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PubMed2000

An evidence-based approach to the management of uninvestigated dyspepsia in the era of Helicobacter pylori. Canadian Dyspepsia Working Group.

OBJECTIVES: To provide Canadian primary care physicians with an evidence-based clinical management tool, including diagnostic and treatment recommendations, for patients who present with uninvestigated dyspepsia. RECOMMENDATIONS: The management tool has 5 key decision steps addressing the following: (1) evidence that symptoms originate in the upper gastrointestinal tract, (2) presence of alarm features, (3) use of nonsteroidal anti-inflammatory drugs (NSAIDs), (4) dominant reflux symptoms and (5) evidence of Helicobacter pylori infection. All patients over 50 years of age who present with new-onset dyspepsia and patients who present with alarm features should receive prompt investigation, preferably by endoscopy. The management options for patients with uninvestigated dyspepsia who use NSAIDs regularly are: (1) to stop NSAID therapy and assess symptomatic response, (2) to treat with NSAID prophylaxis if NSAID therapy cannot be stopped or (3) to refer for investigation. Gastroesophageal reflux disease can be diagnosed clinically if the patient's dominant symptoms are heartburn or acid regurgitation, or both; these patients should be treated with acid suppressive therapy. The remaining patients should be tested for H. pylori infection, and those with a positive result should be treated with H. pylori-eradication therapy. Those with a negative result should have their symptoms treated with optimal antisecretory therapy or a prokinetic agent. VALIDATION AND EVIDENCE: Evidence for resolution of the dyspepsia symptoms was the main outcome measure. Supporting evidence for the 5 steps in the management tool and the recommendations for treatment were graded according to the strength of the evidence and were endorsed by consensus of committee members. If no randomized controlled clinical trials were available, the recommendations were based on the best available evidence. LITERATURE REVIEW: Evidence was obtained from MEDLINE searches for pertinent articles published from 1966 to October 1999. The searches focused on dyspepsia, diagnosis and treatment. Additional articles were retrieved through a manual search of bibliographies and abstracts from international gastroenterology conferences.

Anti-Inflammatory Agents, Non-Steroidal↗
PubMed1987

Prognosis of chronic unexplained dyspepsia. A prospective study of potential predictor variables in patients with endoscopically diagnosed nonulcer dyspepsia.

The aim of this study was to determine if there were predictors of the symptomatic course of patients with chronic unexplained (essential) dyspepsia. After endoscopic assessment, 111 patients with essential dyspepsia were followed up by telephone interview every second month. Data were gathered, for a mean of 17 mo per patient, on the number of days of upper abdominal pain (the response variable) each month. In the 6-mo period before entry to the study the following predetermined predictor variables were collected: demographic factors (age, sex, social grade), number of pain days in the 6 mo before diagnosis, environmental factors (analgesics, nonsalicylate nonsteroidal antiinflammatory drugs, alcohol, smoking, coffee, tea), length of dyspepsia history, and past history of peptic ulcer. Prospectively for each month of follow-up, the following additional variables were recorded: environmental factors, treatment, and development of gastroesophageal reflux symptoms. It was found that patients with more pain before diagnosis were significantly more likely to have pain over the follow-up, and the taking of medications for dyspepsia and development of gastroesophageal reflux were associated with more days of pain over the follow-up (all p less than 0.001). Demographic and environmental factors, length of dyspepsia history, and a past history of ulcer were of no significant predictive value. There was a decrease in pain over the follow-up period (p = 0.002), but this effect was limited to the first two periods after endoscopic diagnosis.

Chronic Disease↗
PubMed2002

Treating Helicobacter pylori infection in primary care patients with uninvestigated dyspepsia: the Canadian adult dyspepsia empiric treatment-Helicobacter pylori positive (CADET-Hp) randomised controlled trial.

