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The meaning and definition of dyspepsia continues to challenge clinical investigators and has led to the setting up of several international working teams. However, confusion continues to reign around this term. The effort to classify patients with dyspepsia into subgroups according to their most predominant symptoms has failed to provide clues to the underlying disease, or even to discriminate between functional and organic dyspepsia. With these limitations in mind, the question arises: is there any reason for putting further effort into developing a world-wide definition of dyspepsia when, in addition to the aforementioned shortcomings, further variables such as geographical region, ethnic background, culture and sanitary resources come into play? The answer is that only by establishing a reproducible methodology for individual symptom assessment using a well-defined protocol will comparisons of the prevalence of dyspepsia and the impact of different therapeutic interventions become possible around the world. The data on dyspepsia prevalence, nearly all arising from studies in a few developed geographical areas and countries, are of the order of 1-4% of all consultations in all primary care medicine. However, estimates of adults affected by dyspepsia are as high as 20-40%. The magnitude of these statistics underlines the necessity for further work on the concept of dyspepsia and its major functional subgroups, following the exclusion of any organic causes. Issues such as 'investigate dyspepsia before starting with any kind of treatment or treat dyspepsia before further investigation' or the debate about whether to 'eradicate or ignore Helicobacter pylori in functional dyspepsia' will remain unresolved unless studies performed throughout the world use widely comparable and acceptable definitions and criteria for these conditions. Since the first international working party report in 1988, definitions of dyspepsia have included the description of 'upper abdominal pain or discomfort' and, more recently, have specified 'pain or discomfort centered in the upper abdomen' in order to emphasise further the site of origin as the upper alimentary tract (stomach-duodenum). However, a major change was evident in the more recent Rome I and Rome II reports, in which the symptoms heartburn, acid regurgitation, and belching were excluded from the definition of dyspepsia because of their relation to gastroesophageal reflux disease (GERD) and aerophagia. The intention to define a set of symptoms for dyspepsia is good, but we continue to be faced with overlaps. How should the patient with epigastric pain and heartburn after endoscopic exclusion of duodenal ulcer and reflux esophagitis be classified: dyspepsia or GERD? In cases of abnormal gastroesophageal reflux, 24-h pH monitoring could help to resolve this dilemma, but what if this investigation turns out to be normal? In this field, we need to perform careful studies. In addition, we need to consider the lifestyle and cultural habits of people around the world when translating upper gastrointestinal symptoms into dyspepsia. A step forward in the definition of dyspepsia was attempted by the recent working party for the Rome II consensus on functional gastrointestinal disorders (N. Talley et al.). In this project, the symptoms of dyspepsia were individually described not by a single term, but by painting a 'word picture', to make it easier for patients to express their symptoms, and give doctors and clinical investigators a better understanding of the 'dyspeptic problem' of each individual. It is advisable to follow this approach, since a clear picture of a patient's symptoms, including their duration and intensity, in association with the modern technical approaches that allow investigation beyond organic causes of dyspepsia, will lead to progress in our understanding and better communication about this problem within the medical community, and ultimately to better treatment.
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PMID:Current concepts in dyspepsia: a world perspective. 1044 9

Establishing a reasonable diagnosis and treatment plan in patients with chronic abdominal pain can be difficult and frustrating. Most cases involve a common and readily identified condition (e.g., gallbladder disease, GERD, irritable bowel syndrome). Other cases, however, resist ready diagnosis because they offer no intra-abdominal explanation. In this article, the authors summarize several diverse possibilities as the source of the pain, and they describe how to approach evaluation to avoid unnecessary testing.
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PMID:What could be causing chronic abdominal pain? Anything from common peptic ulcers to uncommon pancreatic trauma. 1049 71

