Severe Dyspeptic Symptoms Research Articles

A34 GLUTEN-FREE DIET IMPROVES DYSPEPTIC SYMPTOMS IN PATIENTS WITH TYPE 1 DIABETES IN WHOM CELIAC DISEASE WAS EXCLUDED

BackgroundPatients with type 1 Diabetes Mellitus (T1DM) often suffer from dyspeptic symptoms, such as abdominal pain, bloating, early satiety, nausea and vomiting. T1DM shares genetic risk factors (HLA-DQ2 and DQ8) with celiac disease, an autoimmune disorder caused by an immune reaction to gluten. Patients with concomitant T1DM and celiac disease benefit from a gluten-free diet (GFD), as it improves their symptoms, gastric emptying and small intestinal inflammation. However, it is unknown whether GFD has any benefit in patients with T1DM without celiac disease, who present with symptoms of dyspepsia or gastroparesis.AimsTo investigate the role of a GFD in the management of moderate to severe dyspeptic symptoms in non-celiac patients with T1DM.MethodsWe enrolled 13 adult T1DM patients, in whom celiac disease was ruled out, suffering from two or more upper GI symptoms. The patients were instructed to adhere to a strict GFD for a period of 1 month, under the supervision of a dietitian. Glycemic levels were monitored by a continuous glucose monitoring device (CGM) for 2 weeks before, and at the end of the GFD period. Standardized questionnaires were used to assess upper GI symptoms (Gastroparesis Cardinal Symptoms Index, Short Form Leeds Dyspepsia questionnaire), general quality of life (Patient Assessment of Upper GI Disorders Quality of Life), and anxiety and depression (Hospital Anxiety Depression scale). Blood samples were collected to assess glycaemia (Hb1Ac) and immune markers. Scintigraphy and videofluoroscopy were used to assess gastric emptying.ResultsAfter one month on a GFD, T1DM patients reported a significant improvement in nausea (p<0.05), sensation of fullness (p<0.001) and bloating (p<0.0001). Overall dyspepsia symptoms also improved (p<0.01), with 92% of patients reporting decreased dyspepsia scores. Moreover, there was an improvement in the quality of life (p<0.01), and decreased scores of anxiety and depression (p<0.01 and p<0.05, respectively). There were no changes in gastric emptying or glycemic management metrics, such as mean glucose level, time in target, glucose variance or HbA1c levels. Interestingly, one year after the end of the study, 63.6% of participants continued to follow a GFD. The most common reason to remain on a GFD reported by these patients was “because it improved GI symptoms”. Questionnaire data collected at the follow-up demonstrated that the improvement of dyspeptic symptoms persisted after 1 year on GFD (p<0.001).ConclusionsGFD improves dyspeptic symptoms in T1D patients without concomitant celiac disease, without affecting their glycemic levels or gastric emptying. Although these results need to be validated in a larger study, our data suggest that GFD could be used as a therapeutical tool for T1DM patients grappling with burdensome upper GI symptoms. Gluten-Free diet improves dyspepsia symptoms in Type 1 Diabetes patients, after 1 month and 1 yearFunding AgenciesCIHR

Isolated Congenital Bronchoesophageal Fistula in a Pediatric Patient: Case Report

Abstract Introduction/Objective Congenital bronchoesophageal fistula (BEF) results from an undue passageway caudal to the foregut lung anlage. BEF may be associated with esophageal atresia and commonly involves the right lung. Herein we present a pediatric case of isolated congenital BEF masqueraded by severe dyspeptic symptoms. Methods A five-year-old child with a longstanding history of gastroesophageal reflux was hospitalized because of acute onset sharp lower chest/epigastric abdominal pain associated with emesis. Imaging disclosed a left lung abscess and empyema that responded to intravenous antibiotics, chest tPA instillation and drainage. After resolution of her empyema, she experienced severe dysphagia, chocking sensation, vomiting, and intermittent hematemesis. Esophogram disclosed a fistulous tract to the left lower chest cavity. Esophagoscopy revealed severe esophagitis and a stricture just proximal to a 0.6 to 0.8 cm ostium of a fistulous tract at 26 cm from the incisors, 2 cm above the gastroesophageal junction. Results A 103 g, 12 x 7.5 x 5.0 cm thoracoscopic left lower lobectomy showed a focally ulcerated fistulous tract that entered a 1.9 cm in diameter cyst that connected to a basilar-medial segmental bronchus. The passage was lined by stratified squamous epithelium, continuous with columnar ciliated epithelium, and was surrounded by intense chronic inflammation. The fistulous lumen contained partially degraded vegetable matter. Diagnosing BEF can be clinically challenging. Symptoms are often intermittent, alternating between digestive and pulmonary in nature. Often, cough, gastroesophageal reflux, pneumonia, and bronchopulmonary suppuration can lead to medical management that is only masking, not definitively treating the underlying pathology. While tracheoesophageal fistulas are relatively common in presentation, and usually diagnosed in the newborn period, BEFs are rare and with varied clinical expression, which may explain delayed diagnosis. Conclusion BEF is a rare anomaly that may manifest ambiguous symptoms, thus delaying the diagnosis and options for earlier, less invasive curative interventions.