OBJECTIVE: To determine whether a "test for Helicobacter pylori and treat" strategy improves symptoms in patients with uninvestigated dyspepsia in primary care. DESIGN: Randomised placebo controlled trial. SETTING: 36 family practices in Canada. PARTICIPANTS: 294 patients positive for H pylori ((13)C- urea breath test) with symptoms of dyspepsia of at least moderate severity in the preceding month. INTERVENTION: PARTICIPANTS were randomised to twice daily treatment for 7 days with omeprazole 20 mg, metronidazole 500 mg, and clarithromycin 250 mg or omeprazole 20 mg, placebo metronidazole, and placebo clarithromycin. Patients were then managed by their family physicians according to their usual care. MAIN OUTCOME MEASURES: Treatment success defined as no symptoms or minimal symptoms of dyspepsia at the end of one year. Societal healthcare costs collected prospectively for a secondary evaluation of actual mean costs. RESULTS: In the intention to treat population (n=294), eradication treatment was significantly more effective than placebo in achieving treatment success (50% v 36%; P=0.02; absolute risk reduction=14%; number needed to treat=7, 95% confidence interval 4 to 63). Eradication treatment cured H pylori infection in 80% of evaluable patients. Treatment success at one year was greater in patients negative for H pylori than in those positive for H pylori (54% v 39%; P=0.02). Eradication treatment reduced mean annual cost by $C53 (-86 to 180) per patient. CONCLUSIONS: A "test for H pylori with (13)C-urea breath test and eradicate" strategy shows significant symptomatic benefit at 12 months in the management of primary care patients with uninvestigated dyspepsia.

Adolescent↗
PubMed1998

The one-stop dyspepsia clinic--an alternative to open-access endoscopy for patients with dyspepsia.

The most sensitive investigative tool for the upper gastrointestinal tract is endoscopy, and many gastroenterologists offer an open-access endoscopy service to general practitioners. However, for patients with dyspepsia, endoscopy is not always the most appropriate initial investigation, and the one-stop dyspepsia clinic allows for different approaches. We have audited, over one year, the management and outcomes of patients attending a one-stop dyspepsia clinic. All patients seen in the clinic were included, and for those not endoscoped the notes were reviewed one year after the end of the study to check for reattendances and diagnoses originally missed. Patients' and general practitioners' views of the service were assessed by questionnaire. 485 patients were seen, of whom 301 (62%) were endoscoped at first attendance. In 66 patients (14%), endoscopy was deemed inappropriate and only one of these returned subsequently for endoscopy. 118 patients (24%) were symptom-free when seen in the clinic and were asked to telephone for an appointment if and when symptoms recurred; half of these returned and were endoscoped. Oesophagitis and duodenal ulcer were significantly more common in this 'telephone endoscopy' group than in those endoscoped straight from the clinic. Overall, 25% of patients referred were not endoscoped. Important additional diagnoses were made from the clinic consultation. General practitioners and patients valued the system, in particular the telephone endoscopy service. 84% of general practitioners said they would prefer the one-stop dyspepsia clinic to open-access endoscopy.

Diagnosis, Differential↗
PubMed2001

Dyspepsia, non-ulcer dyspepsia, and Helicobacter pylori.

Since the discovery of Helicobacter pylori and its role in peptic ulcer disease, two strategies for low-cost treatment of uninvestigated dyspepsia have emerged: "test and treat" and "test and scope." The efficacy of these strategies is examined, with a review of several recent studies. Controversy exists as to the usefulness of eradication of H. pylori in the treatment of non-ulcer dyspepsia. Results of four large trials are presented as an illustration of this controversy. Guidelines for the management of dyspepsia and non-ulcer dyspepsia are reviewed.

Dyspepsia↗
PubMed1994

[The effectiveness of ranitidine in non-ulcer dyspepsia (functional dyspepsia) in comparison with an antacid].

BACKGROUND: It is generally accepted that functional dyspepsia is caused by heterogeneous pathogenetic factors. From the clinical point of view acid-related symptoms as heartburn, acid regurgitation and epigastric pain (acid-type) can be separated from general dyspeptic symptoms as predominant fullness, nausea/vomiting (dysmotility-type). PATIENTS AND METHODS: In the present study, the influence of a four-week-treatment with ranitidine (twice 150/d, n = 346) in comparison with an antacid (40 mmol/d, n = 340) on the severity and course of symptoms in patients suffering from an acid-related functional dyspepsia was investigated. RESULTS: With ranitidine, acid-related as well as general dyspeptic symptoms disappeared in a significantly higher percentage after two and four weeks compared with antacid. Complete disappearance of symptoms was documented with ranitidine after two weeks in 37% and after four weeks in 66% compared with antacid in 13% and 30% respectively (p < 0.005). Patients with severe symptoms, history of ulcer and long-term dyspepsia and slight endoscopic changes in the upper gastrointestinal tract showed a significant faster and more distinct response. Both kinds of treatment were well tolerated. CONCLUSION: It is concluded that in acid-related functional dyspepsia ranitidine is superior to antacid in relieving symptoms. Therefore, a probative treatment with ranitidine up to four weeks is recommended as a practical therapeutic alternative in this syndrome.

