AGA technical review: evaluation of dyspepsia. American Gastroenterological Association.
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Clinical Trials as Topic↗
Biomedical subjects
N J Talley
Publications and source records attributed to N J Talley.
Natural history of prostatism: high American Urological Association Symptom scores among community-dwelling men and women with urinary incontinence.
OBJECTIVES: The American Urological Association Symptom Index (AUASI) has been reported to be nonspecific for benign prostatic hyperplasia. Comparable scores occur in patients with lower urinary tract symptoms of varying etiology, and even among women. The purpose of this study was to determine the association between the AUASI and urinary incontinence among community-dwelling men and women. METHODS: In 1994, a randomly selected cohort of 1540 men and women aged 50 years or older from Olmsted County, Minnesota completed a self-administered questionnaire that assessed urinary symptom severity (AUASI score) and estimated the prevalence of urinary incontinence in the previous 12 months. The association between moderate to severe urinary symptom (AUASI score greater than 7) and urinary incontinence was investigated using multiple logistic regression, with adjustments for gender and age. RESULTS: Mean and median AUASI scores increased with age, and were higher among those respondents with urinary incontinence and among men. All seven urologic items in the AUASI were more prevalent among respondents with urinary incontinence and among men. Nocturia was highly prevalent among respondents with and without urinary incontinence, but urgency, frequency, and weak urinary stream were more prevalent among respondents with incontinence than among respondents without incontinence. When urinary incontinence, gender, and age were considered simultaneously, the respondents with urinary incontinence (odds ratio [OR] = 4.4, 95% confidence interval [CI] = 3.4, 5.5), men (OR = 1.9, 95% CI = 1.5, 2.5), and respondents 65 years or older (OR = 1.5, 95% CI = 1.2, 1.9) were more likely to have moderate to severe urinary symptoms. CONCLUSIONS: Our findings suggest that men and women with urinary incontinence and older men and women are significantly more likely to have moderate to severe urinary symptoms. These findings suggest that urinary incontinence may contribute to a high AUASI score in both sexes. Thus, these data indicate that the similarity in the distribution of the AUASI in men and women is, in part, an artifact introduced by the confounding effects of continence status.
Age Distribution↗
Relation of colonic transit to functional bowel disease in older people: a population-based study.
OBJECTIVE: The pathophysiology underlying chronic constipation in older people is poorly understood. Our objective was to determine if functional bowel disease (particularly constipation) in this population is associated with risk factors (age, immobility, low dietary fiber intake, and medication use) or directly with slow colonic transit. METHODS: A previously validated questionnaire was administered to a random sample of older residents (age range 65-104 years, n = 1609) of Olmsted County, MN. A random subset who met standard diagnostic criteria for functional constipation (n = 52) or irritable bowel syndrome (IBS) (n = 55) and a group without gastrointestinal symptoms (n = 93) were selected for further study. Each subject underwent structured interview and physical examination. Total caloric and fiber intake were assessed by dietitian interview, a food frequency questionnaire, and a food diary. Physical activity was assessed using a previously validated instrument. Medication use was determined by self-report, physician interview, and review of medical records. Total and segmental colonic transit was assessed radiographically using radioopaque markers. RESULTS: Total colonic transit times were prolonged in subjects with functional constipation (median 50.4 hours) but not in subjects with IBS (median 34.2 hours) or in healthy controls (median 28.8 hours); however, only rectosigmoid transit was delayed significantly. Age, gender, physical activity, and dietary fiber intake were not associated with total transit times, nor could they discriminate among the three patient groups. Laxative use was associated with prolonged total transit times independent of patient group. CONCLUSIONS: Older subjects can be classified by abdominal pain and bowel symptoms, which reflect colonic transit times. Older subjects with constipation symptoms generally have prolonged rectosigmoid transit. Other potential risk factors do not distinguish symptom subgroups, nor are they associated with altered colonic transit although older people who use laxatives regularly have prolonged colonic transit.
Case-Control Studies↗
Helicobacter pylori infection, reflux esophagitis, and atrophic gastritis: an unexplored triangle.
