiety was associated with the risk of delayed liquid emptying (OR 1.902, 95% CI = 1.90-3.30).

CONCLUSIONS

A subset of dyspeptic patients has delayed gastric emptying of solids or of liquids. Delayed gastric emptying of solids was constantly associated with postprandial fullness and with vomiting. Delayed emptying for liquids was also associated with postprandial fullness and with severe early satiety.

Efficacy of omeprazole in functional dyspepsia: double-blind, randomized, placebo-controlled trials (the Bond and Opera studies)

BACKGROUND

The efficacy of H2-receptor antagonists in functional dyspepsia is equivocal and the therapeutic place of proton pump inhibitors in functional dyspepsia is unknown.

AIM

To evaluate the efficacy of proton pump inhibitor therapy in functional dyspepsia.

METHODS

Patients (n = 1262) with a clinical diagnosis of functional dyspepsia (persistent or recurrent epigastric pain or discomfort for at least 1 month and a normal upper gastrointestinal endoscopy) were randomized to receive omeprazole 20 mg, 10 mg or identical placebo, for 4 weeks. Symptoms were assessed using validated measures. Helicobacter pylori status was determined pre-entry by a 13C-urea breath test.

RESULTS

On an intention-to-treat analysis (n=1248), complete symptom relief was observed in 38% on omeprazole 20 mg, compared with 36% on omeprazole 10 mg and 28% on placebo (P = 0.002 and 0.02, respectively). Among those with ulcer-like and reflux-like dyspepsia, complete symptom relief was achieved in 40% and 54% on omeprazole 20 mg, and 35% and 45% on omeprazole 10 mg, respectively, compared with 27% and 23% on placebo (all P < 0.05, except omeprazole 10 mg in ulcer-like dyspepsia, P = 0.08). There was no significant benefit of omeprazole over placebo in dysmotility-like dyspepsia. Symptom relief was similar in H. pylori-positive and negative cases.

CONCLUSIONS

Omeprazole is modestly superior to placebo in functional dyspepsia at standard (20 mg) and low doses (10 mg) but not in patients with dysmotility-like dyspepsia.

Gastrointestinal tract symptoms and self-reported abuse: a population-based study

BACKGROUND/AIMS

A link between abuse and irritable bowel syndrome (IBS) has been reported in outpatients but remains controversial. No population-based studies have investigated this issue. The aim of this study was to determine the prevalence of abuse and its association with symptoms in a representative community sample.

METHODS

An age- and sex-stratified random sample of residents of Olmsted County, Minnesota ranging in age from 30 to 49 years was mailed a valid self-report symptom questionnaire. Abuse was assessed by standard published criteria.

RESULTS

Of the 919 responders (74%), the age-adjusted prevalence of any abuse was 41% in women and 11% in men, resulting in an age- and sex-adjusted prevalence of 26%. Symptoms of IBS, dyspepsia, and frequent heartburn were reported by 14%, 23%, and 12%, respectively. There was a significant association between IBS and sexual abuse, emotional or verbal abuse, and abuse in childhood and adulthood. Similarly, dyspepsia and heartburn were both significantly associated with abuse. In the population, 31% had visited a physician for gastrointestinal symptoms; the odds of visiting a physician were highest in those reporting abuse in adulthood and childhood.

CONCLUSIONS

Self-reported abuse is common in middle-aged subjects; those who report abuse are more likely to have symptoms consistent with IBS, dyspepsia, or heartburn and to visit a physician for bowel symptoms.

Topographic patterns of intestinal metaplasia and gastric cancer

OBJECTIVE

The role of intestinal metaplasia in gastric oncogenesis has been demonstrated by both cross-sectional and longitudinal studies. This study was designed to determine whether, in a population at high risk for gastric cancer, different topographical patterns and phenotypes of intestinal metaplasia were associated with different degrees of cancer risk.

METHODS

A total of 68 Colombian patients with gastric cancer and 67 controls with nonulcer dyspepsia were studied by an extensive biopsy protocol. Intestinal metaplasia was assessed semiquantitatively by histology and was characterized histochemically. In both patients and controls, the Spearman's correlation test was applied to the test if the gastric distribution of metaplastic lesions resulted in specific topographical patterns associated with different risks for cancer.

