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Singh AD, Ellias S, Singh P, Ahuja V, Makharia GK. The Prevalence of the Celiac Disease in Patients with Dyspepsia: A Systematic Review and Meta-Analysis. Dig Dis Sci 2022; 67:3067-3079. [PMID: 34268659 DOI: 10.1007/s10620-021-07142-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 06/28/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Patients with celiac disease (CeD) can commonly present with symptoms of dyspepsia. We conducted a systematic review and meta-analysis of the present literature to assess the prevalence of CeD in patients diagnosed with dyspepsia. METHODS We searched MEDLINE and EMBASE databases for the keywords: celiac disease, coeliac disease, anti-gliadin, tissue transglutaminase antibody, anti-endomysial antibody, dyspepsia and functional gastrointestinal disorder. All the studies published from January 1991 till May 2021 were included. Diagnosis of CeD was based on the European Society of Pediatric Gastroenterology, Hepatology and Nutrition guidelines. A random-effects model was used to pool the data. RESULTS Twenty-one studies screening 10,275 patients with dyspepsia were included. The pooled seroprevalence of CeD based on a positive anti-tissue transglutaminase antibody and/or anti-endomysial antibody was 4.8% (95% CI [2.8, 6.7%], I2 = 87.7%). The pooled biopsy-confirmed CeD prevalence was 1.5% (95% CI [1.0, 1.9%]; I2 = 59.8%) in these patients. Both seroprevalence (Odds ratio: 1.8; 95% CI [0.8, 4.0%]; I2 = 0%) and prevalence of biopsy-confirmed CeD (Odds ratio: 1.4; 95% CI [0.8, 2.4]; I2 = 0%) were not higher in patients with dyspepsia compared to controls. There was a moderate risk of selection bias and significant heterogeneity in the pooled results. CONCLUSIONS The pooled prevalence of CeD in patients with dyspepsia was 1.5% and it was not significantly higher than the general population. These results do not support screening of patients with dyspepsia for CeD.
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Affiliation(s)
- Achintya D Singh
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH, 44195, USA.
| | - Samia Ellias
- Department of Gastrointestinal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Prashant Singh
- Department of Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - Vineet Ahuja
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Govind K Makharia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
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Seroreactivity against Helicobacter pylori VacA,50kDa and 30kDa along with alarm features may improve the diagnostic approach to uninvestigated dyspepsia: A pilot study. VOJNOSANIT PREGL 2022. [DOI: 10.2298/vsp200720134m] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background/Aim. Alarm features (AF) are of limited utility in predicting endoscopic findings, and the majority of patients with uninvestigated dyspepsia will have no organic pathology identified at upper gastrointestinal endoscopy. In our previous study, we highlighted seroreactivity against Helicobacter pylori (HP) antigens VacA, 50 kDa, and 30 kDa as biomarkers for gastric cancer, peptic ulcers, and functional dyspepsia. We designed and conducted this pi-lot study in order to compare the diagnostic utility of seroreactivity against HP VacA, 50 kDa, and 30 kDa with AF and investigate the possibility and adequacy of its synchronous application. Method. A careful history and physical examination with special attention to AF, esophagogastroduodenoscopy with biopsy, abdominal ultra-sound or computer tomography, complete blood count (CBC) and blood biochemistry, a Western Blot IgG against HP antigens VacA, 50 kDa, and 30 kDa, were per-formed in 123 patients with dyspepsia: 31 with gastric cancer, 31 with duodenal ulcer, 31 with gastric ulcer, and 30 with gastritis and functional dyspepsia. AF vs various combinations of seroreactivity against HP VacA, 50 kDa, and 30 kDa in patients with functional dyspepsia and others were analyzed in this study. Synchronous and alternative seroreactivity against VacA, 50 kDa, and 30 kDa, along with/without AF in patients with functional dyspepsia and other groups of patients were also analyzed. Results. VacA and 50 kDa seropositivity or AF had excellent case-findings clinical utility index for investigating dyspepsia. The absence of AF and seroreactivity against VacA either with: 50 kDa or 30 kDa seropositivity or 50 kDa and 30 kDa seropositivity had an excellent screening clinical utility index for investigating dyspepsia. Conclusion. Se-roreactivity against HP antigens VacA, 50 kDa, and 30 kDa might improve our approach to patients in investigating dyspepsia if used along with AF.
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Gastroesophageal Reflux Disease-Functional Dyspepsia Overlap: Do Birds of a Feather Flock Together? Am J Gastroenterol 2020; 115:1167-1182. [PMID: 32453043 DOI: 10.14309/ajg.0000000000000619] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Gastroesophageal reflux disease (GERD) and functional dyspepsia (FD) are 2 of the most prevalent upper gastrointestinal (GI) disorders in the Western world. Previous Rome definitions excluded patients with predominant heartburn from the definition of FD because they were considered to have GERD. However, more recent studies showed that heartburn and acid regurgitation are also common symptoms in patients with FD. The aim of this study is to provide an overview of the prevalence of overlap between GERD and FD, the underlying pathophysiology and implications for treatment. METHODS A review of the literature was performed using the PubMed database, and a meta-analysis with random effects model was completed. RESULTS This review showed considerable overlap between GERD and FD. A meta-analysis on the data included in this review showed 7.41% (confidence interval [CI]: 4.55%-11.84%) GERD/FD overlap in the general population, 41.15% (CI: 29.46%-53.93%) GERD with FD symptoms, and 31.32% (CI: 19.43%-46.29%) FD with GERD symptoms. Although numerous committees and consensus groups attempted to develop uniform definitions for the diagnosis of GERD and FD, various diagnostic criteria are used across studies and clinical trials (frequency, severity, and location of symptoms). Several studies showed that the overlap between GERD and FD can be explained by a shared pathophysiology, including delayed gastric emptying and disturbed gastric accommodation. DISCUSSION For diagnoses of GERD and FD, uniform definitions that are easy to implement in population studies, easy to interpret for physicians, and that need to be well explained to patients to avoid overestimation or underestimation of true prevalence are needed. Both GERD and FD coexist more frequently than expected, based on coincidence, suggesting a potential pathophysiological link. More research is needed to explore the common GERD/FD overlap population to identify the underlying pathophysiological mechanisms, which may lead to a more effective therapeutic approach.
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Clinical measurement of gastrointestinal motility and function: who, when and which test? Nat Rev Gastroenterol Hepatol 2018; 15:568-579. [PMID: 29872118 DOI: 10.1038/s41575-018-0030-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Symptoms related to abnormal gastrointestinal motility and function are common. Oropharyngeal and oesophageal dysphagia, heartburn, bloating, abdominal pain and alterations in bowel habits are among the most frequent reasons for seeking medical attention from internists or general practitioners and are also common reasons for referral to gastroenterologists and colorectal surgeons. However, the nonspecific nature of gastrointestinal symptoms, the absence of a definitive diagnosis on routine investigations (such as endoscopy, radiology or blood tests) and the lack of specific treatments make disease management challenging. Advances in technology have driven progress in the understanding of many of these conditions. This Review serves as an introduction to a series of Consensus Statements on the clinical measurements of gastrointestinal motility, function and sensitivity. A structured, evidence-based approach to the initial assessment and empirical treatment of patients presenting with gastrointestinal symptoms is discussed, followed by an outline of the contribution of modern physiological measurement on the management of patients in whom the cause of symptoms has not been identified with other tests. Discussions include the indications for and utility of high-resolution manometry, ambulatory pH-impedance monitoring, gastric emptying studies, breath tests and investigations of anorectal structure and function in day-to-day practice and clinical management.
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Association of Low Fecal Elastase-1 and Non-Ulcer Dyspepsia. J Clin Med 2018; 7:jcm7060155. [PMID: 29914168 PMCID: PMC6025585 DOI: 10.3390/jcm7060155] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Revised: 06/11/2018] [Accepted: 06/15/2018] [Indexed: 02/05/2023] Open
Abstract
Non-ulcer dyspepsia (NUD) is a term used to define a set of symptoms that are believed to originate from the gastroduodenal region, and no underlying organic, systemic, or metabolic reason can be found. The majority of patients suffer from chronic symptoms although half of the patients report improvement in symptoms with time. The potential role exocrine pancreatic insufficiency in NUD patients has not been clarified yet. We aimed to identify exocrine pancreas function with pancreatic fecal elastase-1 in patients diagnosed with non-ulcer dyspepsia and no typical exocrine pancreatic insufficiency (EPI) symptoms. Thirty-five patients referred to gastroenterology clinics with NUD and 35 people with no dyspeptic symptoms as a control group were included in this prospective study. Non-ulcer dyspepsia patients were classified as group 1 and control subjects classified as group 2. Upper gastrointestinal endoscopies were performed in both groups. Assessment of exocrine pancreatic function was performed by measuring fecal elastase-1 concentration with a commercial ELISA kit using polyclonal antibodies (BioServ Diagnostics) in NUD patients compared to control subjects. Mean fecal elastase-1 levels were significantly lower in group 1 patients compared with group 2 (367.47 ± 43.27; 502.48 ± 50.94 respectively; p = 0.04). The percentage of the patients with EPI was significantly higher in group 1 (p = 0.02). Patients with NUD should be re-evaluated if they do not show satisfactory improvement with treatment. Exocrine pancreatic insufficiency was significantly higher in patients with NUD in our study. Evaluation for the presence of EPI can be a cost effective approach in management of refractory patients during the process of ruling out organic reasons.
