Outcomes of High-Frequency Gastric Electric Stimulation for the Treatment of Severe, Medically Refractory Gastroparesis in Finland.

BACKGROUND AND AIMS: Severe, medically uncontrollable gastroparesis is a rare entity, which can be treated using a high-frequency gastric electric stimulator implanted surgically. Previous follow-ups have proven positive outcomes with gastric electric stimulator in patients with gastroparesis. The aim of this study was to evaluate the efficacy and safety of gastric electric stimulator in patients, in whom gastroparesis could not be controlled by conservative means in our country. MATERIALS AND METHODS: This is a retrospective multi-center cohort comprising all patients who had been implanted gastric electric stimulator for severe, medically refractory gastroparesis during 2007-2015 in Finland. RESULTS: Fourteen patients underwent implantation of gastric electrical stimulator without any postoperative complications. Laparoscopic approach was used in 13 patients (93%). Prior implantation, all patients needed frequent hospitalization for parenteral feeding, 13 had severe nausea, 11 had severe vomiting, 10 had notable weight loss, and 6 had frequent abdominal pain. After operation, none of the patients required parenteral feeding, 11 patients (79%) gained median of 5.1 kg in weight (P < 0.01), and symptoms were relieved markedly in 8 and partially in 3 patients (79%). Of partial responders, two continued to experience occasional vomiting and one mild nausea. Five patients needed medication for gastroparesis after the operation. One patient did not get any relief of symptoms, but gained 6 kg in weight. No major late complications occurred. CONCLUSION: Gastric electrical stimulator seems to improve the nutritional status and give clear relief of the symptoms of severe, medically uncontrollable gastroparesis. Given the low number of operations, gastric electrical stimulator seems to be underused in Finland.

Randomised clinical trial: low-FODMAP rye bread vs. regular rye bread to relieve the symptoms of irritable bowel syndrome.

BACKGROUND: Grains are high in FODMAPs (Fermentable Oligo-, Di-, Monosaccharides And Polyols) and often considered as triggers of IBS symptoms. AIM: To evaluate if rye bread low in FODMAPs would be better tolerated than regular rye bread in subjects with IBS. METHODS: The study was conducted as a randomised double blind controlled cross-over study (n = 87). Participants were supplied with both regular rye bread and low-FODMAP rye bread for 4 weeks. Symptoms were measured with a symptom severity scoring system (IBS-SSS) and visual analogue scale (VAS) assessments of individual symptoms. Quality of life was monitored. Colonic fermentation was measured by the breath hydrogen test and dietary intake by food diaries. RESULTS: Dietary fibre intake increased during both study periods compared to baseline. Many signs of IBS i.e. flatulence, abdominal pain, cramps and stomach rumbling were milder on the low-FODMAP rye bread (P-values: 0.04; 0.049; 0.01 and 0.001). The mean of VAS measurements was favourable towards LF bread [-3 (95% CI): -6 to -1, P = 0.02] but no differences were detected in IBS-SSS or quality of life. The AUC of breath hydrogen values was significantly lower during the low-FODMAP bread period (median 52.9 vs. 72.6; P = 0.01). CONCLUSIONS: Low-FODMAP rye bread helps IBS patients to control their symptoms and reduces gastrointestinal gas accumulation. However, replacing regular rye bread by low-FODMAP bread without concomitant broader dietary changes does not improve quality of life or IBS-SSS. Nonetheless, inclusion of low-FODMAP rye bread in diet might be one way that IBS patients could increase their fibre intake.

Diminished salivary epidermal growth factor secretion: a link between Sjögren's syndrome and autoimmune gastritis?