A193 GLUTEN-FREE DIET IMPROVES DYSPEPSIA-LIKE SYMPTOMS IN A PILOT STUDY OF PATIENTS WITH TYPE 1 DIABETES MELLITUS

Abstract Background Patients with type 1 Diabetes Mellitus (T1DM) often suffer with gastrointestinal (GI) symptoms, such as abdominal pain, bloating, early satiety, nausea and vomiting. T1DM patients are at a higher risk to develop celiac disease, and those patient with both disorders benefit from a gluten-free diet (GFD). However, it is unknown whether GFD has any benefit in patients with T1DM without celiac disease who present with upper GI symptoms. Aims To investigate the role of GFD in the management of moderate to severe dyspeptic symptoms in non-celiac patients with T1DM. Methods We enrolled adult T1DM patients, in whom celiac disease was ruled out by serology and/or endoscopy, suffering with two or more of upper GI symptoms. The patients were instructed to undergo a strict GFD for a period of 1 month, under supervision of a dietitian. Glycemic levels were monitored by a continuous glucose monitoring device (CGM) for 2 weeks before, and for 2 weeks at the end of the GFD period. Upper GI symptoms, general quality of life, anxiety and depression were assessed using standardized questionnaires. Blood samples were collected to assess glycaemia (Hb1Ac) and lipid profiles. Scintigraphy and videofluoroscopy were used to assess gastric emptying. Results Seven patients finished the study so far. They reported a significant improvement in nausea (p&amp;lt;0.05), sensation of fullness (p&amp;lt;0.01), bloating (p&amp;lt;0.01), feeling of excessive fullness after meals (p&amp;lt;0.01) and having stomach visibly larger after meals (p&amp;lt;0.01). 5 out of the 7 patients reported an improvement in general quality of life, based on PAGI-QOL (Patient Assessment of Upper Gastrointestinal Disorders – Quality of Life), and decreased anxiety levels (HADS, Hospital Anxiety and Depression Score). There was no significant change in mean glucose level, time in target, glucose variance and HbA1c levels after GFD. However, there was a trend for less time spent in hypoglycemia, namely in those patients who experienced frequent hypoglycemia prior to GFD. Overall, there was no change in serum lipid profile or gastric emptying. Conclusions One month of GFD improved dyspepsia-like symptoms, general quality of life and anxiety levels in T1D patients without concomitant celiac disease. GFD also improved the blood glucose management of patients with frequent hypoglycemia. Thus, this dietary intervention appears to improve upper GI symptoms in T1D patients but the results need to be replicated in a larger patient cohort. Funding Agencies CIHR

Noninvasive Helicobacter pylori Diagnostic Methods in Indonesia.

Although the prevalence of Helicobacter pylori infection in Indonesia is lower than that in other countries, H. pylori is still an essential pathogen associated with severe gastric mucosal damage and dyspeptic symptoms. Invasive diagnostic methods are not ideal due to the lack of endoscopic centers and high costs without full coverage by social insurance. Among the noninvasive methods, the urea breath test is widely available in Indonesia and has been suggested as the primary option to ensure the successful eradication of H. pylori. There has been no local validation for the urea breath test utilizing 13C or 14C. The stool antigen test is inexpensive and suitable for use in active infections before and after eradication; however, customs and habits are obstacles to delivering fresh stool on time. Only polyclonal antibodies and qualitative stool antigen test kits with low sensitivity are available. Serology is a widely validated method and has good accuracy, but it cannot distinguish between active and inactive infections. According to our observations, serology is the main choice of experts and patients, as it is simple, inexpensive and widely known. The urine test is an alternative for reducing costs and endoscopic workload, with high accuracy but low sensitivity. Further studies are necessary to prove the validity of the urine test to be used throughout Indonesia, especially in areas with a low prevalence of H. pylori infection. In conclusion, the validated urea breath test and the stool antigen test are considered noninvasive practical approaches for the detection of H. pylori infection in Indonesia, with serological and urine tests as alternatives.

