Helicobacter pylori “test-and-treat” strategy is not suitable for the management of patients with uninvestigated dyspepsia in Shanghai

Objective. The safety of Helicobacter pylori “test-and-treat” and “test-and-endoscopy” strategies for the management of young patients with uninvestigated dyspepsia has not been evaluated in Shanghai. Material and methods. A total of 14,101 consecutive patients with dyspepsia receiving endoscopy in our hospital from October 2002 to December 2003 were retrospectively studied. The detection rates of esophageal or gastroduodenal malignancies and alarm symptoms were investigated, and H. pylori status was assessed. Results. A total of 202 (1.4%) gastrointestinal (GI) malignancies were found, including 162 cases (1.15%) of gastric cancer, 4 of gastric lymphoma, 35 (0.25%) of esophageal cancer and 1 case of duodenal cancer. Among those patients with GI malignancies, 99 (49.0%) were infected with H. pylori and 108 (53.5%) presented with alarm symptoms. Eighteen patients (0.46%, 18/3952) under 45 years of age were diagnosed as having gastric cancer. Of these patients, 5 (27.8%) presented with alarm symptoms and 13 (72.2%) were infected with H. pylori. If the H. pylori “test-and-treat” strategy were used in dyspeptic patients under the age of 45 years without alarm symptoms in the Shanghai region, then 13 cases (72.2%) of gastric cancer would be missed. If the H. pylori “test-and-endoscopy” strategy were applied, then 3 cases (16.7%) of gastric cancer would be missed. Conclusions.H. pylori “test-and-treat” and “test-and-endoscopy” strategies are both not suitable for the management of patients with uninvestigated dyspepsia in Shanghai. For most Shanghai dyspeptic patients, prompt endoscopy should be recommended as the first-line initial management option.     

Gastric cancer in young patients with no alarm symptoms: focus on delay in diagnosis,stage of neoplasm and survival

Background: The test and treat strategy for Helicobacter pylori infection has raised some concern since young gastric cancer patients may have no alarm symptoms. In this study the frequency of alarm symptoms was assessed in a series of young gastric cancer patients, as well as the impact of absence of alarm symptoms on delay in diagnosis and stage of gastric cancer at diagnosis and survival. Methods: A retrospective study was carried out on 92 gastric cancer patients?≤?45 years of age identified from databases in four hospitals between January 1985 and December 2001. Characteristics analysed included duration and features of dyspeptic symptoms, presence of alarm symptoms, time interval from the onset of symptoms to diagnosis, pTNM stage and survival. Results: Of the 92 patients, 54 (58.7%) presented uncomplicated dyspepsia and 38 (41.3%) alarm symptoms. In those with uncomplicated dyspepsia, epigastric pain was the most common complaint (64.1%) followed by vomiting (30.4%), heartburn and nausea. Weight loss was the most common alarm symptom (30.4%), followed by anorexia (10.9%), dysphagia or anaemia (7.6%). The mean delay from first symptoms to final diagnosis was 16.8?±?13.9 weeks in patients with alarm symptoms and 29.3?±?39.9 weeks in patients without alarm symptoms (P:ns). Patients without alarm symptoms showed significantly less aggressive gastric cancer compared to patients with alarm symptoms in relation to TNM stage and survival (cumulative 5‐year survival rate: 76% versus 49% P: 0.01). The survival rate, at 5 years, of patients without alarm symptoms, and with a history of dyspepsia of more than 24 weeks, was higher than that in patients with early diagnosis (93.4% versus 66.5%; P: 0.05). Conclusions: A large proportion of young gastric cancer patients present without alarm symptoms. Despite the delay in diagnosis, these patients have a better outcome than those with alarm symptoms. Thus the delay in diagnosis of patients without alarm symptoms does not affect survival.     

