Imaging studies in dyspepsia.

Patients with functional dyspepsia have discomfort centred in the upper abdomen in the absence of oesophagitis, ulcer, cancer or other pathology which could have explained the dyspepsia. It is generally accepted that neither endoscopy, nor other imaging modalities give any positive findings supporting the diagnosis. However, recent investigations have shown that both endoscopic and ultrasonographic imaging show changes: erosive prepyloric changes (EPC) and accommodation abnormalities, respectively, in a high percentage of the patients. The diagnostic sensitivity and specificity of the changes are not yet known, but the fact that they are also seen in several other conditions characterised by dyspepsia, for instance in gallstone disease, may simply indicate that they are linked to epigastric discomfort in general, and not to a specific dyspeptic condition. Ultrasonographic imaging is a non-invasive, widely available, convenient, and reliable method for evaluation of gastric emptying, gastric motility, transpyloric flow and accommodation disturbances, which may play a crucial role in the pathogenesis of dyspepsia.

Autonomous hyperparathyroidism in X-linked hypophosphataemia.

Four patients with familial hypophosphataemic rickets developed significant hypercalcaemia which persisted after discontinuation of vitamin D therapy. They had increased PTH levels and were operated for hyperparathyroidism at the ages of 18, 20, 24 and 45 years, respectively. Three of the patients had previously received phosphate treatment and one patient developed hyperparathyroidism 7 years after treatment with calcitriol. Histological evaluation revealed different degrees of parathyroid hyperplasia in all patients, with persistently increased PTH and/or calcium levels after surgery. The possibility of autonomous hyperparathyroidism should be evaluated in the follow-up of patients with X-linked hypophosphataemic rickets.

Erosive prepyloric changes--a manifestation of stress?

To study the relationship between stress and the endoscopic diagnosis of erosive prepyloric changes (EPC), upper gastrointestinal endoscopy was performed twice in 19 cadets from the Military Academy, once in a 'non-stressed' situation and once after exposure to a standardized stress model. Five biopsy specimens per examination were obtained from the prepyloric mucosa, and the features of acute and chronic inflammation, erosion, and campylobacter-like structures (CLS) were evaluated. The endoscopy showed a significant (p less than 0.001) aggravation of EPC after stress. The histologic examination showed an increase of acute inflammation (p less than 0.05) and a higher density of CLS (p less than 0.01) after stress, as compared with the findings under non-stressed conditions. No association was observed between CLS and EPC. The study sheds new light on the pathogenesis of EPC, as it shows that EPC is aggravated during stress.

Follow-up study of erosive prepyloric changes.

A follow-up study of erosive prepyloric changes (EPC) was undertaken in 60 patients who originally presented with non-ulcer dyspepsia and EPC grade 2 or 3. After 45 (range, 24-60) months EPC grade 2 or 3 was still present in 80% of the patients, and 82% had unchanged dyspeptic symptoms. Most of the patients (77%) experienced a 'stressful' life situation. None of the patients had developed peptic ulceration during the follow-up period, and there were no indications of active or healed ulcerations or cancer at the follow-up study. The results indicate that EPC are chronic changes in the gastric mucosa closely associated with long-lasting dyspeptic symptoms.

The influence of prolonged physical stress on gastric juice components in healthy man.

Eight healthy men were exposed to 5 days of continuous heavy exercise combined with caloric deficiency and sleep deprivation. Immediately after the stress period the fasting and postprandial intragastric bile acid concentration, pepsin concentration, and gastric juice acidity were measured. Compared with a control experiment performed 8 weeks later, the results from the stress period showed a sevenfold increase in the fasting concentration of intragastic bile acids (from 35 mumol/l to 256 mumol/l; p less than 0.02), there was a tendency towards an increase in the fasting intragastric pepsin concentration, and there was an increase (p less than 0.05) in the intragastric pH level throughout the 3rd postprandial hour. It appears that physical stress induces changes in the intragastric milieu that might dispose for mucosal lesions.

Intragastric bile acid concentrations in patients with erosive prepyloric changes.