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Petrarca L, Nenna R, Mastrogiorgio G, Florio M, Brighi M, Pontone S. Dyspepsia and celiac disease: Prevalence, diagnostic tools and therapy. World J Methodol 2014; 4:189-196. [PMID: 25332916 PMCID: PMC4202456 DOI: 10.5662/wjm.v4.i3.189] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Revised: 06/17/2014] [Accepted: 09/10/2014] [Indexed: 02/06/2023] Open
Abstract
The prevalence of dyspepsia is up to 40% in population-based study. Functional dyspepsia is an exclusion diagnosis and it is classified as a chronic abdominal pain-related functional disorder, characterized by the presence of persistent or recurrent pain or discomfort centered in the upper abdomen, neither relief by defecation, nor association with the onset of a change in stool frequency or form. Celiac disease (CD) is a common autoimmune enteropathy, with a prevalence around 1% in the general population. Its diagnosis includes a serological screening and an upper gastrointestinal endoscopy with multiple biopsies. Gluten-free diet is the only effective treatment. CD diagnosis is often delayed in asymptomatic patients or in individuals with less clinical gastrointestinal symptoms. Several studies performed coeliac disease screening in patients with symptoms suggestive of dyspepsia, showing a biopsy-proved prevalence that ranged from 0.5% to 2%. The typical endoscopic markers of villous atrophy are not sufficiently sensitive, so some endoscopic techniques, such as “water immersion” and confocal endomicroscopy were proposed to improve the diagnostic sensitivity and target biopsies. A recent meta-analysis estimated that the prevalence of CD was higher in patients with dyspepsia, but not in a statistically significant way. However this assumption should be confirmed further larger studies.
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Siao D, Somsouk M. Helicobacter pylori: evidence-based review with a focus on immigrant populations. J Gen Intern Med 2014; 29:520-8. [PMID: 24065381 PMCID: PMC3930769 DOI: 10.1007/s11606-013-2630-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2013] [Revised: 07/26/2013] [Accepted: 09/09/2013] [Indexed: 12/24/2022]
Abstract
Helicobacter pylori has been causally linked to a number of diseases, including peptic ulcer disease, gastric adenocarcinoma, mucosa-associated lymphoid tissue lymphoma, and dyspepsia. It is the most prevalent bacterial pathogen in humans, and while the overall prevalence in the United States is about 30 %, the distribution is heterogeneous amongst different ethnic groups. Recent immigrants from high prevalence areas such as Korea, Japan, and China bear an increased burden of its disease and complications. There is clear evidence that treatment of H. pylori resolves peptic ulcer disease, and increasing evidence for protection against development of gastric adenocarcinoma. However, H. pylori treatment failure is common and alternative regimens may be necessary. The following case-based review will highlight these issues, including the epidemiology of H. pylori in the immigrant population, an approach to dyspepsia, and the role of H. pylori in gastric adenocarcinoma.
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Affiliation(s)
- Derrick Siao
- Department of Medicine, Division of Gastroenterology, University of California San Francisco, 513 Parnassus Ave., Rm-357, San Francisco, CA, 94143, USA,
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Levy O, Iyer S, Atoun E, Peter N, Hous N, Cash D, Musa F, Narvani AA. Propionibacterium acnes: an underestimated etiology in the pathogenesis of osteoarthritis? J Shoulder Elbow Surg 2013; 22:505-11. [PMID: 22981447 DOI: 10.1016/j.jse.2012.07.007] [Citation(s) in RCA: 146] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2012] [Revised: 07/08/2012] [Accepted: 07/16/2012] [Indexed: 02/01/2023]
Abstract
BACKGROUND Propionibacterium acnes is a common pathogen in infections after shoulder surgery. Recent reports found positive P acnes cultures in a high percentage of patients who had revision shoulder arthroplasty for "aseptic loosening" without any overt signs of infection. Isolation of P acnes is difficult, and by use of conventional microbiological protocols of 48-hour incubation, a considerable proportion of patients with possible P acnes infection may remain unidentified. We recently noted P acnes in shoulder joint cultures in patients undergoing primary shoulder replacement for glenohumeral arthropathy without any signs of infection. METHODS We collected aspirates and biopsy specimens from 55 consecutive patients with arthritic shoulders undergoing primary joint replacement and examined them for the presence of P acnes. Special measures were taken to ensure that the specimens were carefully taken from within the joint to reduce the risk of contamination to minimal. RESULTS In 23 of 55 consecutive patients (41.8%) undergoing primary shoulder joint replacement, P acnes was found in the joint fluid and tissues taken before the insertion of the implants. All these patients were treated early postoperatively with pathogen-directed specific dual oral antibiotic treatment for 4 weeks. In none have any signs of infection developed. DISCUSSION AND CONCLUSION This finding of a high incidence of P acnes in joints before arthroplasty may suggest a role of P acnes in the pathogenesis of glenohumeral arthropathy. In addition, it raises the question of whether development of painful joint replacement later on and presumed aseptic loosening do, in fact, comprise an unrecognized low-grade infection that has been present since before the index operation.
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Affiliation(s)
- Ofer Levy
- Reading Shoulder Unit, Royal Berkshire Hospital, Reading, England.
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Khademi H, Radmard AR, Malekzadeh F, Kamangar F, Nasseri-Moghaddam S, Johansson M, Byrnes G, Brennan P, Malekzadeh R. Diagnostic accuracy of age and alarm symptoms for upper GI malignancy in patients with dyspepsia in a GI clinic: a 7-year cross-sectional study. PLoS One 2012; 7:e39173. [PMID: 22720064 PMCID: PMC3374763 DOI: 10.1371/journal.pone.0039173] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Accepted: 05/16/2012] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES We investigated whether using demographic characteristics and alarm symptoms can accurately predict cancer in patients with dyspepsia in Iran, where upper GI cancers and H. pylori infection are common. METHODS All consecutive patients referred to a tertiary gastroenterology clinic in Tehran, Iran, from 2002 to 2009 were invited to participate in this study. Each patient completed a standard questionnaire and underwent upper gastrointestinal endoscopy. Alarm symptoms included in the questionnaire were weight loss, dysphagia, GI bleeding, and persistent vomiting. We used logistic regression models to estimate the diagnostic value of each variable in combination with other ones, and to develop a risk-prediction model. RESULTS A total of 2,847 patients with dyspepsia participated in this study, of whom 87 (3.1%) had upper GI malignancy. Patients reporting at least one of the alarm symptoms constituted 66.7% of cancer patients compared to 38.9% in patients without cancer (p<0.001). Esophageal or gastric cancers in patients with dyspepsia was associated with older age, being male, and symptoms of weight loss and vomiting. Each single predictor had low sensitivity and specificity. Using a combination of age, alarm symptoms, and smoking, we built a risk-prediction model that distinguished between high-risk and low-risk individuals with an area under the ROC curve of 0.85 and acceptable calibration. CONCLUSIONS None of the predictors demonstrated high diagnostic accuracy. While our risk-prediction model had reasonable accuracy, some cancer cases would have remained undiagnosed. Therefore, where available, low cost endoscopy may be preferable for dyspeptic older patient or those with history of weight loss.
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Affiliation(s)
- Hooman Khademi
- Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
- International Agency for Research on Cancer, Lyon, France
| | - Amir-Reza Radmard
- Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Malekzadeh
- Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Farin Kamangar
- Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
- Department of Public Health Analysis, School of Community Health and Policy, Morgan State University, Baltimore, Maryland, United States of America
| | - Siavosh Nasseri-Moghaddam
- Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Graham Byrnes
- International Agency for Research on Cancer, Lyon, France
| | - Paul Brennan
- International Agency for Research on Cancer, Lyon, France
| | - Reza Malekzadeh
- Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Pajala M, Heikkinen M, Hintikka J. Association between mental distress, gastrointestinal symptoms, and health-care utilization in functional dyspepsia: a prospective 7-year follow-up study. Scand J Gastroenterol 2012; 47:407-13. [PMID: 22229887 DOI: 10.3109/00365521.2011.650193] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The association between psychosocial factors and gastrointestinal symptoms is unclear. It has been proposed that they simply drive health-care seeking of patients. We therefore aimed to study whether mental distress would increase health-care utilization in functional dyspepsia (FD). METHODS 171 primary care FD patients completed questionnaires screening gastrointestinal symptoms, mental distress, and health-care utilization between 1993 and 2000. These included the Bowel Disease Questionnaire and 12-item General Health Questionnaire. The patients' medical records were reviewed in primary care centers, Kuopio University Hospital, local hospitals, and private clinics. RESULTS The majority of patients revisited their general practitioner (GP), and most of them were prescribed antisecretory medication. Repeated gastroscopy and lower gastrointestinal endoscopy were performed in 26% of the patients. A radiological reinvestigation, usually upper abdominal ultrasound, was performed in one-third. Nine percent were hospitalized due to gastrointestinal reasons. A single additional bowel symptom increased the probability of repeated endoscopy by 19%, a visit to the GP by 19%, and an inpatient period by 51%. Neither an increase in the dyspepsia score nor the presence of mental distress or suspicion of serious illness increased the probability of health-care utilization. CONCLUSION There is no association between mental distress and health-care utilization for gastrointestinal symptoms.
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Affiliation(s)
- Markku Pajala
- Department of Internal Medicine, Kuopio University Hospital, Kuopio, Finland.
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Manabe N, Haruma K, Kamada T, Kusunoki H, Inoue K, Murao T, Imamura H, Matsumoto H, Tarumi KI, Shiotani A, Hata J. Changes of upper gastrointestinal symptoms and endoscopic findings in Japan over 25 years. Intern Med 2011; 50:1357-1363. [PMID: 21720053 DOI: 10.2169/internalmedicine.50.4731] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND AND AIMS In Japan, the prevalence of Helicobacter pylori infection has decreased recently, but there has been little longitudinal research on the changes of symptoms and endoscopic findings over many years. The aim of this study was to evaluate the changes in endoscopic findings and symptoms over time in patients undergoing upper gastrointestinal endoscopy for assessment of upper abdominal symptoms. METHODS Over a period of 25 years, between 1981 and 2005, we performed three investigations (1981-2, 1990-1 and 2004-5) on the symptoms and endoscopic findings of patients undergoing endoscopy at Kawasaki Medical School Hospital for the assessment of upper abdominal symptoms. RESULTS The most common complaint for all ages was "discomfort and/or pain". Over time, the percentage of patients complaining of "heartburn" increased almost 5-fold. With respect to endoscopic findings, the prevalence of peptic ulcers decreased, whereas the detection of no abnormalities and the detection of erosive esophagitis increased. CONCLUSION In the future in Japan, there will be fewer patients with peptic ulcers and more patients with gastro-esophageal reflux disease or dyspeptic patients who display no endoscopic abnormal findings.
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Affiliation(s)
- Noriaki Manabe
- Division of Endoscopy and Ultrasonography, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School, Japan.