Prevalence of organic disease at colonoscopy in patients with symptoms compatible with irritable bowel syndrome: cross-sectional survey

Abstract

Objective. Guidelines for the management of irritable bowel syndrome (IBS) encourage a positive diagnosis, but some evidence suggests organic disease may be missed unless investigations are performed. We examined yield of colonoscopy in a cohort of secondary care patients meeting criteria for IBS. Materials and methods. Demographic data, symptoms and findings at colonoscopy were recorded prospectively in consecutive, unselected adults with gastrointestinal (GI) symptoms compatible with IBS according to the Rome III criteria. Prevalence of organic GI disease was compared between those meeting criteria for IBS, according to the presence or absence of co-existent alarm features, and by IBS subtype. Results. A total of 559 patients met Rome III criteria for IBS, of whom 423 reported ≥1 alarm feature and 136 none. There was a significantly higher prevalence of organic GI disease among those reporting alarm features (117 [27.7%]), compared with those without (21 [15.4%]) (p = 0.002). In the latter group of 136 patients, Crohn’s disease was the commonest finding (10 [7.4%] subjects), followed by coeliac disease (4 [2.9%] subjects), and microscopic colitis (3 [2.2%] subjects). Regardless of presence or absence of alarm features, patients with constipation-predominant IBS were less likely to exhibit organic GI disease than those with diarrhea-predominant or mixed IBS (12.7% vs. 32.1% and 23.8%, p = 0.006). Conclusions. One in six patients with symptoms compatible with IBS without alarm features in this selected group exhibited organic GI disease following investigation. Assessment of alarm features in a comprehensive history is vital to reduce diagnostic uncertainty that can surround IBS.     

Gastrin vaccination against gastrointestinal and pancreatic cancer

Objective. Upper gastrointestinal complaints are common in the general population. The aim of this study was to establish whether age and occurrence of alarm symptoms are predictors of malignancy in primary care open-access endoscopy. Material and methods. The material comprised 10,061 consecutive patients referred for gastroscopy by general practitioners from 1989 to 2000. The presenting symptoms were recorded; alarm symptoms comprised dysphagia, weight loss, gastrointestinal bleeding, anaemia and vomiting. Results. In all, 13.0% (1310) of the patients had alarm symptoms. Malignancy was detected in 0.7% (72 patients) in the whole series, in 0.3% (13 patients) aged 55 years or younger and in 1.1% (59 patients) over 55 years of age; the respective percentages in patients with alarm symptoms were 2.5% (33 patients), 1.0% (5 patients) and 3.4% (28 patients). Alarm symptoms (odds ratios 3.98; confidence interval 2.47–6.41), age (1.07/year; 1.05–1.09) and male gender (1.95; 1.22–3.12) were significantly associated with gastrointestinal malignancy. Conclusions. The total number of malignancies in the primary care open-access gastroscopy series was low. Alarm symptoms increased the risk 5–6-fold; such patients should therefore undergo endoscopy without delay. At a further one year of age the risk was increased by 7%, but no definite age limit for endoscopy could be asserted.     

Low social class is linked to upper gastrointestinal symptoms in an Australian sample of urban adults

Objective. The epidemiology of gastrointestinal (GI) symptoms has been described in population surveys, yet their distribution by socio-economic (social) class remains largely uninvestigated. The aim of this study was to evaluate the influence of social class on GI symptoms in an urban sample of Australian adults.

Material and methods. The prevalence of 25 GI symptoms was determined by postal questionnaire. Five latent symptom groups were identified by a principal components analysis (PCA) (Esophageal, Dysmotility-like, Nausea/vomiting, Constipation and Diarrhea). These components were used to model the association between GI symptoms and adult social class. Social class was assigned according to a census-based measure of area disadvantage, and to highest level of completed education. Age- and sex-adjusted odds ratios – as identified by unconditional logistic regression – were used to describe the relationship between symptom groups and adult social class.

Results. The effects of area disadvantage and education on Esophageal and Dysmotility-like symptoms were pronounced, with persistent trends for elevated symptom rates amongst the lower social classes (all p<0.01 on age- and sex-adjusted effects). When defined by area disadvantage, the odds ratios for Nausea/vomiting were significantly elevated among the lowest social class group (p=0.01), whereas the odds for Constipation were significantly elevated among the upper–middle social class when defined by education (p=0.001). Diarrhea was not associated with social class whether defined by area disadvantage or education.

Conclusions. Low social class is a risk factor for upper GI complaints.     