A splenic artery aneurysm presenting with multiple episodes of upper gastrointestinal bleeding: a case report

BackgroundSplenic artery aneurysm is rare and its diagnosis is challenging due to the nonspecific nature of the clinical presentation. We report a case of a splenic artery aneurysm in which the patient presented with chronic dyspepsia and multiple episodes of minor intragastric bleeding.Case presentationA 60-year-old, previously healthy Sri Lankan man presented with four episodes of hematemesis and severe dyspeptic symptoms over a period of 6 months. The results of two initial upper gastrointestinal endoscopies and an abdominal ultrasound scan were unremarkable. A third upper gastrointestinal endoscopy detected a pulsatile bulge at the posterior wall of the gastric antrum. A contrast-enhanced computed tomogram of his abdomen detected a splenic artery aneurysm measuring 3 × 3 × 2.5 cm. While awaiting routine surgery, he developed a torrential upper gastrointestinal bleeding and shock, leading to emergency laparotomy. Splenectomy and en bloc resection of the aneurysm with the posterior stomach wall were performed. Histology revealed evidence for a true aneurysm without overt, acute, or chronic inflammation of the surrounding gastric mucosa. He became completely asymptomatic 2 weeks after the surgery.ConclusionsSplenic artery aneurysms can result in recurrent upper gastrointestinal bleeding. The possibility of impending catastrophic bleeding should be remembered when managing patients with splenic artery aneurysms after a minor bleeding. Negative endoscopy and ultrasonography should require contrast-enhanced computed tomography to look for the cause of recurrent upper gastrointestinal bleeding.

Sa1343 Effects of GC7101, a Novel Prokinetic Agent on Gastric Motor Function: In Vitro Study

G A A b st ra ct s 62.5% vs. 27.3%)and severe somatic symptom severity (PHQ-15; 31.3% vs. 1.8%). Consistent with differences in overall physical and emotional function as captured by the MSIS29, MS patients with dyspepsia had a significantly worse quality of life based on the PAGIQOL (3.09 +/-0.29 vs. 4.09 +/0.11). Using bivariate analysis, the MSIS-29 subscores, HADS scores for anxiety and depression, and PHQ-15 scores significantly correlated with the PAGI-SYM total score. Using a stepwise forward regression modeling strategy, only the PHQ-15 and the MSIS 29 physical subscores independently predicted the severity of dyspepsia. CONCLUSIONS: Moderate to severe dyspeptic symptoms commonly affect MS patients and significantly impair their quality of life. Our findings suggest that dyspeptic symptom severity is principally associated with the physical rather than the emotional manifestations of MS disease.

Sa1347 Association Between the C825T Polymorphism of the G Protein Beta3-Subunit Gene and Functional Dyspepsia: A Meta-Analysis

G A A b st ra ct s 62.5% vs. 27.3%)and severe somatic symptom severity (PHQ-15; 31.3% vs. 1.8%). Consistent with differences in overall physical and emotional function as captured by the MSIS29, MS patients with dyspepsia had a significantly worse quality of life based on the PAGIQOL (3.09 +/-0.29 vs. 4.09 +/0.11). Using bivariate analysis, the MSIS-29 subscores, HADS scores for anxiety and depression, and PHQ-15 scores significantly correlated with the PAGI-SYM total score. Using a stepwise forward regression modeling strategy, only the PHQ-15 and the MSIS 29 physical subscores independently predicted the severity of dyspepsia. CONCLUSIONS: Moderate to severe dyspeptic symptoms commonly affect MS patients and significantly impair their quality of life. Our findings suggest that dyspeptic symptom severity is principally associated with the physical rather than the emotional manifestations of MS disease.