In the search for pathogenetic mechanisms behind EPC, intragastric bile acids were measured in 60 patients with non-ulcer dyspepsia (NUD) and grade 2 or 3 erosive prepyloric changes (EPC) and in 20 control subjects. Intragastric bile acid concentrations tended to be higher in the control subjects than in the EPC patients, but the difference did not reach statistical significance. The results neither support nor disprove the hypothesis that bile acid-induced mucosal damage may be involved in the pathogenesis of EPC.

Histological findings in erosive prepyloric changes.

To study the histology of erosive prepyloric changes (EPC), 5 bioptic specimens per examination were obtained from the prepyloric mucosa during 161 upper endoscopies in persons with and without EPC. The macroscopic erosions of EPC grade 3 were histologically verified in 88% of the cases. Histologically diagnosed erosions were always accompanied by an element of acute inflammation. The incidence of acute inflammation increased with increasing grades of EPC, from 5% in grade 0 and 1, through 26% in grade 2, to 96% in grade 3. The incidence of chronic inflammation was 0 in grade 0, 50% in grade 1, 46% in grade 2, and 90% in grade 3. On the whole, gastritis was found in 98% of the cases with EPC grade 3, as compared with approximately 50% in grades 2 and 1. Fibrosis was diagnosed in all the cases. The mean thickness of the foveolar layer increased with increasing grades of EPC, the values being significantly higher in grades 2 and 3 than in grade 0, with, however, considerable overlapping between groups. Cimetidine was found to have no effect on the histological features of chronic/acute inflammation and erosion.

Effect of cimetidine in patients with non-ulcer dyspepsia and erosive prepyloric changes.

A double-blind, placebo-controlled trial was performed, using 400-mg cimetidine tablets or placebo twice daily for 4 weeks in 100 patients with non-ulcer dyspepsia (NUD) and erosive prepyloric changes (EPC) grade 2 or 3. Symptomatic assessment was made weekly and endoscopic assessment on completion of the treatment period. Symptomatically, a significant effect of cimetidine versus placebo on epigastric pain/discomfort was recorded after 2 weeks' treatment (p less than 0.05). Endoscopically, there was a significant improvement, according to our grading scale of EPC, in the cimetidine-treated group, as compared to the placebo-treated group (p less than 0.05). On the basis of our findings, patients with NUD and EPC who have epigastric pain/discomfort as a prominent symptom seem to profit from treatment with cimetidine.

Erosive prepyloric changes in persons with and without dyspepsia.

A specified endoscopic picture, consisting of standing prepyloric mucosal folds, injection, and erosions, is denoted erosive prepyloric changes (EPC) and is divided into three grades. In a prospective study in 1001 patients referred for routine upper endoscopy, active EPC (grades 2 and 3) was found in 25.8%, rising to 32.2% in dyspeptic patients with non-ulcer conditions. EPC was significantly more frequent in those below than those above 50 years of age, the male to female ratio being 1.1. In 34.5% of the EPC patients, EPC was an isolated finding. Maximal acid output was, on an average, significantly lower in patients with EPC than in duodenal ulcer patients and similar to that of healthy subjects. Non-ulcer conditions were significantly more frequent, and ulcer in general significantly less frequent, in the EPC group than in a randomly selected control group without EPC. In 34 asymptomatic volunteers the frequency of EPC was 17.6%, significantly lower than in patients of comparable age with non-ulcer conditions. The findings indicate that EPC is related to non-ulcer dyspepsia. The recognition of this condition may lead to a more accurate definition of a patient group with ulcer-like symptoms, without ulcer, and thus, in turn, result in more efficient treatment procedures.

Influence of fiber on postprandial intragastric juice acidity, pepsin, and bile acids in healthy subjects.

The effect of a fiber-enriched wheat bran product, Fiberform, and a guar gum preparation, Guarem, on postprandial intragastric juice acidity and pepsin and bile acid concentrations was studied in healthy subjects. Fiber-enriched wheat bran prolonged significantly the meal-induced elevation of pH and decrease in pepsin. Both fiber products reduced postprandial intragastric bile acid concentration.