Adolescent↗
PubMed1998

Organic causes of dyspepsia, and discriminating functional from organic dyspepsia.

A wide variety of disorders affecting the upper gastrointestinal tract, as well as systemic disorders, are associated with symptoms of dyspepsia. The more important of these conditions are considered in this chapter, with particular reference to their symptom patterns on presentation. The differentiation, on clinical grounds, between these organic causes of dyspepsia and functional dyspepsia remains an important area of research. Those aspects of the history and physical examination most relevant to this distinction are also considered.

Adult↗
PubMed2000

Patient-based assessment in dyspepsia: development and validation of Dyspepsia Symptom Severity Index (DSSI).

This paper describes the development and testing of a new self-report measure, the Dyspepsia Symptom Severity Index (DSSI), for assessing the severity of symptoms commonly associated with dyspepsia. The instrument was based on the literature, focus groups, and feedback from gastroenterologists; 48 patients and 24 controls participated in testing. Patients completed the DSSI and a symptom diary to test concurrent validity; one-week reproducibility was evaluated in 21 stable patients. Three subscales comprise the 20-item DSSI, representing reflux-, ulcer-, and dysmotility-like symptoms. Subscale internal consistency levels (alpha) were high (0.84-0.89), total score alpha levels were very good (0.76, 0.80), and scores were reproducible (ICC = 0.90-0.92). Correlations between the DSSI and diary were moderate to strong (r = 0.33-0.77; P < 0.05). Patients reported significantly more severe symptoms than controls (P < 0.001). Results indicate the DSSI is a reliable and valid tool for evaluating symptom severity in patients with functional dyspepsia.

Adult↗
PubMed1998

The effect of cisapride on dyspepsia symptoms and the electrogastrogram in patients with non-ulcer dyspepsia.

BACKGROUND: The electrogastrogram (EGG), which records gastric myoelectrical activity, is abnormal in one-third of adult patients with non-ulcer dyspepsia (NUD). AIM: To observe the effects of cisapride on EGG in adults with NUD. METHODS: Twenty-seven NUD patients who had undergone a pre- and post-prandial EGG were entered into an open study. All patients completed a dyspepsia symptom questionnaire and were then treated with cisapride 10 mg t.d.s. The dyspepsia questionnaire was repeated in all those completing 4 weeks of treatment. Those with an initial abnormal EGG (< 70% of slow wave activity at 2-4 cycles per minute) had a repeat EGG at the end of the study. RESULTS: Treatment with cisapride was associated with a significant improvement in the post-prandial EGG (P = 0.007). After 4 weeks of treatment, 7 of 13 abnormal EGGs normalized. Symptom scores improved significantly in the 13 patients with an abnormal EGG who completed treatment (P < 0.0003), but not in NUD patients with a normal EGG (P = 0.48). CONCLUSION: In this open study, treatment of NUD with cisapride was associated with significant symptom improvement in patients with an abnormal pre-treatment EGG, but not those with a normal EGG, with a significant improvement of the post-prandial EGG.

Adult↗
PubMed2000

Validation of phone interview for follow-up in clinical trials on dyspepsia: evaluation of the Glasgow Dyspepsia Severity Score and a Likert-scale symptoms test.