BACKGROUND: Major complications of modern bariatric operations are infrequent but can be quite disabling to the patient and pose therapeutic challenges to the surgeon. We present our experience with five patients who underwent gastrectomy for complications following gastric reduction procedures. PATIENTS AND METHODS: Between 1991 and 1995, four women and one man, average age 46.8 years (34-66), underwent total gastrectomy and Roux-en-Y end-to-side esophagojejunostomy (4), or near-total gastrectomy with esophagogastrostomy (1). The decision to perform total gastrectomy was based on the poor quality of the remaining gastric pouch and the surgeon's judgement. Preoperative diagnoses included gastric outlet obstruction secondary to anastomotic ulcer or stricture, gastroesophageal reflux with esophagitis, chronic gastrocutaneous fistula, and iatrogenic linitis secondary to gastric wrap with mesh. Preoperatively, the patients complained of intolerable nausea, vomiting, abdominal pain, and dysphagia. RESULTS: in the five patients who underwent total or near-total gastrectomy, there was no operative mortality or morbidity; however, one patient (near-total gastrectomy) has required a second operation for pyloroplasty. Although one patient was lost to follow-up 6 months after surgery, the average follow-up for the remaining four patients is 2 years. These four patients were interviewed and all report complete satisfaction with their surgery and much improvement in their symptoms. Presently, they consume an average of three meals per day (range 2-6), with each meal measuring about 2 cups in size. All report the sensation of satiety after meals. All patients receive supplemental iron, B12, and multivitamins. From a nutritional standpoint, there has not been a significant change in the levels of albumin, total protein, hematocrit, weight and BMI since total gastrectomy. CONCLUSIONS: In our experience, total gastrectomy with Roux-en-Y end-to-side esophagojejunostomy is an appropriate therapy with low morbidity and mortality in highly selected patients with complications resulting from gastric reduction procedures.
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PMID:Gastrectomy for Complications of Bariatric Procedures. 1072 78

In the past 20 years the association between gastroesophageal reflux and otorhinolaryngological and/or respiratory affections became more evident by many studies. At the same time it is known that regurgitation, abdominal pain, growth retard, among others signs, could be generated by gastroesophageal reflux in infants, and when these signals are present the suspicious must be considered and they could be referred to perform pH studies. Sixty children were referred to our center to perform pH monitoring with gastroesophageal reflux suspicious, with digestive symptoms, respiratory problems or otorhinolaryngological manifestations. The patients were divided in two groups: the first, with 25 children, suffering from digestive manifestations. The second, 35 patients, including otorhinolaryngological or pulmonary symptoms. The children with digestive manifestations and with otorhinolaryngological or pulmonary symptoms were included in the first group. The pH analysis were considered positive for reflux when Boix-Ochoa Index (for 8 months of age or less) or DeMeester index (for 9 months or more) were above 11.99 or 14.72, respectively. The data were also compared to the results of scintigraphic studies for reflux or endoscopic findings in 22 patients. The pH monitoring test were positive in 62% patients with digestive manifestations. In the group with otorhinolaryngological or pulmonary symptoms the positivity was only 29%. In the group of children with both affections, the positivity was 66%. In patients that performed scintigraphic test or endoscopy, the pH test positivity were similar, 63%, without correlation if these other tests were positive or not. Patients with abnormal endoscopy or positive scintigraphic tests for gastroesophageal reflux presented 37% of positivity in pH test. We conclude that pH monitoring tests could be altered mainly when referred to investigate digestive manifestations when compared to primary otorhinolaryngological or pulmonary indications. Digestive endoscopy or scintigraphic study altered do not mean positive pH test and the inverse situation could be find too. Digestive symptoms coexisting with otorhinolaryngological or pulmonary afections do not increase the positivity frequency of the pH tests when compared with digestive manifestations exclusively.
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PMID:[Importance of esophageal pH monitoring in the screening of gastroesophageal reflux in children]. 1088 12

