Investigation Of Dyspepsia Research Articles

Comparison of patient tolerance and acceptability of magnet-controlled capsule endoscopy and flexible endoscopy in the investigation of dyspepsia.

Background and study aims Oropharyngeal intubation during Esophagogastroduodenoscopy (EGD) is uncomfortable, associated with aerosol generation and transmission of airborne microbes. Less-invasive alternatives may be better tolerated. In this study, patient tolerance and acceptability of EGD and transnasal endoscopy (TNE) have been compared with magnet-controlled capsule endoscopy (MACE). Patients and methods A comparison of MACE with EGD and TNE in the investigation of dyspepsia was performed. Factors affecting patient tolerance and acceptability were examined using the Endoscopy Concerns Scale (ECS) and Universal Patient Centeredness Questionnaire (UPC-Q). Results Patients were significantly more distressed (scoring least to most distress: 1–10) by gagging (6 vs 1), choking (5 vs 1), bloating (2 vs 1), instrumentation (4 vs 1), discomfort during (5 vs 1) and after (2 vs 1) EGD compared to MACE (all P < 0.0001). Patients were more distressed by instrumentation (5 vs 1) and discomfort during (5 vs 1) TNE compared to MACE ( P = 0.001). Patients were more accepting of MACE than EGD and TNE with a UPC-Q score (scoring least to most acceptable: 0–100) lower for EGD (50 vs 98, P < 0.0001) and TNE (75 vs 88, P = 0.007) than MACE, and a post-procedure ECS score (scoring most to least acceptable: 10–100) higher for EGD (34 vs 11, P < 0.0001) and TNE (25 vs 10.5, P = 0.001) than MACE. MACE would be preferred by 83 % and 64 % of patients even if EGD or TNE respectively was subsequently recommended to obtain biopsies in half of examinations. Conclusions Gagging and choking during instrumentation, the main causes of patient distress during EGD, occurred less during TNE but tolerance, acceptability and patient experience favored MACE.

A226 INCIDENTAL FINDING OF A LARGE GASTRIC VARIX ASSOCIATED WITH NEONATAL UMBILICAL VEIN CANALIZATION

Abstract Results A 41-year old Asian male, who immigrated to Canada many years ago, and who had previously been successfully treated for Helicobacter pylori infection underwent gastroscopy for investigation of dyspepsia. His gastroscopy was normal except for a large subepithelial abnormality that was noted close to the gastroesophageal junction. Routine gastric biopsies from the antrum and body were normal. Subsequent endoscopic ultrasound revealed flow through the anechoic tortuous lesion and confirmed it was a very large isolated gastric varix type 1. Abdominal CT scan revealed chronic occlusion of the portal vein, splenic vein, and the portal confluence with extensive collateralization in the upper abdomen. There was complete cavernous transformation of the portal vein. Of the numerous varices in the upper abdomen, a very large varix drained into the left renal vein and indented into the posterior wall of the fundus of the stomach which accounted for the endoscopic finding. Multiple mesenteric veins were identified that connected to varices adjacent to the inferior aspect of the pancreas and duodenum. Notably, there was no evidence of cirrhosis or chronic pancreatitis. Liver enzymes, albumin, and INR were normal. Further collateral history revealed that he was hospitalized as a neonate for pneumonia with catheterization of the umbilical vein, which is known to be associated with thrombosis of the portal vein. Conclusions Detection of congenital absence of the portal vein (CAPV) is recognized more often due to advances in diagnostic imaging. Radiologically, the absence of the portal vein in CAPV is distinguished from portal vein thrombosis by the lack of venous collaterals or sequalae of portal hypertension, such as ascites or splenomegaly. A more gradual thrombosis of the portal vein may permit collaterals to develop without acute changes and is not equivalent to portal vein aplasia or agenesis as intrahepatic bile ducts are normal. The gold standard for diagnosis of CAPV is histologic absence of the portal vein in the liver on catheter angiography. CAPV is associated with abnormal embryologic development of the portal vein and frequently presents with complications of portal hypertension or portosystemic encephalopathy or the sequalae of venous shunts, hepatic or cardiac abnormalities found on imaging. Our case is an incidentally discovered absence of the portal venous system due to chronic thrombosis with extensive collateralization and an enlarged gastric varix protruding into the proximal stomach. It is well documented that canalization of the umbilical vein in infancy is associated with portal vein thrombosis, with incidences up to 68%. This case highlights the importance of eliciting a childhood hospitalization history in cases of non-cirrhotic portal hypertension. Funding Agencies None

