1
Department of Gastroenterology,
2
Research Center for Gastroenterology and Liver Disease, Shahid Beheshti
University M.C.,
ABSTRACT
Aim:
To evaluate endoscopic results of a large number of Iranian patients with
dyspepsia.
Background:
Dyspepsia is quite common among adults and has a great impact on the
patient’s quality of life. The present study was designed to investigate the
structure of dyspepsia and to determine existing symptoms and endoscopic
findings.
Patients and methods:
Over a period
of 14 months (April 2003– June 2004), 940 consecutive outpatients referred
for upper gastrointestinal endoscopy because of dyspepsia. The value of the
criteria distinguishing between the two major diagnostic groups, peptic
ulcer and non-ulcer dyspepsia, was assessed by comparing the group of
non-ulcer dyspepsia with the group of patients with peptic ulcer.
Results:
Ulcer-like presentation (69.3%) was the predominant symptom. Totally, 133
(14.1%) have peptic ulcer disease (PUD). Alcohol use and smoking were
significantly higher in PUD group. H.Pylori was higher in PUD (68.4% in PUD
versus 41.5% in NUD, p=0.000).
Conclusion:
Regardless of numerous studies and trials, dyspepsia still remains a
controversial issue. The analysis of the data of the overall patient
population remains the subject of future research
Keywords:
Dyspepsia, Helicobacter pylori, Peptic ulcer disease, Non- ulcer disease,
(Gastroenterology and Hepatology from bed to bench 2008;1(1):25-31).
INTRODUCTION
Dyspepsia
is not a diagnosis, but merely a cluster of symptoms believed to be referable to
the upper gastrointestinal tract (1-4). According to the
Several studies have shown
that dyspeptic symptoms are nonspecific for differentiating between diagnoses
(22-25). However, the initial management plan in primary care has to be
established on clinical grounds. Recent studies suggest that analysis of
predominant symptoms and overlapping digestive syndromes can identify dyspepsia
subgroups with different underlying pathophysiological features and aid in
selecting appropriate treatment, especially in presence of gastro-esophageal
reflux disease (26). Meanwhile, clinical prediction models of various causes of
dyspepsia have been published (27). It is mostly conducted in non-primary care
settings of Western countries with a known H. pylori prevalence of less than 50%
among the population (28).
The aim of the study was to
investigate the patterns of dyspepsia and to determine existing symptoms and
endoscopic findings in patients referred for upper endoscopy in a country with a
high prevalence of H. pylori infection.
PATIENTS and METHODS
Over a period of 14 months
(April 2003–June 2004), 940 consecutive outpatients referred to gastroenterology
clinic of Jahrom university of medical sciences for upper gastrointestinal
endoscopy because of dyspepsia. Dyspepsia was defined as persistent or recurrent
abdominal pain or abdominal discomfort, centered in the upper abdomen, with
duration of at least 3 months. Discomfort was characterized by early satiety,
fullness, nausea, retching, upper abdominal bloating, and anorexia (30,31). The
following exclusion criteria were applied at baseline: use of antibiotics,
bismuth compounds, or proton pump inhibitors four weeks prior to endoscopy,
current anticoagulant therapy, jaundice, bleeding, and anemia. Demographic data,
NSAIDs use, smoking and alcohol use during the recent month was obtained by the
investigator. The pattern of dyspepsia was categorized as ulcer-like,
dysmotility-like or unspecified.
Patients were examined using
an Olympus endoscope (Olympus,
The study was carried out in
accordance with the Helsinki Declaration and was approved by the Ethics
Committee of the Jahrom University of Medical Sciences. All patients were
requested to fill an informed content.
Statistical analysis was
achieved using SPSS 11.5 for Windows (SPSS Inc.,
P-value of 0.05 was
considered the significance level. A logistic regression model developed to
predict PUD from NUD using a forward conditional manner, including age
(reference: above 40 years old), sex (reference: male), NSAIDs use, smoking,
H.pylori positivity and alcohol use.
RESULTS
The
study population included 442 males and 498 females with the mean age (±
standard deviation) of 39.4±14.9 years. Men were slightly older than women
(41.0±15.2 versus 37.9±14.4 years, P=0.001). Most of the cases (73%) aged 21 to
50 years (table 1).