Helicobacter pylori infection and gastroduodenal lesions in children with chronic kidney disease stage V

This study aimed to investigate the dyspeptic symptoms, endoscopic findings, and frequency of Helicobacter pylori (Hp) infection in children with chronic kidney disease (CKD) stage V, and to compare findings in peritoneal dialysis (PD) and hemodialysis (HD) patients. Sixty-five patients on PD (n = 36) or HD (n = 29) were included. Age, gender, duration and type of dialysis, and dyspeptic complaints were recorded. All patients underwent endoscopy. Rapid urease tests were performed in all patients and antral biopsy examinations done in suitable patients to investigate presence of Hp infection. The mean age of patients (55 % male) was 13.9 ± 3.6 years. Frequency of dyspepsia was 43 % and was similar in HD and PD groups. The most frequent dyspeptic symptoms were early satiety (21.5 %) and bloating (17 %). Abnormal endoscopic findings were present in 81.5 % of patients (similar in both groups), and the most common lesion was gastritis (35.5 %). Hp positivity was determined in 37 % of the patients, which was similar in both groups. No significant relationship was found between dyspeptic symptoms and Hp infection. Hp infection was found to be significantly higher in 41.5 % of the patients with gastroduodenal lesions. Abnormal endoscopic findings were significantly higher in severely dyspeptic patients (88.9 %). We think performing an upper gastrointestinal tract examination and Hp screening may be helpful in renal transplant candidates with severe dyspeptic symptoms.

Pediatric Patients With Dyspepsia Have Chronic Symptoms, Anxiety, and Lower Quality of Life as Adolescents and Adults

Little is known about long-term health outcomes of children with dyspeptic symptoms. We studied the natural history of pediatric patients with dyspeptic symptoms, with and without histologic reflux, compared with healthy controls. We performed a prospective study of consecutive new patients, ages 8-16 years, who underwent evaluation for dyspepsia, including upper endoscopy. Patients were assigned to groups with histologic evidence of reflux esophagitis (n = 50), or normal histology results (n = 53). Healthy children were followed up as controls (n = 143). Patients and controls were evaluated 5-15 years later. They provided self-reports on severity of dyspeptic symptoms, use of acid suppression, quality of life, anxiety, and depression. When the study began, the groups with histologic evidence of esophagitis and normal histologies did not differ in severity of dyspeptic symptoms, functional disability, or depression. After a mean 7.6-year follow-up period, each group had significantly lower quality-of-life scores and more severe dyspeptic symptoms and functional disability than controls, but did not differ significantly from each other; both groups were significantly more likely than controls to meet criteria for an anxiety disorder. At time of follow-up evaluation, use of acid-suppression medication was significantly greater in the group with histologic evidence for esophagitis, compared with patients who had normal histology findings when the study began. Among pediatric patients with dyspepsia evaluated by endoscopy and biopsy, those with histologic evidence for esophagitis or normal histology findings are at increased risk for chronic dyspeptic symptoms, anxiety disorder, and reduced quality of life in adolescence and young adulthood.

Comparative genomics of Helicobacter pylori and the human-derived Helicobacter bizzozeronii CIII-1 strain reveal the molecular basis of the zoonotic nature of non-pylori gastric Helicobacter infections in humans.

BackgroundThe canine Gram-negative Helicobacter bizzozeronii is one of seven species in Helicobacter heilmannii sensu lato that are detected in 0.17-2.3% of the gastric biopsies of human patients with gastric symptoms. At the present, H. bizzozeronii is the only non-pylori gastric Helicobacter sp. cultivated from human patients and is therefore a good alternative model of human gastric Helicobacter disease. We recently sequenced the genome of the H. bizzozeronii human strain CIII-1, isolated in 2008 from a 47-year old Finnish woman suffering from severe dyspeptic symptoms. In this study, we performed a detailed comparative genome analysis with H. pylori, providing new insights into non-pylori Helicobacter infections and the mechanisms of transmission between the primary animal host and humans.ResultsH. bizzozeronii possesses all the genes necessary for its specialised life in the stomach. However, H. bizzozeronii differs from H. pylori by having a wider metabolic flexibility in terms of its energy sources and electron transport chain. Moreover, H. bizzozeronii harbours a higher number of methyl-accepting chemotaxis proteins, allowing it to respond to a wider spectrum of environmental signals. In this study, H. bizzozeronii has been shown to have high level of genome plasticity. We were able to identify a total of 43 contingency genes, 5 insertion sequences (ISs), 22 mini-IS elements, 1 genomic island and a putative prophage. Although H. bizzozeronii lacks homologues of some of the major H. pylori virulence genes, other candidate virulence factors are present. In particular, we identified a polysaccharide lyase (HBZC1_15820) as a potential new virulence factor of H. bizzozeronii.ConclusionsThe comparative genome analysis performed in this study increased the knowledge of the biology of gastric Helicobacter species. In particular, we propose the hypothesis that the high metabolic versatility and the ability to react to a range of environmental signals, factors which differentiate H. bizzozeronii as well as H. felis and H. suis from H. pylori, are the molecular basis of the of the zoonotic nature of H. heilmannii sensu lato infection in humans.