We prospectively evaluated the initial presenting symptoms in 261 patients with Zollinger-Ellison syndrome (ZES) over a 25-year period. Twenty-two percent of the patients had multiple endocrine neoplasia-type 1 (MEN-1) with ZES. Mean age at onset was 41.1 +/- 0.7 years, with MEN-1 patients presenting at a younger age than those with sporadic ZES (p < 0.0001). Three percent of the patients had onset of the disease < age 20 years, and 7% > 60 years. A mean delay to diagnosis of 5.2 +/- 0.4 years occurred in all patients. A shorter duration of symptoms was noted in female patients and in patients with liver metastases. Abdominal pain and diarrhea were the most common symptoms, present in 75% and 73% of patients, respectively. Heartburn and weight loss, which were uncommonly reported in early series, were present in 44% and 17% of patients, respectively. Gastrointestinal bleeding was the initial presentation in a quarter of the patients. Patients rarely presented with only 1 symptom (11%); pain and diarrhea was the most frequent combination, occurring in 55% of patients. An important presenting sign that should suggest ZES is prominent gastric body folds, which were noted on endoscopy in 94% of patients; however, esophageal stricture and duodenal or pyloric scarring, reported in numerous case reports, were noted in only 4%-10%. Patients with MEN-1 presented less frequently with pain and bleeding and more frequently with nephrolithiasis. Comparing the clinical presentation before the introduction of histamine H2-receptor antagonists (pre-1980, n = 36), after the introduction of histamine H2-receptor antagonists (1981-1989, n = 118), and after the introduction of proton pump inhibitors (PPIs) (> 1990, n = 106) demonstrates no change in age of onset; delay in diagnosis; frequency of pain, diarrhea, weight loss; or frequency of complications of severe peptic disease (bleeding, perforations, esophageal strictures, pyloric scarring). Since the introduction of histamine H2-receptor antagonists, fewer patients had a previous history of gastric acid-reducing surgery or total gastrectomy. Only 1 patient evaluated after 1980 had a total gastrectomy, and this was done in 1977. The location of the primary tumor in general had a minimal effect on the clinical presentation, causing no effect on the age at presentation, delay in diagnosis, frequency of nephrolithiasis, or severity of disease (strictures, perforations, peptic ulcers, pyloric scarring). Disease extent had a minimal effect on symptoms, with only bleeding being more frequent in patients with localized disease. Patients with advanced disease presented at a later age and with a shorter disease history (p = 0.001), were less likely to have MEN-1 (p = 0.0087), and tended to have diarrhea more frequently (p = 0.079). A correct diagnosis of ZES was made by the referring physician initially in only 3% of the patients. The most common misdiagnosis made were idiopathic peptic ulcer disease (71%), idiopathic gastroesophageal reflux disease (GERD) (7%), and chronic idiopathic diarrhea (7%). Other less common misdiagnosis were Crohn disease (2%) and various diarrhea diseases (celiac sprue [3%], irritable bowel syndrome [3%], infectious diarrhea [2%], and lactose intolerance [1%]). Other medical disorders were present in 55% of all patients; patients with sporadic disease had fewer other medical disorders than patients with MEN-1 (45% versus 90%, p < 0.00001). Hyperparathyroidism and a previous history of kidney stones were significantly more frequent in patients with MEN-1 than in those with sporadic ZES. Pulmonary disorders and other malignancies were also more common in patients with MEN-1. These results demonstrate that abdominal pain, diarrhea, and heartburn are the most common presenting symptoms in ZES and that heartburn and diarrhea are more common than previously reported. The presence of weight loss especially with abdominal pain, diarrhea, or heartburn is an important clue suggesting the presence of gastrinoma. The presence of prominent gastric body folds, a clinical sign that has not been appreciated, is another important clue to the diagnosis of ZES. Patients with MEN-1 presented at an earlier age; however, in general, the initial symptoms were similar to patients without MEN-1. Gastrinoma extent and location have minimal effects on the clinical presentation. Overall, neither the introduction of successful antisecretory therapy nor widespread publication about ZES, attempting to increase awareness, has shortened the delay in diagnosis or reduced the incidence of patients presenting with peptic complications. The introduction of successful antisecretory therapy, however, has dramatically decreased the rate of surgery in controlling the acid secretion and likely led to patients presenting with less severe symptoms and fewer complications. (ABSTRACT TRUNCATED)
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PMID:Zollinger-Ellison syndrome. Clinical presentation in 261 patients. 1114 36

