Absence Of Alarm Symptoms Research Articles

Protocolo diagnóstico de la pirosis retroesternal

Pyrosis is one of the typical symptoms of gastroesophageal reflux disease. It is one of the most common causes for consultation in primary care and gastrointestinal department clinical practice. In Spain, it has been reported that approximately one out of every three people has pyrosis on a regular basis. Therefore, its diagnosis is of utmost importance. Pyrosis’ favorable response to empirical treatment with proton pump inhibitors allows for diagnosing it in the absence of alarm symptoms. If alarm signs are present, an upper gastrointestinal endoscopy (UGIE) should be performed as soon as possible. Patients who do not respond to medical treatment and whose UGIE does not show abnormalities compatible with gastroesophageal reflux disease should undergo a pH meter test±esophageal impedance testing without treatment.

MICROSCOPIC COLITIS: CONSIDERATIONS FOR GASTROENTEROLOGISTS, ENDOSCOPISTS, AND PATHOLOGISTS.

•Diagnosis of microscopic colitis necessitates effective communication among gastroenterologists, endoscopists, and pathologists. •The gastroenterologist should refer every patient with chronic watery diarrhea to perform a colonoscopy in spite of the benign course of the disease and the absence of alarm symptoms. •The endoscopist should take 2 or 3 biopsy samples of the colonic mucosa from the right and left colon, put in separate recipients, despite that the mucosa looked macroscopically normal. •The pathologist should be encouraged to use objective histological criteria to make the diagnosis. Microscopic colitis is a chronic inflammatory bowel disease characterized by non-bloody diarrhea that can range from mild to severe. It is difficult to attribute up to 10-20% of chronic diarrhea to microscopic colitis. The three determinants factors of the diagnosis are characteristic clinical symptoms, normal endoscopic picture of the colon, and pathognomonic histological picture. This manuscript aimed to update considerations and recommendations for professionals involved (gastroenterologist, endoscopists and pathologist) in the diagnosis of MC. In addition, a short recommendation about treatment.

Paediatric gastrointestinal endoscopy in the Asian-Pacific region: Recent advances in diagnostic and therapeutic techniques.

There has been a rapid expansion in the knowledge of paediatric gastroenterology over the recent decade, with a fast-growing repertoire of diagnostic techniques and management strategies for a wide spectrum of childhood gastrointestinal (GI) diseases. Paediatric GI endoscopy is a core competency every paediatric gastroenterologist should possess, and represents one of the most common procedures performed in children for both diagnostic and therapeutic purposes. Yet there remains a dearth of literature on the utility and outcomes of paediatric GI endoscopy in the Asia-Pacific region. Data on the diagnostic value of paediatric GI endoscopy would be an important aspect of discussion, with the emergence of inflammatory bowel disease (IBD) and eosinophilic GI disease as increasingly common endoscopic diagnoses. Time-based trends in paediatric GI endoscopy do point towards more IBD and gastroesophageal reflux disease-related complications being diagnosed, with a declining incidence of GI bleeding. However, the real-world diagnostic value of endoscopy in Asia must be contextualised to the region-specific prevalence of paediatric GI diseases. Helicobacter pylori infection, particularly that of multidrug-resistant strains, remains a highly prevalent problem in specific regions. Paediatric functional GI disorders still account for the majority of childhood GI complaints in most centres, hence the diagnostic yield of endoscopy should be critically evaluated in the absence of alarm symptoms. GI therapeutic endoscopy is also occasionally required for children with ingested foreign bodies, intestinal polyposis or oesophageal strictures requiring dilation. Endoscopic haemostasis is a potentially life-saving skill in cases of massive GI bleeding typically from varices or peptic ulcers. Advanced endoscopic techniques such as capsule endoscopy and balloon-assisted enteroscopy have found traction, particularly in East Asian centres, as invaluable diagnostic and therapeutic tools in the management of IBD, obscure GI bleeding and intestinal polyposis. State of the art endoscopic diagnostics and therapeutics, including the use of artificial intelligence-aided endoscopy algorithms, real-time confocal laser endomicroscopy and peroral endoscopic myotomy, are expected to gain more utility in paediatrics. As paediatric gastroenterology matures as a subspecialty in Asia, it is essential current paediatric endoscopists and future trainees adhere to minimum practice standards, and keep abreast of the evolving trends in the diagnostic and therapeutic value of endoscopy. This review discusses the available published literature on the utility of paediatric GI endoscopy in Asia Pacific, with the relevant clinical outcomes.