RESULTS

Four topographical patterns of intestinalization emerged: 1) "Focal," in 14 cancer patients and 16 controls; 2) "Antrum-predominant," in seven cancer patients and six controls; 3) "Magenstrasse" (involving the lesser curvature from cardia to pylorus) in 25 cancer patients and four controls. This pattern was associated with higher cancer risk (OR = 5.7; 95% CI: 1.3-26) than were the two less extensive patterns; and 4) "Diffuse," involving essentially the entire gastric mucosa with the exception of the fundus, was unique to 13 cancer patients. The OR for cancer was 12.2; 95% CI: 2.0-72.9. Incomplete-type metaplasia significantly correlated with the extent of total metaplasia and was also associated with greater cancer risk.

CONCLUSIONS

In a population with high risk for gastric cancer, the extension of intestinal metaplasia correlates with the extent of its "incomplete" phenotype and is significantly associated with increased cancer risk. Both the extent and location of intestinal metaplasia along the lesser curvature (from the cardia to the prepyloric zones) identify patients with the highest cancer risk.

Functional Dyspepsia and Gastroparesis in Tertiary Care are Interchangeable Syndromes With Common Clinical and Pathologic Features

BACKGROUND

The aim of this study was to clarify the pathophysiology of functional dyspepsia (FD), a highly prevalent gastrointestinal syndrome, and its relationship with the better-understood syndrome of gastroparesis.

METHODS

Adult patients with chronic upper gastrointestinal symptoms were followed up prospectively for 48 weeks in multi-center registry studies. Patients were classified as having gastroparesis if gastric emptying was delayed; if not, they were labeled as having FD if they met Rome III criteria. Study analysis was conducted using analysis of covariance and regression models.

RESULTS

Of 944 patients enrolled during a 12-year period, 720 (76%) were in the gastroparesis group and 224 (24%) in the FD group. Baseline clinical characteristics and severity of upper gastrointestinal symptoms were highly similar. The 48-week clinical outcome was also similar but at this time 42% of patients with an initial diagnosis of gastroparesis were reclassified as FD based on gastric-emptying results at this time point; conversely, 37% of patients with FD were reclassified as having gastroparesis. Change in either direction was not associated with any difference in symptom severity changes. Full-thickness biopsies of the stomach showed loss of interstitial cells of Cajal and CD206+ macrophages in both groups compared with obese controls.

CONCLUSIONS

A year after initial classification, patients with FD and gastroparesis, as seen in tertiary referral centers at least, are not distinguishable based on clinical and pathologic features or based on assessment of gastric emptying. Gastric-emptying results are labile and do not reliably capture the pathophysiology of clinical symptoms in either condition. FD and gastroparesis are unified by characteristic pathologic features and should be considered as part of the same spectrum of truly "organic" gastric neuromuscular disorders. CLINICALTRIALS.

GOV IDENTIFIER

NCT00398801, NCT01696747.

Chronic Abdominal Pain In Children: a Technical Report of the American Academy of Pediatrics and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Chronic abdominal pain, defined as long-lasting intermittent or constant abdominal pain, is a common pediatric problem encountered by primary care physicians, medical subspecialists and surgical specialists. Chronic abdominal pain in children is usually functional-that is, without objective evidence of an underlying organic disorder. The Subcommittee on Chronic Abdominal Pain of the American Academy of Pediatrics and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition has prepared this report based on a comprehensive, systematic review and rating of the medical literature. This report accompanies a clinical report based on the literature review and expert opinion. The subcommittee examined the diagnostic and therapeutic value of a medical and psychologic history, diagnostic tests, and pharmacological and behavioral therapy. The presence of alarm symptoms or signs (such as weight loss, gastrointestinal bleeding, persistent fever, chronic severe diarrhea and significant vomiting) is associated with a higher prevalence of organic disease. There was insufficient evidence to state that the nature of the abdominal pain or the presence of associated symptoms (such as anorexia, nausea, headache and joint pain) can discriminate between functional and organic disorders. Although children with chronic abdominal pain and their parents are more often anxious or depressed, the presence of anxiety, depression, behavior problems or recent negative life events does not distinguish between functional and organic abdominal pain. Most children who are brought to the primary care physician's office for chronic abdominal pain are unlikely to require diagnostic testing. Pediatric studies of therapeutic interventions were examined and found to be limited or inconclusive.