OBJECTIVE: To validate two widely used dyspepsia scores performed by phone interview. DESIGN: Spanish translations of the Glasgow Dyspepsia Severity Score and a Likert-scale symptomatic test were evaluated. Responsiveness to the treatment, validity of the tests, and reproducibility of tests performed by phone interview were assessed. SETTING: Gastroenterology and endoscopy unit of a county hospital. PARTICIPANTS: Group I consisted of 16 ulcer patients undergoing Helicobacter pylori eradication; Group II consisted of 29 healthy volunteers; and Group III consisted of 95 patients undergoing upper endoscopy. MEASUREMENTS: Glasgow Severity Dyspepsia Score and Likert test. RESULTS: Both tests showed adequate improvement (responsiveness) after H. pylori eradication. With regard to validity, the Glasgow and Likert test were significantly higher in 95 patients undergoing endoscopy than in 29 healthy controls. Analysis of reproducibility showed that intraobserver variation was low on both the Glasgow and Likert scores. No differences were found between consecutive tests regardless of whether both were performed by phone (24 patients) or one by phone and the other by clinical interview (40 patients). Interobserver variation analysis showed that the Glasgow test remained highly reproducible even when performed by different observers using different methods (clinical interview 8.83, phone 8.44, P = 0.12). By contrast, Likert-scale tests showed significant differences between observers for all symptoms except abdominal pain. CONCLUSIONS: (1) The Glasgow score is highly reproducible even when performed by different observers and using different methods. (2) By contrast, Likert tests show greater variability. To be reproducible in different conditions, they need to be performed by the same observer.

Adult↗
PubMed1999

Eradication of Helicobacter pylori in functional dyspepsia: randomised double blind placebo controlled trial with 12 months' follow up. The Optimal Regimen Cures Helicobacter Induced Dyspepsia (ORCHID) Study Group.

OBJECTIVES: To determine whether eradication of Helicobacter pylori relieves the symptoms of functional dyspepsia. DESIGN: Multicentre randomised double blind placebo controlled trial. SUBJECTS: 278 patients infected with H pylori who had functional dyspepsia. SETTING: Predominantly secondary care centres in Australia, New Zealand, and Europe. INTERVENTION: Patients randomised to receive omeprazole 20 mg twice daily, amoxicillin 1000 mg twice daily, and clarithromycin 500 mg twice daily or placebo for 7 days. Patients were followed up for 12 months. MAIN OUTCOME MEASURES: Symptom status (assessed by diary cards) and presence of H pylori (assessed by gastric biopsies and 13C-urea breath testing using urea labelled with carbon-13). RESULTS: H pylori was eradicated in 113 patients (85%) in the treatment group and 6 patients (4%) in the placebo group. At 12 months follow up there was no significant difference between the proportion of patients treated successfully by intention to treat in the eradication arm (24%, 95% confidence interval 17% to 32%) and the proportion of patients treated successfully by intention to treat in the placebo group (22%, 15% to 30%). Changes in symptom scores and quality of life did not significantly differ between the treatment and placebo groups. When the groups were combined, there was a significant association between treatment success and chronic gastritis score at 12 months; 41/127 (32%) patients with no or mild gastritis were successfully treated compared with 21/123 (17%) patients with persistent gastritis (P=0. 008). CONCLUSION: No convincing evidence was found that eradication of H pylori relieves the symptoms of functional dyspepsia 12 months after treatment.

Adult↗
PubMed1997

What role does Helicobacter pylori play in dyspepsia and nonulcer dyspepsia? Arguments for and against H. pylori being associated with dyspeptic symptoms.

A major role for Helicobacter pylori gastritis in nonulcer dyspepsia (NUD) is controversial. Gastroduodenal dysfunction may be associated with H. pylori infection, but there is little evidence for a causal link with dyspepsia. Population-based studies with appropriate methodology have generally failed to confirm an association between H. pylori and NUD. Furthermore, no definite association between subgroups of NUD (ulcer-like, dysmotility-like, reflux-like, and nonspecific) and H. pylori has been identified however the subgroups have been defined, and no specific symptom pattern characterizes patients with H. pylori infection. Whether H. pylori-induced alterations of gastric physiology can explain NUD remains open to debate while we await the results of more specific experiments. Although acid secretion in response to gastrin-releasing peptide may be increased in a subset of NUD patients who are infected with H. pylori, uninfected patients with NUD have not been assessed and the results require confirmation. Most studies suggest no association between H. pylori and gastroduodenal motor or sensory dysfunction in NUD. Treatment trials have been unconvincing. The trials with bismuth therapy have not been adequately blinded. Furthermore, some studies suggest that H. pylori-negative patients with NUD may respond to bismuth treatment, although the results have not been uniform. Therapies aimed at curing H. pylori infection have produced mixed results, with small positive and negative trials. The trials that have used adequate outcome measures have more often than not been negative. Based on current evidence, H. pylori is not established to be of causal importance in NUD.