The COVID-19 Pandemic and Post-Infection Irritable Bowel Syndrome: What Lies Ahead for Gastroenterologists

The COVID-19 Pandemic and Post-Infection Irritable Bowel Syndrome: What Lies Ahead for Gastroenterologists

The yield of upper gastrointestinal endoscopy in patients below 60 years and without alarm symptoms presenting with dyspepsia

Background and aims Upper gastrointestinal (GI) endoscopy is frequently performed in patients with upper abdominal symptoms. Although guidelines recommend withholding an endoscopy in the absence of alarm symptoms, dyspeptic symptoms remain a predominant indication for endoscopy. We aimed to investigate the yield of upper GI endoscopy in patients with low-risk dyspeptic symptoms. Methods We conducted an analysis in a prospectively maintained endoscopy reporting database. We collected the results of all upper GI endoscopy procedures between 2015 and 2019 that was performed in adult patients aged <60 years with dyspeptic symptoms. Patients with documented alarm symptoms were excluded. We categorized endoscopic findings into major and minor endoscopic findings. Results We identified 26,440 patients with dyspeptic symptoms who underwent upper GI endoscopy. A total of 13,978 patients were considered low-risk and included for analysis (median age 46 years, interquartile range (IQR) [36–53], 62% female). In 11,353 patients (81.2%), no endoscopic abnormalities were detected. Major endoscopic findings were seen in 513 patients (3.7%) and minor endoscopic findings in 2178 patients (15.6%). Endoscopic findings indicative of upper GI cancer were reported in 47 patients (0.3%), including 16 (0.1%) oesophageal, 28 (0.2%) gastric and 5 (0.04%) duodenal lesions. Despite an initial unremarkable endoscopy result, 1015 of 11,353 patients (8.9%) underwent a follow-up endoscopy after a median of 428 days [IQR 158–819]. This did not lead to the additional identification of malignancy. Conclusions The yield of upper GI endoscopy in low-risk (<60 years, no alarm symptoms) patients with dyspepsia is very limited. This study further supports a restrictive use of upper GI endoscopy in these patients.

Annals for Educators - 16 June 2020.

Annals for Educators - 16 June 2020.

Functional Constipation: Individualising Assessment and Treatment.

Chronic constipation is one of the five most common symptoms seen by gastroenterologist. In the absence of alarm symptoms, a confident symptom-based diagnosis can often be made using the Rome criteria. Three different subtypes have been identified to date: normal transit constipation, defaecatory disorders and slow transit constipation. Differentiation between these subtypes can be made through functional testing using tests such as anorectal manometry with balloon expulsion and a radio-opaque marker test. In general, patients are initially advised to increase their fluid and fibre intake. When these general lifestyle recommendations do not improve patients' symptoms, a step-wise and add-on treatment approach should be applied. This review summarises the diagnostic criteria to differentiate functional constipation from other causes of chronic constipation. In addition, current drug treatment options, including discussion of new therapeutic targets are discussed. Further, practical treatment approaches (choice and dosing), include discussion of combination/augmentation, treatment failure (adherence/expectations), and relapse prevention are mentioned. Finally, treatment and management of pain and bloating aspects are included.

ESNM/ANMS Review. Diagnosis and management of globus sensation: A clinical challenge.

