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Functional dyspepsia symptoms, gastric emptying and satiety provocative test: analysis of relationships.
BACKGROUND: The correlation between symptoms and observed impaired function in functional dyspepsia is still inconsistent. The aims of the study were to obtain a measure of satiety by a meal test; to verify whether this compares with severity of symptoms assessed using a reproducible questionnaire; and to correlate the parameters of satiety test and gastric emptying with all the dyspeptic symptoms. METHODS: Fifty-two functional dyspepsia patients reported their symptoms on a standardized questionnaire that considered belching, bloating, early satiety, epigastric pain and burning, nausea, postprandial fullness and vomiting. They were monitored for gastric emptying of a solid caloric meal using a radionuclide technique and underwent a test to quantify meal-induced satiety by a liquid caloric meal. RESULTS: The number of kilocalories ingested during the satiety test until the occurrence of maximum satiety in healthy subjects was 110% higher than in the dyspeptic group (mean +/- s(mean): 1110 +/- 23 versus 532 +/- 56; P < 0.01). We found a significant positive correlation between gastric emptying rate and kcal of the satiety test (P < 0.01; r = 0.428). Logistic regression showed a significant inverse association between severity of early satiety-coded as absent, mild, moderate or severe, kcal of meal test (P = 0.01), and gastric emptying lag phase (P = 0.03). Bloating was associated directly with t(1/2) of gastric emptying (P = 0.03) and inversely with lag phase (P = 0.02). CONCLUSIONS: The satiety test gives a fine numerical measure of satiety and confirms the results of a symptoms questionnaire. Our study showed an indirect correlation between severity of early satiety--as measured by the satiety test, and gastric emptying rate, as well as an association between bloating and delayed gastric emptying.
Excessive gas: patient perception vs reality.
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Gastric pathology as an initiator and potentiator of gastroesophageal reflux disease.
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Nissen fundoplication for reflux esophagitis. Long-term clinical and endoscopic results in 109 of 127 consecutive patients.
OBJECTIVE: This study evaluates the clinical and endoscopic long-term results of Nissen fundoplication in reflux esophagitis. SUMMARY BACKGROUND DATA: Nissen fundoplication has been reported to give good results in the treatment of gastroesophageal reflux with success rates up to 78-97%. Most of the previous studies on long-term results of fundoplication have, however, been based on interviews with only sporadic endoscopic examinations. METHODS: Of 127 patients consecutively treated with Nissen fundoplication for reflux esophagitis, 109 were available for follow-up after a median of 77 months. Upper gastrointestinal endoscopy was done in 105 cases, and all the patients with reflux symptoms or abnormal endoscopic observations were referred to esophageal 24-hour pH monitoring and manometry. RESULTS: No symptoms of gastroesophageal reflux were reported by 73 of the 109 patients, but dysphagia was present in 47. Endoscopy showed defective fundic wrap in 24 patients. Objective evidence of reflux was found in 24 patients (endoscopic esophagitis in 18 and pathologic 24-hour pH score without esophagitis in 6). Esophagitis was found in 14 of the 24 patients with defective wrap, but in only 4 of the 81 with infact wrap. CONCLUSIONS: Nissen fundoplication alleviated symptoms of gastroesophageal reflux and cured esophagitis in great majority of cases. The main determinant of outcome was the state of the fundic wrap.
Division of short gastric vessels at laparoscopic nissen fundoplication: a prospective double-blind randomized trial with 5-year follow-up.
OBJECTIVE: To determine whether division of the short gastric vessels at laparoscopic fundoplication confers long-term clinical benefit to patients. SUMMARY BACKGROUND DATA: Dividing the short gastric vessels during surgery for gastroesophageal reflux is controversial. This prospective randomized study was designed to determine whether there is a benefit in terms of patient outcome at a minimum of 5 years after primary surgery. METHODS: Between May 1994 and October 1995, 102 patients undergoing a laparoscopic Nissen fundoplication were randomized to have their short gastric vessels either divided or left intact. By September 2000, 99 (50 no division, 49 division) patients were available for follow-up, and they all underwent a detailed telephone interview by an independent and masked investigator. RESULTS: There were no significant differences between the groups at 5 years of follow-up in terms of the incidence of epigastric pain, regurgitation, odynophagia, early satiety, inability to belch, anorexia, nausea, vomiting, nocturnal coughing, and nocturnal wheezing. There was also no difference between the groups in the incidence of heartburn when determined by either yes/no questioning or a 0-to-10 visual analog scale. There was no difference between the groups in terms of the incidence and severity of dysphagia determined by yes/no questioning, 0-to-10 visual analog scales, or a composite dysphagia score. There was a significantly increased incidence of flatus production and epigastric bloating and a decreased incidence of ability to relieve bloating in patients who underwent division of the short gastric vessels. CONCLUSIONS: Division of the short gastric vessels during laparoscopic Nissen fundoplication does not improve any measured clinical outcome at 5 years of follow-up and is associated with an increased incidence of "wind-related" problems.