OBJECTIVE: H. pylori causes chronic gastritis, which may progress to peptic ulcer, gastric atrophy, or gastric cancer. However, little is known about the role of H. pylori infection in reflux esophagitis and the relationship between reflux esophagitis and atrophic gastritis needs to be clarified. We sought to identify the possible interrelationships among Helicobacter pylori infection, reflux esophagitis, and atrophic gastritis, to signal areas in which researchers should consider focusing their attention. METHODS: A broad-based Medline search was performed to identify all related publications addressing H. pylori infection, atrophic gastritis, gastroesophageal reflux disease (GERD), secretion of gastric acid, and gastric motility published between 1966 and July 1997. RESULTS: Whereas some studies have shown no significant association between H. pylori infection and reflux esophagitis, others have observed that the prevalence of H. pylori infection was lower in patients with GERD, implying a protective role. Eradication of H. pylori leads to occurrence of reflux esophagitis in some cases, but the mechanisms inducing posteradication reflux esophagitis are unknown. H. pylori infection may lead to atrophic gastritis (and hence hypochlorhydia) through both bacterial and host factors, although gastric atrophy and subsequent intestinal metaplasia are hostile to H. pylori because of hypochlorhydria. Although it has been reported that long-term proton pump inhibitor therapy for refractory reflux esophagitis may induce or enhance the development of gastric atrophy in H. pylori-infected patients, this relationship has been disputed. CONCLUSIONS: H. pylori infection may be negatively associated with reflux esophagitis, but this requires confirmation. Research then needs to focus on whether this is explained through motility- or acid-related mechanisms. The potential costs of maintenance antireflux therapy may need to be taken into account when evaluating the cost effectiveness of anti-H. pylori therapy.
Esophagitis, Peptic↗
Is the association between irritable bowel syndrome and abuse explained by neuroticism? A population based study.
BACKGROUND: In outpatients and the community, an association between abuse (particularly sexual abuse) and irritable bowel syndrome (IBS) has been observed, but whether there is a causal link continues to be disputed. AIMS: To test the hypothesis that psychological factors explain the apparent association between abuse and IBS. METHODS: A sample of residents of Penrith (a Sydney suburb sociodemographically similar to the Australian population) selected randomly from the electoral rolls (that by law include the entire population of age 18 years and above) was mailed a validated self report questionnaire. Measured were gastrointestinal (GI) symptoms including the Rome criteria for IBS, abuse (including the standardised Drossman questions), neuroticism (Eysenck Personality Questionnaire), and psychological morbidity (General Health Questionnaire). RESULTS: The response rate was 64% (n = 730); 12% fulfilled the Rome criteria for IBS. Overall abuse in childhood (odds ratio (OR) = 2.02, 95% confidence interval (CI) 1.29 to 3.15) but not adulthood (OR = 1.39, 95% CI 0.88 to 2.19) was associated with IBS univariately. Neuroticism and psychological morbidity were also univariately associated with abuse in childhood, abuse in adulthood and IBS, respectively. However, by logistic regression, abuse in childhood was not associated with IBS after controlling for age, gender, and psychological factors (OR = 1.34, 95% CI 0.83 to 2.17). The results were not altered by restricting the analyses to more severe forms of abuse, and were not explained by interactions between abuse and psychological variables. CONCLUSION: There is an association between abuse and IBS in the community, but this may be explained in part by other psychological factors. Based on a path analysis, we postulate that abuse may induce the expression of neuroticism that in turn leads to IBS.
Adult↗
Dyspepsia: current understanding and management.
Dyspepsia, defined as "pain or discomfort centered in the upper abdomen" is reported by one in four adults in Western societies. The most important causes are non-ulcer (functional) dyspepsia, peptic ulcer, gastroesophageal reflux, and, rarely, gastric cancer. Persons with heartburn alone are not considered to have dyspepsia. The division of dyspepsia into symptom-based subgroups (ulcer-like, dysmotility-like, reflux-like, and unspecified dyspepsia) has proven to be of doubtful value for the clinician, as it has a low predictive value for identifying the causes of dyspepsia. Upper endoscopy remains the "gold standard" test; ultrasound and blood tests have a low yield. The role of Helicobacter pylori in peptic ulcer disease is well known, but the clinical role of the infection in non-ulcer dyspepsia remains very controversial. In uninvestigated dyspeptic patients who are H. pylori infected based on a non-invasive test, empiric anti-H. pylori therapy is a reasonable and probably cost-effective option. In documented non-ulcer dyspepsia, prokinetics are superior to placebo while antisecretory therapy is of less certain efficacy.