Globus is a non-painful sensation of a tightness or a lump/foreign body in the throat that is not associated with dysphagia and may actually improve during meals. While several otorhinolaryngologic, thyroid, and esophageal disorders have been linked to globus, cause-and-effect relationships are difficult to establish. Consequently, though part of the evaluation, objective otorhinolaryngologic and esophageal testing is often negative. The presence of alarm symptoms, particularly pain, weight loss, dysphagia, or odynophagia is indications for objective testing. A diagnosis of idiopathic globus requires exclusion of pharyngeal, laryngeal, and esophageal disorders with laryngoscopy, endoscopy, high-resolution manometry, barium radiography, and/or ambulatory reflux monitoring. A trial of acid-suppressive therapy may be reasonable in the absence of alarm symptoms, especially if concurrent reflux symptoms are identified. Ablation of heterotopic gastric mucosa in the proximal esophagus has been reported to improve globus symptoms. Beyond these specific approaches, further management of idiopathic globus consists of reassurance, neuromodulators, and complementary approaches. Globus has a benign course with no long-term consequences, and the overall prognosis is good as the magnitude of symptoms may decline over time.

Age is a predictor of significant endoscopic findings in dyspepsia patients in South Africa

Dyspepsia is the commonest indication for endoscopy. Current American guidelines recommend that all dyspepsia patients ≥ 60 years undergo endoscopy to exclude significant pathology. The use of this age cut-off has never been analysed in South Africa. We aimed to compare different age cut-offs as predictors of significant endoscopic findings in patients with a primary diagnosis of dyspepsia. A retrospective chart review of 1 000 consecutive endoscopies done at Madadeni Provincial Hospital, KwaZulu-Natal, from 2014 to 2016 was performed. All patients with dyspepsia were identified and divided into age ≥ 60 and < 60 cohorts and < 45 and ≥ 45 cohorts. Demographic data, significant endoscopic findings (tumour, ulcer, and stricture) and non-significant findings (gastritis, hiatus hernia, candidiasis, and oesophagitis, normal) were recorded. 584 patients (58.4%) presented with dyspepsia, with a median age of 49 years (interquartile range: 14-87). There were 142 males (24.4%) and 442 females (75.6%). 432 (74%) patients in the age < 60 cohort and 152 (26%) in the age ≥ 60 cohort . There were 238 (41%) patients in the < 45 cohort and 346 (59%) patients in the ≥ 45 cohort. In the age < 60 cohort, 6.7% of patients had significant findings, compared to 17.1% of patients in the age ≥ 60 cohort (p-value < 0.001). In the age ≥ 60 cohort, the positive predictive value (PPV) of endoscopy was 17%, negative predictive value (NPV) (93%) and odds ratio (OR) (2.87) p < 0.001. In the age < 45 cohort, 4.2% of patients had significant findings, compared to 13% of patients in the ≥ 45 cohort (p-value < 0.001). In the age ≥ 45 cohort, the PPV was 13%, NPV (96%) and OR (3.41) p < 0.001. There is no overall difference in significant endoscopic findings between the age ≥ 45 and age ≥ 60 groups (p = 0.230). Age is a predictor of significant endoscopic findings in dyspepsia patients. Patients ≥ 60 years with dyspepsia symptoms should undergo a routine endoscopy in the absence of alarm symptoms. The current ACG guidelines can be applied in the South African context.

Utility of Esophagogastroduodenoscopy in the Evaluation of Uncomplicated Abdominal Pain in Children.

Esophagogastroduodenoscopy (EGD) is commonly performed for abdominal pain in children, and in the presence of alarm symptoms, the diagnostic yield of this procedure is high. The aim of this study was to investigate the utility of EGD when performed for uncomplicated abdominal pain in children in the absence of alarm symptoms. Charts of all children less than 18 years of age who underwent EGD at the University of Florida between January 2016 and October 2018 were reviewed. Of 1478 children who underwent EGD for any indication, 287 patients (male-to-female = 123:164) were discovered to have undergone EGD, in the absence of colonoscopy, for uncomplicated acute or chronic abdominal pain, nausea, vomiting, gastroesophageal reflux, and/or dyspepsia, with no alarm symptoms. A significant change in clinical management was noted in 20 (7.0%) children. The findings of this procedure changed clinical management in a minority of our study participants.

Combining Rome III criteria with alarm symptoms provides high specificity but low sensitivity for functional gastrointestinal disorders in children.