Pattern of gastric emptying in patients with systemic sclerosis.
Gastric emptying studies, using an indigenously prepared radiolabeled solid food marker in the form of Indian bread called Chapati, were performed on 13 patients with systemic sclerosis. Six patients had limited cutaneous disease and seven had diffuse cutaneous disease. Earlier, the procedure was standardized in 30 healthy volunteers. Seven of the 13 (54%) patients (five with diffuse and two with limited cutaneous disease) had delayed gastric emptying. Most of these patients had gastric symptoms. This pattern of gastric emptying may be clinically significant, particularly in patients with diffuse cutaneous disease.
Gastrointestinal mucosal integrity after prolonged exercise with fluid supplementation.
PURPOSE: Studies on the effect of exercise on gastrointestinal (GI) mucosal integrity have been limited to occult-blood tests, which were often nonspecific for human blood. The aim of our study was to investigate more aspects of this integrity. METHODS: We examined the effect of prolonged exercise and carbohydrate (CHO) supplementation on mucosal integrity in 22 male triathletes by measuring fecal lysozyme, alpha1-antitrypsin, and occult-blood loss, which was examined by two tests specific for human blood (Colon-Albumin and Monohaem test). Exercise consisted of two 150-min tests (alternately running, cycling, and running at 70-75% VO2max), either with a 7.0% CHO drink or water (W). Furthermore, GI symptoms during exercise were registered by questionnaire. RESULTS: Three subjects showed human albumin only in the first stool after exercise: twice with W and once with CHO. However, human hemoglobin (Hb) could not be detected in these samples. Four other subjects showed an elevated lysozyme concentration after exercise with CHO but not with W. Elevated alpha1-antitrypsin values were found in three of seven specimens in which either positive albumin tests and/or an elevated lysozyme concentration were demonstrated. Twenty-one subjects (95%) reported one or more GI symptoms during exercise. Incidence rates of different GI symptoms varied from 5 to 68%. Most symptoms were more frequent and lasted longer during running than during cycling but did not differ significantly between supplements and were not related to any mucosal integrity parameter. CONCLUSIONS: GI blood loss during exercise is of no clinical importance, at least in our study design with a group of well-trained male subjects who consumed a relatively high amount of fluid (up to 2.3 L). Nevertheless, an increased alpha1-antitrypsin and lysozyme concentration may indicate a transient local mucosal damage with an inflammatory response.
Hyperglycaemia affects proximal gastric motor and sensory function in normal subjects.
OBJECTIVE: Hyperglycaemia delays gastric emptying in normal subjects and patients with diabetes mellitus by uncertain mechanisms and may affect the perception of somatic sensations. The effects of hyperglycaemia on the motor function of the proximal stomach and the perception of gastric distension were evaluated in normal subjects. DESIGN: Paired studies were performed in randomized order in 10 healthy volunteers on separate days during euglycaemia and hyperglycaemia (blood glucose approximately equal to 15 mmol/l). METHODS: With a barostat and a balloon positioned in the proximal stomach, tasting subjects underwent a stepwise gastric distension. Each 2 mmHg step was maintained at a constant pressure for 2 min. The volume of the barostat balloon was measured and perception of the sensations of fullness, desire to belch, nausea, abdominal discomfort and hunger was scored at each step. RESULTS: Hyperglycaemia was associated with an increase in proximal gastric compliance (P < 0.01) evident from 2 mmHg above basal intragastric pressure. Perception scores for the sensations of nausea and desire to belch were greater during hyperglycaemia than euglycaemia (P < 0.05) in relation to both pressure at each step and volume. Hyperglycaemia did not affect perception of the sensations of abdominal discomfort, fullness or hunger. CONCLUSIONS: Hyperglycaemia increases proximal gastric compliance, reflecting a reduction in gastric tone. This may contribute to the previously observed delay in gastric emptying associated with hyperglycaemia. Hyperglycaemia appears to increase the perception of some of the sensations induced by gastric distension.
Prevalence of atypical symptoms and their association with typical symptoms of gastroesophageal reflux in Spain.