OBJECTIVES: Healthy human labial salivary glands produce epidermal growth factor (EGF). In Sjögren's syndrome (SS), EGF staining is diminished. SS is also associated with chronic autoimmune corpus gastritis. We therefore hypothesized that EGF secretion would be diminished in SS and that this could affect gastric target cells. METHODS: Salivary EGF secretion in SS was compared to that in healthy controls using an enzyme-linked immunosorbent assay (ELISA). EGF receptor (EGFR) immunoreactive cells in the gastric corpus of healthy human subjects were analysed using immunostaining. RESULTS: Salivary secretion of EGF was diminished in SS patients (232.4, range 52.6-618.4, vs. 756.6, range 105.3-1631.6 pg/min, p = 0.002). Proton-pump positive parietal cells were mostly EGFR immunoreactive whereas very few pepsinogen I (PGI)-positive cells were EGFR positive. CONCLUSIONS: As EGF is relatively acid resistant, salivary gland-derived EGF might participate in an exo/endocrine mode of parietal cell maintenance in the gastric corpus. Deficiency of salivary gland-derived EGF in SS patients may cause impairment of gastric parietal cells resulting in exposure of immunogenic cryptic antigens and loss of immunological self-tolerance.

Incidence and complications of peptic ulcer disease requiring hospitalisation have markedly decreased in Finland.

BACKGROUND: The characteristics of peptic ulcer disease (PUD) are changing. AIM: To evaluate time trends in the incidence of PUD and its complications in hospitalised patients at the beginning of the 21st century, drug therapies in out-patient care as a risk factor for recurrent PUD, and medication used by PUD patients compared with the background population. METHODS: In this retrospective epidemiologic cohort study, data from the years 2000-2008 came from The Hospital District of Helsinki and Uusimaa, and the Finnish Care Register. All hospitalised adult patients with PUD in the capital region of Finland were included. The data were linked with nationwide Prescription Register of the Finnish Social Insurance Institution allowing detailed individual medicine purchase data. RESULTS: A total of 9951 peptic ulcers were detected among 8146 individual patients during the study period. The mean annual incidence of all peptic ulcers decreased from 121/100,000 (95% CI: 117-125) in 2000-2002, to 79 (95% CI: 76-82) in 2006-2008 [Incidence rate ratio = 0.62 (95% CI: 0.58-0.64), P < 0.001 after age and sex adjustment]. Decrease in incidence was seen in all age groups and in both sexes. The overall rate of severe complications of PUD was reduced. One-year cumulative incidence of recurrent ulcers was 13%. Use of several drugs was associated with increased risk for recurrence. The purchases of various drugs were more common among PUD patients compared with background population. CONCLUSIONS: Both the incidence and complication rates have markedly decreased during the study period. Recurrent peptic ulcer disease was associated with polypharmacy.

Upper abdominal symptoms in patients with Type 1 diabetes: unrelated to impairment in gastric emptying caused by autonomic neuropathy.

AIMS: Diabetic gastroparesis is a common condition occurring in some 30-50% of patients with long-term diabetes. Some studies have found a relationship between autonomic neuropathy and diabetic gastroparesis. In addition to autonomic neuropathy, acute changes in plasma glucose concentration can also affect gastric emptying. The objective was to examine the relationship between autonomic nerve function, glucose concentration, gastric emptying, and upper abdominal symptoms in Type 1 diabetic patients. METHODS: Gastric emptying of solids and liquids was measured with scintigraphy in 27 patients with longstanding Type 1 diabetes with upper abdominal symptoms. Autonomic nerve function was examined by standardized cardiovascular tests, and plasma glucose concentrations were measured during scintigraphy. Severity of abdominal symptoms and quality of life were explored by validated questionnaires. RESULTS: Seven patients (26%) had delayed gastric emptying of solids and three (11%) of liquids. Mean gastric half-emptying time of solids was 128 +/- 116 min and of liquids 42 +/- 30 min. Of the 26 patients undergoing tests, 16 (62%) had autonomic nerve dysfunction. Autonomic neuropathy score (1.6 +/- 1.7) correlated positively with the gastric emptying rate of solids (P = 0.006), a rate unrelated to symptom scores or plasma glucose concentrations during scintigraphy. Quality of life in patients with abdominal symptoms was lower than in the normal Finnish population. CONCLUSIONS: Impaired gastric emptying of solids in patients with Type 1 diabetes is related to autonomic neuropathy, but not to actual glycaemic control. The upper abdominal symptoms observed in these patients cannot be explained, however, by impaired gastric emptying.