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Tosetti C, Bellentani S, Benedetto E, Ubaldi E, Cardin F, Bozzani A. The management of patients with new onset of upper gastro-intestinal symptoms in primary care. Dig Liver Dis 2010; 42:860-864. [PMID: 20558116 DOI: 10.1016/j.dld.2010.05.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2009] [Revised: 04/14/2010] [Accepted: 05/06/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND Data dealing with dyspepsia management in general practice are lacking, and most of the studies investigated a subset of patients with suspected peptic ulcer disease either with or without previous complaints. AIMS To evaluate the one-year management of patients presenting new onset upper abdominal symptoms without alarming features. METHODS 275 patients were enrolled by 63 Italian general practitioners. RESULTS Referral to upper gastro-intestinal tract endoscopy resulted significantly higher in patients with predominant epigastric pain compared to subjects with non-painful symptoms or non-dominant symptoms. Amongst drug therapies, only prokinetics and antacids and anti-secretory therapies were prescribed differently amongst clinical subgroups. The rate and type of management and referrals resulted were not influenced by the age of patients or the use of anti-inflammatory drugs. The most frequent diagnosis at one-year follow-up was reflux oesophagitis. The absence of organic disease was less frequent in patients with dominant epigastric pain than non-painful or non-dominant symptoms. CONCLUSION The management of these patients in primary care in Italy is mainly determined by clinical presentation, independent of age. Any judgement about appropriateness of the treatment should consider not only conventional features such as age, but the more complex individual frameworks as well.
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Affiliation(s)
- Cesare Tosetti
- Primary Care Gastroenterology Study Group of the Italian Society of Gastroenterology (SIGE), Italy.
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Abstract
Dyspepsia is a common clinical problem seen by both primary care physicians and gastroenterologists. Initial evaluation should focus on the identification and treatment of potential causes of symptoms such as gastroesophageal reflux disease (GERD), peptic ulcer disease, and medication side effects but also on recognizing those at risk for more serious conditions such as gastric cancer. This manuscript discusses the evaluation and management of dyspepsia including the role of proton-pump inhibitors, treatment of Helicobacter pylori, and endoscopy. Finally, treatment of refractory functional dyspepsia is addressed.
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Vakil N, Talley N, van Zanten SV, Flook N, Persson T, Björck E, Lind T, Bolling-Sternevald E. Cost of detecting malignant lesions by endoscopy in 2741 primary care dyspeptic patients without alarm symptoms. Clin Gastroenterol Hepatol 2009; 7:756-61. [PMID: 19364542 DOI: 10.1016/j.cgh.2009.03.031] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2009] [Revised: 03/26/2009] [Accepted: 03/28/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Current guidelines recommend empirical, noninvasive approaches to manage dyspeptic patients without alarm symptoms, but concerns about missed lesions persist; the cost savings afforded by noninvasive approaches must be weighed against treatment delays. We investigated the prevalence of malignancies and other serious abnormalities in patients with dyspepsia and the cost of detecting these by endoscopy. METHODS We studied 2741 primary-care outpatients, 18-70 years in age, who met Rome II criteria for dyspepsia. Patients with alarm features (dysphagia, bleeding, weight loss, etc) were excluded. All patients underwent endoscopy. The cost and diagnostic yield of an early endoscopy strategy in all patients were compared with those of endoscopy limited to age-defined cohorts. Costs were calculated for a low, intermediate, and high cost environment. RESULTS Endoscopies detected abnormalities in 635 patients (23%). The most common findings were reflux esophagitis with erosions (15%), gastric ulcers (2.7%), and duodenal ulcers (2.3%). The prevalence of upper gastrointestinal malignancy was 0.22%. If all dyspeptic patients 50 years or older underwent endoscopy, 1 esophageal cancer and no gastric cancers would have been missed. If the age threshold for endoscopy were set at 50 years, at a cost of $500/endoscopy, it would cost $82,900 (95% CI, $35,714-$250,000) to detect each case of cancer. CONCLUSIONS Primary care dyspeptic patients without alarm symptoms rarely have serious underlying conditions at endoscopy. The costs associated with diagnosing an occult malignancy are large, but an age cut-off of 50 years for early endoscopy provides the best assurance that an occult malignancy will not be missed.
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Affiliation(s)
- Nimish Vakil
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin 53233, USA.
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Ford AC, Ching E, Moayyedi P. Meta-analysis: yield of diagnostic tests for coeliac disease in dyspepsia. Aliment Pharmacol Ther 2009; 30:28-36. [PMID: 19416130 DOI: 10.1111/j.1365-2036.2009.04008.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The prevalence of coeliac disease (CD) may be increased in individuals with dyspepsia, but evidence is conflicting. AIMS To conduct a systematic review and meta-analysis of studies reporting prevalence of CD in dyspepsia. METHODS MEDLINE, EMBASE, and CINAHL were searched up to February 2009. Case series and case-control studies applying serological tests and/or distal duodenal biopsy for CD to unselected adults with dyspepsia were eligible. Prevalence of positive coeliac serology and biopsy-proven CD were pooled for all studies and compared between cases and controls using an odds ratio (OR) and 95% confidence interval (CI). RESULTS Fifteen studies were identified. Prevalence of positive coeliac serology was higher in cases with dyspepsia (7.9%) compared with controls (3.9%), but not significantly so (OR for positive endomysial antibodies or tissue transglutaminase 1.89; 95% CI 0.90-3.99). Prevalence of biopsy-proven CD following positive serology was also higher (3.2% in cases vs. 1.3% in controls), but again this was not statistically significant (OR 2.85; 95% CI 0.60-13.38). Prevalence of biopsy-proven CD was 1% in ten studies performing duodenal biopsy first-line. CONCLUSION Prevalence of biopsy-proven CD in subjects with dyspepsia was 1% and was higher than in controls, although this difference was not statistically significant.
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Affiliation(s)
- A C Ford
- Gastroenterology Division, McMaster University, Health Sciences Centre, Hamilton, ON, Canada.
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Daher R, Yazbeck T, Jaoude JB, Abboud B. Consequences of dysthyroidism on the digestive tract and viscera. World J Gastroenterol 2009; 15:2834-2838. [PMID: 19533804 PMCID: PMC2699000 DOI: 10.3748/wjg.15.2834] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2009] [Revised: 04/07/2009] [Accepted: 04/14/2009] [Indexed: 02/06/2023] Open
Abstract
Thyroid hormones define basal metabolism throughout the body, particularly in the intestine and viscera. Gastrointestinal manifestations of dysthyroidism are numerous and involve all portions of the tract. Thyroid hormone action on motility has been widely studied, but more complex pathophysiologic mechanisms have been indicated by some studies although these are not fully understood. Both thyroid hormone excess and deficiency can have similar digestive manifestations, such as diarrhea, although the mechanism is different in each situation. The liver is the most affected organ in both hypo- and hyperthyroidism. Specific digestive diseases may be associated with autoimmune thyroid processes, such as Hashimoto's thyroiditis and Grave's disease. Among them, celiac sprue and primary biliary cirrhosis are the most frequent although a clear common mechanism has never been proven. Overall, thyroid-related digestive manifestations were described decades ago but studies are still needed in order to confirm old concepts or elucidate undiscovered mechanisms. All practitioners must be aware of digestive symptoms due to dysthyroidism in order to avoid misdiagnosis of rare but potentially lethal situations.
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Role of Quantitative Cholescintigraphy for Planning Laparoscopic Cholecystectomy in Patients With Gallbladder Dyskinesia and Chronic Abdominal Pain. Surg Laparosc Endosc Percutan Tech 2009; 19:16-9. [DOI: 10.1097/sle.0b013e31818eb2e5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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18
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Assimakopoulos SF, Thomopoulos KC, Louvros E, Theocharis G, Giannikoulis C, Katsakoulis E, Nikolopoulou VN. Changes in indications for upper gastrointestinal tract endoscopy and endoscopic findings during the last fifteen years in south-western Greece. Am J Med Sci 2008; 336:21-26. [PMID: 18626231 DOI: 10.1097/maj.0b013e31815adeea] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND During the past years, major advances in the management of upper gastrointestinal diseases have been achieved. The aim of this study was to determine if changes in indications for upper gastrointestinal endoscopy and endoscopic findings have occurred during the last 15 years in our area. METHODS Indications for upper gastrointestinal tract endoscopy and endoscopy findings of patients who underwent upper endoscopy in years 1990, 1995, 2000, and 2005 in our department were compared. RESULTS Over the 15-year period, the number of diagnostic endoscopies performed in our department in years 1990, 1995, 2000, and 2005 increased (953, 1245, 2350, and 2528, respectively). Acute upper gastrointestinal bleeding had become less frequent (40%, 42.8%, 19.7%, 14.3%, P<0.001), but dyspepsia (24.4%, 33.6%, 54.3%, 51.3%, P=0.002) and reflux (1.8%, 1.3%, 5.1%, 10.8%, P=0.005) more frequent indications for upper endoscopy. The endoscopic findings of duodenal ulcer (39.1%, 22.5%, 20.5%, 9.3%, P<0.001), gastric ulcer (15.9%, 8.3%, 5.7%, 4.6%, P=0.036) as well as erosive gastroduodenitis (35.6%, 22.2%, 15.3%, 4.7%, P<0.001) decreased, whereas that of reflux esophagitis (3.1%, 10.1%, 12%, 16%, P=0.034) increased. Moreover, the percentage of patients with negative endoscopy or minimal endoscopic findings (eg, nonerosive gastritis) increased (12.8%, 33.7%, 54.1%, 64.4%, P<0.001). CONCLUSIONS In south-western Greece, dyspepsia and reflux as an indication for upper endoscopy have been increasing, whereas acute upper gastrointestinal bleeding has been decreasing. The finding of peptic ulcers at the upper gastrointestinal tract endoscopy has become significantly less frequent, while the percentage of patients with negative results of endoscopy seems to have been increasing rapidly.
