Symptoms that can be attributed to the gastroduodenal region represent one of the main subgroups among functional gastrointestinal disorders. A slightly modified classification into the following 4 categories is proposed: (1) functional dyspepsia, characterized by 1 or more of the following: postprandial fullness, early satiation, epigastric pain, and epigastric burning, which are unexplained after a routine clinical evaluation; and includes 2 subcategories: postprandial distress syndrome that is characterized by meal-induced dyspeptic symptoms and epigastric pain syndrome that does not occur exclusively postprandially; the 2 subgroups can overlap; (2) belching disorders, defined as audible escapes of air from the esophagus or the stomach, are classified into 2 subcategories, depending on the origin of the refluxed gas as detected by intraluminal impedance measurement belching: gastric and supragastric belch; (3) nausea and vomiting disorders, which include 3 subcategories: chronic nausea and vomiting syndrome; cyclic vomiting syndrome; and cannabinoid hyperemesis syndrome; and (4) rumination syndrome.
Section snippets
Definition
FD is a medical condition that significantly impacts on the usual activities of a patient and is characterized by one or more of the following symptoms: postprandial fullness, early satiation, epigastric pain, and epigastric burning that are unexplained after a routine clinical evaluation.1
Symptom definitions remain somewhat vague, and potentially difficult to interpret by patients, practicing physicians and investigators alike, as documented by the major misunderstandings that characterize
Gastroduodenal Disorders
B1. Functional Dyspepsia
Diagnostic criteria
1.
One or more of the following:
a.
Bothersome postprandial fullness
b.
Bothersome early satiation
c.
Bothersome epigastric pain
d.
Bothersome epigastric burning
AND
2.
No evidence of structural disease (including at upper endoscopy) that is likely to explain the symptoms
aMust fulfill criteria for B1a. PDS and/or B1b. EPS.
bCriteria fulfilled for the last 3 months with symptom onset at least 6 months before diagnosis.
B1a. Postprandial Distress Syndrome
Diagnostic criteria
Must
Definition
Belching is defined as an audible escape of air from the esophagus or the stomach into the pharynx. It occurs commonly and can only be considered a disorder when it is excessive and becomes troublesome. Depending on the origin of the refluxed gas, belching is classified into 2 types: the gastric belch and the supragastric belch.
Epidemiology
The epidemiology of excessive belching in the general population remains to be carefully defined; however, it is not encountered uncommonly in the clinical setting.
Diagnostic Criteria
The
Definitions
Nausea is a subjective symptom and can be defined as an unpleasant sensation of the imminent need to vomit typically experienced in the epigastrium or throat. Vomiting refers to the forceful oral expulsion of gastrointestinal contents associated with contraction of the abdominal and chest wall muscles.
Epidemiology
Nausea is less prevalent than epigastric pain or meal-related symptoms in the community.36 Unexplained chronic nausea is often associated with other gastroduodenal symptoms. Unexplained vomiting
Definition
In human patients, rumination syndrome is characterized by the repetitive, effortless regurgitation of recently ingested food into the mouth followed by rechewing and reswallowing or expulsion of the food bolus.
Epidemiology
Although initially described in infants and the developmentally disabled, it is now known that rumination syndrome occurs in males and females of all ages and cognitive function. The epidemiology of adult rumination syndrome is not well characterized. In a large database of patients with
Review article: adherence to Rome criteria in therapeutic trials in functional dyspepsia
Aliment Pharmacol Ther
(2014)
J. Tack et al.
The use of pictograms improves symptom evaluation by patients with functional dyspepsia
Aliment Pharmacol Ther
(2014)
S. Mahadeva et al.
Epidemiology of functional dyspepsia: a global perspective
World J Gastroenterol
(2006)
Y. Shaib et al.
The prevalence and risk factors of functional dyspepsia in a multiethnic population in the United States
Am J Gastroenterol
(2004)
H. Piessevaux et al.
Dyspeptic symptoms in the general population: a factor and cluster analysis of symptom groupings
Neurogastroenterol Motil
(2009)
J. Tack et al.
Functional dyspepsia—symptoms, definitions and validity of the Rome III criteria
Nat Rev Gastroenterol Hepatol
(2013)
R. Bisschops et al.
Relationship between symptoms and ingestion of a meal in functional dyspepsia
Gut
(2008)
A. Pauwels et al.
The gastric accommodation response to meal intake determines the occurrence of transient lower esophageal sphincter relaxations and reflux events in patients with gastro-esophageal reflux disease
Neurogastroenterol Motil
(2014)
O.S. Palsson et al.