Helicobacter pylori infection and gastric function in patients with chronic idiopathic dyspepsia

Helicobacter pylori infection, histological features of the gastric mucosa, and gastric motor and secretory functions were evaluated in 45 consecutive patients with chronic idiopathic dyspepsia. H. pylori infection was found in 60% of dyspeptic patients, compared with 33% of 15 healthy controls (P = 0.1). No difference was detected in basal or stimulated gastric acid secretion between dyspeptic patients and healthy controls. Gastric emptying was significantly (P less than 0.01) delayed in dyspeptic patients compared with healthy controls when standardized for age and sex. Delayed gastric emptying was associated with a low frequency of H. pylori infection, female gender, and young age. Epigastric pain or burning and postprandial fullness were, respectively, more severe in patients with H. pylori infection (P less than 0.02) and in those with delayed gastric emptying (P less than 0.01). These findings support the existence of separate subsets of patients with chronic idiopathic dyspepsia. Despite the presence of overlaps, there appear to be partially different functional derangements and clinical features in different subgroups of dyspeptic patients.

Dyspeptic symptoms in the general population: a factor and cluster analysis of symptom groupings

Both dyspeptic and gastro-oesophageal reflux-like symptoms are frequent in the general population, but their degree of overlap is unknown. In severe functional dyspepsia (FD), symptoms are organized in factors associated with pathophysiological mechanisms. The aims of this study were: (i) to assess the prevalence of dyspeptic symptoms with and without overlapping reflux symptoms in the general population and their impact on daily life and on healthcare utilization; and (ii) to compare symptom groupings in the general population to FD patients. A total of 2025 subjects, representative of the Belgian general population, were used in this study. The subjects were submitted to a questionnaire with validated questions on their dyspeptic and reflux symptoms and with evaluators of impact on daily life and use of healthcare resources. Significant dyspeptic symptoms were found in 417 (20.6%). Overlapping reflux symptoms were present in 141 (33.8%). In this group, symptoms were more frequent and more severe. Dyspeptic symptoms induced weight loss (12.7%) and absenteeism (12.4%), affected daily life (61.2%) and generated use of healthcare resources, such as medical consultations (61.4%) and medication (70.9%). Factor analysis revealed a three-component structure with factor 1 including fullness, bloating and early satiety, factor 2 including nausea and vomiting and factor 3 including discomfort, pain, belching and reflux. If forced in a four-factor model, the analysis separates belching as independent factor. Dyspeptic symptoms are frequent in the general population, with overlapping reflux symptoms and increased symptom burden in about a third.

Sleep disturbances in clinic patients with functional bowel disorders

OBJECTIVE

Sleep deprivation can lower visceral perception thresholds and nonregenerative sleep has been implicated as an etiological factor in chronic hyperalgesia syndromes. The aims of our study were to quantify the self-reported prevalence and type of sleep disturbances in patients with different functional bowel disorders (FBD) and to determine if this prevalence is related to involvement of the upper or lower gastrointestinal (GI) tract, perceived disease severity, or psychological comorbidity.

METHODS

We enrolled 505 new FBD patients from an academic referral center specializing in functional GI disorders and 247 community based healthy controls. All patients and controls were prospectively evaluated by validated bowel symptom and sleep questionnaires. A psychological profile was obtained by SCL-90R.

RESULTS

We found that 68% of functional dyspepsia (FD), 71.2% of irritable bowel syndrome (IBS)+FD, 50.2% of IBS, and 55.1% of the normal subjects reported having sleep disturbances. Waking up repeatedly during the night and waking up in the morning feeling tired or not rested were the most commonly reported sleep patterns; 57.2% of the patients reported that their abdominal ache awakened them from sleep during the night. Self-reported sleep disturbance was directly related to the perceived intensity of GI symptoms. Self-reported sleep disturbances were equally common in both male (57%) and female (58.4%) FBD patients. There was no significant difference between the mean anxiety and depression scores between patients with and without sleep dysfunction.

CONCLUSIONS

FD patients, but not IBS patients, reported sleep disturbances more frequently than healthy control subjects. Abdominal pain or discomfort that awaken FBD patients from sleep during the night were common, and thus a poor discriminating factor between organic and functional disorders.

Prevalence of acid reflux in functional dyspepsia and its association with symptom profile

AIM

A subset of functional dyspepsia patients respond to acid suppressive therapy, but the prevalence of non-erosive reflux disease in functional dyspepsia and its relevance to symptoms have never been established. The aim of the present study was to study 24 hour pH monitoring in consecutive functional dyspepsia patients.