This study aimed to validate the Rome III criteria and alarm symptoms with regard to their ability to discriminate between organic and functional diagnoses in children with gastrointestinal complaints. We recruited 258 children aged four years to 17 years who consulted a paediatrician in secondary or tertiary care in Stockholm from January 2013 to May 2014 due to gastrointestinal complaints. A symptom questionnaire based on the official Questionnaire on Pediatric Gastrointestinal Symptoms Rome III, including questions on alarm symptoms, was used. A diagnostic review of their medical records was also carried out. The reference diagnoses were organic (16%), pain-predominant functional gastrointestinal disorders (54%) and other functional diseases (30%). When the reported symptoms that fulfilled the Rome III criteria for pain-predominant functional gastrointestinal disorders were combined with an absence of alarm symptoms, they had a high specificity (0.90) for a functional diagnosis, but a low sensitivity (0.15). Alarm symptoms were equally common in patients with organic (83%) and functional diseases (80%, p = 0.66). Combining the Rome III criteria and an absence of alarm symptoms from patient questionnaires had high specificity but low sensitivity when diagnosing pain-predominant functional gastrointestinal disorders in children seeking medical care for gastrointestinal complaints.

Validation of the Rome III criteria and alarm symptoms for recurrent abdominal pain in children.

Rome criteria were formulated to define functional gastrointestinal disorders (Rome III criteria, 2006) excluding organic diagnoses when alarm symptoms were absent. The aims of the study were to validate the Rome III criteria as to their capacity to differentiate between organic and functional abdominal pain and to assess the role of alarm symptoms in this differentiation. During 2 years all of the patients (ages 4-16 years) presenting with recurrent abdominal pain (Apley criteria) and referred to secondary care were included. Clinical diagnoses were based on protocolized evaluation and intervention with 6-month follow-up. Alarm symptoms were registered. Rome III criteria for functional pain syndromes were assigned independently. Descriptive statistical analyses were performed. In 200 patients (87 boys, mean age 8.8 years), organic (17%), functional (40%), combined organic and functional (9%), spontaneous recovery (27%), and other (8%) clinical diagnoses were established. Alarm symptoms were found in 57.5% (organic causes 56%, functional causes 61%). The evaluation for Rome symptom clusters revealed symptoms of irritable bowel syndrome in 27%, functional dyspepsia in 15%, functional abdominal pain in 28%, functional abdominal pain syndrome in 14.5%, and no pain syndrome in 15.5%. Rome diagnoses, based on symptoms and absence of alarm symptoms, predicted functional clinical diagnosis with sensitivity 0.35 (95% confidence interval 0.27-0.43), specificity 0.60 (0.46-0.73), positive predictive value 0.71 (0.61-0.82), and negative predictive value of 0.24 (0.17-0.32). The Rome III criteria for abdominal pain are not specific enough to rule out organic causes. Alarm symptoms do not differentiate between organic and functional abdominal pain.

Diagnosis and treatment of gastroesophageal reflux disease.

Gastroesophageal reflux disease (GERD) is a common disease with a prevalence as high as 10%-20% in the western world. The disease can manifest in various symptoms which can be grouped into typical, atypical and extra-esophageal symptoms. Those with the highest specificity for GERD are acid regurgitation and heartburn. In the absence of alarm symptoms, these symptoms can allow one to make a presumptive diagnosis and initiate empiric therapy. In certain situations, further diagnostic testing is needed to confirm the diagnosis as well as to assess for complications or alternate causes for the symptoms. GERD complications include erosive esophagitis, peptic stricture, Barrett's esophagus, esophageal adenocarcinoma and pulmonary disease. Management of GERD may involve lifestyle modification, medical therapy and surgical therapy. Lifestyle modifications including weight loss and/or head of bed elevation have been shown to improve esophageal pH and/or GERD symptoms. Medical therapy involves acid suppression which can be achieved with antacids, histamine-receptor antagonists or proton-pump inhibitors. Whereas most patients can be effectively managed with medical therapy, others may go on to require anti-reflux surgery after undergoing a proper pre-operative evaluation. The purpose of this review is to discuss the current approach to the diagnosis and treatment of gastroesophageal reflux disease.