Dyspepsia↗
PubMedDate not supplied

Eradication of Helicobacter pylori infection in the management of patients with dyspepsia and non-ulcer dyspepsia.

Although H. pylori infection has been recognized as a major etiological agent for the development of chronic active gastritis, duodenal ulcer and benign non-NSAID related gastric ulcer, its role in the development of symptoms in patients with dyspepsia remains uncertain. Results from population-based epidemiological studies have been conflicting regarding a causal link between H. pylori infection and dyspepsia. Abnormalities in gastric acid secretion may exist in some dyspeptic patients. Whether disordered gastric motility seen in dyspeptic patients is related to the infection is not clear based on the results in the literature. Numerous clinical trials have been undertaken to eradicate H. pylori infection and improve the symptoms in dyspeptic patients; however, the results have been discrepant between studies. Many published studies suffer from methodological problems that have made interpretation difficult. Large, well-conducted, randomized, placebo-controlled, clinical trials with long-term follow-up are needed to justify the beneficial effect of H. pylori eradication treatment in dyspeptic patients seen in some small studies. H. pylori eradication therapy is cost-effective in H. pylori-infected dyspeptic patients although this benefit may take a long time to accrue, especially in younger patients.

Chronic Disease↗
PubMed1999

[Dyspepsia--can we follow dogmatic guidelines in a nuanced reality? Individual management of patients with dyspepsia with risk of stomach ulcer].

A review of subject literature suggests management strategies for the treatment of dyspepsia to be characterised by marked differences. In some strategies the possibility of indirect Helicobacter pylori testing (e g, breath tests) is ignored and endoscopy recommended as the only appropriate investigation; only those with verified disease are treated, and the risk of antibiotic overuse is minimised. In other strategies, indirect H pylori testing is recommended for younger patients (< 45 years of age) without alarming symptoms, either to select patients for endoscopy or to eradicate the infection (i.e., irrespective of whether the patient has peptic ulcer disease or not, on the grounds that the risk of having or developing such disease is thus minimised. The article consists in discussion of the different strategies, and suggests a choice of investigations tailored to the needs of the individual patient to be preferable to dogmatic adoption of either approach, though endoscopy should be available without delay if required. Moreover, the accuracy of the various indirect H pylori tests needs to be considered. To be acceptable for use in primary care, it is suggested that recommendations regarding interventions for the various disorders associated with dyspepsia should be characterised by reasonably comparable risk levels. An algorithm with alternative strategies suited to available facilities and the patient's needs and wishes is also presented.

Blood Chemical Analysis↗
PubMed1996

[Non-ulcer dyspepsia or gastric dyskinesia dyspepsia].

The non ulcer dyspepsia (N.U.D) syndrome is a functional disease; according with new concepts obtained from pharmacology and sustented by therapy, the anti H2 drugs (not the antacids one) has an prokinetic action upon the stomach and control the gastric distention which is the cause of the pain, and not the increase of the gastric acidity. For these reasons and by observing the good response to therapy, the author proposed the name of Gastric Dyskinesia Dyspepsia.

Abdominal Pain↗
PubMed1998

[Determination of gastric emptying time of functional dyspepsia and clinical study on therapeutic effect of Weihuigui decoction on functional dyspepsia].

OBJECTIVE: To observe the gastric emptying time (GET) of and the therapeutic effect of Weihuigui Decoction (WHGD) upon functional dyspepsia (FD). METHODS: GET of 64 FD patients and 20 healthy volunteers was measured by real time ultrasonography. The measurements were performed at fasting, 0, 10, 20, 30, 40 and 50 min after drinking water, the area of gastric antrum, internal diameter of the section of anterior posterior walls in corpus ventriculi fundus junction region, intitating time of gastric contraction and contractive times in 2 min were recorded. Twenty patients selected randomly were treated with WHGD 100 ml, three times a day, for 2 weeks consecutively, to observe the improvement of clinical effect and gastric emptying. RESULTS: GET was delayed in 66% of 64 FD patients as compared with that of control, and it was related with gastric contraction initiating time and contraction times in 2 min. WHGD could improve the clinical symptoms and GET of FD patients. CONCLUSION: WHGD has obvious therapeutic effect in treating FD.

Adolescent↗