Adult↗
Short-chain fatty acids in the treatment of radiation proctitis: a randomized, double-blind, placebo-controlled, cross-over pilot trial.
PURPOSE: Treatment of chronic radiation proctitis remains unsatisfactory. Short-chain fatty acids are the preferred energy source for the colonic epithelium. We aimed to determine for the first time whether topical butyric acid enemas relieve symptoms and improve the macroscopic and microscopic findings in chronic radiation proctitis. METHODS: A randomized, double-blind, placebo-controlled, cross-over pilot trial compared patients given two weeks of butyric acid enemas (40 mmol) twice per day with those given placebo, with a one-week washout period; 15 patients were randomized and 12 completed both arms of the trial. A total symptom score combined six symptom items per week (rectal pain, episodes of rectal bleeding, amount of blood passed, days with diarrhea, number of stools, and urgency). Symptom, endoscopic, and histologic scores were obtained at the beginning of the study and again at the last week of each treatment arm. RESULTS: Total symptom score at baseline (median, 5.5) improved for those patients receiving active treatment (median, 3.5), but compared with placebo (median, 4.5), the change was not significant. Endoscopic appearances were largely unaltered by active treatment. Histology was abnormal in 82 percent of patients receiving placebo compared with 55 percent of those given butyric acid enemas (P = not significant). CONCLUSION: Butyric acid enemas do not appear to be superior to placebo in the treatment of chronic radiation proctitis.
Administration, Topical↗
Prevalence and clinical spectrum of gastroesophageal reflux: a population-based study in Olmsted County, Minnesota.
BACKGROUND & AIMS: Gastroesophageal reflux is considered a common condition, but detailed population-based data on reflux in the United States are lacking. The aim of this study was to determine the prevalence and clinical spectrum of gastroesophageal reflux in Olmsted County, Minnesota. METHODS: A reliable and valid self-report questionnaire was mailed to an age- and sex-stratified random sample of 2200 Olmsted County residents aged 25-74 years. RESULTS: The prevalence per 100 of heartburn and/or acid regurgitation experienced at least weekly was 19.8 (95% confidence interval [95% CI], 17.7-21.9). Heartburn and acid regurgitation were associated with noncardiac chest pain (odds ratio [OR], 4.2; 95% CI, 2.9-6.0), dysphagia (OR, 4.7; 95% CI, 2.9-7.4), dyspepsia (OR, 3.1; 95% CI, 1.9-5.0), and globus sensation (OR, 1.9; 95% CI, 1.0-3.6) but not with asthma, hoarseness, bronchitis, or a history of pneumonia. Among subjects with reflux symptoms, 1.0% reported an episode of hematemesis and 1.3% had a past esophageal dilatation. CONCLUSIONS: Symptoms of reflux are common among white men and women who are 25-74 years of age. Heartburn and acid regurgitation are significantly associated with chest pain, dysphagia, dyspepsia, and globus sensation. The percentage of patients reporting complications is low, but the absolute number is probably considerable given the high prevalence of the condition in the community.
Adult↗
What role does Helicobacter pylori play in dyspepsia and nonulcer dyspepsia? Arguments for and against H. pylori being associated with dyspeptic symptoms.