METHODS

A total of 247 patients with dyspeptic symptoms (166 women, mean age 44 (SEM 1) year), with a negative upper gastrointestinal endoscopy and without dominant symptoms of heartburn participated in the study. In all patients, the severity of dyspeptic symptoms and the presence of heartburn was assessed by a questionnaire and a 24 hour oesophageal pH monitoring study was performed. All patients underwent a gastric emptying breath test and in 113 a gastric barostat study was performed.

RESULTS

Abnormal pH monitoring (acid exposure >5% of time) was found in 58 patients (23%). Of 21 patients with a positive heartburn questionnaire, 76% had pathological pH monitoring, while this was the case in only 18.5% of patients with a negative heartburn questionnaire. Demographic characteristics and the prevalence of other pathophysiological mechanisms did not differ between heartburn negative patients with normal or abnormal acid exposure. Pathological acid exposure in heartburn negative patients was associated with the presence of epigastric pain (65 v 84%, p<0.005) and of moderate or severe pain (48 v 69%, p = 0.005).

CONCLUSION

Pathological oesophageal acid exposure is only present in a subset of heartburn negative functional dyspepsia patients, which are characterised by a higher prevalence of epigastric pain.

Relations between upper abdominal symptoms and gastric distension abnormalities in dysmotility like functional dyspepsia and after vagotomy

Postprandial bloating and fullness are commonly found both in dysmotility like functional dyspepsia, and after vagotomy but the relation between gastric accommodation and symptom production has not been investigated. Intragastric pressure levels and symptoms developed during controlled distension of the gastric fundus were recorded in nine patients with functional dyspepsia, in seven patients after truncal vagotomy, and in 11 healthy volunteers. The procedure was repeated after ingestion of a liquid nutrient meal (250 ml; 250 kcal). Gastric tone, expressed as the average value of pressure over the distension period was lower in controls (median: 11.3 mm Hg) than in either the dyspeptic patients (median: 16.48 mm Hg) or postvagotomy patients (median: 19.12 mm Hg) (p < 0.05). Meal ingestion reduced gastric tone in controls, but no significant change occurred in either the dyspepsia or the postvagotomy patients. Volumes at which discomfort was elicited by distension during fasting were lower both in dyspeptic patients (median: 210 ml) and in postvagotomy patients (median: 180 ml) than in healthy volunteers (median: 660 ml) (p < 0.05). Discomfort thresholds were unaffected by meal ingestion. These results suggest that a disturbance of gastric relaxation may be related to symptom development in dysmotility like functional dyspepsia, while similarities between dyspeptic patients and postvagotomy patients suggest that the impaired gastric accommodation in functional dyspepsia may be due to an underlying vagal defect.

Abdominal pain-predominant functional gastrointestinal diseases in children and adolescents: prevalence, symptomatology, and association with emotional stress

BACKGROUND AND OBJECTIVE

Functional gastrointestinal disorders (FGD) are common among children, but little is known regarding their prevalence in developing countries. We assessed the prevalence of abdominal pain-predominant FGD, in addition to the predisposing factors and symptomatology, in Sri Lankan children.

PATIENTS AND METHODS

A cross-sectional survey was conducted among a randomly selected group of 10- to 16-year-olds in 8 randomly selected schools in 4 provinces in Sri Lanka. A validated, self-administered questionnaire was completed by children independently in an examination setting. FGD were diagnosed using Rome III criteria.

RESULTS

A total of 2180 questionnaires were distributed and 2163 (99.2%) were included in the analysis (1189 [55%] boys, mean age 13.4 years, standard deviation 1.8 years). Of them, 270 (12.5%) had at least 1 abdominal pain-predominant FGD. Irritable bowel syndrome (IBS) was seen in 107 (4.9%), functional dyspepsia in 54 (2.5%), functional abdominal pain in 96 (4.4%), and abdominal migraine (AM) in 21 (1.0%) (2 had AM and functional dyspepsia, 6 had AM and IBS). Extraintestinal symptoms were more common among affected children (P < 0.05). Abdominal pain-predominant FGD were higher in girls and those exposed to stressful events (P < 0.05). Prevalence negatively correlated with age (r = -0.05, P = 0.02).

CONCLUSIONS

Abdominal pain-predominant FGD affects 12.5% of children ages 10 to 16 years and constitutes a significant health problem in Sri Lanka. IBS is the most common FGD subtype present. Abdominal pain-predominant FGD are higher in girls and those exposed to emotional stress. Prevalence of FGD decreased with age. Extraintestinal symptoms are more frequent in affected children.