Chronic gastritis according to age and Helicobacter pylori in Thailand: histopathological patterns

Objectives We aimed to evaluate the histopathological characteristics of chronic gastritis in dyspeptic patients without visible mucosal lesions in different age groups and different biopsy sites. Methods Patients who underwent upper endoscopy for the investigation of dyspepsia as the sole indication were recruited. We selected data from patients without visible mucosal lesions for the study. Gastric biopsy specimens were evaluated by Update Sydney classification according to age, Helicobacter pylori (Hp), and biopsy sites. Results A total of 626 patients were retrospectively studied. 58.2% had histopathological features of chronic gastritis, while 41.8% had normal gastric mucosa. The prevalence of glandular atrophy, intestinal metaplasia, and Hp infection was 36.7, 19.3 and 36.6%. Complete and incomplete metaplasia was found to be 17.0 and 2.2%. The mean score of chronic inflammation, neutrophil activity, glandular atrophy, and intestinal metaplasia was significantly higher in the antrum than in the corpus. The positivity of gastritis increases with age; however, Hp positivity decreased considerably with advanced age. Concerning gastritis’s topography, antral-predominant gastritis and corpus-predominant gastritis increased with age. The prevalence of glandular atrophy and intestinal metaplasia markedly increased with age, especially after age 50. Gastric atrophy and intestinal metaplasia were significantly higher in patients positive for Hp than in negative patients. Conclusion Overall chronic gastritis is common in dyspeptic patients without visible lesions. Prevalence, grading, and severity of chronic gastritis increase with age and Hp infection. Temporal changes of the gastric mucosa are caused by aging rather than by Hp alone.

Helicobacter pylori: prevalence of antimicrobial resistance in clinical isolates

This study aims to determine the in vitro susceptibility of Helicobacter pylori to clarithromycin, metronidazole, amoxycillin and tetracycline, the four antibiotics commonly used in eradication therapies. These data are used to evaluate the efficacy of current empiric treatment of H. pylori infection in the Southern Region of Ireland. Culture is performed on gastric biopsy samples obtained from 147 consecutive patients undergoing gastroscopy for investigation of dyspepsia. Susceptibility testing to metronidazole, clarithromycin, amoxycillin and tetracycline is performed on the isolates by Etest. Isolates demonstrating clarithromycin resistance are subjected to polymerase chain reaction (PCR) amplification and nucleotide sequence analysis to identify the presence of point mutations in the peptidyltransferase region of the 23S rRNA gene previously associated with resistance to clarithromycin. Prevalence of H. pylori in the population studied was 31% (45 isolates). Antimicrobial resistance to metronidazole and clarithromycin was detected in nine (20%) and four (8.9%) of the isolates, respectively. A single isolate demonstrated co-resistance to metronidazole and clarithromycin (2.2%). No resistance was detected to either amoxycillin or tetracycline. The low level of resistance demonstrated among this group of isolates indicates that the empiric treatment currently in place in the Southern Region of Ireland is likely to be successful.

Stool antigen testing for the diagnosis and confirmation of eradication of Helicobacter pylori infection: a prospective blinded trial