A major role for Helicobacter pylori gastritis in nonulcer dyspepsia (NUD) is controversial. Gastroduodenal dysfunction may be associated with H. pylori infection, but there is little evidence for a causal link with dyspepsia. Population-based studies with appropriate methodology have generally failed to confirm an association between H. pylori and NUD. Furthermore, no definite association between subgroups of NUD (ulcer-like, dysmotility-like, reflux-like, and nonspecific) and H. pylori has been identified however the subgroups have been defined, and no specific symptom pattern characterizes patients with H. pylori infection. Whether H. pylori-induced alterations of gastric physiology can explain NUD remains open to debate while we await the results of more specific experiments. Although acid secretion in response to gastrin-releasing peptide may be increased in a subset of NUD patients who are infected with H. pylori, uninfected patients with NUD have not been assessed and the results require confirmation. Most studies suggest no association between H. pylori and gastroduodenal motor or sensory dysfunction in NUD. Treatment trials have been unconvincing. The trials with bismuth therapy have not been adequately blinded. Furthermore, some studies suggest that H. pylori-negative patients with NUD may respond to bismuth treatment, although the results have not been uniform. Therapies aimed at curing H. pylori infection have produced mixed results, with small positive and negative trials. The trials that have used adequate outcome measures have more often than not been negative. Based on current evidence, H. pylori is not established to be of causal importance in NUD.
Dyspepsia↗
Recurrence of Helicobacter pylori infection after successful eradication: nature and possible causes.
Recurrence of Helicobacter pylori infection after successful eradication occurs and is associated with relapse of gastroduodenal diseases. The aims of this paper were to assess the incidence and identify the nature and possible causes of recurrence of the infection. A broad-based Medline search was performed to identify all related publications addressing recurrence of the infection between 1986 and 1995. The 12-month recurrence rate varied among the different studies from 0 to 41.5%. A few studies showed 18- to 24-month recurrence rates, which ranged between 0 and 21.4%. Limited data, obtained using molecular fingerprinting techniques, have shown that in most cases recurrence is due to recrudescence of the original strain; a few cases appear to be due to reinfection with a new strain. Recrudescence is most likely during the first 12 months after apparent eradication. Despite the high sensitivity and specificity of the available individual tests for detecting H. pylori infection in untreated patients, no technique alone is sensitive enough to monitor eradication when the four-week-rule definition for eradication is used. A combination of two or more techniques increases sensitivity. Sensitivity and specificity are increased when biopsies are taken from both gastric antrum and corpus. The best treatments have the lowest recurrence rates and recurrence is rare when the eradication rate is over 90%. Individual susceptibility and reexposure to H. pylori are suggested as two major causes of reinfection.
Breath Tests↗
Dyspepsia due to eosinophilic gastroenteritis.
Classical eosinophilic gastroenteritis is a rare disease but may be misdiagnosed in clinical practice. We report eosinophilic gastroenteritis that was diagnosed in six patients (four males and two females; mean age 31.5 years) using standard criteria (presence of gastrointestinal symptoms, a predominant eosinophilic infiltrate on biopsy, and exclusion of other causes of eosinophilia). All had gastric mucosal disease and presented with dyspepsia. The median duration of symptoms prior to diagnosis was three months (range five weeks to 13 years). Epigastric pain or discomfort was the most common symptom (100%) followed by anorexia, nausea, and vomiting (67%, 67% and 33%, respectively). None had diarrhea. Half the patients had a history of allergy, while 67% had peripheral eosinophilia. All responded to oral steroids within two months; one third needed to continue on a small dose of maintenance steroids to remain in remission. A high degree of suspicion and biopsy at upper endoscopy is necessary for diagnosis of this rare disease.
Adolescent↗
Is the Glasgow Dyspepsia Severity Score a tool for the global measurement of dyspepsia?
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Dyspepsia↗
Short segment Barrett's oesophagus: prevalence, diagnosis and associations.