Uninvestigated dyspepssia in the US general population resutls from the Rome Normative Gastrointestinal Symptoms Survey (RNGSS)
Gastroenterology
(2014)
H. Vanheel et al.
Changes in gastrointestinal tract function and structure in functional dyspepsia
Nat Rev Gastroenterol Hepatol
(2013)
V. Stanghellini et al.
Gastroparesis: separate entity or just a part of dyspepsia?
Gut
(2014)
L.E. Troncon et al.
Abnormal intragastric distribution of food during gastric emptying in functional dyspepsia patients
Gut
(1994)
J. Bratten et al.
Prolonged recording of duodenal acid exposure in patients with functional dyspepsia and controls using a radiotelemetry pH monitoring system
J Clin Gastroenterol
(2009)
N.J. Talley et al.
Functional dyspepsia
N Engl J Med
(2015)
H. Suzuki et al.
Helicobacter pylori infection in functional dyspepsia
Nat Rev Gastroenterol Hepatol
(2013)
M.M. Walker et al.
Duodenal eosinophilia and early satiety in functional dyspepsia: confirmation of a positive association in an Australian cohort
J Gastroenterol Hepatol
(2014)
N. Gathaiya et al.
Novel associations with dyspepsia: a community-based study of familial aggregation, sleep dysfunction and somatization
Neurogastroenterol Motil
(2009)
P. Henningsen et al.
Medically unexplained physical symptoms, anxiety, and depression: a meta-analytic review
Disorders of gut–brain interaction are characterized by chronic gastrointestinal symptoms in the absence of abnormal endoscopic or radiologic findings or objective biomarkers that can be identified during routine clinical evaluation. The assessment of the symptom pattern and severity, therefore, is the key modality to evaluate the presence, impact, and evolution of these conditions, for both clinical and regulatory purposes. Patient-reported outcomes are structured symptom assessment questionnaires designed to evaluate symptom patterns, quantify severity of symptoms, and evaluate response to treatment at follow-up. This review provides an overview of currently available patient-reported outcomes for evaluating the main disorders of gut–brain interaction, specifically, functional dyspepsia; irritable bowel syndrome; and chronic constipation. It summarizes their content, level of validation for clinical practice and for research, and the regulatory approach to these conditions. Expected future developments and need for further research on patient-reported outcomes for these and other disorders of gut–brain interaction are highlighted.
Nearly all peptic ulcers are caused by either Helicobacter pylori infection or the use of non-steroidal anti-inflammatory drugs (NSAIDs), including aspirin. As H. pylori infection is becoming less prevalent in developed countries, NSAIDs are an increasingly important cause of ulceration, including ulcers complicated by gastrointestinal (GI) bleeding. Only about 15% of H. pylori-infected individuals develop an ulcer, with the risk determined by the virulence of the H. pylori strain, host genetics and environment (particularly smoking). NSAID-induced ulcers are largely the result of suppression of gastroprotective cyclooxygenase (COX)-1. The presence and type of ulcer cannot be accurately predicted from the symptoms, and the differential diagnosis is broad. Older dyspeptic individuals and those with ‘alarm’ symptoms or signs require upper GI endoscopy to exclude upper GI cancer and make a diagnosis. Younger patients with simple dyspepsia are treated empirically with a course of proton pump inhibitors (PPIs) or an H. pylori ‘test-and-treat’ strategy. For H. pylori-associated ulcers, H. pylori eradication treatment induces healing and prevents relapse. NSAID ulcers are treated by NSAID withdrawal and a course of PPI; NSAID-naive users requiring continuing treatment who are positive for H. pylori need bacterial eradication, whereas others should be prescribed a concomitant PPI or selective COX-2 inhibitor. Treatment of functional dyspepsia is difficult and requires a multifactorial approach.
La dispepsia es el conjunto de síntomas originados en la región gastroduodenal. Es un término complejo y difícil de definir, en el que algunos síntomas se confunden o solapan con otras patologías. Los principales son ardor o dolor en epigastrio, plenitud postprandial y saciedad precoz. Se clasifica según el origen de los síntomas en orgánica o funcional, siendo la fisiopatología de esta última multifactorial, con múltiples factores implicados como el enlentecimiento del vaciamiento gástrico, la hipersensibilidad visceral o la acomodación gástrica, entre otros. Se trata de una patología relevante, con una prevalencia importante en la población (20%) que genera costes elevados y un impacto en la calidad de vida de los pacientes. Para el diagnóstico es fundamental descartar organicidad en los pacientes con síntomas de alarma mediante una panendoscopia oral. Cuando no existen estos síntomas, el primer paso es detectar y tratar la infección por Helicobacter pylori. Si tras ello persisten los síntomas, el tratamiento de primera línea son los supresores de ácido, seguidos de antidepresivos tricíclicos y procinéticos.