Helicobacter pylori infection is usually acquired during childhood, and evidence-based guidelines regarding diagnosis and treatment of infected children have been recently published. Diseases associated with H. pylori infection are gastritis, duodenal ulcers, mucosal-associated lymphoid-type (MALT) lymphoma, and gastric adenocarcinoma. The association of specific symptoms with H. pylori infection in children and adults (ie, recurrent abdominal pain and nonulcer dyspepsia) remains controversial. Additionally, the role of H. pylori in gastroesophageal reflux disease or in extra-gastrointestinal diseases (ie, coronary artery disease) lacks sufficient evidence to demonstrate causality. The diagnosis of H. pylori-associated diseases in children can reliably be made through gastroduodenal endoscopy with biopsies. Clinical trials are underway for the validation of noninvasive diagnostic tests for the H. pylori-infected child, and current guidelines recommend eradication therapy for infected children with duodenal and gastric ulcer, gastric lymphoma, and atrophic gastritis with intestinal metaplasia. The natural history of childhood H. pylori infection is poorly described. Moreover, rational approaches to the prevention and control of childhood H. pylori infection are critically needed, requiring characterization of the determinants for acquisition and persistence and the disease outcomes following eradication.
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PMID:New approaches to Helicobacter pylori infection in children. 1135 61

The pharmacology, pharmacokinetics, clinical efficacy, adverse effects, and dosage and administration of pantoprazole are reviewed. Pantoprazole is a gastric hydrogen-potassium adenosine triphosphatase (H+/K(+)-ATPase) inhibitor. It shares the same core structure as other currently available proton-pump inhibitors (PPIs). The FDA-labeled indication is the short-term treatment of erosive esophagitis. PPIs act by selectively inhibiting H+/K(+)-ATPase in the secretory canaliculus of the stimulated parietal cell. Understanding the pharmacodynamics of PPIs is more relevant than knowing their pharmacokinetics, since the duration of action depends on the rate of de novo proton-pump regeneration, not the duration of drug circulation in the body. Pantoprazole is well absorbed, undergoes little first-pass metabolism, and has an absolute bioavailability of approximately 77%. Pantoprazole has been evaluated in more than 100 clinical trials involving more than 11,000 patients. It is effective in treating erosive esophagitis and duodenal and gastric ulcers. It is also effective as adjunctive treatment with antimicrobials in patients infected with Helicobacter pylori. Pantoprazole has been shown to control acid production in Zollinger-Ellison syndrome. Pantoprazole is well tolerated. The most commonly reported adverse effects are headache, diarrhea, and abdominal pain. The recommended oral dosage for erosive esophagitis is 40 mg once a day for up to eight weeks. The recommended i.v. dose is 40 mg given over 15 minutes once a day in patients with gastroesophageal reflux disease who are unable to take oral medication. Pantoprazole appears to be as safe and effective as other PPIs in acid-related disorders.
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PMID:Pantoprazole. 1140 94

Lansoprazole is an inhibitor of gastric acid secretion and also exhibits antibacterial activity against Helicobacter pylori in vitro. Current therapy for peptic ulcer disease focuses on the eradication of H. pylori infection with maintenance therapy indicated in those patients who are not cured of H. pylori and those with ulcers resistant to healing. Lansoprazole 30 mg combined with amoxicillin 1g, clarithromycin 250 or 500mg, or metronidazole 400 mg twice daily was associated with eradication rates ranging from 71 to 94%, and ulcer healing rates were generally >80% in well designed studies. In addition, it was as effective as omeprazole- or rabeprazole-based regimens which included these antimicrobial agents. Maintenance therapy with lansoprazole 30 mg/day was significantly more effective than either placebo or ranitidine in preventing ulcer relapse. Importantly, preliminary data suggest that lansoprazole-based eradication therapy is effective in children and the elderly. In the short-term treatment of patients with gastro-oesophageal reflux disease (GORD), lansoprazole 15, 30 or 60 mg/day was significantly more effective than placebo, ranitidine 300 mg/day or cisapride 40 mg/day and similar in efficacy to pantoprazole 40 mg/day in terms of healing of oesophagitis. Lansoprazole 30 mg/day, omeprazole 20 mg/day and pantoprazole 40 mg/day all provided similar symptom relief in these patients. In patients with healed oesophagitis. 12-month maintenance therapy with lansoprazole 15 or 30 mg/day prevented recurrence and was similar to or more effective than omeprazole 10 or 20 mg/day. Available data in patients with NSAID-related disorders or acid-related dyspepsia suggest that lansoprazole is effective in these patients in terms of the prevention of NSAID-related gastrointestinal complications, ulcer healing and symptom relief. Meta-analytic data and postmarketing surveillance in >30,000 patients indicate that lansoprazole is well tolerated both as monotherapy and in combination with antimicrobial agents. After lansoprazole monotherapy commonly reported adverse events included dose-dependent diarrhoea, nausea/vomiting, headache and abdominal pain. After short-term treatment in patients with peptic ulcer, GORD, dyspepsia and gastritis the incidence of adverse events associated with lansoprazole was generally < or = 5%. Similar adverse events were seen in long-term trials, although the incidence was generally higher (< or = 10%). When lansoprazole was administered in combination with amoxicillin, clarithromycin or metronidazole adverse events included diarrhoea, headache and taste disturbance. In conclusion, lansoprazole-based triple therapy is an effective treatment option for the eradication of H. pylori infection in patients with peptic ulcer disease. Preliminary data suggest it may have an important role in the management of this infection in children and the elderly. In the short-term management of GORD, lansoprazole monotherapy offers a more effective alternative to histamine H2-receptor antagonists and initial data indicate that it is an effective short-term treatment option in children and adolescents. In adults lansoprazole maintenance therapy is also an established treatment option for the long-term management of this chronic disease. Lansoprazole has a role in the treatment and prevention of NSAID-related ulcers and the treatment of acid-related dyspepsia; however, further studies are needed to confirm its place in these indications. Lansoprazole has emerged as a useful and well tolerated treatment option in the management of acid-related disorders.
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PMID:Lansoprazole: an update of its place in the management of acid-related disorders. 1169 67