Mental distress, obesity and body fat distribution in middle-aged men

Previous epidemiological studies have suggested that psychiatric symptoms are associated with obesity and abdominal distribution of body fat in women. The aim of the present study was to examine this in middle-aged men. In 1992 a cluster selected cohort of 1040 men born in 1944 (participation rate 79.9%) was examined. Registrations of symptoms of depression and anxiety, sleep disturbances, psychosomatic disease as well as degree of life satisfaction were analyzed in relation to body mass index (BMI) and the waist/hip circumference ratio (WHR). In univariate analyses both BMI and WHR correlated with these factors. BMI and WHR were, however, closely interrelated (p = 0.61), necessitating analyses of separate, independent relationships in multivariate analyses. When adjusted for WHR all the significant relationships with BMI disappeared. In contrast the WHR, adjusted for BMI, showed remaining significant associations with the use of anxiolytics (p = 0.018), hypnotics (p = 0.029), antidepressive drugs (p = 0.008), degree of melancholy (p = 0.002), and life satisfaction (p = 0.002, negative), difficulties to sleep (p = 0.014) and fall asleep (p = 0.047), tendency to wake up from sleep (borderline, p = 0.070) and dyspepsia (p < 0.001). Since smoking and alcohol are known to influence on the WHR, these factors were, in addition to BMI, entered into the analyses as confounding variables. The mentioned associations then remained statistical significant (use of hypnotics borderline, p = 0.074) except difficulties to fall asleep and tendency to wake up. It was concluded that in contrast to BMI, the WHR is associated with symptoms of depression and anxiety with associated sleep disturbances, as well as psychosomatic symptoms and dissatisfaction. It was hypothesized that the mechanism involved might be increased secretion of cortisol, directing storage fat to central adipose tissue depots.

Campylobacter associated gastritis in patients with non-ulcer dyspepsia: a double blind placebo controlled trial with colloidal bismuth subcitrate

Fifty consecutive patients with non-ulcer dyspepsia and a Campylobacter associated gastritis (CAG) were randomly assigned to treatment with colloidal bismuth subcitrate (CBS) 240 mg twice daily or placebo, according to a double blind study design. After the blind treatment an 'open' treatment with CBS was started in both groups. Twenty six patients treated with CBS showed a significant reduction in colonisation with Campylobacter pylori and a significant improvement in the Whitehead gastritis score. No significant changes were recorded in twenty four patients treated with placebo. After an additional course of CBS no further improvement in gastritis score was noted but there was a further reduction in Campylobacter colonisation. CBS did not greatly alter subjective complaints. Subjective complaints were improved in both treatment groups except for nausea and meteorism that improved more in the CBS treated patients. This finding again questions the clinical significance of gastritis and also casts doubt on the clinical relevance of therapeutical measures aimed at eradication of C pylori.

The association between non-ulcer dyspepsia and other gastrointestinal disorders

Non-ulcer dyspepsia (NUD) is defined as dyspepsia in which investigation shows no evidence of focal gastroduodenal disease or oesophagitis. The aim of the present study was to determine the proportion of NUD patients with other identifiable diseases. We interviewed 327 consecutive patients who had at least 1 month of dyspepsia before a panendoscopy that showed no evidence of oesophagitis, malignancy, or peptic ulcer. Symptoms were assessed by a structured history questionnaire. The existence of gallstones was excluded radiologically. Of the subjects studied, 75 (23%) had irritable bowel syndrome and 71 (22%) gastro-oesophageal reflux, whereas 63 (19%) had both, 25 (8%) had aerophagy, and 14 (4%) had gallstones. Of the remaining 79 patients (24%) 6 had duodenitis and 10 gastritis, whereas 1 had both. Sixty-two subjects (19%) had entirely normal endoscopic results and no ascertainable cause of their dyspepsia (termed provisionally essential dyspepsia). It is concluded that, whereas three-quarters of NUD patients have diseases that fall into other diagnostic categories, nearly one-quarter have essential dyspepsia.