Prevalence of gastrointestinal complaints in runners competing in a long-distance run: An internet-based observational study in 1281 subjects

Objective. To assess the prevalence, risk factors and timing of gastrointestinal (GI) complaints in a large group of runners competing in a long-distance run. GI symptoms indicating GI ischaemia were of specific interest. Material and methods. A questionnaire was sent by e-mail to 2076 athletes who had competed in a recreational run and 1281 (62% response rate) were returned. Reported GI complaints were related to variables such as age, gender, distance, fluid and food ingestion and running experience. For statistical analyses, χ² tests and logistic regression analyses were used. Results. The run was completed by 98% of the runners. Three athletes dropped out because of GI complaints, 45% had at least one GI complaint during running, while 11% of the runners suffered from serious GI complaints during the run, the last mentioned being significantly related to runners who were not familiar with fluid ingestion, those of younger age, female gender and those who did not complete the run. Of the runners, 2.7% had complaints during the first 24 h after the run. This was significantly related to female gender and GI complaints during the run. Conclusions. The prevalence of GI complaints during and after running was low compared with that reported in other studies, which is partly due to the definition of “symptomatic” used in our study. The risk factors associated with becoming symptomatic were identical to those in other studies. The relationship between complaints during the run and the type of complaints afterwards suggests a role of GI ischaemia in the pathophysiology of running-induced GI symptoms.     

'Alarm symptoms' in patients with dyspepsia: a three-year prospective study from general practice

BACKGROUND: Ten percent of patients consulting a general practitioner (GP) because of dyspepsia report one or more alarm symptom(s): anemia, black stools, blood in stools, dysphagia, jaundice, weight loss. We observed the consequence of such symptoms prospectively over 3 years. METHODS: Postal questionnaires were sent to GPs to obtain recorded information from patients who had consulted the GP because of dyspepsia. Mortality and gastrointestinal morbidity per 1000 person years were studied in two cohorts of patients, one presenting with, the other without, alarm symptoms and compared to expected rates from the general population. The incidence of ulcers was compared between the two cohorts. The predictive value of alarm symptoms for the development of cancer and ulcer was calculated. RESULTS: Compared to the general population, dyspeptic patients without alarm symptoms had an insignificant increase in mortality (OR = 1.5 (0.9-2.4)) and a significant increase in gastrointestinal (GI) cancers (OR = 2.4 (1.1-7.1)), whereas in patients with alarm symptoms both mortality (OR = 2.3 (1.7-3.2)) and GI cancers (OR = 6.3 (3.6-11.0)) were significantly raised. In dyspeptic patients, the presence of alarm symptoms increased the risk of developing peptic ulcers significantly (OR = 5.3 (3.1-9.1)) and gastrointestinal cancer insignificantly (OR = 1.9 (0.9-4.1)). Positive predictive values for development of cancer and ulcer were 4% and 14%, respectively. During 3 years of observation, patients with alarm symptoms were diagnosed with a malignancy in 4%, ulcers in 11% and minor gastrointestinal diseases in 25% of cases. CONCLUSION: Although the presence of alarm symptoms predicts a bad prognosis, the positive predictive values were low and negative predicted values high, reflecting low incidences of the diseases in the population at risk. The majority of patients who developed cancer or ulcer did not present with alarm symptom(s) at the initial consultation.     

'Alarm Symptoms' in Patients with Dyspepsia: a Three-year Prospective Study from General Practice