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Punkkinen J, Färkkilä M, Mätzke S, Korppi-Tommola T, Sane T, Piirilä P, Koskenpato J. Upper abdominal symptoms in patients with Type 1 diabetes: unrelated to impairment in gastric emptying caused by autonomic neuropathy. Diabet Med 2008; 25:570-7. [PMID: 18445170 DOI: 10.1111/j.1464-5491.2008.02428.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
AIMS Diabetic gastroparesis is a common condition occurring in some 30-50% of patients with long-term diabetes. Some studies have found a relationship between autonomic neuropathy and diabetic gastroparesis. In addition to autonomic neuropathy, acute changes in plasma glucose concentration can also affect gastric emptying. The objective was to examine the relationship between autonomic nerve function, glucose concentration, gastric emptying, and upper abdominal symptoms in Type 1 diabetic patients. METHODS Gastric emptying of solids and liquids was measured with scintigraphy in 27 patients with longstanding Type 1 diabetes with upper abdominal symptoms. Autonomic nerve function was examined by standardized cardiovascular tests, and plasma glucose concentrations were measured during scintigraphy. Severity of abdominal symptoms and quality of life were explored by validated questionnaires. RESULTS Seven patients (26%) had delayed gastric emptying of solids and three (11%) of liquids. Mean gastric half-emptying time of solids was 128 +/- 116 min and of liquids 42 +/- 30 min. Of the 26 patients undergoing tests, 16 (62%) had autonomic nerve dysfunction. Autonomic neuropathy score (1.6 +/- 1.7) correlated positively with the gastric emptying rate of solids (P = 0.006), a rate unrelated to symptom scores or plasma glucose concentrations during scintigraphy. Quality of life in patients with abdominal symptoms was lower than in the normal Finnish population. CONCLUSIONS Impaired gastric emptying of solids in patients with Type 1 diabetes is related to autonomic neuropathy, but not to actual glycaemic control. The upper abdominal symptoms observed in these patients cannot be explained, however, by impaired gastric emptying.
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Affiliation(s)
- J Punkkinen
- Department of Gastroenterology, Helsinki University Central Hospital, Helsinki, Finland.
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20
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Koskenpato J, Punkkinen JM, Kairemo K, Färkkilä M. Nizatidine and gastric emptying in functional dyspepsia. Dig Dis Sci 2008; 53:352-7. [PMID: 17682943 DOI: 10.1007/s10620-007-9898-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2006] [Accepted: 06/04/2007] [Indexed: 12/09/2022]
Abstract
In clinical practice, H2-receptor antagonists, including nizatidine, in addition to their use in the treatment of peptic ulcer and gastroesophageal reflux, are also useful in alleviating dyspeptic symptoms. Patients with functional dyspepsia show a tendency to delayed gastric emptying. Results of preliminary studies have demonstrated that nizatidine has a prokinetic effect due to its cholinergic properties. The aim of this study was to evaluate the effect of nizatidine on gastric emptying in patients with functional dyspepsia. Sixteen patients with dyspeptic symptoms referred for gastroscopy by primary care physicians were enrolled in this randomized, placebo-controlled, double-blind cross-over study. They received nizatidine 150 mg twice daily or placebo for 2 months. After a 1-month washout period, the 2-month treatment was repeated, with these patients acting as their own controls. Gastric emptying was measured by scintigraphy, and dyspeptic symptoms and quality of life were evaluated at the end of both treatment periods. Gastric emptying of solids during nizatidine therapy was prolonged (T1/2 110.1 +/- 76.7 vs. 65.6 +/- 23.2 min, P = 0.03), but nizatidine had no effect on gastric emptying of liquids. Nizatidine improved the symptom scores and seven of eight aspects of quality of life - but not significantly. In conclusion, nizatidine decreases the gastric emptying rate of solids without having a significant effect on symptoms or quality of life in functional dyspepsia.
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Affiliation(s)
- Jari Koskenpato
- Department of Gastroenterology, Helsinki University Central Hospital, Helsinki, Finland
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21
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Flier SN, Rose S. Is functional dyspepsia of particular concern in women? A review of gender differences in epidemiology, pathophysiologic mechanisms, clinical presentation, and management. Am J Gastroenterol 2006; 101:S644-53. [PMID: 17177870 DOI: 10.1111/j.1572-0241.2006.01015.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Dyspepsia is a remarkably common symptom in the general population. Although multiple definitions have been used to describe the symptom, the most common explanation is that of chronic or recurrent pain or discomfort (a subjective negative feeling that may be associated with early satiety, fullness, bloating, or nausea) centered in the upper abdomen. When a thorough evaluation of a dyspeptic patient fails to identify a cause for her symptoms, the label of nonulcer or functional dyspepsia is applied. Functional dyspepsia is a heterogeneous disorder characterized by relapsing and remitting symptoms. Treatment strategies should focus on alleviating the most bothersome symptom and can be based on the proposed underlying pathophysiology. The effect of gender on mechanisms of disease, symptom presentation, and treatment response is an area of increasing interest and study. As with other functional gastrointestinal disorders, there appear to be some gender-specific features of functional dyspepsia. Specifically, gender-related differences have been observed in some studies of both the prevalence of individual dyspepsia symptoms, and in gastric emptying and proximal gastric motor function. There also appear to be gender differences in the psychosocial realm, with dyspeptic women experiencing a lesser sense of well-being than dyspeptic men, as well as an association of an abuse history with functional dyspepsia. This review will highlight specific gender differences related to the symptom presentation, pathophysiology, and approach to treatment of functional dyspepsia, while noting where differences have not been found and where further investigation is warranted.
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Affiliation(s)
- Sarah N Flier
- Department of Medicine, Division of Gastroenterology, Mount Sinai School of Medicine, New York, New York 10029, USA
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Pajala M, Heikkinen M, Hintikka J. A prospective 1-year follow-up study in patients with functional or organic dyspepsia: changes in gastrointestinal symptoms, mental distress and fear of serious illness. Aliment Pharmacol Ther 2006; 24:1241-6. [PMID: 17014583 DOI: 10.1111/j.1365-2036.2006.03108.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Psychosocial factors are common among patients with functional gastrointestinal disorders (FGIDs). Whether they affect the course of the disease remains unresolved. AIM To evaluate whether reassuring investigations of primary care patients with functional dyspepsia (FD) and organic dyspepsia (OD) influence gastrointestinal (GI) symptoms and psychological factors, and to assess whether these changes are correlated. METHODS Four hundred consecutive patients with dyspepsia were referred for thorough examinations. Patients completed questionnaires screening symptoms at baseline and on 1-year follow-up. RESULTS At baseline, there was no difference in GI symptoms, prevalence of mental distress or fear of serious illness between patients with FD or OD. On follow-up, the patients with FD had more GI symptoms, but there was no difference in mental distress or fear of serious illness. Relevant GI symptom reduction related to alleviation of mental distress (53.4% vs. 20.5%, P < 0.001) and fear of serious illness (56.5% vs. 23.7%, P = 0.002), but reached statistical significance only in patients with OD. CONCLUSIONS Gastrointestinal symptoms in FD patients are long lasting compared with those with organic diseases. Reassuring investigations could lower mental distress and fear of serious illness in these patients. Psychological factor change correlates with the change in GI symptom severity and is not specific to FGIDs.
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Affiliation(s)
- M Pajala
- Department of Internal Medicine, Kuopio University Hospital, PO Box 1777, FI-70211 Kuopio, Finland.
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Jarbol DE, Bech M, Kragstrup J, Havelund T, Schaffalitzky de Muckadell OB. Economic evaluation of empirical antisecretory therapy versus Helicobacter pylori test for management of dyspepsia: a randomized trial in primary care. Int J Technol Assess Health Care 2006; 22:362-71. [PMID: 16984065 DOI: 10.1017/s0266462306051269] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES An economic evaluation was performed of empirical antisecretory therapy versus test for Helicobacter pylori in the management of dyspepsia patients presenting in primary care. METHODS A randomized trial in 106 general practices in the County of Funen, Denmark, was designed to include prospective collection of clinical outcome measures and resource utilization data. Dyspepsia patients (n = 722) presenting in general practice with more than 2 weeks of epigastric pain or discomfort were managed according to one of three initial management strategies: (i) empirical antisecretory therapy, (ii) testing for Helicobacter pylori, or (iii) empirical antisecretory therapy, followed by Helicobacter pylori testing if symptoms improved. Cost-effectiveness and incremental cost-effectiveness ratios of the strategies were determined. RESULTS The mean proportion of days without dyspeptic symptoms during the 1-year follow-up was 0.59 in the group treated with empirical antisecretory therapy, 0.57 in the H. pylori test-and-eradicate group, and 0.53 in the combination group. After 1 year, 23 percent, 26 percent, and 22 percent, respectively, were symptom-free. Applying the proportion of days without dyspeptic symptoms, the cost-effectiveness for empirical treatment, H. pylori test and the combination were 12,131 Danish kroner (DKK), 9,576 DKK, and 7,301 DKK, respectively. The incremental cost-effectiveness going from the combination strategy to empirical antisecretory treatment or H. pylori test alone was 54,783 DKK and 39,700 DKK per additional proportion of days without dyspeptic symptoms. CONCLUSIONS Empirical antisecretory therapy confers a small insignificant benefit but costs more than strategies based on test for H. pylori and is probably not a cost-effective strategy for the management of dyspepsia in primary care.
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Affiliation(s)
- Dorte Ejg Jarbol
- The Research Unit for General Practice, University of Southern Denmark, Odense.