Guidelines for the management of Helicobacter pylori infection in Italy: The III Working Group Consensus Report 2015

Knowledge on the role of Helicobacter pylori (HP) infection is continually evolving, and treatment is becoming more challenging due to increasing bacterial resistance. Since the management of HP infection is changing, an update of the national Italian guidelines delivered in 2007 was needed. In the III Working Group Consensus Report 2015, a panel of 17 experts from several Italian regions reviewed current evidence on different topics relating to HP infection. Four working groups examined the following topics: (1) "open questions" on HP diagnosis and treatment (focusing on dyspepsia, gastro-oesophageal reflux disease, non-steroidal anti-inflammatory drugs or aspirin use and extra-gastric diseases); (2) non-invasive and invasive diagnostic tests; (3) treatment of HP infection; (4) role of HP in the prevention of gastric cancer. Statements and recommendations were discussed and a consensus reached in a final plenary session held in February 2015 in Bologna. Recommendations are based on the best current evidence to help physicians manage HP infection in Italy. The guidelines have been endorsed by the Italian Society of Gastroenterology and the Italian Society of Digestive Endoscopy.

Crohn's disease of the stomach and duodenum

Clinical and radiological abnormalities in 12 patients with gastroduodenal involvement were encountered amongst 300 patients followed by one of us between 1944 and 1969. Symptoms of dyspepsia were relatively mild and obstructive symptoms when present were readily relieved by bypass surgery. The patients have been followed for a mean of 9.7 years (range 1-20); two have died of other causes but the remaining 10 are well.

Double blind, randomised, placebo controlled study of four weeks of lansoprazole for the treatment of functional dyspepsia in Chinese patients

BACKGROUND

The use of proton pump inhibitors for the treatment of functional dyspepsia is controversial and the role of Helicobacter pylori infection in functional dyspepsia is uncertain.

AIM

To evaluate the efficacy of different doses of lansoprazole for the treatment of functional dyspepsia in Chinese patients.

METHOD

Patients with a clinical diagnosis of functional dyspepsia according to the Rome II criteria and normal upper gastrointestinal endoscopy were recruited and randomised to receive: (1) lansoprazole 30 mg, (2) lansoprazole 15 mg, or (3) placebo, all given daily for four weeks. Dyspepsia symptom scores and quality of life (SF-36 score) were evaluated before and four weeks after treatment.

RESULTS

A total of 453 patients were randomised. There was no difference in the proportion of patients with complete symptom relief in the lansoprazole 30 mg (23%) and lansoprazole 15 mg (23%) groups compared with the placebo group (30%). The proportion of H pylori positive patients with a complete response was similar with lansoprazole 30 mg (34%) and lansoprazole 15 mg (20%) versus placebo (22%). All symptom subgroups (ulcer-like, dysmotility-like, reflux-like, and unspecified dyspepsia) had similar proportions of patients with complete symptom relief after treatment.

CONCLUSION

Proton pump inhibitor treatment is not superior to placebo for the management of functional dyspepsia in Chinese patients.

Abnormal sensitivity to duodenal lipid infusion in patients with functional dyspepsia

BACKGROUND AND OBJECTIVES

Patients with functional dyspepsia exhibit increased sensitivity to gastric distension (mechanoreceptors) and to meals rich in fat (chemoreceptors). The aim of this study was to test whether these patients were abnormally sensitive to intraduodenal lipid, and whether this stimulus altered gastric mechanosensitivity.

METHODS AND DESIGN

Experiments were conducted on 10 patients and 10 healthy controls. The stomach was distended with a flaccid bag during duodenal infusion of either 10% Intralipid or 0.9% saline. Intragastric pressure was recorded continuously, and the participants were asked to report gastric sensations of fullness and discomfort.

RESULTS

Intragastric pressure profiles during distension were similar in patients and controls. Lipid decreased intragastric pressure and reduced phasic contractility. Patients showed enhanced sensitivity to gastric distension compared with controls during both saline and lipid infusions. In the controls, threshold volumes for fullness and discomfort were higher during lipid than saline infusion. In the patients, the sensation of fullness occurred at lower volumes during lipid infusion, whereas discomfort occurred at similar volumes but lower intragastric pressures. Most patients experienced nausea and bloating and three patients vomited during lipid infusion, but remained asymptomatic during saline infusion. Controls reported no symptoms during either infusion.

CONCLUSION

Dyspeptic patients have increased sensitivity to both gastric distension and intraduodenal lipid. In contrast to controls, lipid sensitizes their stomachs to distension.