Serotonin receptor 3A polymorphism c.-42C &gt; T is associated with severe dyspepsia

BackgroundThe association between anxiety and depression related traits and dyspepsia may reflect a common genetic predisposition. Furthermore, genetic factors may contribute to the risk of having increased visceral sensitivity, which has been implicated in dyspeptic symptom generation. Serotonin (5-HT) modulates visceral sensitivity by its action on 5-HT3 receptors. Interestingly, a functional polymorphism in HTR3A, encoding the 5-HT3 receptor A subunit, has been reported to be associated with depression and anxiety related traits. A functional polymorphism in the serotonin transporter (5-HTT), which terminates serotonergic signalling, was also found associated with these psychiatric comorbidities and increased visceral sensitivity in irritable bowel syndrome, which coexistence is associated with higher dyspeptic symptom severity. We investigated the association between these functional polymorphisms and dyspeptic symptom severity.MethodsData from 592 unrelated, Caucasian, primary care patients with dyspepsia participating in a randomised clinical trial comparing step-up and step-down antacid drug treatment (The DIAMOND trial) were analysed. Patients were genotyped for HTR3A c.-42C > T SNP and the 44 bp insertion/deletion polymorphism in the 5-HTT promoter (5-HTTLPR). Intensity of 8 dyspeptic symptoms at baseline was assessed using a validated questionnaire (0 = none; 6 = very severe). Sum score ≥20 was defined severe dyspepsia.ResultsHTR3A c.-42T allele carriers were more prevalent in patients with severe dyspepsia (OR 1.50, 95% CI 1.06-2.20). This association appeared to be stronger in females (OR 2.05, 95% CI 1.25-3.39) and patients homozygous for the long (L) variant of the 5-HTTLPR genotype (OR 2.00, 95% CI 1.01-3.94). Females with 5-HTTLPR LL genotype showed the strongest association (OR = 3.50, 95% CI = 1.37-8.90).ConclusionsThe HTR3A c.-42T allele is associated with severe dyspeptic symptoms. The stronger association among patients carrying the 5-HTTLPR L allele suggests an additive effect of the two polymorphisms. These results support the hypothesis that diminished 5-HT3 mediated antinociception predisposes to increased visceral sensitivity of the gastrointestinal tract. Moreover, the HTR3A c.-42C > T and 5-HTTLPR polymorphisms likely represent predisposing genetic variants in common to psychiatric morbidity and dyspepsia.

Characterization of Multiple Helicobacter bizzozeronii Isolates From a Finnish Patient With Severe Dyspeptic Symptoms and Chronic Active Gastritis

Helicobacter pylori is the primary cause of gastritis and peptic ulceration in humans. In a minority of patients with upper gastrointestinal symptoms, long tightly coiled spiral bacteria, provisionally named "Helicobacter heilmannii," are observed in gastric biopsies. These bacteria are extremely fastidious and only one previous study has succeeded in obtaining an isolate in vitro. We used two different selective media to isolate "H. heilmannii" from the gastric mucosa of a Finnish patient presenting with severe dyspeptic symptoms. The isolates were characterized by testing for urease and catalase activity, by using light and electron microscopy, and by sequencing of the partial 16S rRNA and ureAB genes. Single-enzyme amplified fragment length polymorphism (sAFLP) was used to analyze the genetic diversity among the isolates. We obtained 15 isolates from different gastric biopsies prior and three after unsuccessful treatment of the patient. The isolates were identified as Helicobacter bizzozeronii. Eradication therapy was unsuccessful most probably due to high level of resistance to metronidazole. Persistent colonization by the same H. bizzozeronii clone was confirmed by sAFLP, however, small differences between the profiles suggested long-term colonization of the patient. Helicobacter bizzozeronii remains the only "H. heilmannii" species isolated from human gastric mucosa although it has been an infrequent observation among "H. heilmannii"-infected patients in PCR-based screening studies. The relevance of H. bizzozeronii and other potentially zoonotic gastric Helicobacter spp. in human disease remains to be determined.