BACKGROUND: Prevalence of short segment Barrett's (SSB) oesophagus, defined as the absence of macroscopic Barrett's but histologically identifiable intestinal metaplasia, has been reported to be 18% based on haematoxylin and eosin (H&E) staining. AIMS: To define the prevalence of SSB oesophagus using H&E and alcian blue staining and to determine whether SSB oesophagus is associated with inflammation at the gastro-oesophageal junction (GOJ). SUBJECTS: Consecutive patients (n = 158) presenting for endoscopy completed a structured interview. METHODS: Two biopsy specimens taken from the GOJ were stained with H&E, alcian blue and Giemsa. A third specimen was obtained from the distal oesophagus. Intestinal metaplasia was diagnosed if goblet cells were definitely identified by two independent observers. RESULTS: SSB oesophagus was present in 46 (prevalence 36%, 95% confidence interval (CI) 28.5-43.5) using alcian blue staining. If H&E had been the sole staining method used, 50% cases of intestinal metaplasia would have been overlooked. There were no cases of intestinal metaplasia identified by H&E but missed by alcian blue staining. Logistic regression analysis identified age (odds ratio (OR) per decade 1.03, 95% CI 1.01-1.06), histological oesophagitis (OR 3.2, 95% CI 1.4-7.2) and inflammation at the gastrooesophageal junction (OR 5.9, 95% CI 2.2-15.6) as independent risk factors for SSB oesophagus. CONCLUSION: Unrecognised SSB oesophagus is highly prevalent in patients presenting for diagnostic upper endoscopy if alcian blue staining is applied.
Adult↗
Predictors of health care seeking for irritable bowel syndrome: a population based study.
BACKGROUND: It has been suggested that psychological factors rather than symptoms drive subjects with irritable bowel syndrome (IBS) to seek medical care, but this issue has not been tackled in a population based study. AIM: To identify whether psychological factors or abuse explain health care seeking for IBS. METHODS: A sample of residents of Penrith (a Sydney suburb representative of the Australian population) selected randomly from the electoral rolls (that by law include the entire population > or = 18 years) was mailed a validated self-report questionnaire. Measured were gastrointestinal symptoms including the Manning (and Rome) criteria for IBS, health care seeking, neuroticism (Eysenck Personality Questionnaire), psychological morbidity (General Health Questionnaire: GHQ) and sexual, physical and emotional abuse (including the standardised Drossman questions). RESULTS: Among 730 subjects, 96 (13%, 95% confidence interval (CI) 11-16%) had IBS by the Manning criteria. Of those with IBS, 73% (95% CI 63-81%) had sought medical care for abdominal pain or discomfort. Only increasing pain severity (odds ratio (OR) = 2.10, 95% CI 1.11-3.95) and duration of pain (OR = 1.53, 95% CI 1.10-2.13) were independently associated with seeking health care for IBS. Pain severity was also predictive of recent care seeking (OR = 1.74, 95% CI 1.12-1.96). Neuroticism, psychological morbidity and abuse history were not significant predictors. CONCLUSION: Psychological factors do not seem to explain health care seeking among community subjects with IBS.
Australia↗
Visceral analgesics and functional dyspepsia: have we found the Holy Grail?
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Analgesics↗
Functional dyspepsia and irritable bowel syndrome: is there a common pathophysiological basis?
OBJECTIVES: Alterations of mechanosensitive thresholds occur in a subset of patients with functional dyspepsia and irritable bowel syndrome (IBS). However, symptoms associated with these two conditions frequently overlap. It is not known how often subjects with and without symptom overlap have abnormal intestinal sensory thresholds. Our objective was to assess the pattern of symptoms and small intestinal sensory thresholds in patients with functional disorders. METHODS: We studied 157 consecutive patients who had undergone extensive diagnostic work-up to exclude organic disease. Abdominal symptoms were assessed with a validated instrument, and patients were categorized as having functional dyspepsia, IBS, or both. With a barostat device, we tested small intestinal mechanosensitive function in 22 randomly selected patients from this population (with functional dyspepsia, IBS, or both) and 22 healthy controls. RESULTS: Sixty-seven patients (43%) reported simultaneous symptoms of functional dyspepsia and IBS, whereas symptoms of functional dyspepsia or of IBS alone occurred in 68 (43%) and 22 (14%) patients, respectively. Thresholds for first perception and maximum tolerated pressure (mm Hg +/-SD) were significantly lower in patients (21.0 +/- 2.0 and 31.0 +/- 1.0) than in controls (32.0 +/- 1.8 and 39.0 +/- 0.9, p < 0.001). However, thresholds for first perception and maximum tolerated pressure did not differ (p > 0.6) in patients with functional dyspepsia alone (20.1 +/- 3.2 and 28.9 +/- 2.5, n = 9), functional dyspepsia and concomitant IBS (19.9 +/- 2.7 and 30.7 +/- 2.2, n = 8), or IBS alone (23.5 +/- 2.3 and 33.3 +/- 3.0, n = 5). CONCLUSIONS: Small intestinal mechanosensitive pathways are disturbed in patients with functional dyspepsia and IBS. Differences in the pattern and localization of symptoms probably do not reflect differences in small intestinal sensory thresholds. Functional dyspepsia and IBS cannot be distinguished on the basis of altered small intestinal sensory thresholds.
