|LETTER TO THE EDITOR
|Year : 2021 | Volume
| Issue : 4 | Page : 170-172
Clinical and endoscopic characterization of patients with dyspepsia
Mayank Jain, Vinodini Agrawal
Department of Gastroenterology, Arihant Hospital and Research Centre, Indore, Madhya Pradesh, India
|Date of Submission||04-May-2021|
|Date of Decision||26-May-2021|
|Date of Acceptance||31-May-2021|
|Date of Web Publication||24-Sep-2021|
Department of Gastroenterology, Arihant Hospital and Research Centre, 283-A Gumasta Nagar, Indore - 452 009, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Jain M, Agrawal V. Clinical and endoscopic characterization of patients with dyspepsia. Gastroenterol Hepatol Endosc Pract 2021;1:170-2
Rome IV criteria were published in 2016 for better characterization of functional gastrointestinal disorders. In these criteria, functional dyspepsia (FD) has been used as an umbrella term for patients with postprandial distress syndrome (PDS) and epigastric pain syndrome (EPS). Patients with these presentations have bothersome postprandial fullness, early satiety, epigastric pain, and/or burning after meals. Patients may have an overlap of these presentations, which appears to be more common in hospital-based studies than in the community setting. The present study was done to determine the clinical and endoscopic characteristics of patients with dyspepsia who underwent upper gastrointestinal endoscopy at our center.
This is a retrospective analysis of prospectively maintained database of patients who underwent upper gastrointestinal endoscopy at our center between May 2019 and April 2021. For the analysis, we included all patients above 18 years of age who underwent endoscopic evaluation for dyspeptic symptoms as per Rome IV criteria. We excluded patients with alarm symptoms such as weight loss, dysphagia, vomiting, palpable abdominal mass, and anemia. Patients who had taken Helicobacter pylori eradication treatment in the past, used proton-pump inhibitors or H2 receptor blockers or antibiotics in the preceding 2 weeks, had upper gastrointestinal malignancy on endoscopic evaluation, and had associated features of irritable bowel syndrome were excluded.
As per our department policy, we note patient's demographic and clinical details on a predesigned standard pro forma on the day of the procedure. Clinical data recorded are age, sex, use of alcohol or tobacco, and comorbid disease states. Provisional clinical diagnosis, duration of symptoms, and drug history are noted for all cases. Endoscopy was done by a single experienced observer using Fujifilm EG-760 R endoscope. For detection of H. pylori infection, two biopsy samples were taken – one each from antrum and body and tested using rapid urease test (RUT, Gastrocure systems, Kolkata, India). A positive test up to 24 h after placing the mucosal specimen in the kit indicated the presence of H. pylori infection. Endoscopic data analyzed included findings on endoscopy and presence of H. pylori infection.
An ulcer was defined as an area of the denuded epithelium of 5 mm or more. Gastric or duodenal erosions were defined as a mucosal break of ≤5 mm in diameter. All gastric ulcers were biopsied for histology. Esophagitis was diagnosed based on the Los Angeles classification. Dyspepsia was subclassified into EPS, PDS, and EPS + PDS overlap based on Rome IV criteria. FD was defined as dyspepsia without any structural disease that was likely to explain symptoms. As per earlier studies,, we included cases with gastritis or gastric erosions in FD. Organic dyspepsia included cases with duodenitis or duodenal erosions, peptic ulcer, and erosive esophagitis.
The collected data were entered in Microsoft Excel sheet. Continuous data were summarized as mean (standard deviation) or median (range). Categorical data were presented as proportions. Comparison of categorical data between groups was done by Chi-square test. Continuous data between two groups were compared using Student's t-test. Continuous data between more than two groups were compared using Kruskal–Wallis H test. A P < 0.05 was considered significant. Data were analyzed by SPSS version 21 (SPSS, Inc., Chicago, IL, USA).
The study was approved by the ethics committee of the institute.