Are alarm symptoms predictive of cancer survival?

BackgroundAlarm symptom presentations are predictive of cancer diagnosis but may also be associated with cancer survival.AimTo evaluate diagnostic time intervals, and consultation patterns after presentation with alarm symptoms, and their association with cancer diagnosis and survival.Design and settingCohort study using the Clinical Practice Research Database, with linked Cancer Registry data, in 158 general practices.MethodParticipants included those with haematuria, haemoptysis, dysphagia, and rectal bleeding or urinary tract cancer, lung cancer, gastro-oesophageal cancer, and colorectal cancer.ResultsThe median (interquartile range) interval in days from first symptom presentation to the corresponding cancer diagnosis was: haematuria and urinary tract cancer, 59 (28–109); haemoptysis and lung cancer, 35 (18–89); dysphagia and gastro-oesophageal cancer, 25 (12–48); rectal bleeding and colorectal cancer, 49 (20–157). Three or more alarm symptom consultations were associated with increased odds of diagnosis of urinary tract cancer (odds ratio [OR] 1.84, 95% CI = 1.50 to 2.27), lung cancer (OR = 1.76, 95% CI = 1.07 to 2.90) and gastro-oesophageal cancer (OR = 2.17, 95% CI = 1.48 to 3.19). Longer diagnostic intervals were associated with increased mortality only for urinary tract cancer (hazard ratio 2.23, 95% CI = 1.35 to 3.69). Patients with no preceding alarm symptom had shorter survival from diagnosis of urinary tract, lung or colorectal cancer than those presenting with a relevant alarm symptom.ConclusionAfter alarm symptom presentation, repeat consultations are associated with cancer diagnoses. Longer diagnostic intervals appeared to be associated with a worse prognosis for urinary tract cancer only. Mortality is higher when cancer is diagnosed in the absence of alarm symptoms.

Funktionelle Magen-Darm-Erkrankungen

Functional dyspepsia (FD) and irritable bowel syndrome (IBS) are the most important functional gastrointestinal diseases (FGID), and both affect about 5-15 % of the German population. The patients' symptoms are caused by disturbances of gastrointestinal (GI) motility, secretion and sensitivity. Central processing of visceral afferences is disturbed, and the course of the disease and individual symptom perception are influenced by psychosocial factors. Diagnosis of FD and IBS is based on a compatible symptom pattern, absence of alarm symptoms and exclusion of relevant differential diagnoses. The diagnosis of FD requires a normal upper GI endoscopy. Current German guidelines also demand a normal colonoscopy for diagnosis of IBS. Basic therapeutic measures include explanation of the nature of the disease and its harmlessness quo ad vitam . Individual trigger factors should be identified and eliminated if possible. Drug therapy of persisting complaints is guided by the dominant symptom.

Application of the Rome III criteria is not likely to reduce the number of unnecessary referrals for colonoscopy in primary care

To determine to what extent the Rome III criteria for irritable bowel syndrome can contribute towards safely reducing unnecessary referrals for colonoscopy in primary care patients with lower gastrointestinal (GI) complaints. Data from the CEDAR study were used: a cross-sectional study in 810 patients with lower GI complaints suggestive for organic bowel disease who were referred by their general practitioner for secondary care colonoscopy. Fulfilment of the Rome III criteria was ascertained by a questionnaire. General practitioners recorded the presence or absence of alarm symptoms. Outcome was determined by colonoscopy and histology. Of 810 participants, 222 fulfilled the Rome III criteria [27%, 95% confidence interval (CI) 24-31%]. The majority of these patients presented with alarm symptoms. Only 39 participants fulfilled the Rome III criteria and lacked alarm symptoms (overall frequency 5%, 95% CI 4-7). Overall, organic bowel disease was diagnosed in 141 participants (17%). Participants who fulfilled the Rome III criteria had a significantly lower risk of organic bowel disease compared with participants who did not [12% (95% CI 8-17) vs. 20% (95% CI 17-23), P<0.01]. The lowest risk was observed in patients without alarm symptoms who fulfilled the Rome III criteria (3%, 95% CI 0-14). A minority of referred primary care patients with lower GI complaints both fulfilled the Rome III criteria for irritable bowel syndrome and lacked alarm symptoms. Although organic bowel disease could be ruled out safely in this small group, application of the Rome III criteria is not likely to lead to a considerable reduction in unnecessary referrals for colonoscopy in these patients.