Background: Ten percent of patients consulting a general practitioner (GP) because of dyspepsia report one or more alarm symptom(s): anemia, black stools, blood in stools, dysphagia, jaundice, weight loss. We observed the consequence of such symptoms prospectively over 3 years. Methods: Postal questionnaires were sent to GPs to obtain recorded information from patients who had consulted the GP because of dyspepsia. Mortality and gastrointestinal morbidity per 1000 person years were studied in two cohorts of patients, one presenting with, the other without, alarm symptoms and compared to expected rates from the general population. The incidence of ulcers was compared between the two cohorts. The predictive value of alarm symptoms for the development of cancer and ulcer was calculated. Results: Compared to the general population, dyspeptic patients without alarm symptoms had an insignificant increase in mortality (OR = 1.5 (0.9-2.4)) and a significant increase in gastrointestinal (GI) cancers (OR = 2.4 (1.1-7.1)), whereas in patients with alarm symptoms both mortality (OR = 2.3 (1.7-3.2)) and GI cancers (OR = 6.3 (3.6-11.0)) were significantly raised. In dyspeptic patients, the presence of alarm symptoms increased the risk of developing peptic ulcers significantly (OR = 5.3 (3.1-9.1)) and gastrointestinal cancer insignificantly (OR = 1.9 (0.9-4.1)). Positive predictive values for development of cancer and ulcer were 4% and 14%, respectively. During 3 years of observation, patients with alarm symptoms were diagnosed with a malignancy in 4%, ulcers in 11% and minor gastrointestinal diseases in 25% of cases. Conclusion: Although the presence of alarm symptoms predicts a bad prognosis, the positive predictive values were low and negative predicted values high, reflecting low incidences of the diseases in the population at risk. The majority of patients who developed cancer or ulcer did not present with alarm symptom(s) at the initial consultation.     

Comorbidity and use of health-care services among irritable bowel syndrome sufferers

Objective. Patients suffering from irritable bowel syndrome (IBS) have more somatic and psychiatric comorbidity and use more health-care services for comorbid conditions than do other patients. Little is known about the frequency of comorbid symptoms among IBS sufferers in the general population and their influence on use of health-care facilities. The objective of this study was to compare the frequency of somatic and psychiatric symptoms between IBS sufferers and controls in the general population, and to study how comorbidity rates are distributed among consulters and non-consulters and how they predict the use of health care-services. Material and methods. By means of a questionnaire sent to 5000 randomly selected adults IBS was identified according to the Rome II criteria. The questionnaire also covered upper GI symptoms, non-GI somatic symptoms, depression and anxiety. A logistic regression analysis with 26 variables was carried out to determine the independent predictors of health-care seeking for GI and non-GI complaints. Results. The response rate was 73% and prevalence of IBS 5.1% (95% CI 4.4–5.8%). Dyspeptic symptoms, somatic extra-GI symptoms and psychiatric symptoms were reported by 45%, 69% and 51% of IBS sufferers, respectively, and 6%, 35% and 27%, of controls, respectively. Visiting a physician because of GI complaints was associated with disturbing abdominal symptoms, but not with depression or anxiety. Of the present GI conditions, only dyspeptic symptoms were associated with an increased consultation rate also for non-GI complaints. Conclusions. In the general population, both IBS consulters and non-consulters demonstrate high rates of comorbidity. Seeking health care for abdominal complaints is associated with abdominal symptoms rather than psychiatric comorbidity.     

Gastric cancer in young patients with no alarm symptoms: focus on delay in diagnosis, stage of neoplasm and survival

BACKGROUND: The test and treat strategy for Helicobacter pylori infection has raised some concern since young gastric cancer patients may have no alarm symptoms. In this study the frequency of alarm symptoms was assessed in a series of young gastric cancer patients, as well as the impact of absence of alarm symptoms on delay in diagnosis and stage of gastric cancer at diagnosis and survival. METHODS: A retrospective study was carried out on 92 gastric cancer patients < or = 45 years of age identified from databases in four hospitals between January 1985 and December 2001. Characteristics analysed included duration and features of dyspeptic symptoms, presence of alarm symptoms, time interval from the onset of symptoms to diagnosis, pTNM stage and survival. RESULTS: Of the 92 patients, 54 (58.7%) presented uncomplicated dyspepsia and 38 (41.3%) alarm symptoms. In those with uncomplicated dyspepsia, epigastric pain was the most common complaint (64.1%) followed by vomiting (30.4%), heartburn and nausea. Weight loss was the most common alarm symptom (30.4%), followed by anorexia (10.9%), dysphagia or anaemia (7.6%). The mean delay from first symptoms to final diagnosis was 16.8 +/- 13.9 weeks in patients with alarm symptoms and 29.3 +/- 39.9 weeks in patients without alarm symptoms (P:ns). Patients without alarm symptoms showed significantly less aggressive gastric cancer compared to patients with alarm symptoms in relation to TNM stage and survival (cumulative 5-year survival rate: 76% versus 49% P: 0.01). The survival rate, at 5 years, of patients without alarm symptoms, and with a history of dyspepsia of more than 24 weeks, was higher than that in patients with early diagnosis (93.4% versus 66.5%: P: 0.05). CONCLUSIONS: A large proportion of young gastric cancer patients present without alarm symptoms. Despite the delay in diagnosis, these patients have a better outcome than those with alarm symptoms. Thus the delay in diagnosis of patients without alarm symptoms does not affect survival.     