Drinking Capacity and Severity of Dyspeptic Symptoms During a Water Load Test After Nissen Fundoplication

Up to 30% of subjects undergoing Nissen fundoplication develop dyspeptic symptoms. Previous studies using the water load test have shown that functional dyspepsia patients have a diminished drinking capacity due to increased visceral sensitivity. Here we investigate drinking capacity and severity of symptoms in 9 patients with dyspeptic symptoms after fundoplication, 9 patients without symptoms after surgery, 18 functional dyspepsia patients, and 18 controls. The water load test was performed by having subjects drinking room-temperature tap water at a predetermined rate of 15 ml/min. The presence and severity of symptoms during the test were evaluated every 5 min using a Likert scale. We found that patients with dyspeptic symptoms after fundoplication had a significantly lower drinking capacity and higher symptoms scores than controls (P<0.05) but values similar to those of functional dyspepsia patients (P>0.05). In contrast, drinking capacity in patients without symptoms after surgery was similar to that in controls (P>0.05). These findings suggest that, as in functional dyspepsia, severe dyspeptic symptoms after Nissen fundoplication are associated with an impaired drinking capacity, reflecting visceral hypersensitivity or impaired gastric accommodation or both.

Prospective 14- to 18-year follow-up study after parietal cell vagotomy.

One hundred and thirty-five patients underwent elective parietal cell vagotomy for duodenal, pyloric or prepyloric ulcers. The patients were followed prospectively at intervals of 1-3 years in order to detect postvagotomy symptoms and recurrent ulcers; 14-18 years after surgery 106 patients were studied with regard to recurrent ulceration and 84 concerning postvagotomy symptoms. Thirty-two patients (30 per cent) had developed proven recurrent ulcers and a further 9 per cent were suspected of having recurrences. Two patients were reoperated for gastric outlet obstruction and one for bile reflux gastritis. Four patients had severe dyspeptic symptoms and four severe dyspepsia plus dumping. No patient had severe diarrhoea. Forty-three patients were regarded as failures after parietal cell vagotomy. After treatment of these failures 88 per cent of the patients available for subsequent follow-up had satisfactory results. The alternatives to parietal cell vagotomy are discussed. It is concluded that although parietal cell vagotomy has a high long-term recurrence rate, this disadvantage is outweighed by the low incidence severe postvagotomy symptoms.

Controversies in dyspepsia

Even in the absence of visible lesions like an ulcer, cancer or oesophagitis, patients with functional dyspepsia may complain of severe dyspeptic symptoms and have a poor quality of life. Characteristically, these patients also often have a low estimate of their own health and have complaints from several organ systems. The cause of the disease is not known. Both central nervous system and gastric disturbances appear to be involved, and their relative importance is controversial. There is no clear beneficial effect of acid suppression or H. pylori eradication although effects of such therapy may be seen in minor subgroups. New findings emphasise the importance of distinguishing between functional dyspepsia and gastro-oesophageal reflux disease, which exhibit completely different gastric accommodation patterns to a meal and have very different therapeutic potential. The effect of drugs like glyceryl trinitrate, glucagon, sumatriptan and buspirone which all concomitantly improve symptoms and gastric accommodation support the important role of abnormal gastric accommodation to meals in patients with functional dyspepsia. A hypothetical model for the pathogenesis of functional dyspepsia is presented. It incorporates four established abnormalities: various psychological abnormalities, low vagal tone, impaired gastric relaxation, and visceral hypersensitivity, in a logical interplay along the brain-gut axis.

