Dyspepsia in general practice in Denmark. A 1-year analysis of consulters in general practice.

OBJECTIVE: To estimate the incidence rate of patients with dyspepsia in general practice, related to age, gender and dwelling and to classify the patients into dyspepsia subgroups. DESIGN: In a background population of 123,610 persons under the National Health Insurance System a systematic, prospective registration of dyspepsia patients consulting in general practice was done. Each patient was subject to a structured interview covering 18 dyspepsia symptoms and six alarm symptoms. A diagnostic chart was used to classify the patients into subgroups. SETTING: General practice: 93 general practitioners in 63 centres in Denmark. PATIENTS: Patients consulting the general practitioner with dyspepsia as their main complaint. RESULTS: 4215 dyspepsia patients were registered within 1 year. The annual incidence rate of dyspepsia was 3.4%. Alarm symptoms were present in 11.7% of the patients. The highest incidence rates were related to middle age, female gender and rural dwelling. Of these 34% had dysmotility-like, 30% had reflux-like, 17% ulcer-like and 3% uncharacteristic dyspepsia, while 16% were classified into two or more groups. Dysmotility-like dyspepsia was predominant in women and reflux-like dyspepsia was predominant in men. CONCLUSIONS: Within 1 year 34 patients out of 1000 will seek medical advise in general practice with a new episode of dyspepsia. Based on the registration of symptoms 28 of 34 can be classified into a single subgroup of dyspepsia; 4 of 34 patients will present with one or more alarm symptom.

Bile acids in health and disease.

Over the last quarter of a century Danish research on bile acids has comprised studies of their physical and chemical properties, their physiology, pathophysiology, metabolism, and kinetics, and their clinical applicability. In the beginning of the period a major contribution was made to the understanding of the factors involved in the solubility of cholesterol in bile. The growing international understanding of the potential importance of the bile acids in health and disease gave raise to a substantial Danish contribution in the 1970s and 1980s in parallel with international achievements. Emphasis was on the possible clinical implications of bile acids. Studies on physiology and pathophysiology were in focus. Patients who have had an intestinal bypass operation for obesity served as a model for obtaining new knowledge on various aspects of the properties of the bile acids. Also the analytical methods were improved. Important physiological research on the mechanisms of hepatic bile flow was conducted. An intestinal perfusion model served as a tool providing information on absorption kinetics and on transmucosal water and electrolyte movements. The gallstone disease, liver diseases, inflammatory bowel disease, fat malabsorption, and other intestinal disorders were studied. The 'idiopathic ileopathy' as a cause for bile acid malabsorption causing diarrhoea was established as a new disorder. Thus, in the time period concerned, substantial Danish contributions emerged on major and minor topics of the bile acid field.

Longitudinal study of influence of Helicobacter pylori on current risk of duodenal ulcer relapse. The Hvidovre Ulcer Project Group.

Seventy-four patients with duodenal ulcer were followed up longitudinally for 2 years after initial ulcer healing. Endoscopy including biopsy of the antral mucosa was performed every 3rd month and whenever clinical symptoms of relapse occurred. The presence of Helicobacter pylori in the biopsy specimens was scored as 0 (none), 1 (sporadic occurrence), 2 (clusters), and 3 (numerous bacteria found diffusely in the mucus layer). The incidence rates of ulcer relapse per patient-month, grouped in accordance with these scores, were (with 95% confidence intervals) 0.073 (0.048-0.111), 0.083 (0.052-0.133), 0.123 (0.096-0.157), and 0.069 (0.041-0.116), respectively. No significant differences in incidence rates across H. pylori scores were observed when taking into account the observation period after healing of the first ulcer, number of ulcer recurrence (1st, 2nd, 3rd), sex, age, smoking habits, peak acid output, time of healing of the preceding ulcer, treatment of the present ulcer (cimetidine, antacids, or no treatment), or type and degree of gastritis. Thus, although H. pylori is prevalent in patients with duodenal ulcer disease, the present study indicates that H. pylori does not have a substantial note in the precipitation of active duodenal ulcer.

[Extracorporeal shockwave crushing of gallstones. Preliminary report]. / Ekstrakorporal galdestensknusning. En praeliminaer rapport. Hvidovre Hospitals Galdestensgruppe.

Extracorporeal shock wave lithotripsy (ESWL) was used for treatment of symptomatic x-ray negative stones in 23 patients. The number of ESWL sessions per patient was 1.8 (range 1-4). In 18 patients (78%), adequate fragmentation was seen comparable to results obtained elsewhere. Oral bile acid therapy was used after ESWL in the 18 patients mentioned and the mean follow-up period was five months (range 3-8 months). Four patients had by now passed all stones while 12 patients still had remaining stone fragments and one patient a gallstone. After ESWL, one patient was and one patient a gallstone. After ESWL, one patient was referred for cholecystectomy at his own request. Of the remaining five patients, cholecystectomy was performed in two and was scheduled for in three. Complications after ESWL were seen in two patients who developed acute pancreatitis. Thus, our preliminary experience shows that ESWL resulted in fragmentation and passing of gallbladder stones, but not without complications. Like the gallstone groups in Lyon, Montreal and Munich we are convinced that ESWL should be performed in accordance with prospectively designed protocols in order to establish optimal planning of indications and strategies for future treatment.