The association between normalising attributions and help-seeking for cancer alarm symptoms in the community: a cross-sectional survey

BackgroundAttribution of early symptoms to non-pathological factors such as age or diet (normalising) is often identified retrospectively by patients with cancer as an explanation for delay in presentation. However, there have been no community-based studies. We aimed to assess associations between normalising attributions and help-seeking in a community sample of patients reporting cancer alarm symptoms.MethodsA questionnaire was mailed to 4858 adults (≥50 years with no cancer diagnosis) through primary care, asking about symptom experience in the previous 3 months. Respondents were asked, within a longer symptom list, whether they had experienced any of ten cancer alarm symptoms in the previous 3 months. Follow-up questions addressed perceived cause (free text), with responses categorised into normalisation (age, external factors), non-cancer disease, psychological factors, cancer, or “don't know”. Blank responses were treated as missing and excluded from analyses. Respondents were asked whether they had consulted a doctor (yes or no).FindingsResponse rate was 35% (n=1724). Normalising was common for four symptoms: persistent cough or hoarseness (81/296, 27%), persistent change in bowel habit (88/216, 41%), persistent change in bladder habit (67/166, 40%), and change in the appearance of a mole (27/71, 38%). Age (ie, an effect of getting older) was a common attribution for all symptoms except persistent cough, which was often attributed to smoking. Change in diet was a common attribution for change in bowel habit, and sun exposure for change in a mole. Missing attribution data (n=280) ranged from 15% (n=53) for cough to 42% (n=51) for change in mole. Logistic regression showed that normalising attributions were associated with being less likely to having contacted a general practitioner for persistent cough (odds ratio 0·46, 95% CI 0·27–0·79), after controlling for demographic characteristics, and the same effect was observed across symptoms. No sex or socioeconomic differences in help-seeking were seen.InterpretationAttributing symptoms to normal everyday causes was associated with delayed help-seeking for four cancer alarm symptoms. Attributions such as smoking and sun exposure, which are themselves risk factors for cancer, were among the attributions that undermined help-seeking. The substantial proportion of missing data for the attribution item suggests some reluctance to complete open text responses. More research is needed into how people make help-seeking decisions.FundingThis work was supported by a Cancer Research UK Postdoctoral Fellowship grant (C33872/A13216) awarded to KLW.     

Delay in gastric emptying in patients with chronic renal failure

Background: Gastrointestinal (GI) symptoms are common in patients with chronic renal failure (CRF). Delayed gastric emptying might be a possible pathophysiological mechanism. The aims of this study were to evaluate gastric emptying in patients with CRF and to correlate the findings with GI symptoms and evaluate the impact of Helicobacter pylori infection in CRF patients on gastric emptying. Methods: Thirty‐nine patients with CRF (17 F, 22 M) were compared with 131 healthy subjects (74 F, 57 M). A standardized breakfast was given with 20 spherical, radiopaque markers (ROMs). The emptying was followed by fluoroscopy after 4, 5 and 6?h. Gastric emptying was assessed by calculating the individual mean percentual gastric retention of markers, 4 to 6?h after the meal. The perceived severity of GI symptoms was assessed with a validated questionnaire. Because of gender differences in gastric emptying, men and women were compared separately and a percentile of 95 was chosen as the upper reference value. H. pylori infection was assessed using a serological method. Results: Delayed gastric emptying was found in 14 out of 39 (36%) of the CRF patients. There was no relationship between delayed gastric emptying and age, GI symptoms, H. pylori infection or underlying renal disease. However, a higher proportion of patients in peritoneal dialysis demonstrated delayed gastric emptying compared with predialytic patients (6 of 9 versus 2 of 13, P?=?0.026). Men with CRF had a higher gastric retention compared with healthy men (16.6 (0–63.3)% versus 0 (0–2.1)%, P?P?P?=?0.93), but 4 women with CRF had delayed gastric emptying (P?=?0.02). Eighteen of the CRF patients had GI symptoms (6 F, 12 M) and 21 were asymptomatic (11 F, 10 M). There was no difference in mean gastric retention in patients with CRF with and without GI symptoms (M: 13.3 (0–55.0)% versus 47.5 (5.0–65.0)%, P?=?0.51, F: 16.6 (0–63.3)% versus 13.3 (0–59.2)%, P?=?0.96). Gastric emptying in CRF patients with and without H. pylori infection showed no difference. Conclusions: Delayed gastric emptying is common in patients with chronic renal failure, particularly in men. The delay was not associated with the presence of GI symptoms, underlying renal disease or H. pylori infection. However, the dialytic status might have an impact on gastric emptying in patients with CRF.     