The role of gender and bowel habit predominance on visceral perception in IBS

toms and 0ol over time, there were subgroups of patients which showed no improvement of 9ol (O-) or dyspeptic symptoms (S-) after 1 year (26.7% and 28.1%) and 2 years (22.4% and 21.0%). Although of similar size these two subgroups were not identical, with about half of each group showing overlap (S-/O13.3%, S-/Q + 14.9%, S +/O13.4%, S +/Q + 58.4%). Compared with responder (S+/Q+), S-/Qshowed more male (49% vs 39%) and S-/G+ more female (67% vs. 61%). Symptom non-resonders (S-) showed a higher age (52 vs. 48 y.), a lower prevalence of smoking (22.4 vs. 28.7%), a higher rate of tea consumption (57.5% vs. 49.0%), but no differences in body size, body weight, weight gain/loss over 2 years, consumption of alcohol, history of smoking, or the symptom classification (ulcer-, reflux-, dysmotilify-, undetermined type). They were more likely to have initally severe/very severe dyspeptic symptoms, and during follow up they were more likely to experience their current life situation as continuous stress (Svs. S +: intial visit 43.4% vs. 47.8%, at t year 41.4% vs. 29.6%, at 2 years 31.9% vs. 26.2%). Management with initial endoscopy was associated with lower rates of non-responders (S-/Q8.0%, S-/O+ 11.4%, S+/Q11.4%) than initial empirical therapy (S-/O13.6%, S-/Q+ 15.0%, S+/Q14.1%) or no initial therapy (S-/020.4%, S-/O+ 20.4%, S+/Ot3.0%). Conclusion: Patients with FD not responding with symptom improvement during long term follow up can be subdivided in a group which shows improvement of qualify of life and one which does not. Both clinical management factors as well as individual behaviors of the patients showed characteristic differences between responders and non-responders, but none of this factors alone was able to predict non-responsiveness during the follow up. (Study supported by an educational grant from Janssen Cilag, Germany).

Helicobacter pylori infection in persons with intellectual disability in residential care in Israel.

Helicobacter pylori (formerly Campylobacter pylori) was identified in 1982 by researchers from Australia as a pathogenic factor in peptic ulcer disease. Due to the few studies on H. pylori infection conducted in the population of persons with intellectual disability it was decided to conduct a clinical study in Israel. The purpose of the study was to determine the occurrence of H. pylori infection in persons who presented with severe dyspeptic symptoms and to monitor clinically the effect of treatment. The Division for Mental Retardation in Israel provides service to 6,022 persons in 53 residential care centers and 1 in central Israel was selected for this pilot study. The study has been performed since 1999 and each patient who came to the medical clinic of the institution with severe dyspeptic symptoms was examined clinically and a blood specimen drawn for IgG antibodies to H. pylori (ELISA, Pharmatop Millenia). In case of positive serology, triple drug treatment (amoxycillin, metronidazole, and pantoprazole or omepra-zole) was initiated for 1 week. Since 1999 a total of 43 persons (total population in care was 224) had severe dyspeptic symptoms and 42 persons (98%, 26 males, 16 females, mean age 45 years, mean institutionalization 20 years) had Helicobacter infection. All patients were treated for 1 week, but six patients received an extra month of omeprazole due to persistent symptoms. At follow-up, clinically all patients had improvement and only seven still had minor complaints (83% treatment success). Persons with developmental disability, intellectual disability, or mental retardation in residential care presenting with severe dyspeptic symptoms had a high incidence of H. pylori infection. Therefore, we recommend serology or urea breath investigations in this population presenting with dyspeptic symptoms and triple drug treatment for 1 week in case of positive findings.

Gastric manometric abnormalities in patients with dyspeptic symptoms after fundoplication.

We describe six patients in whom severe dyspeptic symptoms developed after fundoplication. The symptoms began immediately after operation (three patients) or shortly thereafter (three and eight months). There were no other known predisposing factors to gastroparesis. Seven, age-matched, healthy volunteers served as controls. Pressure activity from antrum (two sites), duodenum (two sites), and jejunum (one site) was recorded by a low compliance perfusion system connected to external strain gauge transducers. Activity was recorded for three hours during fasting and for two hours after the ingestion of a solid and a liquid meal. To determine whether an inadvertent vagotomy had been performed, basal acid output and the response to insulin (Hollander's test) were measured on a separate day. Manometric studies revealed postprandial hypomotility in these patients, whereas fasting antral and intestinal activities were normal. Acid output increased in all patients during insulin induced hypoglycaemia. In three patients, an antrectomy was subsequently performed, and they were relieved of their symptoms. We conclude that, after fundoplication, symptoms associated with postprandial antral hypomotility may develop in some patients. The pathophysiologic mechanism is unknown, but a positive acid response to insulin induced hypoglycaemia does not support the occurrence of incidental vagotomy. We do not know the prevalence of this motor abnormality among asymptomatic patients with prior fundoplication. A favourable symptomatic response to antrectomy in several of our patients, however, suggests that the symptoms were related to antral motor dysfunction.