850 Small Bowel Bacterial Overgrowth is Found in 71% of IBS Patients and Associated Symptoms Respond Well to Rifaximine in a Phase IV Trial

Background: The prevalence of small intestinal bowel bacterial overgrowth (SIBO) in patients with irritable bowel syndrome (IBS) ranges from 43% to 78% as determined by the lactulose hydrogen breath (LHBT) test. Although rifaximine, a non-absorbable antibiotic, has been able to decrease global IBS symptoms as well as bloating in placebo-controlled randomized trials, these results were not repeated in phase IV studies in daily clinical practice. Aim: To assess the prevalence of SIBO in an IBS cohort and to evaluate the treatment response in the IBS cohort affected by SIBO. Methods: Enrolled patients were diagnosed with IBS using the following criteria: fulfillment of the Rome III criteria, absence of alarm symptoms (anemia, weight loss, nocturnal symptoms etc), normal fecal calproectin, normal endoscopic workup including histology. Celiac disease was excluded by serology and/or duodenal biopsy. All patients underwent lactulose hydrogen breath testing (LHBT) for SIBO diagnosis. Patients with SIBO were treated with rifaximine tablets (400mg twice daily for 14 days). Both before and at week 6 after rifaximin treatment, patients completed a questionnaire, where the following criteria were assessed individually using 11-point Likert scales: the bloating, flatulence, abdominal pain, diarrhea, and overall well-being. Results: Hundred-fifty IBS patients were enrolled (76% female, mean age 44 ± 16 years), of whom 106 (71%) were diagnosed with SIBO and consequently treated with rifaximine. Rifaximine treatment significantly reduced the following symptoms as assessed by the symptom questionnaire: bloating (5.5 ± 2.6 before vs. 3.6 ± 2.7 after treatment, p <0.001), flatulence (5 ± 2.7 vs. 4 ± 2.7, p = 0.015), diarrhea (2.9 ± 2.4 vs. 2 ± 2.4, p = 0.005), abdominal pain (4.8 ± 2.7 vs. 3.3 ± 2.5, p <0.001) and resulted in improved overall well-being (3.9 ± 2.4 vs. 2.7 ± 2.3, p <0.001). Thirteen of the 106 treated patients were lost to follow-up (12%). The LHBT was repeated 2-4 weeks after rifaximine treatment in 65/93 (70%) patients. Eradication of SIBO was documented in 85% of all patients (55/65), whereas 15% of patients (10/65) tested positive for SIBO as determined by the LHBT testing. Conclusions: The results of our phase IV trial indicate that a high proportion of IBS patients tested positive for SIBO. IBS symptoms (bloating, flatulence, diarrhea, pain, overall well-being) were significantly diminished following a 2-week treatment with rifaximine. These results support the previous findings of randomized controlled trials that the presence of SIBO is associated with symptom generation in IBS patients and that reduction and/or elimination of SIBO may help to alleviate IBSassociated symptoms.