Predictors of Mortality in Patients Admitted to Hospital for Acute Upper Gastrointestinal Hemorrhage

Background: Although the ‘test‐and‐treat’ strategy is suggested as first‐line therapy for uninvestigated dyspepsia, no large‐scale studies in a real‐life setting are available. Methods: 1552 dyspeptic patients aged between 25 and 60 with no alarm symptoms were recruited to the study. After screening with a ¹³ C‐urea breath test, they were randomized into three treatment arms: Helicobacter pylori‐positive either to eradication therapy with OAM (omeprazole, amoxycillin and metronidazole) (Hp+/erad) or omeprazole 20?mg daily (Hp+/ome) for 10 days, whereas H. pylori‐negative patients (Hp?/ome) were treated with 20?mg omeprazole for 10 days. Gastrointestinal symptoms were registered at baseline at 1 and 2 years on the Gastrointestinal Symptom Rating Scale (GSRS) and quality of life with the Psychological General Well‐Being index (PGWB). Additional visits, referrals for and number of endoscopies and their findings were registered during the 2 years' follow‐up. Results: Of the 1552 patients, 583 were H. pylori‐positive (37.6%), and 288 of these were randomized for omeprazole and 295 to OAM. The Hp?/ome group had fewer general practitioner (GP) contacts (P?H. pylori‐positive groups. Eradication therapy significantly improved general well‐being and reduced upper gastrointestinal symptoms: abdominal pain (P?=?0.0001), heartburn (P?=?0.0061), acid regurgitation (P?=?0.003), hunger pain (P?=?0.009), especially in Hp+/erad. Peptic ulcer was found in 6.2%, 1.0%, 0.2% in Hp+/ome, Hp?+/erad and Hp?/ome, respectively (P?=?0.0007). Only 3 patients (1.0%) developed peptic ulcers in Hp?+/erad, all eradication failures. Conclusions: In uninvestigated dyspepsia, a negative test result for H. pylori reduces the number of GP contacts and endoscopy referrals compared to H. pylori‐positive regardless of eradication therapy. Applied in real life, the test‐and‐treat strategy failed to reduce the number of endoscopies, but significantly reduced peptic ulcer disease and improved dyspeptic symptoms and quality of life.     

Upper gastrointestinal symptoms and associated endoscopic and histological features in patients receiving immune checkpoint inhibitors

Background: Immune checkpoint inhibitors (ICIs) have demonstrated effectiveness in treating many malignancies. Gastrointestinal (GI) adverse events are commonly reported; however, few reports describe upper GI tract toxic effects. We aimed to describe clinical features of upper GI injury related to ICI.

Methods: We studied consecutive patients who received ICIs between April 2011 and March 2018 and developed upper GI symptoms requiring esophagogastroduodenoscopy (EGD).