Helicobacter pylori infection and gastric neoplasia: correlations with histological gastritis and tumor histology

OBJECTIVE

Several authors have reported an association between Helicobacter pylori (H. pylori) and gastric carcinoma, but the data are conflicting. Atrophic gastritis and intestinal metaplasia (IM) have also been linked to gastric carcinoma, especially the intestinal tumor type. We investigated the relationship between H. pylori infection, gastric neoplasms, and histological gastritis.

METHODS

A total of 105 patients with gastric carcinoma, 36 patients with gastric adenoma, and 105 age- and sex-matched control subjects were examined for H. pylori infection and histological gastritis. H. pylori status was evaluated by Giemsa staining and IgG serology. Mucosal inflammation, atrophy, and IM were evaluated in biopsy specimens from antrum and corpus.

RESULTS

H. pylori seroprevalence was higher in patients with gastric carcinoma (98 of 105, 93%) and adenoma (34 of 36, 94%) than in control subjects (82 of 105, 71%, p < 0.05). H. pylori was more prevalent in patients with noncardia (OR, 5.67; 95% CI, 2.25-14.44) than cardia (OR, 5.20; 95% CI, 0.65-41.68) tumors. Histologic types and tumor stage (early; OR, 6.60; 95% CI, 2.23-19.69, advanced; OR, 4.27; 95% CI, 1.21-15.03) showed no difference in H. pylori prevalence. Atrophy and IM scores were higher in patients with the intestinal- but not diffuse-type of carcinoma and adenoma than in H. pylori-positive control subjects. Smoking was associated with gastric carcinoma (OR, 3.05; 95% CI, 1.58-5.93) but not alcohol or coffee use, blood group A, or a family history of gastric cancer.

CONCLUSIONS

Our results confirm a strong association between H. pylori and gastric carcinoma and adenoma. The intestinal-type gastric carcinoma is associated with atrophic gastritis and IM.

Comparative effects of levosulpiride and cisapride on gastric emptying and symptoms in patients with functional dyspepsia and gastroparesis

BACKGROUND

The efficacy of several prokinetic drugs on dyspeptic symptoms and on gastric emptying rates are well-established in patients with functional dyspepsia, but formal studies comparing different prokinetic drugs are lacking.

AIM

To compare the effects of chronic oral administration of cisapride and levosulpiride in patients with functional dyspepsia and delayed gastric emptying.

METHODS

In a double-blind crossover comparison, the effects of a 4-week administration of levosulpiride (25 mg t.d.s.) and cisapride (10 mg t.d.s.) on the gastric emptying rate and on symptoms were evaluated in 30 dyspeptic patients with functional gastroparesis. At the beginning of the study and after levosulpiride or cisapride treatment, the gastric emptying time of a standard meal was measured by 13C-octanoic acid breath test. Gastrointestinal symptom scores were also evaluated.

RESULTS

The efficacy of levosulpiride was similar to that of cisapride in significantly shortening (P < 0.001) the t1/2 of gastric emptying. No significant differences were observed between the two treatments with regards to improvements in total symptom scores. However, levosulpiride was significantly more effective (P < 0.01) than cisapride in improving the impact of symptoms on the patients' every-day activities and in improving individual symptoms such as nausea, vomiting and early postprandial satiety.

CONCLUSION

The efficacy of levosulpiride and cisapride in reducing gastric emptying times with no relevant side-effects is similar. The impact of symptoms on patients' everyday activities and the improvement of some symptoms such as nausea, vomiting and early satiety was more evident with levosulpiride than cisapride.

Endoscopic evaluation of patients with dyspepsia: results from the national endoscopic data repository

BACKGROUND & AIMS

Endoscopy is commonly performed to evaluate symptoms of dyspepsia. The aim of this study was to characterize patients who receive endoscopy for dyspepsia and measure predictors of primary endoscopic outcomes, utilizing a large national endoscopic database.

METHODS

The Clinical Outcomes Research Initiative (CORI) receives endoscopy reports from a network of 74 sites in the United States. Sixty-one percent of reports come from private practice settings. Patients with reflux dyspepsia and nonreflux dyspepsia were identified from January 2000 to June 2002. Patients with dysphagia and known Barrett's esophagus were excluded. Primary endoscopic outcomes included esophageal inflammation and stricture, gastric ulcer, duodenal ulcer, suspected Barrett's esophagus (> or =2 cm), and suspected esophageal and gastric malignancy. The presence or absence of alarm symptoms (vomiting, weight loss, and evidence of GI blood loss) was determined. Adjusted relative risk (RR) for predicting serious outcomes was calculated in a multivariate model.