First-line eradication therapy for Helicobacter pylori in primary health care based on antibiotic resistance: results of three eradication regimens.

AIM: To determine the efficacy of three Helicobacter pylori eradication regimens and factors affecting the eradication results in Finland. METHODS: A total of 342 H. pylori-positive adult patients from primary health care referred for gastroscopy at 23 centres in different parts of Finland were randomized to receive either (i) lansoprazole 30 mg b.d., amoxicillin 1 g b.d. and metronidazole 400 mg t.d.s. (LAM), (ii) lansoprazole 30 mg b.d., amoxicillin 1 g b.d. and clarithromycin 500 mg b.d. (LAC), or (iii) ranitidine bismuth citrate 400 mg b.d., metronidazole 400 mg t.d.s. and tetracycline 500 mg q.d.s. (RMT). A (13)C-urea breath test was performed 4 weeks after therapy. RESULTS: The eradication result could be assessed in 329 cases. Intention-to-treat cure rates of LAM, LAC, and RMT were 78, 91 and 81%. The difference was significant between LAM and LAC (P = 0.01) and between LAC and RMT (P = 0.04). The eradication rates in cases with metronidazole-susceptible vs. -resistant isolates were for LAM 93% vs. 53% (P = 0.00001), for LAC 95% vs. 84%, and for RMT 91% vs. 67% (P = 0.002). Previous antibiotic use, smoking, and coffee drinking reduced the efficacy of therapy. CONCLUSIONS: In unselected patients in primary health care, LAC was the most effective first-line eradication.

Non-endoscopic diagnosis of atrophic gastritis with a blood test. Correlation between gastric histology and serum levels of gastrin-17 and pepsinogen I: a multicentre study.

BACKGROUND AND AIMS: Serum levels of gastrin-17 (S-G-17) and pepsinogen I (S-PGI) are biomarkers of gastric antral and corpus mucosa, respectively. In a prospective multicentre investigation, we determined whether these tests, together with the assay of Helicobacter pylori antibodies, are a non-endoscopic tool for the diagnosis of atrophic gastritis. MATERIALS AND METHODS: The series comprised 404 consecutive adult outpatients undergoing diagnostic upper-gastrointestinal endoscopy for various dyspeptic symptoms in five outpatient clinics. Gastric biopsies from the antrum and corpus (at least two biopsies from both sites) were available from all patients, and they were evaluated according to the guidelines of the updated Sydney system. S-PGI and S-G-17 were assayed with ELISA methods using monoclonal antibodies to pepsinogen I and amidated gastrin-17. In addition to the fasting level (S-G-17(fast)), a postprandial S-G-17 (S-G-17(prand)) level was measured 20 min after ingestion of a protein-rich drink. H. pylori antibodies were determined using a polyclonal EIA method. RESULTS: S-G-17(prand) (and S-G-17(fast)) and S-PGI levels decreased with increasing grade of atrophy of the antrum or corpus, respectively. S-G-17(prand) levels were significantly lower in patients with advanced (moderate or severe) atrophic antral H. pylori gastritis than in those with non-atrophic H. pylori gastritis. All patients with a resected antrum demonstrated S-G-17(prand) levels that were almost undetectable. Of the nine patients with an H. pylori-positive moderate or severe atrophic antral gastritis, six had S-G-17(prand) levels below 5 pmol/l. Similarly, S-PGI levels were significantly lower in patients with advanced corpus atrophy than in those without. Of the 45 patients with moderate or severe corpus atrophy in endoscopic biopsies, 35 patients had S-PGI levels < 25 microg/l. By using the cut-off levels for S-G-17(prand) and S-PGI with the best discrimination, the sensitivity and specificity of the blood test panel in delineation of patients with advanced atrophic gastritis (either in the antrum or the corpus, or both) were 83% and 95%, respectively. The predictive values of the positive and negative test results were 75% and 97%, respectively. In the diagnosis of atrophic gastritis, the application of S-G-17(fast) showed a slightly lower sensitivity and specificity than the application of S-G-17(prand) as a biomarker for antral atrophy. CONCLUSIONS: The diagnosis of atrophic gastritis obtained with the blood test panel of S-G-17, S-PGI and H. pylori antibodies is in good agreement with the endoscopic and biopsy findings. The panel is a tool for non-endoscopic diagnosis and screening of atrophic gastritis.