Results: Sixty patients developed upper GI symptoms between ICI initiation and 6 months after the last infusion. Among patients who had both EGD and colonoscopy (n?=?38), 21 had endoscopic evidence of inflammation involving both the upper and lower GI tract. Overall, histological signs of inflammation of the stomach were evident in 83% of patients, but inflammation of the duodenum in 38%. Total of 42 patients had other risk factors of gastritis, i.e., chemotherapy, radiotherapy, and non-steroidal anti-inflammatory drugs. Only isolated gastric inflammation was seen on endoscopy in patients without these risk factors. The rates of ulceration were similar in the cohorts with and without other risk factors for gastritis. Isolated upper GI inflammation was related to anti-PD-1/L1 in 47% of patients. Immunosuppressive therapy in our cohort with upper GI toxicity consisted of steroids (42%) and infliximab or vedolizumab (23%). Most isolated upper GI symptoms were treated with proton pump inhibitors (65%) or H₂ blockers (35%).

Conclusion: We observed a correlation between ICI use and onset of upper GI inflammation even when other risk factors were excluded. Gastric involvement was evident more often than duodenal involvement on endoscopic and histological level.     

Gastrointestinal symptoms related to the irritable bowel syndrome – a longitudinal population-based register study

Objective Functional gastrointestinal (GI) symptoms can develop into persistent states often categorised as the irritable bowel syndrome (IBS). In the severe end of the GI symptom continuum, other coexisting symptoms are common. We aimed to investigate the GI symptom continuum in relation to mortality and development of GI diseases, and to examine if coexisting symptoms had an influence on the outcomes. Material and methods A longitudinal population-based study comprising two 5-year follow-up studies: Dan-Monica1 (1982–1987) and Inter99 (1999–2004). IBS was defined according to a population-based IBS definition. The pooled cohort (n?=?7278) was followed until December 2013 in Central Registries. Results Fifty-one percent had no GI symptoms, 39% had GI symptoms but never fulfilled the IBS definition, 8% had fluctuating IBS and 2% had persisting IBS. There was no significant association between symptom groups and mortality (p?=?0.47). IBS and GI symptoms with abdominal pain were significantly associated with development of GI diseases. Only GI symptoms with abdominal pain were associated with development of severe GI diseases (HR: 1.38; 95% CI: [1.06–1.79]). There were no statistically significant interactions between symptom groups and coexisting symptoms in relation to the two outcomes. Conclusions GI diseases were seen more frequently, but IBS was not associated with severe GI diseases or increased mortality. Clinicians should be more aware when patients do not fulfil the IBS definition, but continue to report frequent abdominal pain. Coexisting symptoms did not influence mortality and development of GI diseases.     

Association between mental distress,gastrointestinal symptoms,and health-care utilization in functional dyspepsia: a prospective 7-year follow-up study

Abstract

Objective. The association between psychosocial factors and gastrointestinal symptoms is unclear. It has been proposed that they simply drive health-care seeking of patients. We therefore aimed to study whether mental distress would increase health-care utilization in functional dyspepsia (FD). Methods. 171 primary care FD patients completed questionnaires screening gastrointestinal symptoms, mental distress, and health-care utilization between 1993 and 2000. These included the Bowel Disease Questionnaire and 12-item General Health Questionnaire. The patients' medical records were reviewed in primary care centers, Kuopio University Hospital, local hospitals, and private clinics. Results. The majority of patients revisited their general practitioner (GP), and most of them were prescribed antisecretory medication. Repeated gastroscopy and lower gastrointestinal endoscopy were performed in 26% of the patients. A radiological reinvestigation, usually upper abdominal ultrasound, was performed in one-third. Nine percent were hospitalized due to gastrointestinal reasons. A single additional bowel symptom increased the probability of repeated endoscopy by 19%, a visit to the GP by 19%, and an inpatient period by 51%. Neither an increase in the dyspepsia score nor the presence of mental distress or suspicion of serious illness increased the probability of health-care utilization. Conclusion. There is no association between mental distress and health-care utilization for gastrointestinal symptoms.     