BACKGROUND: The association between typical and atypical symptoms of gastroesophageal reflux (GER) has received little attention in population-based studies. This study therefore sought to examine the prevalence of atypical symptoms, and their association with typical GER symptoms in Spain. METHODS: A telephone survey using a validated questionnaire was conducted in 2002 on 2500 subjects aged 40-79 years, randomly selected from the general population of Spain. The questionnaire included items on typical GER symptoms (heartburn and acid regurgitation) and several atypical symptoms (chest pain, dysphagia, belching, dyspepsia, globus, hoarseness, hiccups, chronic cough and asthma). The association between typical GER symptoms and each atypical symptom was summarized using odds ratios obtained from logistic regression. RESULTS: The response rate was 71.2%. A total of 60.8% (95% confidence interval 59.0-62.8%) of subjects reported suffering from at least one atypical symptom during the year preceding the interview. The prevalence rates varied from 26.7% for hoarseness to 6.6% for asthma. The prevalence of atypical symptoms was higher among the 791 subjects with typical GER symptoms than among the 1709 subjects reporting no typical GER symptoms (79.6 versus 52.2%). It was also higher among those reporting frequent typical GER symptoms compared with those reporting occasional symptoms (87.8 versus 58%). After adjustment for age, sex, coffee, alcohol and tobacco consumption, and psychosomatic symptoms, an association (P<0.05) was observed between typical symptoms and the respective atypical symptoms, with odds ratios ranging from 1.4 for asthma to 4.6 for belching. After additional adjustment for the remaining atypical symptoms, chest pain, dysphagia, dyspepsia, belching and globus were each independently associated with typical reflux symptoms. CONCLUSION: The prevalence of atypical GER symptoms is extremely high. There is an association between typical and atypical GER symptoms, particularly chest pain, dysphagia, dyspepsia, belching and globus.
Clinical features of pathologic childhood aerophagia: early recognition and essential diagnostic criteria.
OBJECTIVE: This study investigated the early recognition and diagnosis of pathologic childhood aerophagia to avoid unnecessary diagnostic approaches and serious complications. METHODS: Between 1995 and 2003, data from 42 consecutive patients with pathologic childhood aerophagia, aged 2 to 16 years, were reviewed. An esophageal air sign was defined as an abnormal air shadow on the proximal esophagus adjacent to the trachea on a full-inflated chest radiograph. RESULTS: Of the 42 patients, the chief complaints were abdominal distention (52.4%), recurrent abdominal pain syndrome (21.4%), chronic diarrhea (11.9%), acute abdominal pain (7.1%) and others (7.2%). Mean symptom duration before diagnosis was 10.6 months (range, 1 to 60 months), and it exceeded 12 months for 16 (38.1%) patients. The clinical features common to all patients were abdominal distention that increased progressively during the day, increased flatus on sleep, increased bowel sound on auscultation and an air-distended stomach with increased gas in the small and large bowel by radiography. Visible or audible air swallowing (26.2%) and repetitive belching (9.5%) were also noted. Esophageal air sign was observed in 76.2% of the patients and in 9.7% of the controls (P=0.0001). The subgroups of pathologic childhood aerophagia divided by underlying associations were pathologic childhood aerophagia without severe mental retardation (76.2%), which consisted of psychological stresses and uncertain condition, and pathologic childhood aerophagia with severe mental retardation (23.8%). CONCLUSIONS: The common manifestations of pathologic childhood aerophagia may be its essential diagnostic criteria, and esophageal air sign may be useful for the early recognition of pathologic childhood aerophagia. Our observations show that the diagnostic clinical profiles suggested by Rome II criteria should be detailed and made clearer if they are to serve as diagnostic criteria for pathologic childhood aerophagia.
Impedance signature of pharyngeal gaseous reflux.
BACKGROUND: Pharyngeal impedance changes induced by various pharyngeal reflux events have not been characterized. OBJECTIVES: To characterize pharyngeal impedance changes induced by participant-perceived belching events. METHODS: We systematically evaluated pharyngeal impedance and pH changes related to 453 belch events in 11 gastroesophageal reflux disease, 10 reflux attributed-laryngitis patients and 16 controls. RESULTS: Of 453 belch events, 362 were analyzable. Of these, 72% occurred within 10 s, 93% within 20 s, 99% within 30 s and 100% within 40 s of the time that participants marked a belch event. In 15% impedance changes in the pharynx preceded, in 12% they were simultaneous and in 73% they occurred after the start of the impedance change in the proximal esophagus. Time interval between the two events ranged between 0.4+/-0.03 and 0.7+/-0.1 s. In all, there were three types of belch-induced impedance changes: (a) impedance increase, (b) impedance decrease and (c) multiphasic. Twenty percent of impedance events associated with belching had less than 50% change from baseline, whereas in 51% changes exceeded or were equal to 50%. Among events with a drop in pharyngeal impedance, only two satisfied the criteria for the liquid reflux event. CONCLUSIONS: Pharyngeal ventilation of gastric gaseous content seems to have a unique impedance signature. During pharyngeal gas reflux events, impedance changes may start before or after proximal esophageal changes. Belching may induce negative pharyngeal changes that do not meet the criteria for liquid reflux. These findings need to be taken into consideration in the analysis of pharyngeal reflux events.