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Ahlawat SK, Cuddihy MT, Locke GR. Gender-related differences in dyspepsia: a qualitative systematic review. ACTA ACUST UNITED AC 2006; 3:31-42. [PMID: 16638599 DOI: 10.1016/s1550-8579(06)80192-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2005] [Indexed: 02/07/2023]
Abstract
BACKGROUND Relative to men, women are diagnosed more frequently with functional gastrointestinal (GI) disorders. With increased awareness of basic gender differences in perception and treatment of visceral pain, there has been new interest in research on gender disparity in the care of people with functional GI disorders. Past attention has focused on irritable bowel syndrome, whereas gender differences in other disorders are less well described. OBJECTIVE Our aim was to systematically review studies that have examined gender-related differences among patients with dyspepsia. METHODS MEDLINE, HealthSTAR, and PsycINFO databases were searched for English-language articles on dyspepsia published between 1966 and August 2001. Epidemiologic studies, clinical trials, review articles, and conceptual articles from peer-reviewed journals were included for review. Findings were summarized and discussed within a framework of biological and psychosocial factors. Statistical analysis of combined data was inappropriate because of the inconsistent definition of dyspepsia among different studies and wide variation in the types of articles reviewed. RESULTS Studies that examine gender-related differences in patients with dyspepsia have focused their investigations on the clinical epidemiology and pathophysiology of dyspepsia. In most epidemiologic studies, no gender analysis was performed beyond a description of sample demographics, and when statistical significance was tested, few consistent gender differences were found. Overall, it appears that men and women with dyspepsia possibly differ with respect to pattern of symptoms, pain perception or modulation, and antinociceptive mechanisms, but these observations have not been confirmed. No study evaluated the clinical implications of these possible differences. CONCLUSIONS Future efforts should be directed to not only examine gender-related differences in the clinical epidemiology of dyspepsia, but also understand their clinical significance. Therefore, well-designed population-based studies using a consistent definition of dyspepsia are needed to investigate the prevalence of dyspepsia symptoms and patterns of dyspepsia management among men and women.
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Affiliation(s)
- Sushil K Ahlawat
- Division of Gastroenterology, Department of Medicine, Georgetown University Hospital, Washington, DC 20007, USA.
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Abstract
Functional dyspepsia represents a heterogeneous group of gastrointestinal disorders marked by the presence of upper abdominal pain or discomfort. Although its precise definition has evolved over the last several decades, this disorder remains shrouded in controversy. The symptoms of functional dyspepsia may overlap with those of other functional bowel disorders including irritable bowel syndrome and non-erosive reflux disease. There may be coexistent psychological distress or disease complicating its presentation and response to therapy. Given the prevalence and chronicity of functional dyspepsia, it remains a great burden to society. Suspected physiological mechanisms underlying functional dyspepsia include altered motility, altered visceral sensation, inflammation, nervous system dysregulation and psychological distress. Yet the exact pathophysiological mechanisms that cause symptoms in an individual patient remain difficult to delineate. Numerous treatment modalities have been employed including dietary modifications, pharmacological agents directed at various targets within the gastrointestinal tract and central nervous system, psychological therapies and more recently, complementary and alternative treatments. Unfortunately, to date, all of these therapies have yielded only marginal results. A variety of emerging therapies are being developed for functional dyspepsia. Most of these therapies are intended to normalize pain perception and gastrointestinal motor and reflex function in this group of patients.
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Affiliation(s)
- R J Saad
- University of Michigan Medical Center, Ann Arbor, MI 48109, USA
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26
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Abstract
Gastro-oesophageal reflux disease refers to reflux of gastric contents into the oesophagus leading to oesophagitis, reflux symptoms sufficient to impair quality of life, or long-term complications. Transient relaxation of the lower oesophageal sphincter is believed to be the primary mechanism of the disease although the underlying cause remains uncertain. Obesity and smoking are weakly associated with the disease and genetic factors might be important. A negative association with Helicobacter pylori exists, but eradication of H pylori does not seem to cause reflux disease. Diagnosis is imprecise as there is no gold standard. Reflux symptoms are helpful in diagnosis but they lack sensitivity. Ambulatory oesophageal pH monitoring also seems to be insensitive despite high specificity. Empirical acid suppression with a proton-pump inhibitor (PPI) has reasonable sensitivity but poor specificity. Some evidence suggests that once patients develop the disease, severity is determined early and patients seem to continue with that phenotype long term. Unfortunately, most patients do not respond to life-style advice and require further therapy. H2 receptor antagonists and PPIs are better than placebo in oesophagitis, with a number needed to treat of five and two, respectively. In non-erosive reflux disease, acid suppression is better than placebo but the response rate is lower. Most patients need long-term treatment because the disease usually relapses. The role of endoscopic therapy is uncertain. Anti-reflux surgery is probably as effective as PPI therapy although there is a low operative mortality and morbidity.
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Affiliation(s)
- Paul Moayyedi
- Department of Medicine, Division of Gastroenterology, McMaster University Medical Centre, Hamilton, ON, Canada
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Aro P, Storskrubb T, Ronkainen J, Bolling-Sternevald E, Engstrand L, Vieth M, Stolte M, Talley NJ, Agréus L. Peptic ulcer disease in a general adult population: the Kalixanda study: a random population-based study. Am J Epidemiol 2006; 163:1025-34. [PMID: 16554343 DOI: 10.1093/aje/kwj129] [Citation(s) in RCA: 116] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The authors' aim in this study was to explore the prevalence, symptomatology, and risk factors for peptic ulcer in a general adult population. Between December 1998 and June 2001, the authors surveyed a random sample (n=3,000) of the adult population (n=21,610) in two communities in northern Sweden using a validated questionnaire, the Abdominal Symptom Questionnaire (response rate=74%). A subsample (n=1,001) of the responders was randomly invited to undergo esophagogastroduodenoscopy and symptom assessment (response rate=73%). The prevalence of peptic ulcer was 4.1% (20 gastric ulcers and 21 duodenal ulcers). Nausea and gastroesophageal reflux were significant predictors of peptic ulcer disease, but epigastric pain/discomfort was not. Six persons with gastric ulcer and two persons with duodenal ulcer were asymptomatic. Eight subjects with duodenal ulcer (38%) lacked evidence of current Helicobacter pylori infection. Five (25%) of the gastric ulcers and four (19%) of the duodenal ulcers were idiopathic (no use of aspirin or nonsteroidal antiinflammatory drugs, no H. pylori infection). Smoking, aspirin use, and obesity were risk factors for gastric ulcer; smoking, low-dose (<or=160 mg) aspirin use, and H. pylori infection were risk factors for duodenal ulcer. Peptic ulcer disease often coexists with atypical symptoms or no symptoms at all, and idiopathic duodenal ulcer may be more common than anticipated.
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Affiliation(s)
- Pertti Aro
- Centre for Family Medicine, Karolinska Institutet, Stockholm, Sweden.
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28
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Delgado-Aros S. [Gastric emptying and functional dyspepsia]. GASTROENTEROLOGIA Y HEPATOLOGIA 2006; 29:34-9. [PMID: 16393629 DOI: 10.1157/13083250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Dyspeptic syndrome includes symptoms such as upper abdominal pain, nausea and/or vomiting. These symptoms are common to highly diverse processes such as duodenal ulcer, pancreatitis and even intestinal ischemia, among many others. However, most patients who consult for this syndrome do not have any of these well known processes. New mechanisms have been proposed that could explain the symptoms presented by these patients. Among these mechanisms are those relating to an alteration of normal gastroduodenal motor function, such as alterations of gastric compliance, antral distension, gastric accommodation to anomalous ingestion, and alterations of gastric emptying. The present review evaluates the role of gastric emptying in producing dyspeptic symptoms according to the evidence available to date. We discuss gastric emptying in patients with functional or idiopathic dyspepsia compared with that in the healthy population, the correlation between gastric emptying and dyspeptic symptoms, and the response of dyspeptic symptoms to the prokinetic therapies carried out to date.
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Affiliation(s)
- S Delgado-Aros
- Fisiopatología Digestiva y Hepatología, Fundación Vall d'Hebron, Barcelona, Spain.
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Tan HJ, Rizal AM, Rosmadi MY, Goh KL. Role of Helicobacter pylori virulence factor and genotypes in non-ulcer dyspepsia. J Gastroenterol Hepatol 2006; 21:110-115. [PMID: 16706821 DOI: 10.1111/j.1440-1746.2005.04063.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM The role of Helicobacter pylori (HP) in non-ulcer dyspepsia is debatable. Eradicating HP will help a small group of non-ulcer dyspeptic patients. However, it is unclear which subgroup of patients will benefit from eradication therapy. The aim of the present study was to compare the cagA and cagE status, as well as vacA genotypes, of HP in non-ulcer dyspeptic patients who responded successfully to eradication therapy compared with those patients who did not. METHODS Consecutive patients with moderate to severe (Likert 2 or 3) non-ulcer dyspepsia with HP were recruited prospectively. Gastric biopsies were taken, DNA extracted and polymerase chain reaction performed to determine the cagA and cagE status and vacA alleles. Eradication therapy was offered until HP was eradicated successfully. The HP status was checked 1 month after eradication therapy using the [(13)C]-urea breath test. All patients were assessed by one interviewer using Gastrointestinal Symptom Rating Scale (GSRS), a four-point Likert scale, and SF-36 for quality of life over 12 months. Treatment success was defined as minimal or no symptoms (Likert 1 or 0). The cagA, cagE and vacA status was blinded to the investigators until completion of the study. RESULTS Seventy-three patients (36 males, 37 females) were recruited to the study. The mean+/-SD patient age was 53.38+/-12.09 years. When the 36 patients who improved (group A) were compared with the 37 (group B) who did not, no significant difference was found in the cagE positive rate (55.6 vs 43.2%, respectively; P=0.638), cagA positive rate (83.1 vs 73.0%, respectively; P=0.247), vacA m1 versus m2 subtype (84.0 vs 55.6%, respectively; P=0.472) or vacA s1a versus s1c (39.4 vs 57.1%, respectively; P=0.166). There was also no significant difference noted in the SF-36 scores between the two groups after the conclusion of eradication therapy. CONCLUSIONS Stratification of HP genotypes and virulence factor has no significant impact on the treatment success of non-ulcer dyspepsia.