During the study period, a total of 966 upper gastrointestinal endoscopies were done. Of these, 234 (24.2%) patients satisfied the study criteria and were included in the analysis. Based of Rome IV criteria, they were subclassified as EPS (18, 7.7%), PDS (116, 49.6%), and overlap of EPS + PDS (100, 42.7%). The median age of the study cohort was 43 years (18–82 years), and majority were male (134, 57.3%). The endoscopic findings noted were normal study (79, 33.8%), gastritis or gastric erosions (133, 56.8%), duodenal erosions (11, 4.7%), duodenal ulcer (11, 4.7%), and erosive esophagitis (14, 6%). Thus, FD was noted in 85% (199) of cases. H. pylori infection was detected in 114 cases (48.7%). H. pylori infection was significantly more common (P = 0.01) in those with OD (24/35, 68.6%) than those with FD (90/199, 45.2%).
As noted from [Table 1], there was no significant difference between the three subtypes of dyspepsia in terms of age, sex, use of alcohol or tobacco, and comorbid states. The prevalence of H. pylori infection was higher in the EPS group (61.1%), though not statistically significant (P = 0.24). On the other hand, the prevalence of OD was statistically significant in the EPS subgroup (P = 0.001).
|Table 1: Clinical and endoscopic characteristics of patients with epigastric pain syndrome, postprandial distress syndrome, and overlap of epigastric pain syndrome + postprandial distress syndrome|
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The present study highlights that PDS is the most common presentation of dyspepsia, followed by EPS + PDS overlap in our patients. OD is noted in 15% of cases with dyspepsia and is significantly more common in those with EPS. Rapid urease test for H. pylori infection is positive in 48.7% of cases with dyspepsia and significantly more common in those with OD.
Community-based studies from India and Bangladesh have noted a similar low prevalence of EPS but much higher prevalence of overlap of EPS and PDS.
OD was noted in 15% of cases with dyspepsia. The recent community-based study from Bangladesh reported that nearly one-third of the dyspeptic patients defined by the Rome III criteria had OD. This suggests that Rome criteria may not entirely exclude OD in Southeast Asian population. This discrepancy may be related to differences in psychosocial and sociocultural parameters and higher prevalence of H. pylori.
Earlier studies from India have shown that the rate of H. pylori infection in dyspeptic patients is as high as 70% based on RUT. Another Indian study among people belonging to low socioeconomic strata found the prevalence of positive H. pylori serology to be 79%. A hospital-based study from southern India noted the prevalence of H. pylori in dyspeptic patients to be 41.9%, and male sex was associated with a greater risk for infection. However, a community-based study from Bangladesh has noted H. pylori prevalence of 78% in patients with dyspepsia. In our single-center study, we observed a positivity rate of 48.9% in patients with dyspepsia. Significantly higher positivity was noted in patients with OD which is unlike previous studies. As noted from studies, there is a discrepancy between community-based and hospital-based prevalence rates. This is probably related to high exposure to antibiotics in general population and the use of a variety of diagnostic techniques for documenting H. pylori infection. Risk factors for H. pylori infection include poor hygiene, unprotected drinking water, low educational level, overcrowding, large family size, and low socioeconomic status. With improvements in socioeconomic status and better hygiene practices, we expect a decline in H. pylori infection rate. Further, liberal use of antibiotics in clinical practice may reduce the burden of infection in the community.
The present study has several limitations. It is a single-center, retrospective study with small sample size. Hence, the findings cannot be generalized. Moreover, details of anthropometry, use/abuse of alcohol or tobacco, and socioeconomic status were not available. Histology was not used to confirm the diagnosis of H. pylori infection. Follow-up of patients was not done to determine the response to drug treatment. Fifty-two cases (22.2%) had an overlap of reflux symptoms, and they were not excluded. This could have led to changes in prevalence of OD.
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Conflicts of interest
There are no conflicts of interest.
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