Helicobacter pylori is an established pathogen for a wide spectrum of gastroduodenal diseases. We investigated the usefulness of H. pylori stool antigen test (HpSA) before and after eradication therapy on patients referred for gastroscopy. Over a 12-month period, 127 adult patients (47% males) underwent HpSA and gastroscopy with dual biopsies from the antrum and proximal body of the stomach for urease and histology. The positive patients (histology, urease or combined positive) received triple therapy consisting of clarithromycin 500 mg, amoxycillin 1 g and omeprazole 20 mg, each given twice daily for 7 days. Six weeks post-therapy, eradication was verified with the 13C-urea breath test (UBT) and the HpSA results compared on a second stool sample. Pre-therapy, 23/113 patients were positive by urease test, 22/112 by histology and 22/112 were combined positive. For the HpSA, compared to combined urease and histology as the reference standards, the sensitivity and specificity were 79 and 92% while the positive and negative predictive values (PPV and NPV) were 68 and 96%, respectively. Post-therapy, UBT was adopted as the reference standard and 18 paired samples were available for analysis: three were positive and 15 were negative. Sensitivity and specificity were 67 and 100% while the PPV and NPV were 100 and 94%, respectively. In this prospective study, HpSA was found to be a reasonably useful diagnostic test for H. pylori infection. Post-eradication, it was highly specific and similar to UBT in terms of PPV and NPV. The test is non-invasive and cheaper than the urease test or the UBT, making it a candidate in the investigation of dyspepsia.

Are sinister symptoms useful in predicting serious endoscopic findings in dyspeptic patients?

iNTRODUCTION: Early endoscopy is recommended for investigating dyspeptic patients when sinister symptoms are present. This is based upon the assumption that serious pathology will be more prevalent in patients with such symptoms. The association has never been validated prospectively. AIMS: To compare endoscopic findings in patients referred for investigation of dyspepsia with and without sinister symptoms. METHODS: As part of a large prospective trial, 923 patients aged 3kg, dysphegia, persistent vomiting, recent evidence of GI bleeding, family history of gastric cancer, history of gastric surgery. 215 patients had one or more of these sinister symptoms and were endoscoped. Of the 708 without sinister symptoms, half were randornised to endoscopic examination as part of the trial protocol. The endoscopic diagnosis in the 215 (mean age = 38y) with and 362 (mean age = 35y) without sinister symptoms was compared. RESULTS: Those with and without sinister symptoms had a similar prevalence of normal endoscopy (49% vs 56%), duodenal ulcer (6.9% ve 8.0%), gastric ulcer (4.4% vs 3.9%) and oesopbagitis Gd I (12.5% vs 13.3%) and Gd it (2.3% vs 2.0%) and gastric cancer (0% v 0%). In routine biopsies, low grade MALToma was found in one patient without, and subtotal villous atrophy in one patient with sinister symptoms. Serious oesophageal disease was the only finding more prevalent in those with (6/216) versus without (0/352) sinister symptoms (p<O.05). This consisted of Gd Ill oesophegitis, Barrett's oesophagus and oesophageal cancer in 2, 3 and 1 patient(s) respectively. Five of the 6 patients with severe oesophegeal pathology had dysphegia as their sinister symptom. Dyspbagla was reported by 39.5% of those with sinister symptoms. The prevalence of severe oesopbageal pathology (Gd III oesophagitis, Barrett's oesophagus or oesophegeal cancer) in those with dysphagia was 5/85 (6%). CONCLUSIONS: (1) In the absence of sinister symptoms, serious endoscopic pathology is very rare. (2) The presence of sinister symptoms is associated with an increased prevalence of serious oesophageal pathology (3) Dysphagia is the most important sinister symptom.

Helicobacter pylori and Bleeding Duodenal Ulcer: Prevalence of the Infection and Role of Non-steroidal Anti-inflammatory Drugs