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Yakoob J, Jafri W, Abid S, Jafri N, Hamid S, Shah HA, Rizvi L, Islam M, Shaikh H. Giardiasis in patients with dyspeptic symptoms. World J Gastroenterol 2005; 11:6667-6670. [PMID: 16425362 PMCID: PMC4355762 DOI: 10.3748/wjg.v11.i42.6667] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2005] [Revised: 04/07/2005] [Accepted: 04/09/2005] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the prevalence of giardiasis in patients with dyspeptic symptoms. METHODS Clinical records of consecutive patients who attended Gastroenterology Department at Aga Khan University Hospital from January 2000 to June 2003 and had esophagogastroduodenoscopy (EGD) with duodenal biopsies and international classification of diseases 9th revision with clinical modifications (ICD-9-CM) coded with giardiasis were studied. RESULTS Two hundred and twenty patients fulfilled the above criteria. There were 44% (96/220) patients who were giardiasis positive, 72% (69/96) of them were males and 28% (27/96) of them were females. There were 65% (81/124) males and 35% (43/124) females who were giardiasis negative. The mean age of patients with giardiasis was 28+/-17 years, while that of giardiasis negative patients was 40+/-18 years (P<0.001). In patients with giardiasis, abdominal pain was present in 71% (68/96) of patients (P = 0.02) and diarrhea in 29% (28/96) (P = 0.005); duodenitis in 25% (24/96) on EGD (P = 0.006) and in 68% (65/96) on histopathology (P = 0.002). CONCLUSION Giardiasis occurs significantly in young people with abdominal pain, while endoscopic duodenitis is seen in only 25% of giardiasis positive cases, which supports routine duodenal biopsy.
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Affiliation(s)
- Javed Yakoob
- Department of Medicine, Aga Khan University Hospital, Karachi 74800, Pakistan.
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31
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Talley NJ, Vakil NB, Moayyedi P. American gastroenterological association technical review on the evaluation of dyspepsia. Gastroenterology 2005; 129:1756-80. [PMID: 16285971 DOI: 10.1053/j.gastro.2005.09.020] [Citation(s) in RCA: 261] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Nicholas J Talley
- Division of Gastroenterology and Hepatology and Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
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32
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Heikkinen M, Räsänen H, Färkkilä M. Clinical value of ultrasound in the evaluation of dyspepsia in primary health care. Scand J Gastroenterol 2005; 40:980-4. [PMID: 16165712 DOI: 10.1080/00365520510015845] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE In general practice, upper abdominal ultrasound (US) is widely used in the evaluation of patients with dyspepsia. However, there is a dearth of published data on the role of US in the dyspepsia work-up. There are no data on the use of US as a follow-up study in functional dyspepsia. The aims of this study were to assess the role of US in evaluating dyspepsia, and to assess the long-term clinical relevance of minor findings revealed by US in patients with functional dyspepsia. MATERIAL AND METHODS Four hundred consecutive dyspeptic patients were recruited. At baseline, all patients underwent gastroscopy and US. Patients were divided into two groups: "endoscopy-negative patients" and "endoscopy-positive patients". "The endoscopy-negative" group included all cases in which the final diagnoses could not be settled after gastroscopy. US was repeated after 6-7 years in patients who had functional dyspepsia. RESULTS In the endoscopy-negative group, gallstones were detected in 21 patients, but this was considered to be a cause of symptoms in 9 patients. No malignant lesions were detected by US in the endoscopy-negative group. In the endoscopy-positive group, a malignant tumor in the kidney was suspected in 3 patients. Only one of these tumors turned out to be an incidental small carcinoma. Moreover, several minor findings were shown by US: usually these consisted of abnormal echogenicity of the liver. During the follow-up period, 6 patients developed gallstones. At the end of the follow-up period, two clinically significant findings were diagnosed: a small renal cancer and hydronephrosis. CONCLUSIONS This study shows that the wide, untargeted use of abdominal US in the evaluation of patients with dyspepsia following a gastroscopy is not necessary. Repeated US examination in cases of functional dyspepsia is not recommended, and rarely changes the diagnosis.
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Affiliation(s)
- Markku Heikkinen
- Department of Medicine, Unit of Gastroenterology, Kuopio University Hospital, Finland.
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Pallotta N, Pezzotti P, Calabrese E, Baccini F, Corazziari E. Relationship between gastrointestinal and extra-gastrointestinal symptoms and delayed gastric emptying in functional dyspeptic patients. World J Gastroenterol 2005; 11:4375-81. [PMID: 16038037 PMCID: PMC4434665 DOI: 10.3748/wjg.v11.i28.4375] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: Delayed gastric emptying and an enlarged fasting gastric antrum are common findings in functional dyspepsia but their relationship with gastrointestinal (GI), and the frequently associated extra-GI symptoms remains unclear. This study evaluated the relationship between GI and extra-GI symptoms, fasting antral volume and delayed gastric emptying in functional dyspepsia.
METHODS: In 108 functional dyspeptic patients antral volume and gastric emptying were assessed with ultraso-nography (US). Symptoms were assessed with standardized questionnaire. The association of symptoms and fasting antral volume with delayed gastric emptying was estimated with logistic regression analysis.
RESULTS: Delayed gastric emptying was detected in 39.8% of the patients. Postprandial drowsiness (AOR 11.25; 95%CI 2.75-45.93), nausea (AOR 3.51; 95%CI 1.19-10.32), fasting antral volume (AOR 1.93; 95%CI 1.22-3.05), were significantly associated with delayed gastric emptying. Symptoms, mainly the extra-GI ones as postprandial drowsiness and nausea, combined with fasting antral volume predicted the modality of gastric emptying with a sensitivity and specificity of 78%.
CONCLUSION: In functional dyspeptic patients, (1) an analysis of fasting antral volume and of symptoms can offer valuable indication on the modality of gastric emptying, and (2) it seems appropriate to inquire on postprandial drowsiness that showed the best correlation with delayed gastric emptying.
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Affiliation(s)
- N Pallotta
- Dpt di Scienze Cliniche, Universito La Sapienza, Policlinico Umberto I, V.le del Policlinico, Rome 00161, Italy
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Pajala M, Heikkinen M, Hintikka J. Mental distress in patients with functional or organic dyspepsia: a comparative study with a sample of the general population. Aliment Pharmacol Ther 2005; 21:277-81. [PMID: 15691302 DOI: 10.1111/j.1365-2036.2005.02296.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND It has been argued that patients with functional gastrointestinal disorders have mental disorders more often than healthy controls and patients with organic disease. Most studies surveying psychological factors at the population level have relied on symptom questionnaires to diagnose functional dyspepsia. However, the symptom patterns alone are unable to adequately discriminate organic from functional dyspepsia. AIM To evaluate the frequency of mental distress in primary care patients with organic or functional dyspepsia and compare the findings with a sample of the Finnish general population. METHODS Four-hundred consecutive, unselected dyspeptic patients were referred for upper gastrointestinal endoscopy and other diagnostic examinations. All patients compiled a self-administered questionnaire including the 12-item General Health Questionnaire to detect cases of recent mental disorders. RESULTS The prevalence of mental distress among patients with functional and organic dyspepsia was 38 and 36.4% respectively. The sex- and age-adjusted risk of having mental distress was nearly fourfold higher among patients with dyspepsia than in the general population. CONCLUSION Mental distress is common among patients with functional or organic dyspepsia. Nevertheless, there is no difference between patients with functional or organic dyspepsia in the prevalence or risk of mental distress.
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Affiliation(s)
- M Pajala
- Department of Internal Medicine, Kuopio University Hospital, Kuopio, Finland.
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Shaib Y, El-Serag HB. The prevalence and risk factors of functional dyspepsia in a multiethnic population in the United States. Am J Gastroenterol 2004; 99:2210-6. [PMID: 15555004 DOI: 10.1111/j.1572-0241.2004.40052.x] [Citation(s) in RCA: 109] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The prevalence of functional dyspepsia (FD) in the general population is not known. The aim of this study is to measure the prevalence of FD and its risk factors in a multiethnic volunteer sample of the U.S. population. METHODS One thousand employees at the Houston VA Medical Center were targeted with a symptom questionnaire asking about upper abdominal symptoms, followed by a request to undergo endsocopy. Dyspepsia was defined by the presence of epigastric pain, fullness, nausea, or vomiting, and FD was defined as dyspepsia in the absence of esophageal erosions, gastric ulcers, or duodenal ulcers or erosions. The presence of dyspepsia and FD was examined in multiple logistic regression analyses. RESULTS A total of 465 employees completed the relevant questions and of those 203 had endoscopic examination. The age-adjusted prevalence rate of dyspepsia was 31.9 per 100 (95% CI: 26.7-37.1), and 15.8 per 100 (95% CI: 9.6-22.0) if participants with concomitant heartburn or acid regurgitation were excluded. Subjects with dyspepsia were more likely to report smoking, using antacids, aspirin or nonsteroidal antiinflammatory drugs (NSAIDs), and consulting a physician for their symptoms (p < 0.05) than participants without dyspepsia. Most (64.5%) participants with dyspepsia who underwent endoscopy had FD. The age-adjusted prevalence rate of FD was 29.2 per 100 (95% CI: 21.9-36.5), and 15.0 per 100 (6.7-23.3) if subjects with GERD were excluded. Apart from a trend towards association with older age in the multiple regression analysis, there were no significant predictors of FD among participants with dyspepsia. CONCLUSIONS Most subjects with dyspepsia have FD. The prevalence of FD is high but predictors of FD remain poorly defined.
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Affiliation(s)
- Yasser Shaib
- Section of Health Services Research at The Michael E Debakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas, USA
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Talley NJ. What the physician needs to know for correct management of gastro-oesophageal reflux disease and dyspepsia. Aliment Pharmacol Ther 2004; 20 Suppl 2:23-30. [PMID: 15335410 DOI: 10.1111/j.1365-2036.2004.02043.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Upper gastrointestinal symptoms are highly prevalent; usually those consulting have multiple symptoms, confounding management. Here, common clinically relevant management issues are considered based on the best available evidence. Regardless of the presenting symptoms, determine if there are any alarm features; these have a low positive predictive value for malignancy but all patients with them should be referred for prompt upper gastrointestinal endoscopy. Ask about medications; of most importance are the non-steroidal anti-inflammatory drugs (NSAIDs), both non-selective and COX-2 selective. Try to ascertain if the symptom pattern suggests gastro-oesophageal reflux disease (GERD) or not. Dominant heartburn, however, may be of limited value; if the background prevalence of GERD is 25% and the patient complains of dominant heartburn, then the likelihood that such a patient has GERD as identified by 24-h oesophageal pH testing is only just over 50%. If reflux disease is strongly suspected and there are no alarm features, give an empirical trial of a proton pump inhibitor (PPI). Symptoms cannot separate adequately functional from organic dyspepsia. Endoscopy in dyspepsia with no alarm features is more costly than an empirical management approach. H. pylori testing and treatment remains in most settings the preferable initial choice for managing dyspepsia without obvious GERD. However, a PPI trial may offer a similar outcome and may be preferable in low H. pylori prevalence areas; head-to-head management trials in primary care are lacking.