Helicobacter pylori and different topographic types of gastritis: treatment response after successful eradication therapy in functional dyspepsia.

BACKGROUND: Helicobacter pylori gastritis is usually a lifelong disease which can cause different topographical inflammatory reactions and induce divergent effects on acid secretion in humans. High acid output and antrum-predominant gastritis are associated with duodenal ulcer disease, whereas corpus-predominat gastritis has been associated with low acid output and risk of gastric carcinoma. The objective of this study was to evaluate the role of different gastritis subtypes in the long-term treatment response of H. pylori-positive functional dyspepsia. METHODS: The gastric biopsies from 143 H. pylori-positive patients with functional dyspepsia were classified in accordance with the Sydney System as antrum-predominant gastritis, pangastritis or corpus-predominant gastritis. The patients were randomized to receive either eradication therapy or placebo antibiotics. Moreover, to standardize acid suppression every patient received omeprazole therapy for the first 3 months. Dyspeptic symptoms were evaluated from a questionnaire and the follow-up time was 12 months. In addition, delta-over-baseline (DOB) values of the 13C-urea breath test (UBT) were analysed from a subgroup of 36 patients to measure urease activity of the stomach. RESULTS: After 1 year, the dyspepsia symptom score was 7.4 +/- 3.0 (95% CI 6.6-8.2) in successfully H. pylori-eradicated patients and 7.6 +/- 3.1 (95% CI 6.9-8.4) in controls (P = ns). Among patients with antrum-predominant gastritis, dyspepsia score was reduced more in subjects whose H. pylori was eradicated than in controls with ongoing infection (-3.6 +/- 2.9 versus -1.7 +/- 2.9; P = 0.05). High urease activity of the stomach was associated with severe or moderate chronic antrum-predominant gastritis. CONCLUSIONS: Patients with antrum-predominant H. pylori-positive chronic gastritis and functional dyspepsia get symptom improvement after successful eradication therapy. A high DOB value of UBT is associated with these patients.

Helicobacter pylori eradication and standardized 3-month omeprazole therapy in functional dyspepsia.

OBJECTIVES: The role of Helicobacter pylori in functional dyspepsia remains unclear. This study evaluated the long term consequences for symptoms and quality of life in patients with H. pylori-positive functional dyspepsia after H. pylori eradication therapy with a standardized 3-month omeprazole treatment. METHODS: A total of 151 H. pylori-positive patients with functional dyspepsia were randomized to receive either eradication therapy or placebo-antibiotics. The initial medication was administered in a double-blinded fashion. In addition, to standardize acid suppression, every patient received omeprazole therapy for the first 3-month period. Dyspeptic symptoms were evaluated by a questionnaire every 3 months, and quality of life was measured by a validated RAND 36-item health survey 1.0 questionnaire at the beginning of the study and after 12 months of follow-up. As the main outcome measure, the scores of patients who had received H. pylori eradication therapy and omeprazole were compared with those who received placebo and omeprazole during the 12 months of follow-up. RESULTS: A total of 136 patients completed the 1-yr follow-up. In all, 77 patients received eradication therapy and 74 patients remained as controls. After 12 months, the mean reduction in the dyspepsia score was 28.8% in patients with H. pylori eradication therapy and 21.7% in the control group. The reduction of dyspepsia was significant (p < 0.0001) in both groups compared to baseline value, but no statistically significant differences in changes of dyspeptic symptoms or in quality of life were demonstrated between the H. pylori eradication therapy group and controls after 1 yr. In both patient groups, regurgitation (p < 0.001) and heartburn (p < 0.01) revealed relapse after cessation of 3-month omeprazole treatment. CONCLUSIONS: No clear differences in symptoms or in quality of life were found between patients treated with H. pylori eradication therapy and omeprazole compared with patients receiving placebo and omeprazole after 1 yr. Regardless of H. pylori status, omeprazole treatment reduced heartburn and regurgitation. The placebo effect on the symptoms of functional dyspepsia and on quality of life was marked.