RESULTS

We received 117,497 endoscopic reports, representing 99,558 unique patients. Dyspepsia, with and without reflux symptoms, accounted for 43% of upper endoscopies. Among dyspeptic patients, 36.5% were younger than 50 years of age without alarm symptoms. Esophageal or gastric malignancy in patients with dyspepsia was associated with increasing age, male sex, Asian race, Native American race, and symptoms of weight loss and vomiting. Suspected Barrett's esophagus (> or =2 cm) was associated with reflux symptoms, male sex, age, and white race. Ulcers were associated with evidence of bleeding, vomiting, male sex, black race, and Hispanic ethnicity.

CONCLUSIONS

These practice-based data reveal important practice behaviors and outcomes.

A Mixture of 3 Bifidobacteria Decreases Abdominal Pain and Improves the Quality of Life in Children With Irritable Bowel Syndrome: A Multicenter, Randomized, Double-Blind, Placebo-Controlled, Crossover Trial

GOALS

We assessed the efficacy of a probiotic mixture of Bifidobacterium infantis M-63, breve M-16V, and longum BB536 in improving abdominal pain (AP) and quality of life (QoL) in children with irritable bowel syndrome (IBS) and functional dyspepsia (FD).

BACKGROUND

AP-associated functional gastrointestinal disorders, particularly IBS and FD, are common in pediatrics, and no well-established treatment is currently available. Although probiotics have shown promising results in adults, data in children are heterogeneous.

STUDY

Forty-eight children with IBS (median age, 11.2 y; range, 8 to 17.9 y) and 25 with FD (age, 11.6 y; range, 8 to 16.6 y) were randomized to receive either a mixture of 3 Bifidobacteria or a placebo for 6 weeks. After a 2-week "washout" period, each patient was switched to the other group and followed up for further 6 weeks. At baseline and follow-up, patients completed a symptom diary and a QoL questionnaire. AP resolution represented the primary outcome parameter.

RESULTS

In IBS, but not in FD, Bifidobacteria determined a complete resolution of AP in a significantly higher proportion of children, when compared with placebo (P=0.006), and significantly improved AP frequency (P=0.02). The proportion of IBS children with an improvement in QoL was significantly higher after probiotics than after placebo (48% vs. 17%, P=0.001), but this finding was not confirmed in FD.

CONCLUSIONS

In children with IBS a mixture of Bifidobacterium infantis M-63, breve M-16V, and longum BB536 is associated with improvement in AP and QoL. These findings were not confirmed in FD subjects. Trial identifier: NCT02566876 (http://www.clinicaltrial.gov).

Eradicating Helicobacter pylori and symptoms of non-ulcer dyspepsia

OBJECTIVE

To examine the effect of eradication of Helicobacter pylori on symptoms of non-ulcer dyspepsia.

DESIGN

Four week prospective study.

SETTING

One hospital outpatient and endoscopy department.

PATIENTS

90 adults with persistent symptoms typical of non-ulcer dyspepsia but no clinical or endoscopic evidence of other peptic, biliary, pancreatic, or malignant disease; all had histological and microbiological evidence of infection with H pylori. 83 patients completed the treatment regimen.

INTERVENTION

Colloidal bismuth subcitrate 120 mg four times a day for four weeks (27 patients); metronidazole 400 mg and amoxycillin 500 mg each three times a day for one week (27); and bismuth subcitrate 120 mg four times a day for four weeks, metronidazole 400 mg three times a day for one week, plus amoxycillin 500 mg three times a day for the first week (29).

MAIN OUTCOME MEASURES

Change in symptom scores determined with questionnaire; histological evidence of gastritis and microbiological evidence of presence of H pylori in biopsy specimens.

RESULTS

Overall, H pylori was eradicated in 41 (49%) patients. Although gastritis scores improved significantly in only patients in whom H pylori had been eradicated (from 1.56 to 0.61, p less than 0.01 v from 1.83 to 1.07, p = 0.52) mean symptom scores after treatment were similar in patients in whom H pylori had or had not been eradicated (3.0 v 2.3, NS). Similarly the mean symptom score improved whether or not gastritis improved (2.8 v 3.1 respectively, p = 0.72). The observations were similar for treatment groups analysed individually.

CONCLUSION

Antral infection with the organism does not seem to have an important aetiological role in non-ulcer dyspepsia short term.