Dyspepsia is a set of symptoms originating in the gastroduodenal region. The term is complex and difficult to define; some symptoms are confused or overlap with other diseases. The main symptoms are burning or pain in the epigastrium, postprandial fullness, and early satiety. It is classified as organic or functional according to the origin of the symptoms. The pathophysiology of the latter is multifactorial, involving multiple factors such as slowing of gastric emptying, visceral hypersensitivity, or gastric accommodation, among others. It is an important disease with a significant prevalence in the population (20%) that generates high costs and an impact on patients’ quality of life. In order to diagnose it, it is essential to rule out an organic nature in patients with alarm symptoms by means of an oral panendoscopy. In the absence of these symptoms, the first step is to detect and treat Helicobacter pylori infection. If symptoms persist afterwards, first-line treatment is acid suppressant medications followed by tricyclic antidepressants and prokinetic agents.
The aims of this study were to investigate analgesic effects of vagus nerve stimulation (VNS) on visceral hypersensitivity (VH) in a rodent model of functional dyspepsia (FD) and to compare invasive VNS with noninvasive auricular VNS (aVNS).
Eighteen ten-day-old male rats were gavaged with 0.1% iodoacetamide (IA) or 2% sucrose solution for six days. After eight weeks, IA-treated rats were implanted with electrodes for VNS or aVNS (n = 6 per group). Different parameters, varying in frequency and stimulation duty cycle, were tested to find the best parameter based on the improvement of VH assessed by electromyogram (EMG) during gastric distension.
Compared with sucrose-treated rats, visceral sensitivity was increased significantly in IA-treated “FD” rats and ameliorated remarkably by VNS (at 40, 60, and 80 mm Hg; p ≤ 0.02, respectively) and aVNS (at 60 and 80 mm Hg; p ≤ 0.05, respectively) with the parameter of 100 Hz and 20% duty cycle. There was no significant difference in area under the curve of EMG responses between VNS and aVNS (at 60 and 80 mm Hg, both p > 0.05). Spectral analysis of heart rate variability revealed a significant enhancement in vagal efferent activity while applying VNS/aVNS compared with sham stimulation (p < 0.01). In the presence of atropine, no significant differences were noted in EMG after VNS/aVNS. Naloxone blocked the analgesic effects of VNS/aVNS.
VNS/aVNS with optimized parameter elicits ameliorative effects on VH, mediated by autonomic and opioid mechanisms. aVNS is as effective as direct VNS and has great potential for treating visceral pain in patients with FD.
Many individuals reduce their bread intake because they believe wheat causes their gastrointestinal (GI) symptoms. Different wheat species and processing methods may affect these responses.
We investigated the effects of 6 different bread types (prepared from 3 wheat species and 2 fermentation conditions) on GI symptoms in individuals with self-reported noncoeliac wheat sensitivity (NCWS).
Two parallel, randomized, double-blind, crossover, multicenter studies were conducted. NCWS individuals, in whom coeliac disease and wheat allergy were ruled out, received 5 slices of yeast fermented (YF) (study A, n = 20) or sourdough fermented (SF) (study B, n = 20) bread made of bread wheat, spelt, or emmer in a randomized order on 3 separate test days. Each test day was preceded by a run-in period of 3 d of a symptom-free diet and separated by a wash-out period of ≥7 d. GI symptoms were evaluated by change in symptom score (test day minus average of the 3-d run-in period) on a 0–100 mm visual analogue scale (ΔVAS), comparing medians using the Friedman test. Responders were defined as an increase in ΔVAS of ≥15 mm for overall GI symptoms, abdominal discomfort, abdominal pain, bloating, and/or flatulence.
GI symptoms did not differ significantly between breads of different grains [YF bread wheat median ΔVAS 10.4 mm (IQR 0.0–17.8 mm), spelt 4.9 mm (−7.6 to 9.4 mm), emmer 11.0 mm (0.0–21.3 mm), P = 0.267; SF bread wheat 10.5 mm (−3.1 to 31.5 mm), spelt 11.3 mm (0.0–15.3 mm), emmer 4.0 mm (−2.9 to 9.3 mm), P = 0.144]. The number of responders was also comparable for both YF (6 to wheat, 5 to spelt, and 7 to emmer, P = 0.761) and SF breads (9 to wheat, 7 to spelt, and 8 to emmer, P = 0.761).
The majority of NCWS individuals experienced some GI symptoms for ≥1 of the breads, but on a group level, no differences were found between different grains for either YF or SF breads.
The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update (CPU) is to review the available evidence and provide expert advice regarding diagnosis and management of cannabinoid hyperemesis syndrome.
This CPU was commissioned and approved by the AGA Institute Clinical Practice Updates Committee (CPUC) and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the CPUC and external peer review through standard procedures of Gastroenterology. This expert commentary incorporates important as well as recently published studies in this field, and it reflects the experiences of the authors.