Table 1.
Age distribution of dyspeptic patients by endoscopic finding and H.pylori
results,
Age
groups (Years) |
All
patients (n=940) |
Endoscopic finding* |
H.pylori** |
||
PUD
(n=133) |
NUD
(n=807) |
Positive (n=426) |
Negative (n=514) |
||
18-20 |
73
(7.8%) |
3
(2.3%) |
70
(8.7%) |
37
(8.7%) |
36(7%) |
21-30 |
254
(27) |
26
(19.5%`) |
228
(28.3%) |
111(26.1%) |
143(27.8%) |
31-40 |
256
(27.2%) |
38
(28.6%) |
218
(27%) |
106(24.9%) |
150(29.2%) |
41-50 |
177
(18.8%) |
34
(25.6%) |
143
(17.7%) |
76(17.8%) |
101(19.6%) |
51-60 |
86
(9.1%) |
13
(9.8%) |
73
(9%) |
48(11.3%) |
38(7.4%) |
61-70 |
55
(5.9%) |
13
(9.8%) |
42
(5.2%) |
24(5.6%) |
31(6%) |
>70 |
39
(4.1%) |
6
(4.5%) |
33
(4.1%) |
24(5.6%) |
15(2.9%) |
PUD:
Peptic ulcer disease, NUD: Non-ulcer disease
* P=0.008, **P=0.084
Table
2.
Characteristics of dyspepsia in PUD and NUD patients, Jahrom, Iran
P-value |
NUD
(n=807) |
PUD
(n=133) |
All patients
(n= 940) |
|
|
Sex |
|
||||
0.000 |
352 (43.6%) |
90
(67.7%) |
442
(47%) |
Male |
|
0.000 |
455 (56.4%) |
43
(32.3%) |
498
(53%) |
Female |
|
Pattern of
dyspepsia |
|
||||
0.000 |
522 (64.7%) |
129
(97%) |
651
(69.3%) |
Ulcer-like |
|
0.000 |
142 (17.6%) |
0 |
142
(15.1%) |
Dysmotility-like |
|
0.000 |
143 (17.7%) |
4
(3%) |
147
(15.6%) |
Unspecified |
|
Risk factors |
|
||||
0.003 |
55
(6.8%) |
19
(14.3%) |
74
(7.9%) |
Alcohol use |
|
0.054 |
77
(9.5%) |
20
(15%) |
97
(10.3%) |
NSAIDs use |
|
0.001 |
127 (15.7%) |
36
(27.1%) |
163
(17.3%) |
Smoking |
|
0.000 |
335 (41.5%) |
91
(68.4%) |
426
(45.3%) |
Helicobacter
pylori positivity |
|
Ulcer-like presentation was the predominant or the most bothersome symptom for
69.3% of the patients thus being the most frequent complaint (table 2).
Totally,
133 (14.1%) patients had peptic ulcer disease (PUD) while the remaining were
categorized as non-ulcer disease (NUD). Duodenal and gastric ulcer were found in
11.1% and 3.1%, respectively. One patient (0.1%) has both duodenal and gastric
ulcer. Gastric cancer was confirmed in one 70-year-old male patient by
histologic evaluation. Alcohol use and smoking were significantly higher in PUD
group (table 2). PUD was more common in patients aged 31-50 years, while NUD was
higher among younger adults (21-40 years) (table 1).
The
overall frequency of H.Pylori was 45.3 %. H.Pylori was found more frequently
among PUD patients when compared with NUD (68.4% versus 41.5%, p=0.000). There
was no significant association between H.pylori and risk factors. H.pylori was
less common in subjects with alcohol intake (43.2% in alcohol versus 45.5% of
non-alcohol users, p=0.7) and NSAIDs ingestion (43.3% in NSAIDs versus 45.6% in
non-NSAIDs users, P=0.7), but it was higher in smokers (46.6% in smokers versus
45% in non- smokers, P=0.7), however, none of the abovementioned risk factors
did reach the statistically significant level. Furthermore, we did not find
age-related increment in H.pylori frequency (table 1). In a multivariate
logistic regression analysis including age (reference: above 40 years old), sex
(reference: male), NSAIDs use, smoking, H.pylori positivity and alcohol use;
H.pylori (OR: 3.19, 95% CI: 2.13-4.76), sex (OR: 2.86, 95% CI:1.92-4.28), NSAIDs
use (OR: 1.83, 95%CI:1.04-3.22) and age above 40 years old (OR:1.55:,
95%CI:1.05-2.28) entered the final model.