Adult↗
Natural acquisition and spontaneous elimination of Helicobacter pylori infection: clinical implications.
OBJECTIVES: The natural history of Helicobacter pylori infection in humans is not well established. We aimed to systematically review the literature on the natural acquisition and spontaneous elimination of the infection and its clinical consequences. METHODS: A broad-based MEDLINE and Current Contents search was performed to identify all related publications between 1986 and 1996. Abstracts from recent major conferences that provided adequate data were also included. RESULTS: The prevalence of H. pylori infection increases with age, the rates being significantly lower in developed countries than in developing countries. However, the overall prevalence is decreasing in both developing and developed countries, which probably is responsible for the steep decline of gastric cancer in some industrialized countries. The natural acquisition of H. pylori infection occurs, for the most part, in childhood, and it appears that the incidence is currently slightly higher in developing countries than in industrialized countries. Spontaneous elimination of the infection also occurs, especially in young children and the elderly. The route of transmission continues to be uncertain, with the best evidence favoring both the gastro-oral and fecal-oral routes. Low socioeconomic status is a major risk factor for acquisition of the infection. Genetics probably plays a role in the acquisition or clearance of H. pylori infection in individuals. CONCLUSIONS: Low rates of natural acquisition and elimination of the infection in adults suggest that it is worthwhile to eradicate the organism from adults, but there should be further evaluation of the need for eradication of H. pylori in children.
Developed Countries↗
Association between H. pylori, duodenal mechanosensory thresholds, and small intestinal motility in chronic unexplained dyspepsia.
Alterations of small intestinal sensory thresholds and small intestinal dysmotility are associated with functional dyspepsia. Because gastric and duodenal afferents partly project to the same areas, we postulated that patients with functional dyspepsia and H. pylori infection would be characterized by lower duodenal sensory thresholds. We evaluated 16 patients with functional dyspepsia and 16 age- and sex-matched controls. All patients had undergone an extensive diagnostic work-up to exclude organic lesions. Mechanosensitive function was tested in the third portion of duodenum utilizing a barostat device, and small intestinal motility was assessed before and during duodenal nutrient infusion with a five-channel low-compliance perfusion system. H. pylori status was assessed by a validated serological test. Small intestinal sensory thresholds (first perception and maximal tolerated pressure) were significantly lower in patients (21.1 +/- 2.1 and 30.9 +/- 1.8 mm Hg) compared to controls (33.0 +/- 2.2 and 38.8 +/- 0.9 mm Hg, all P < 0.003). Nine of 16 patients compared with five of 16 controls were H. pylori positive (P = 0.15). Thresholds for H. pylori-negative (28.7 +/- 2.8 and 36.5 +/- 1.1 mm Hg) or -positive subjects (25.0 +/- 3.0 and 32.7 +/- 2.4 mm Hg) were overall not significantly different (P > 0.3). However, in patients with defined high H. pylori titers (>50 units/ml) defined a priori, thresholds for first perception were significantly lower (14.7 +/- 2.9 mm Hg, N = 5) compared to patients with H. pylori titers below this threshold (24.3 +/- 2.9 mm Hg, N = 4) or without H. pylori infection (23.8 +/- 3.4 mm Hg, P < 0.05). During duodenal nutrient infusion, the duodenal motility index increased (P < 0.03). This increase was not significantly different in patients and controls or in H. pylori-negative or -positive subjects. Sensory abnormalities are present in patients with functional dyspepsia. In a small subgroup of patients with high H. pylori titers, sensory abnormalities may be linked to H. pylori infection.
Adult↗