Background: Several authors have reported low prevalence of Helicobacter pylori infection in patients with upper gastrointestinal bleeding (UGIB). Our aim was to study the prevalence of H. pylori in bleeding duodenal ulcer (DU), with both invasive and non-invasive methods, and to assess the role of non-steroidal anti-inflammatory drugs (NSAIDs). Methods: Ninety-two patients with bleeding DU were prospectively studied. The use of NSAIDs was evaluated by specific questionnaire. As a control group, 428 patients undergoing outpatient evaluation for the investigation of dyspepsia and found to have a DU at endoscopy were included. At endoscopy, two antral biopsies were obtained (H&E stain). A 13C-urea breath test was carried out in all patients. Breath test was repeated in patients treated with omeprazole during the hospitalization if H. pylori was not detected with the first test. Results: Gastric biopsies could be obtained in 39 patients with UGIB. Three patients with UGIB treated with omeprazole and being H. pylori negative with the first breath test were finally considered infected with the second test. Overall, 92.4% (95% CI, 85%-96%) of the patients with UGIB were infected (89.7% with histology and 92.4% with breath test (P = 0.15)). Concordance kappa value for both diagnostic tests was 0.64. NSAID intake was more frequent in patients with UGIB (34%) than in those without UGIB (5.6%) (P < 0.001), while H. pylori infection was less frequent in patients with UGIB (92.4% (85%-96%)) than in those without UGIB (99.1% (98%-100%); P < 0.001). Even in patients with UGIB, NSAID intake was the only risk factor in 5% of cases. The proportion of cases without H. pylori infection and without NSAID intake was very low in both bleeding and non-bleeding ulcers (2% and 0.5%, respectively; P = 0.146). H. pylori prevalence in bleeding ulcers was of 84% (67%-93%) in patients with NSAID intake, and 96.7% (89%-99%) when patients taking NSAIDs were excluded. In the multivariate analysis, NSAID intake (odds ratio, 9.8 (5.2-18.4)) correlated with UGIB; however, neither H. pylori status nor the interaction between H. pylori infection and NSAID intake correlated with UGIB. In the multivariate analysis in the subgroup of patients with UGIB, NSAID use was the only variable which correlated with H. pylori prevalence (odds ratio, 0.18 (0.03-0.97)). Conclusions: The most important factor associated with H. pylori-negative bleeding DU is NSAID use, and if this factor is excluded prevalence of infection is almost 100% (97%), similar to that found in patients with non-bleeding DU (and without NSAID intake). Bleeding DU patients with neither H. pylori infection nor NSAID use are extremely rare (only 2%), which suggests that the pathogenesis of bleeding DU is similar to that of non-complicated DU disease.

Should non-invasive Helicobacter pylori testing replace endoscopy in investigation of dyspepsia?

Our knowledge of Helicobacter pylori infection is now changing the way in which we investigate patients presenting with dyspepsia, with noninvasive H. pylori testing replacing endoscopy. Non-invasive H. pylori testing has been shown to be useful in predicting the underlying diagnosis in patients presenting with dyspepsia. Several studies have shown that 20-50% of dyspeptic patients with a positive H. pylori test will have evidence of underlying ulcer disease or duodenitis. In contrast, less than 5% of dyspeptic patients with a negative H. pylori test will have evidence of ulcer disease and in these subjects, the likeliest diagnosis is gastroesophageal reflux disease. This has led to many groups recommending that noninvasive H. pylori testing should be used in place of endoscopy, with all those testing positive being given anti-H. pylori therapy and those testing negative being treated symptomatically. One concern about nonendoscopic management of dyspeptic patients is the possibility of missing underlying malignancy but studies have shown that in western countries this is rare in patients less than 55 years of age presenting with dyspepsia in the absence of sinister symptoms. There is increasing evidence supporting eradication of H. pylori infection in dyspeptic patients without ulcer disease. Meta-analysis of four prospective randomized trials indicates that such treatment is superior to placebo in about 10% of subjects. H. pylori-positive dyspeptic patients are also recognized to have an increased risk of developing ulcer disease in the future which will be removed by treating the infection. Another justification for eradicating the infection in the absence of ulcer disease is the fact that H. pylori infection is now proven to be a risk factor for gastric cancer. Prospective randomized studies comparing endoscopy with noninvasive H. pylori testing in the management of dyspeptic patients indicate that managing dyspepsia by noninvasive H. pylori testing is at least as effective as endoscopic-based management in producing symptomatic resolution and saves a substantial number of endoscopic procedures. There is therefore now substantial evidence indicating that noninvasive H. pylori testing should be used in place of endoscopy to determine the management of younger dyspeptic patients without sinister symptoms and who are not taking nonsteroidal anti-inflammatory drugs.