Efficacy of cisapride therapy in functional dyspepsia.
AIM: To assess the efficacy of cisapride therapy in relieving symptoms of functional dyspepsia. METHODS: After a 2-week placebo run-in period, 61 out of 74 patients were eligible to enter a 4-week double-blind treatment phase, consisting of treatment with cisapride (10 mg) or placebo tablets t.d.s. Gastric emptying was assessed scintigraphically at entry to the study. Patients were stratified before treatment into those with or without active chronic (Helicobacter pylori) gastritis. Patients were also classified retrospectively into those with 'reflux-like' dyspepsia (n = 29) and those with 'motility-like' dyspepsia (n = 32). RESULTS: At the end of the active treatment phase, there was a similar significant (P < 0.001) reduction in total symptom score from baseline in both cisapride (8.9 +/- 0.5 to 5.8 +/- 0.6) and placebo (9.7 +/- 0.6 to 5.5 +/- 0.6) groups. Scores for heartburn and continual bloating were significantly reduced in the cisapride but not the placebo group; improvement was attributable to patients with normal, rather than delayed, rates of gastric emptying. For continual bloating, significant improvement also occurred in the cisapride subgroup without gastritis, but not in the subgroup with gastritis (mean symptom score reduction 0.48 +/- 0.18, P = 0.03). For global evaluation by the investigator and by the patient, the overall improvement rates were not statistically different between cisapride and placebo groups. In those with normal gastric emptying, however, there was a significant (P = 0.01) improvement in general well-being in the cisapride but not in the placebo group. CONCLUSIONS: We were unable to show major differences in the short-term efficacy of cisapride and placebo in functional dyspepsia. There were indications, however, of beneficial effects of cisapride over placebo in those with 'reflux-like' dyspepsia, and in those without gastroparesis.
Relationships between air swallowing, intragastric air, belching and gastro-oesophageal reflux.
BACKGROUND: With each swallow a certain amount of air is transported to the stomach. The stomach protects itself against excessive distention by swallowed air through belching (gas reflux). The mechanism of belching (transient lower oesophageal sphincter relaxation) is also one of the mechanisms underlying gastro-oesophageal reflux. AIM: To investigate whether swallowing of air leads to an increase in size of the intragastric air bubble and to gastro-oesophageal reflux. METHODS: Multichannel intraluminal impedance measurement was used to quantify the incidence of swallowing of air in 20 healthy volunteers before and after a meal. Radiography was used to measure the size of the intragastric air bubble. Gastro-oesophageal reflux was assessed by concurrent impedance and pH measurement. RESULTS: The rate of air swallowing was correlated to the size of the intragastric air bubble postprandially and to the rate of gaseous gastro-oesophageal reflux. The number of air swallows and the size of the intragastric air bubble did not correlate with the number of liquid acid and non-acid reflux episodes. CONCLUSIONS: In healthy subjects, air swallowing promotes belching but does not facilitate acid reflux.
Dietary influence on electro-gastrography and association of alterations in gastric myoelectrical activity with symptoms in patients with functional dyspepsia.
BACKGROUND AND AIM: It is unclear which type of meal is adequate in measuring electro-gastrography and which parameter of electro-gastrography is of clinical relevance. The aims of the present study were to compare the influence of water and a nutrient drink on electro-gastrography in patients with functional dyspepsia (FD) and in healthy volunteers, and to investigate the association of alterations of electro-gastrography with symptoms. METHOD: In 30 patients with FD and 12 healthy volunteers, the recording of electro-gastrography with symptom assessments was performed pre-prandially and postprandially. Subjects ingested the same volume of water and a nutrient drink at a fixed rate, which was performed in a randomized cross-over design. RESULTS: Unlike water, the power ratio after/before a nutrient drink was significantly lower in patients compared to controls. Patients had more severe bloating and epigastric pain after nutrient ingestion than after water intake. Absent postprandial increase of power was observed in seven of the 30 patients after nutrient intake, and in three of the 30 patients after water intake. The former patients had significantly more severe fullness and bloating. Irrespective of a test meal, the percentage rates of normogastria significantly decreased postprandially in the patient group, but not in the control group. No differences in symptom severity were observed between patients with and without abnormally low percentage rates of normogastria. CONCLUSIONS: Decreased postprandial rates of normogastria and absent postprandial increase of power are electro-gastrographic abnormalities found in a subset of patients with FD. A nutrient drink is more adequate for the detection of such alterations than water. The lack of a postprandial increase of power is associated with the severity of some dyspeptic symptoms, but decreased postprandial rates of normogastria are not.