Clinical usefulness of adherence to gastro-esophageal reflux disease guideline by Spanish gastroenterologists

To investigate usefulness of adherence to gastro-esophageal reflux disease (GERD) guideline established by the Spanish Association of Gastroenterology. Prospective, observational and multicentre study of 301 patients with typical symptoms of GERD who should be managed in accordance with guidelines and were attended by gastroenterologists in daily practice. Patients (aged > 18 years) were eligible for inclusion if they had typical symptoms of GERD (heartburn and/or acid regurgitation) as the major complaint in the presence or absence of accompanying atypical symptoms, such as dyspeptic symptoms and/or supraesophageal symptoms. Diagnostic and therapeutic decisions should be made based on specific recommendations of the Spanish clinical practice guideline for GERD which is a widely disseminated and well known instrument among Spanish in digestive disease specialists. Endoscopy was indicated in 123 (41%) patients: 50 with alarm symptoms, 32 with age > 50 years without alarm symptom. Seventy-two patients (58.5%) had esophagitis (grade A, 23, grade B, 28, grade C, 18, grade D, 3). In the presence of alarm symptoms, endoscopy was indicated consistently with recommendations in 98% of cases. However, in the absence of alarm symptoms, endoscopy was indicated in 33% of patients > 50 years (not recommended by the guideline). Adherence for proton pump inhibitors (PPIs) therapy was 80%, but doses prescribed were lower (half) in 5% of cases and higher (double) in 15%. Adherence regarding duration of PPI therapy was 69%; duration was shorter than recommended in 1% (4 wk in esophagitis grades C-D) or longer in 30% (8 wk in esophagitis grades A-B or in patients without endoscopy). Treatment response was higher when PPI doses were consistent with guidelines, although differences were not significant (95% vs 85%). GERD guideline compliance was quite good although endoscopy was over indicated in patients > 50 years without alarm symptoms; PPIs were prescribed at higher doses and longer duration.

Impact of Pediatric Rome III Criteria of Functional Dyspepsia on the Diagnostic Yield of Upper Endoscopy and Predictors for a Positive Endoscopic Finding

Pediatric Rome III criteria of functional dyspepsia (FD) has eliminated the mandatory use of upper endoscopy and recommended a symptom-based approach. In the absence of alarm symptoms, FD can be positively diagnosed in children having normal physical findings without exclusionary investigations. We aimed to investigate the effectiveness of Rome III guidelines to discriminate organic diseases from FD and to identify the predictors for positive endoscopic findings. A prospective study was conducted on consecutive children fulfilling Rome III criteria of FD. Upper endoscopy was performed in all subjects, both with and without alarm features. Eighty consecutive children ages 7 to 15 were recruited. Nine (11.3%) had experienced alarm features. Five (6.3%) had organic diseases confirmed in upper endoscopy: duodenal ulcer (n = 2), duodenitis with erosion (n = 2), and gastritis with erosion (n = 1), 33.3% of children having alarm features had organic pathology, compared with 2.8% of those without (P < 0.01). A male predominance (80% vs 25.3%, P < 0.01), higher prevalence of alarm features (60% vs 8%, P < 0.01), and higher prevalence of Helicobacter pylori infection (80% vs 5.3%, P < 0.01) were found in children with organic diseases, compared with FD. Multivariate analysis identified H pylori infection (odds ratio 23.2; 95% confidence interval 1.5-333) and nocturnal pain (odds ratio 26.3; 95% confidence interval 1.2-500) to be independent predictors for positive endoscopic findings. Rome III recommendations of screening dyspeptic children for alarm features and investigation for H pylori are effective to identify children who have a higher likelihood of organic diseases and require upper endoscopy before making a diagnosis of FD.

Endoscopy in gastro-oesophageal reflux disease

Although gastro-oesophageal reflux disease is basically a clinical diagnosis, oesophago-gastroduodenoscopy is essential to assess the type and severity of tissue damage. The main role for endoscopy is to detect metaplastic or premalignant changes complicating gastro-oesophageal reflux, and allow for surveillance. Routine biopsies are potentially useful to increase the diagnostic precision in case of minimal mucosal abnormalities. Management algorithms should include endoscopy to be performed early in the course of disease in most patients, even in the absence of alarm symptoms. Routine use of the Los Angeles classification of oesophagitis and the Prague classification for metaplasia is necessary for a precise description and biopsy sampling. Magnification chromoendoscopy is particularly useful in the hands of experienced endoscopists, whereas novel technologies including confocal laser endomicroscopy may become an important method in specialised centres to optimise the surveillance of premalignant mucosa.