[Clinical continuing education of younger physicians. A pedagogic trial with postgraduate clinical training using the clinical decision process]. / Klinisk videreuddannelse af yngre laeger. Paedagogisk forsøg med postgraduat klinisk undervisning med gennemgang af den kliniske beslutningsproces.

The aim of this study was to improve the clinical training of the staff of a department of internal medicine. A total of 16 clinical pathological conferences with patient demonstrations were given. The doctor in charge of the conference motivated his choice of patient and made a critical review of the clinical decision process according to a 16 item check list. The median time used for planning of the presentation was five hours, range 2.5-8 hours. Sixteen of the participants (94%) found the training programme of very high or high quality while 1 (6%) found it less good. Fifteen (88%) of the doctors indicated higher clinical skill after than before the conferences (p less than 0.01). The registrars revealed a significantly better improvement of their clinical skills than did the senior registrars and consultants (p less than 0.05). The median educational value of the items of the check list was stated to be 1.3 (0-2). Statement of the probability of the final diagnosis of the patient, value judgement in clinical decisions and costs of diagnostic examinations were considered of highest educational value, 1.5-1.6. Postgraduate clinical pathological conferences with patient demonstrations including systematic reviews of the clinical decision process are valuable in the clinical training of doctors.

Endoscopically inserted biliary endoprosthesis in malignant obstructive jaundice. A survey of the literature.

Eighty-seven publications in English on endoscopic bile duct stenting for palliation of obstructive jaundice were electronically or manually retrieved. Only eight of these studies were found to represent series of more than 20 patients and to include only a single presentation of data from patients published more than once. These eight studies refer to data on 856 patients, of whom 702 are from four open series, whereas 154 are from four randomized trials comparing endoscopic insertion of endoprosthesis to percutaneous stents or surgical by-pass. Endoscopic insertion was successful in about 90% of the patients. Stent diameters were 7-12 French. Patient survival was not affected as it is governed by the natural history of the underlying malignant disease. Endoscopic endoprosthesis was superior to percutaneous stenting and equal to surgical by-pass, but probably less resource consuming. The most important unsolved problem is the tendency to cholangitis and clogging of endoprostheses. Some suggestions concerning questions to be addressed in a more uniform manner in future publications on this subject are presented.

Duodenal ulcer healing on 2 g of sucralfate daily at bedtime compared to 1 g four times daily.

Seventy-seven patients with endoscopically verified duodenal ulcers were randomized to treatment with either 2 g sucralfate daily at bedtime or 1 g sucralfate q.d.s. in a controlled double-blind comparative study. After a 4-week treatment period, the healing rate was 68% for the former and 69% for the latter treatment.

The personality pattern of duodenal ulcer patients in relation to spontaneous ulcer healing and relapse.

One hundred consecutive out-patients with duodenal ulceration from a hospital and a gastroenterological clinic were tested with the Minnesota Multiphasic Personality Inventory (MMPI). This was carried out in order to investigate whether neuroticism or other personality disorders were characteristics of duodenal ulcer patients, and whether the presence of such possible personality disorders might influence the prognosis of the disease. Neuroticism occurred in 53% of the patients, but only in 5% of controls (P less than 0.0001). Overall, personality disorders were present in 69% of the patients compared with 30% of the controls (P less than 0.0001). Neuroticism was connected with a high frequency of relapse (P less than 0.05) whereas failure of spontaneous ulcer healing had no certain relation to personality disorders. Patients with non-neurotic personality disorders had more frequently suffered stressful life events before entrance to the study (P less than 0.05) and, like the neurotic patients, they had lower ego-strength to cope with such events (P less than 0.05). The results indicate that personality assessments make it possible to distinguish between subgroups of duodenal ulcer patients with different course of the disease.

Low-dose cyclosporin for Crohn's disease: implications for clinical trials.

Cyclosporin is a potent immunosuppressant, which has gained recent interest as a possible treatment for Crohn's disease. Chronic nephrotoxicity, however, has recently been demonstrated as a result of early treatment with high initial cyclosporin doses. We report the effect of a 3-month treatment with low-dose cyclosporin (5-7.5 mg kg-1 day-1) in 11 chronically active, therapy-resistant Crohn's disease patients. Eight of the 11 patients (72%) improved according to a clinical grading score and the Dutch Activity Index whereas 9/11 (82%) improved according to the Crohn's Disease Activity Index (P less than 0.05) after 1 month. Three patients were withdrawn despite clinical improvement. One developed arterial hypertension, one dropped out and one required surgical treatment due to a small bowel stricture. Five patients (45%) completed the treatment period with improved clinical scores. After tapering-off, two patients (18%) were better at follow-up. No serious side-effects were encountered and it is concluded that low-dose cyclosporin treatment should be further investigated in Crohn's disease.

[Abdominal pain precipitated by thoracic segment syndrome]. / Abdominalsmerter udløst af torakale segmentsyndromer.

Referred pain originating from a dysfunctioning thoracic facet joint may simulate abdominal pain. This pain syndrome, the facet syndrome, is probably quite common and perhaps accounts for about 10% of the cases of abdominal pain of unknown origin. Current concepts of the facet syndrome are reviewed and a clinically diagnostic evaluation programme is presented. A case report illustrates the diagnostic problems in daily practice and the need for the clinician to recognize and to look for the facet syndrome.