Laparoscopic Nissen fundoplication is commonly used to treat medically refractory gastroesophageal reflux disease. The most frequent severe complications following laparoscopic Nissen fundoplication are pneumothorax, gastroesophageal leak, and splenic injury. Prompt recognition and treatment of complications are important in reducing subsequent morbidity and mortality. This report describes two postoperative complications: (1) delayed diagnosis of a postoperative gastric perforation despite an unrevealing work-up for postoperative fever and abdominal pain; and (2) postoperative pancreatitis following revision of a fundoplication.
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PMID:Unusual complications following laparoscopic Nissen fundoplication. 1175 43

Functional (nonulcer) dyspepsia refers to upper abdominal pain or discomfort with or without symptoms of early satiety, nausea, or vomiting with no definable organic cause. The current Rome II criteria help to diagnose functional dyspepsia and avoid misdiagnosis of gastroesophageal reflux disease and irritable bowel syndrome as functional dyspepsia. Assessment of gastric emptying with scintigraphy or breath testing may be useful in identifying delayed gastric emptying in patients with dyspeptic symptoms and may be helpful in patient management. Electrogastrography is a noninvasive test that evaluates for gastric dysrhythmias. Satiety testing is being evaluated as an indirect test for impaired fundic relaxation and visceral hypersensitivity. The symptom response to Helicobacter pylori therapy in patients with functional dyspepsia and a negative endoscopy examination but a positive H. pylori test is marginal. Lifestyle modifications often are suggested for initial treatment of functional dyspepsia. Dietary changes such as frequent small meals, low-fat diet, and avoidance of certain aggravating foods may improve symptoms. Additional measures include cessation of smoking, avoiding excess alcohol intake, and minimizing coffee intake. Antacids and over-the-counter histamine type 2 receptor antagonists may be helpful as an "on-demand" therapy for intermittent symptoms. They are safe and relatively inexpensive. Different subgroups of functional dyspepsia are based on the predominant symptom and may help in choosing an appropriate drug to initiate therapy. If the predominant symptom is epigastric pain (ulcer-like functional dyspepsia), histamine-2 receptor antagonists or proton pump inhibitors are the initial treatment of choice. If fullness, bloating, early satiety or nausea is the predominant complaint (dysmotility-like functional dyspepsia), a prokinetic agent may help. Metoclopramide is the only available effective prokinetic agent at present. If metoclopramide is used, short-term treatment and discussion of possible side effects with the patient are advised. If there is no response to these initial treatments, switching therapy from proton pump inhibitor to prokinetic or vice versa can be tried. If these treatment options fail, patient re-evaluation for other disorders (including other functional bowel disorders) is advised. A low-dose tricyclic antidepressant at bedtime may be helpful for treatment of visceral hypersensitivity.
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PMID:Functional (Nonulcer) Dyspepsia. 1187 96


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