Risk of upper gastrointestinal events with the use of various NSAIDs: A case-control study in a general population

Objective. The gastrointestinal (GI) safety of different non-steroidal anti-inflammatory drugs (NSAIDs) in a real-life setting remains ill defined. The aim of this study was to examine the risk of upper GI events associated with various NSAIDs in a general population. Material and methods. A nationwide, register-based, matched case-control study was carried out in outpatient residents of Finland in 2000–04. Cases with upper GI events (n=9191) were drawn from the Hospital Discharge Register and individually matched to controls (n=41,780) from the Population Register. Results. The semi-selective NSAIDs (nimesulide, nabumetone, meloxicam, etodolac) had the highest odds ratio for upper GI events even after adjusting for various potential confounders (adjusted odds ratio (AOR) 3.63; 95% CI 3.08–4.28), followed by non-selective (2.98; 2.70–3.29) and COX-2 selective NSAIDs (2.53; 2.09–3.07). When the current use of semi-selective NSAIDs was compared with that of non-selective and COX-2 selective NSAIDs, the AORs were 1.54 (1.13–2.09) and 1.67 (1.10–2.53), respectively. The AORs for the use of COX-2 selective NSAIDs did not differ statistically from the non-selective NSAIDs (AOR 0.92; 0.65–1.31). The AORs for individual NSAIDs varied across and within categories. Conclusions. As a group, the GI safety of the COX-2 selective NSAIDs was not demonstrated as definitively superior to non-selective NSAIDs. Semi-selective NSAIDs do not seem to offer any GI advantage over other NSAIDs.     

Utility of baseline impedance level measurement in patients with gastroesophageal reflux symptoms

Objective. Twenty-four-hour multichannel intraluminal impedance (MII) and pH monitoring is used for detecting reflux episodes in patients with gastroesophageal reflux (GER) disease. However, the clinical significance of baseline impedance levels (BILs) has not been well studied. We aimed to evaluate whether BILs are related to various reflux events or acid-related parameters and to determine whether BILs during specific intervals could be substituted for 24-h BILs. Material and methods. One-hundred forty-two patients GER symptoms underwent 24-h pH/impedance monitoring. We measured pH [(5 cm above the low esophageal sphincter (LES)] and BILs from three sites (3, 5, and 15 cm above the LES). Results. Eighty-one subjects (57.0%) were diagnosed with gastroesophageal reflux disease, and 53 (37.3%) had acid reflux and 28 (19.7%) had nonacid reflux. The 24-h BILs at distal sites were lower in the “reflux” group than in the “no reflux” group (p < 0.001) and lower in the “acid reflux” group than in the “nonacid reflux” group (p < 0.001). However, there was no significant difference in 24-h BILs at the proximal site among the “no reflux”, “acid reflux”, and “nonacid reflux” groups. The interclass correlation coefficient value of 24-h BILs with daytime 6-h BILs was 0.916 (95% CI 0.882–0.940) and that with nighttime 6-h BILs was 0.909 (95% CI 0.871–0.935). Conclusion. BILs are related to GER, especially acid reflux. Location and duration of assessment for BILs needs to be standardized. Six-hour BILs could be substitutes for 24-h BILs. During analysis of MII-pH, more attention should be paid to BILs in the lower esophagus.     

Acute pancreatitis associated with duodenal obstruction induced by groove pancreatitis: A case report

RationaleGroove pancreatitis (GP) is a rare form of chronic pancreatitis. Since GP presents with nonspecific symptoms, it can be challenging to diagnose. Duodenal obstruction is often caused by malignant diseases; however, when associated with acute pancreatitis, it is rarely induced by groove pancreatitis.Patient''s concernsA 56-year-old man who presented with acute pancreatitis complained of recurrent upper abdominal discomfort. His concomitant symptoms included abdominal pain, postprandial nausea, and vomiting. Contrast-enhanced computed tomography (CT) of the abdomen showed thickening of the duodenum wall. Gastrointestinal radiographs and upper gastrointestinal endoscopy showed an obstruction of the descending duodenum.DiagnosisThe pathologic diagnosis was groove pancreatitis.InterventionsThe patient underwent gastrojejunostomy to relieve the obstruction.OutcomesThe patient had an uneventful recovery with no complications.LessonsGroove pancreatitis should be considered in the differential diagnosis of patients presenting with acute pancreatitis and duodenal obstruction. These data can help to make a precise diagnosis and develop an appropriate treatment plan.