Long-term follow-up study of gastric emptying and Helicobacter pylori eradication among patients with functional dyspepsia.

Studies on the influence of Helicobacter pylori gastritis on gastric motility have produced inconclusive results. We investigated the effect of Helicobacter pylori eradication therapy on gastric emptying in patients with functional dyspepsia in a placebo-controlled double-blind study with one year follow-up. A standardized scintigraphic double-tracer examination was used. Of the 40 subjects, 29 were H. pylori-positive patients with functional dyspepsia and 11 were asymptomatic control subjects. Gastric emptying parameters were: postlag 50% retention time for solids (T50), gastric emptying half-time for liquids (T1/2), solid lag duration, and intragastric distribution of solids. At baseline, the scintigraphic examination was performed for all study subjects to detect any major alterations between dyspeptic patients and asymptomatic control subjects. Thereafter every patient was randomized to receive either H. pylori eradication therapy or placebo; in addition they also received omeprazole 20 mg once a day for three months to stabilize the acid suppression therapy. After one year scintigraphy was repeated for the patients. The solid lagtime was prolonged among dyspeptic patients compared with asymptomatic controls (P = 0.02). After one year there was no significant difference between H. pylori-eradicated and placebo-treated patients in any gastric emptying parameter. However, good reproducibility of the scintigraphic examination showing the gastric emptying rate of solids (r = 0.43, 95% CI: 0.07-0.69; P = 0.02) and liquids (r = 0.44, 95% CI: 0.09-0.69; P = 0.02) continued even after one year of follow-up. In conclusion, eradication of H. pylori has no impact on gastric emptying in patients with functional dyspepsia, but the long-term trend in individual gastric emptying rate is stable.

Role of gastric emptying in functional dyspepsia: a scintigraphic study of 94 subjects.

Many physiological factors can alter gastric emptying, and the role of gastric emptying in functional dyspepsia is controversial. The aim of this study was to assess the effects of different factors (age, sex, the degree of dyspeptic and irritable bowel symptoms, lactase deficiency, smoking habits, the use of antiinflammatory drugs, and H. pylori gastritis) on gastric emptying in patients with functional dyspepsia. The study population consisted of 83 patients with functional dyspepsia and 11 control subjects who underwent a standardized scintigraphic examination to study gastric emptying. This study detected no difference in gastric emptying between different subgroups with functional dyspepsia. There was, however, a slight tendency for delayed gastric emptying among patients with functional dyspepsia compared to controls. Intragastric distribution of the solid content was more distally located in smokers, and the solid lagtime was prolonged among antiinflammatory drug users. The gastric emptying of liquids was delayed among older patients. The subgrouping of dyspeptic symptoms is of minor importance with respect to gastric emptying. Habitual smoking and the use of antiinflammatory drugs are potent factors able to alter the gastric emptying of solids, but the role of H. pylori seems to be less important.

A dual-tracer method for studying intragastric distribution and gastric emptying of solids and liquids in functional dyspepsia.

Twenty-five patients with functional dyspepsia and 11 healthy controls matched for age and sex were examined. The patients were divided into two groups: patients with dysmotility-like symptoms and those with ulcer-like symptoms. In a dual-tracer gastric emptying study, dysmotility-like and ulcer-like symptoms could not be distinguished from each other on the basis of gastric emptying times. The intragastric distribution and the solid lag time in dysmotility-like dyspepsia differed significantly from those of the controls.