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Affiliation(s)
- N J Talley
- Center for Enteric Neurosciences and Translational Epidemiological Research, Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
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Vakil N. Functional dyspepsia: the devil in the details. Am J Med 2004; 116:781-2. [PMID: 15144918 DOI: 10.1016/j.amjmed.2004.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Locke GR, Murray JA, Zinsmeister AR, Melton LJ, Talley NJ. Celiac disease serology in irritable bowel syndrome and dyspepsia: a population-based case-control study. Mayo Clin Proc 2004; 79:476-82. [PMID: 15065612 DOI: 10.4065/79.4.476] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To determine whether undiagnosed celiac disease is associated with irritable bowel syndrome (IBS) or dyspepsia in the community. SUBJECTS AND METHODS A self-report bowel disease questionnaire was mailed to a random sample of Olmsted County, Minnesota, residents aged 20 to 50 years. All respondents who reported symptoms of dyspepsia or IBS (cases) and all respondents without notable gastrointestinal symptoms (controls) were invited to participate (260 eligible subjects; 150 [58%] were studied). Each respondent was examined by a physician, and the medical records of each were reviewed (3 subjects did not meet the criteria for dyspepsia or IBS at the time of the physician interview). Serum was obtained to measure antiendomysial antibodies and tissue transglutaminase (TTg) IgA antibodies using validated assays. RESULTS A total of 34 subjects had dyspepsia (20 had ulcerlike dyspepsia), 50 had IBS (19 had diarrhea-predominant IBS), and 15 met criteria for both dyspepsia and IBS; 78 were asymptomatic healthy controls. The overall prevalence of positive TTg serology was 4% (95% confidence interval [CI], 1.5%-8.5%). The number of subjects who were seropositive for TTg was 2 of 34 (5.9%) with dyspepsia (95% CI, 0.7%-19.7%), 2 of 50 (4.0%) with IBS (95% CI, 0.5%-13.7%), and 2 of 78 (2.6%) of asymptomatic controls (95% CI, 03%-9.0%) (P = .64 IBS vs controls; P = .58 dyspepsia vs controls). No subjects had positive antiendomysial antibodies. CONCLUSION In this community, celiac disease did not explain the presence of either IBS or dyspepsia.
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Affiliation(s)
- G Richard Locke
- Division of Gastroenterology and Hepatology and Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minn 55905, USA.
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Chan DC, Chang TM, Chen CJ, Chen TW, Yu JC, Liu YC. Gallbladder contractility and volume characteristics in gallstone dyspepsia. World J Gastroenterol 2004; 10:721-4. [PMID: 14991946 PMCID: PMC4716917 DOI: 10.3748/wjg.v10.i5.721] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
AIM: It is difficult to differentiate gallstone dyspepsia and functional dyspepsia by clinical symptoms and signs. We hypothesized that gallstone dyspepsia was related to abnormal gallbladder motility. We aimed to differentiate gallstone dyspepsia from functional dyspepsia by measuring gallbladder motility.
METHODS: We measured gallbladder volume changes in response to gastric distension (saline 500 mL) and fatty meal in 10 normal volunteers (controls) and 62 patients with gallstones and dyspepsia before cholecystectomy. Forty cholecystectomized patients were symptom free or had improvement (group I), while the remaining 22 patients had persistent dyspepsia (group II). Gallbladder volume change and ejection fraction were analyzed and compared among the three groups.
RESULTS: In group I, there were significant decreases in gallbladder volumes 5-25 min after gastric distension, compared to fasting volumes. Compared to normal volunteers and group II, group I had significantly decreased gallbladder volumes 10-20 min after drinking 500 mL of normal saline and 10 to 50 min after eating fatty meal.
CONCLUSION: Our results support the hypothesis that increased gallbladder contraction after gastric distension or fatty meal may be related to dyspeptic symptoms in uncomplicated gallstone disease. These findings may be useful in differentiating functional dyspepsia from gallstone dyspepsia, patients with the latter disease may benefit from laparoscopic cholecystectomy.
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Affiliation(s)
- De-Chuan Chan
- Division of General Surgery, Department of Surgery, Tri-Service General Hospital, 325 Section 2, Cheng-Kung Road, Neihu 114, Taipei, Taiwan, China
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Smith T, Verzola E, Mertz H. Low yield of endoscopy in patients with persistent dyspepsia taking proton pump inhibitors. Gastrointest Endosc 2003; 58:9-13. [PMID: 12838213 DOI: 10.1067/mge.2003.308] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Options for the evaluation of dyspepsia include a Helicobacter pylori test-and-treat strategy, empiric acid suppression, and initial endoscopy. The aim of this study was to determine the yield of endoscopy in patients in whom empiric therapy is unsuccessful compared with patients who received no empiric therapy and to identify factors associated with endoscopic findings. METHODS A total of 100 patients with dyspepsia referred for endoscopy completed a questionnaire that included a query concerning response to therapy. EGD findings were compared in patients taking an H2-receptor antagonist, patients taking a proton pump inhibitor, and those not receiving empiric therapy. RESULTS There were fewer endoscopic findings in patients being treated with a proton pump inhibitor compared with those taking an H2-receptor antagonist or those not receiving therapy (p < 0.01). Fewer proton pump inhibitor recipients had esophagitis or ulcer compared with patients in the no therapy group. Lack of symptom relief (<20%) by acid suppression was highly associated with a normal endoscopy (17/17). CONCLUSIONS Patients with persistent dyspepsia being treated with a proton pump inhibitor have fewer endoscopic abnormalities compared with patients with dyspepsia taking an H2-receptor antagonist and those receiving no therapy. For patients with partial symptom relief, proton pump inhibitor therapy may mask endoscopic findings, particularly esophagitis. Interruption of proton pump inhibitors before endoscopy may increase diagnostic yield. Endoscopy is unlikely to yield a positive finding in patients who experience no symptom relief while taking a proton pump inhibitor or H2-receptor antagonist.
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Affiliation(s)
- Terrence Smith
- Vanderbilt University, Department of Medicine, Division of Gastroenterology, Nashville, Tennessee 37232, USA
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Affiliation(s)
- Benjamin Lebwohl
- Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, New York 10032, USA
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Numans ME, de Wit NJ. Reflux symptoms in general practice: diagnostic evaluation of the Carlsson-Dent gastro-oesophageal reflux disease questionnaire. Aliment Pharmacol Ther 2003; 17:1049-55. [PMID: 12694087 DOI: 10.1046/j.1365-2036.2003.01549.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Amongst primary care patients with dyspeptic symptoms, those with reflux-like symptoms or gastro-oesophageal reflux disease are expected to benefit most from empirical proton pump inhibitor therapy. Recognition of this patient group, however, is difficult. The Carlsson-Dent gastro-oesophageal reflux disease questionnaire was developed to justify the selection of primary care patients for empirical proton pump inhibitor treatment. AIM To evaluate the diagnostic test characteristics of the Carlsson-Dent questionnaire in a primary care population. METHODS A prospective, open-label, multi-centre diagnostic prevalence study was conducted amongst primary care adults with reflux symptoms. All patients completed the questionnaire and underwent gastroscopy. If no abnormalities were found, the patients were prescribed 2 weeks of treatment with omeprazole (20 mg daily). Receiver operating characteristic curve analysis was used to determine the overall discriminative value of the questionnaire. Diagnostic test characteristics of both the cut-off score (total diagnostic score) in the questionnaire and the physician's provisional classification were measured using oesophagitis and omeprazole treatment success as the reference tests. RESULTS Of the 536 patients included, 515 underwent endoscopy. No abnormalities were found in 286 (55%). Omeprazole treatment success occurred more frequently in patients with a total diagnostic score of > 7 and oesophagitis II-IV in patients with a total diagnostic score of > 9. The diagnostic test characteristics of the questionnaire were comparable with those of the physician's provisional classification. The area under the receiver operating characteristic curve did not exceed 0.65. Kappa values for observer agreement with the gold standard were far below 0.4. CONCLUSION The diagnostic performance of this version of the Carlsson-Dent questionnaire was poor. It equalled the physician's clinical judgement and therefore its value for clinical use is limited.
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Affiliation(s)
- M E Numans
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
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Arents NLA, Thijs JC, Kleibeuker JH. A rational approach to uninvestigated dyspepsia in primary care: review of the literature. Postgrad Med J 2002; 78:707-16. [PMID: 12509687 PMCID: PMC1757932 DOI: 10.1136/pmj.78.926.707] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
In this paper the rationale and limitations of the four most important approach strategies to dyspepsia in primary care (empiric treatment, prompt endoscopy, "test-and-scope", and "test-and-treat") are analysed. It is concluded that in the absence of alarm symptoms, a "test-and-treat" approach is currently the most rational approach provided that three conditions are met: (1) a highly accurate test should be used, (2) the prevalence of Helicobacter pylori in the population should not be too low, and (3) an effective anti-H pylori regimen should be prescribed taking sufficient time to instruct and motivate the patient.