Gastroduodenal Mucosal Vitamin-C Levels in Helicobacter pylori Infection

Background: Vitamin C is an important endogenous antioxidant, and epidemiologic evidence suggests that it may protect against the development of gastric cancer. We therefore determined mucosal vitamin-C levels in the stomach and duodenum of subjects with and without Helicobacter pylori infection. Methods: The patients were 30 subjects undergoing routine gastroscopy for investigation of dyspepsia. High-performance liquid chromatography with electrochemical detection was used to determine mucosal ascorbic acid and total vitamin-C levels. Results: In H. pylori-negative subjects with normal gastroduodenal histology the antrum contained significantly higher levels of ascorbic acid and total vitamin C than the corpus or duodenum (P < 0.05). No significant changes were seen in gastric mucosal ascorbic acid or total vitamin-C levels in the presence of H. pylori infection and related inflammation. The presence of gastric atrophy did not affect mucosal ascorbic acid or total vitamin C levels. Duodenal ascorbic acid and total vitamin-C levels did not change significantly in the presence of gastric H. pylori or duodenal inflammation. Conclusions: Although high levels of vitamin C are present in the gastroduodenal mucosa, these are not altered in the presence of H. pylori infection and inflammation. These observations suggest that the mucosal antioxidant potential of vitamin C is not impaired by H. pylori infection.

Family history of peptic ulcer and a positive 13C urea breath test are predictive of gastroduodenal ulcer disease in uninvestigated dyspeptic patients

Background/Aim: H. pylori (HP) infection plays an important role in the pathogenesis of peptic ulcer disease. As dyspeptic symptoms are common in the general population, cost-effective strategies have attempted to substitute endoscopy with non-invasive tests for HP status. In this study we evaluated the ability of the 13C urea breath test and other risk factors to predict peptic ulcer disease. Methods: Patients referred to our Gastrointestinal Unit for investigation of dyspepsia were invited to take part in the study. Exclusion criteria were: previous dyspepsia workup, chronic treatment with NSAIDs and use (within the last month) of antibiotics, PPI, H2RA, bismuth preparations. Two hundred seven consecutive dyspeptic patients answered a standard questionnaire and were submitted to the 13C urea breath test and upper gastrointestinal endoscopy (FUJINON EG7-HR2). The Pearson Chi-square test, followed by Logistic regression analysis, was used to identify risk factors independently associated with peptic ulcer disease. Results: The study population included 118 HP-positive (mean age: 47:1: 13; M/F ratio=l.03) and 89 HP-negative (mean age: 38:1: 16; M/F ratio=l.02). Peptic ulcer disease (gastric or duodenal ulcer and erosive duodenitis) was found in 44 patients (21.3%), 37 HP-positive (31.4%) and 7 HP-negative (7.8%). HP infection (p < 0.0001), family history of peptic ulcer disease (p < 0.0001) and male sex (p < 0.005) were significantly associated with endoscopic findings of peptic ulcer disease. Logistic regression analysis revealed, however, that only the former two (OR=2.70, multivariate p < 0.001; OR=2.72, multivariate p < 0.0001, respectively) were significant independent predictors of peptic ulcer disease. Conclusions: Our results confirm that non-invasive H. pylori testing can predict gastroduodenal ulcer disease, particularly when the family history is positive for the latter. This fact should be considered in developing costeffective strategies for the workup of dyspepsia.

Nonulcer Dyspepsia: A Look Into the Future

Nonulcer Dyspepsia: A Look Into the Future

Does age affect barium meal requests for investigation of dyspepsia or reflux oesophagitis

Does age affect barium meal requests for investigation of dyspepsia or reflux oesophagitis

Definition and investigation of dyspepsia. Consensus of an international ad hoc working party.

The dyspeptic patient presents a common and difficult problem in clinical practice. Careful evaluation of symptoms may be unrewarding; however, a thorough clinical and screening psychiatric evaluation are essential. Upper gastrointestinal endoscopy or upper gastrointestinal radiology and ultrasonic examination of the biliary tract and pancreas should be the first investigations. In patients in whom these are noncontributory and in whom symptoms persist, evaluation of upper gastrointestinal function (secretory, motor, provocation tests) may be indicated to determine the cause of functional dyspepsia and to allow appropriate management.