DISCUSSION
The
current study utilizes non-randomly selected subjects and therefore doesn't
avoid the inherent bias that may result from studies, which have involved
volunteers or attendants at health clinics, but it provides us to study a large
number of dyspeptic patients who met the inclusion criteria for endoscopy.
Dyspepsia is a frequent reason for attending primary care consultations (10).
The consensus meeting excluded patients with heartburn or acid regurgitation as
the predominant symptom, as these symptoms were thought to be predictive of
gastro-oesophageal reflux disease (GORD) (32). Nevertheless, many studies on
dyspepsia used other definitions and some do include patients with predominant
heartburn (9-12). Unfortunately, this limits us to compare our results with
others.
Many
dyspeptic patients consult their general practitioner mainly because of fear of
possible serious disease and sometimes mere reassurance may be sufficient
(12,13,33,34). If the symptoms do not abolish spontaneously, it has been
proposed to prescribe a trial of treatment, reserving endoscopy for those
patients who do not respond or whose symptoms recur after stopping treatment
(14-16,35). This strategy has been promoted by several organizations of both
primary and secondary care physicians (2,36,37).
The most
frequent symptom was ulcer-like symptoms such as epigastric pain. This is in
agreement with studies performed in
Like
other studies, NUD was the most frequent finding in upper GI endoscopy. In up to
60 percent of patients with dyspepsia, the diagnostic evaluation discloses no
underlying organic cause (18,40). Such patients are labeled as having non-ulcer
or functional dyspepsia. This disorder is considered to be part of a continuum
of functional gastrointestinal disorders that include irritable bowel syndrome,
functional heartburn, and non-cardiac chest pain. The pathophysiology of
non-ulcer dyspepsia is poorly understood (41,42).
Prior
investigators have reported peptic ulcer disease to occur more frequently in men
(7,43), however, some other studies disagreed (44,45). In our study, peptic
ulcer disease was more common among males. In the present study patients of both
groups suffered from smoking, alcohol consumption, NSAIDs use and H. pylori
infection. Konturek et al. noted that H. pylori infection, NSAID use, smoking
and age play major roles in the pathogenesis of peptic ulcerations and there is
a negative interaction between H. pylori and NSAID on duodenal ulcers,
suggesting that H. pylori reduces the development of these ulcers in NSAID users
(46). On the other hand, about 20% of peptic ulcers occur in patients regardless
of H. pylori or NSAID use (idiopathic ulcers). Although gastric cancer is a
health concern among dyspeptics, the likelihood of this disease is low in
populations.
In our
study the frequency of H. pylori was less than previous population-based study
(29). It could be in part explained by recent blind treatment of H.pylori in
most dyspeptics. The clinical significance of H.
pylori in upper gastrointestinal disorders has been confirmed by prior
studies. This infection plays an important role in the pathogenesis of acute and
chronic gastritis, peptic ulcer disease, gastric adenocarcinoma, and mucosa
associated tissue lymphoma (47). The relationship between H. pylori and
dyspepsia, in absence of peptic ulcer, has continued to be a matter of
controversy (48,49). Although available evidence indicates the absence of a
strong association between H. pylori and dyspepsia, there is yet insufficient
evidence to confirm or refute existence of a moderate association. The fact that
the prevalence of H. pylori infection among dyspeptics was similar to that in
general population rather confirms the absence of the connection between the
infection and dyspepsia.
In
conclusion, there are slight differences in the profile of upper
gastrointestinal diseases, especially dyspeptic complaints in a country with
high prevalence of H. pylori infection in comparison with areas with lower
prevalence (39). Interestingly, approximately half of the NUD patients are not
infected by H pylori (50). According to the multivariate logistic regression
analysis, H. pylori infection, male sex, NSAIDs use and age above 40 years old
are associated with PUD development. Regardless of numerous studies, dyspepsia
still remains a controversial issue.
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