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Affiliation(s)
- N L A Arents
- Regional Public Health Laboratory, Groningen/Drenthe, The Netherlands
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&NA;. Prokinetic agents may be the best drug choice for non-ulcer dyspepsia in the elderly. DRUGS & THERAPY PERSPECTIVES 2002. [DOI: 10.2165/00042310-200218110-00005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Meineche-Schmidt V, Jørgensen T. Fluctuation in dyspepsia subgroups over time. A three-year follow-up of patients consulting general practice for dyspepsia. Dig Liver Dis 2002; 34:332-8. [PMID: 12118950 DOI: 10.1016/s1590-8658(02)80126-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND General practitioners base their treatment and investigation on the symptoms presented by the patients. Subgroups of dyspepsia have been defined in order to guide management. AIM To study prospectively changes over time in the presentation of dyspepsia according to different subtypes in a general practitioner population. SUBJECTS Patients consulting the general practitioner because of dyspeptic complaints. METHODS A random sample of general practitioner patients consulting with different dyspepsia subtypes (ulcer-like, reflux-like, dysmotility-like, uncharacteristic and relapsing dyspepsia) were studied three years after the initial consultation by postal questionnaires to the general practitioners (obtaining information from the patient records) and to the patients (obtaining self-reported symptoms during twelve months). The subtype of dyspepsia at baseline was compared to the subtype in the patient questionnaire. RESULTS Between 20 and 34% of the patients reported no dyspepsia after three years, with so significant difference between the subtypes. Changes from one subtype to another were common, ulcer-like and reflux-like often changed into dysmotility-like dyspepsia. Dysmotility-like dyspepsia was significantly more stable over time. Patients with more than one episode of dyspepsia changed subtype significantly less. CONCLUSIONS Most patients who presented with dyspepsia to the general practitioner still reported symptoms three years later. Few patients with dysmotility-like dyspepsia changed subtype over time, whereas changes from one subtype to another were common in other subtypes. This implies that dyspeptic patients could end up having dysmotility-like complaints possibly due to the lack of effective treatment for this condition, compared to the other dyspepsia subtypes.
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Affiliation(s)
- V Meineche-Schmidt
- Centre of Preventive Medicine, Glostrup University Hospital, Copenhagen, Denmark.
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Abstract
OBJECTIVES We sought to determine the frequency with which patients with upper GI malignancies present with uncomplicated dyspepsia and to determine the impact of changing the threshold for early endoscopy from 45 to 55 yr, as has recently been recommended in European studies. METHODS Three hundred forty-one patients with upper GI malignancies at two Milwaukee teaching hospitals were identified from electronic databases. Trained physician-investigators reviewed the charts using a specifically designed questionnaire. Staging of GI cancers was performed using the TNM classification to determine operability. Uncomplicated dyspepsia was defined as dyspepsia without alarm symptoms/signs (dysphagia, vomiting, weight loss, early satiety, GI bleeding, or anemia). RESULTS There were 341 patients with upper GI malignancies with a mean age of 68 yr (range = 22-94). Twenty-one patients were younger than 45 and 65 were under 55. Uncomplicated dyspepsia was the presenting symptom in five of 65 (7.7%) patients younger than 55 and one of 21 (4.8%) patients under 45 (p = 0.99). Five patients 55 or younger presented with uncomplicated dyspepsia. All had advanced, inoperable disease (stage III or higher). CONCLUSIONS 1) In a racially diverse United States population, upper GI malignancy presenting without alarm symptoms is uncommon. 2) Raising the threshold for immediate endoscopy in uncomplicated dyspepsia from age 45 to 55 increases the risk of missing an underlying malignancy but may not affect outcome, as incurable disease was present at diagnosis within a few weeks of the onset of symptoms.
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Affiliation(s)
- Cristino Canga
- University of Wisconsin Medical School, Milwaukee 53233, USA
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Asante MA. Optimal management of patients with non-ulcer dyspepsia: considerations for the treatment of the elderly. Drugs Aging 2002; 18:819-26. [PMID: 11772122 DOI: 10.2165/00002512-200118110-00003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Optimal therapy for patients with non-ulcer dyspepsia still remains elusive. Increasing consensus on the definition of non-ulcer dyspepsia may improve the design of clinical trials and result in more effective therapies for this common condition. This paper reviews the investigation, pathophysiology and therapy of non-ulcer dyspepsia in order to formulate management strategies in the elderly. The best outcome for the patient can be achieved by detailed evaluation, leading to therapy targeted to obvious precipitating factors such as dyspepsia-inducing medications and other aggravating factors such as slow-transit constipation. Prokinetics and, to a lesser extent, H(2) receptor antagonists are the main medications of choice. Cisapride, the best studied prokinetic, has been withdrawn from the market in certain countries because some patients experienced dangerous cardiac arrhythmias, especially when cisapride was given with potent inhibitors of cytochrome P450 3A4. Time spent on reassurance and judicious use of antidepressants for the right patient can help improve symptoms. In the elderly, however, persistent symptoms should be re-evaluated because of the increased incidence of malignancy.
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Affiliation(s)
- M A Asante
- Department of Gastroenterology, Bromley Hospital, Bromley, England.
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Quartero AO, Numans ME, Post MWM, de Melker RA, de Wit NJ. One-year prognosis of primary care dyspepsia: predictive value of symptom pattern, Helicobacter pylori and GP management. Eur J Gastroenterol Hepatol 2002; 14:55-60. [PMID: 11782576 DOI: 10.1097/00042737-200201000-00010] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND AIMS Dyspepsia is a highly prevalent, heterogeneous condition with a poorly defined clinical course in family practice. We observed its clinical outcome and identified prognostic factors. PATIENTS We studied 583 patients presenting to their general practitioner (GP) with a new episode of dyspeptic complaints. METHODS A validated dyspepsia severity score was used to observe deterioration of dyspepsia. Furthermore, the general health status and the patient's perception of no improvement were registered. As prognostic determinants, demographic characteristics, concomitant conditions, and management were studied. Univariate and multivariate analyses were performed. RESULTS A total of 518 (89%) patients completed the 1-year follow-up. Of these, 111 patients (22%, 95% CI 18% to 25%) had a negative change in their dyspepsia score after 1 year; 46 patients (9%, 95% CI 6% to 11%) noted impairment of general health; and 122 patients (24%, 95% CI 20% to 28%) regarded complaints as not improved. Frequent dyspepsia (>1 episode/year) and a history of peptic ulcer predicted deterioration of dyspepsia, while smoking and little psychological distress predicted impairment of general health. Eradication of Helicobacter pylori reduced the chance of patient's negative judgement for especially those with frequent dyspepsia. CONCLUSION One-quarter of the dyspepsia patients had an unfavourable 1-year prognosis, which was predictable because of frequent complaints and previously diagnosed ulcers. Psychological factors need to be identified, since they are related to general health improvement. The observed benefit of H. pylori eradication on perceived improvement of complaints may well be placebo effect.
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Affiliation(s)
- A Otto Quartero
- Julius Centre for General Practice and Patient Oriented Research, University Medical Centre, Utrecht, The Netherlands.
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Koskenpato J, Farkkilä M, Sipponen P. Helicobacter pylori eradication and standardized 3-month omeprazole therapy in functional dyspepsia. Am J Gastroenterol 2001; 96:2866-72. [PMID: 11693319 DOI: 10.1111/j.1572-0241.2001.04240.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The role of Helicobacter pylori in functional dyspepsia remains unclear. This study evaluated the long term consequences for symptoms and quality of life in patients with H. pylori-positive functional dyspepsia after H. pylori eradication therapy with a standardized 3-month omeprazole treatment. METHODS A total of 151 H. pylori-positive patients with functional dyspepsia were randomized to receive either eradication therapy or placebo-antibiotics. The initial medication was administered in a double-blinded fashion. In addition, to standardize acid suppression, every patient received omeprazole therapy for the first 3-month period. Dyspeptic symptoms were evaluated by a questionnaire every 3 months, and quality of life was measured by a validated RAND 36-item health survey 1.0 questionnaire at the beginning of the study and after 12 months of follow-up. As the main outcome measure, the scores of patients who had received H. pylori eradication therapy and omeprazole were compared with those who received placebo and omeprazole during the 12 months of follow-up. RESULTS A total of 136 patients completed the 1-yr follow-up. In all, 77 patients received eradication therapy and 74 patients remained as controls. After 12 months, the mean reduction in the dyspepsia score was 28.8% in patients with H. pylori eradication therapy and 21.7% in the control group. The reduction of dyspepsia was significant (p < 0.0001) in both groups compared to baseline value, but no statistically significant differences in changes of dyspeptic symptoms or in quality of life were demonstrated between the H. pylori eradication therapy group and controls after 1 yr. In both patient groups, regurgitation (p < 0.001) and heartburn (p < 0.01) revealed relapse after cessation of 3-month omeprazole treatment. CONCLUSIONS No clear differences in symptoms or in quality of life were found between patients treated with H. pylori eradication therapy and omeprazole compared with patients receiving placebo and omeprazole after 1 yr. Regardless of H. pylori status, omeprazole treatment reduced heartburn and regurgitation. The placebo effect on the symptoms of functional dyspepsia and on quality of life was marked.
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Affiliation(s)
- J Koskenpato
- Department of Medicine, Helsinki University Central Hospital, Finland
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Weijnen CF, De Wit NJ, Numans ME, Kuipers EJ, Hoes AW, Verheij TJ. Helicobacter pylori testing in the primary care setting: which diagnostic test should be used? Aliment Pharmacol Ther 2001; 15:1205-10. [PMID: 11472324 DOI: 10.1046/j.1365-2036.2001.01047.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
AIM To identify the most accurate and efficient test for diagnosing Helicobacter pylori infection in primary care patients. STUDY DESIGN A whole blood test, an ELISA, and carbon13 urea breath test (CUBT) were evaluated in a primary care setting and validated against two different gold standards that used gastric biopsies. POPULATION Primary care patients who had dyspeptic complaints lasting at least 2 weeks and were referred for endoscopy. OUTCOMES MEASURED Positive and negative predictive values, sensitivity and specificity were determined for all three noninvasive H. pylori tests. RESULTS Data from the three non-invasive H. pylori tests were available for 136 primary care dyspeptic patients referred for endoscopy. They were compared with data from the gold standards. The positive predictive value of the whole blood test was in the range 71-75%, the ELISA 83-86%, and the CUBT 88-92%, while the negative predictive values were in the ranges 72-77%, 96-100%, and 95-98%, respectively. The sensitivity of the whole blood test was in the range 36-42%, the ELISA 93-100%, and the CUBT 92-97%, while the specificities were in the ranges 92-93%, 90-91% and 93-95%, respectively. The positive predictive value of the ELISA dropped significantly at lower H. pylori infection rates. DISCUSSION Both the ELISA and CUBT are effective in the primary care setting, while the whole blood tests produces inferior results. ELISA might, however, be less suitable for detecting H. pylori infection in a population with a low rate of infection.
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Affiliation(s)
- C F Weijnen
- Julius Center for General Practice and Patient Oriented Research, University Medical Center Utrecht, Utrecht, The Netherlands.
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