Situational syncope induced by belching.
We describe a case of situational syncope induced by belching. The patient showed severe syncope with a high-degree atrioventricular block just after belching, but has not experienced syncope or dizziness over a 3-month follow-up after permanent pacemaker implantation.
Provocation of transient lower esophageal sphincter relaxations by gastric distension with air.
OBJECTIVES: Transient lower esophageal sphincter relaxations (TLESRs) are the major mechanism permitting not only gastroesophageal reflux but also venting of air from the stomach. Triggering of TLESRs is provoked by gastric distension. Antireflux surgery is associated with impaired ability to belch. It is not known whether a reduced capacity to belch results from postoperative reduction in TLESRs. METHODS: We studied the occurrence of TLESRs, common cavities (indicator for gas gastroesophageal reflux), and belching after standardized acute gastric distension by air insufflation (750 ml). Control subjects (n = 10), patients with gastroesophageal reflux disease (GERD) (n = 22), and patients after fundoplication (n = 24) were studied. LES and esophageal motilities were recorded with perfusion manometry. RESULTS: Gastric distension with air significantly (p < 0.05) increased TLESR frequency in controls (1.6+/-0.3 to 3.5+/-1.0 per 20 min), GERD patients (1.2+/-0.3 to 3.1+/-0.5 per 20 min), and patients after fundoplication (0.5+/-0.1 to 1.8+/-0.6 per 20 min). Postfundoplication the number of TLESRs was significantly reduced (p < 0.05) both under fasting conditions and after air insufflation. The number of common cavities and belches after gastric air distension also was significantly reduced (p < 0.05) after fundoplication: 2.3+/-0.6 versus 4.7+/-0.4 in controls and 4.1+/-0.4 in GERD patients. About half of the common cavities occurred during TLESRs, and half during other mechanisms. An impaired ability to belch in daily life correlated with an impaired belching response during the test. An impaired ability to belch occurred only in patients with complete fundoplication and not in patients with partial fundoplication and was associated with a reduced number of common cavities after gastric air insufflation. CONCLUSIONS: Short-lasting gastric air distension 1) provokes TLESRs but does not differentiate GERD patients from controls, 2) reveals impaired belching capacity in patients after complete fundoplication, and 3) shows that common cavities do not exclusively occur during TLESRs.
Symptoms associated with impaired gastric emptying of solids and liquids in functional dyspepsia.
OBJECTIVE: The relationship between functional dyspepsia and delayed gastric emptying of solids or liquids is still unclear. The aim of the present study was to investigate in dyspeptic patients the prevalence of delayed gastric emptying for solids or for liquids and to investigate the relationship to the dyspepsia symptom pattern. METHODS: In 392 and 330 patients with functional dyspepsia, the solid and liquid gastric emptying, respectively, was measured using breath tests, and the severity of eight dyspeptic symptoms was scored. RESULTS: Gastric emptying of solids and liquids were delayed in 23% and 35% of the patients. Multivariate analysis showed that the presence of vomiting and postprandial fullness was associated with delayed solid emptying (OR 2.65, 95% CI = 1.62-4.35 and OR 3.08, 95% CI = 1.28-9.16, respectively). Postprandial fullness was also associated with the risk of delayed liquid emptying when symptom was present (OR 3.5, 95% CI = 1.57-8.68), relevant or severe (OR 2.504, 95% CI = 1.41-4.65), and severe (OR 2.214, 95% CI = 1.34-3.67). Severe early satiety was associated with the risk of delayed liquid emptying (OR 1.902, 95% CI = 1.90-3.30). CONCLUSIONS: A subset of dyspeptic patients has delayed gastric emptying of solids or of liquids. Delayed gastric emptying of solids was constantly associated with postprandial fullness and with vomiting. Delayed emptying for liquids was also associated with postprandial fullness and with severe early satiety.