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Appendix A: The Rome III Diagnostic Criteria for the Functional Gastrointestinal Disorders. IN: Drossman, D., ed. Understanding the Irritable Gut: The Functional Gastrointestinal Disorders. McLean, VA: Degnon Associates, Inc. 2008. pp 183-199.
This appendix is from a book that helps doctors and patients better understand functional gastrointestinal disorders (FGIDs), with text based on information developed by the Rome Foundation to identify, classify, and treat these disorders. This appendix presents the Rome criteria for the diagnoses of FGIDs; the criteria were developed by teams of experts to define patients for scientific study and help practicing doctors more precisely identify the disorders. The disorders covered include functional heartburn, functional chest pain of presumed esophageal origin, functional dysphagia, globus, functional dyspepsia, postprandial distress syndrome, epigastric pain syndrome, belching disorders, chronic idiopathic nausea, functional vomiting disorders, cyclic vomiting syndrome (CVS), rumination syndrome in adults, irritable bowel syndrome, functional bloating, functional constipation, functional diarrhea, functional abdominal pain syndrome (FAPS), functional gallbladder and Sphincter of Oddi disorders, functional fecal incontinence, functional anorectal pain, and functional defecation disorders. The diagnostic criteria for both childhood and adult FGIDs are included, although the remainder of the appendix only focuses on adult disorders. Readers are cautioned that the criteria are not meant for self-diagnosis and that a confident diagnosis can only be safely arrived at after a careful history and physical examination by a doctor. The diagnostic criteria are scheduled to be updated again in 2012.
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Dieting and Gallstones. Bethesda, MD: Weight-Control Information Network. 2008. 6 p.
This fact sheet provides information about dieting and gallstones. The fact sheet answers common questions about gallstones, including a definition of the condition, the causes of gallstones, symptoms, obesity as a risk factor, weight-loss dieting as a risk factor, gallstones associated with weight cycling, surgery to treat obesity and its relationship to gallstone development, how to decrease the risk of gallstones particularly during weight loss, treatment strategies, and balancing the benefits of weight loss with the risk of developing gallstones. Common symptoms of gallstones include severe pain in the upper abdomen, pain under the right shoulder or in the right shoulder blade, nausea or vomiting, and indigestion after eating high-fat foods. Obesity is a strong risk factor for gallstones, especially for women. People who lose a large amount of weight quickly are at greater risk of developing gallstones than those who lose weight at a slower pace. Diets that include 20 to 25 percent of total calories from fat and those that are high in fiber and calcium may reduce the risk of gallstone development. Regular physical activity is related to a lower risk for gallstones. Readers are referred to seven publications for more information. The fact sheet concludes with a brief description of the Weight-control Information Network (WIN), a service of the Federal Government that provides the general public, health professionals, the media, and Congress with up-to-date, science-based health information about weight control, obesity, physical activity, and related nutritional issues. 1 figure. 1 table.
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Functional Gastrointestinal Disorders and the Potential Role of Eosinophils. Gastroenterology Clinics of North America. 37(2): 383-396. June 2008.
This article about functional gastrointestinal disorders and the potential role of eosinophils is from an issue of Gastroenterology Clinics of North America that focuses on eosinophilic and autoimmune gastrointestinal disease. Eosinophils are a type of white blood cell. The authors review the Rome III classification of the functional gastrointestinal disorders (FGIDs), noting that abdominal pain, disordered defecation, and meal-related discomfort are common symptoms for a range of FGIDs. The current model of disease for FGIDs reflects an interaction between psychosocial factors, including stress and anxiety, gut physiology, and the brain-gut axis, which results in visceral hypersensitivity or dysmotility. The article covers eosinophils in the gastrointestinal tract, the normal eosinophil count in the gut, allergy and atopy in FGIDs, infection and gastrointestinal disorders, eosinophils in the duodenum in functional dyspepsia and irritable bowel syndrome (IBS), eosinophil function in the gut, eosinophil interactions in gut mucosa, and eosinophils in gastrointestinal disease. The authors propose that neural-mast cell-eosinophil interaction may cause abdominal pain or meal-related symptoms characteristic of functional disease. The trigger may be a pathogen, food, infection, or other allergen in the gut mucosa. 3 figures. 82 references.
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Functional Gastrointestinal Disorders: Nature and Diagnosis. IN: Drossman, D., ed. Understanding the Irritable Gut: The Functional Gastrointestinal Disorders. McLean, VA: Degnon Associates, Inc. 2008. pp 33-94.
This section of six chapters is from a book that helps doctors and patients better understand functional gastrointestinal disorders (FGIDs), with text based on information developed by the Rome Foundation to identify, classify, and treat these disorders. This section begins with Chapter 5, which outlines the diagnostic strategies and classification for FGIDs. Chapter 6 focuses on irritable bowel syndrome (IBS), the most studied FGID and the one that has validated diagnostic criteria. Chapter 7 covers functional constipation, which must be differentiated from organic disorders, some of which are themselves uncommon and poorly understood. Chapter 8 discusses functional diarrhea, not because it is common, but rather because it may be diagnosed only after meticulous testing for known causes of chronic diarrhea. Chapter 9 covers functional dyspepsia, a condition that is difficult to define and was often called nonulcer dyspepsia. The Rome process has made the diagnosis more inclusive and has altered the classification, subtypes, and criteria of functional dyspepsia. Chapter 10 describes the functional esophageal disorders, which are among the few FGIDs that are best diagnosed by exclusion. Chapter 11 reviews the functional anorectal disorders and Chapter 12 covers the remaining disorders not discussed previously. Each chapter includes black-and-white and color illustrations and concludes with a brief list of recommended sources for more information.
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Gastrointestinal Motility Disorders. IN: Hauser, S., ed. Mayo Clinic Gastroenterology and Hepatology Board Review. 3rd ed. New York, NY: Informa Healthcare USA. 2008. pp 97-110.
This chapter on gastrointestinal (GI) motility disorders is from a comprehensive textbook that provides an in-depth examination of essential knowledge in gastroenterology, hepatology, and the related areas of pathology, endoscopy, nutrition, and radiology. The authors note that motility disorders result from impaired control of the neuromuscular apparatus of the gut. Associated symptoms include recurrent or chronic nausea, vomiting, bloating and abdominal discomfort, constipation, or diarrhea, which occur in the absence of intestinal obstruction. The chapter covers control of GI motor function, gastric and small-bowel motility, the pathogenesis of motility disorders, the management of gastroparesis and pseudo-obstruction, and treatment strategies, including the correction of hydration and nutritional deficiencies, medications, decompression, surgical treatment, and new therapies. An additional section considers functional dyspepsia. The authors conclude that understanding the mechanisms that control motility and the pathophysiologic mechanisms is the key to optimal management. Simple, quantitative measures of transit and an algorithmic approach to identifying the underlying cause may lead to correction of abnormal function. Patient education is essential to avoid aggravation of symptoms caused by dietary indiscretions. The chapter is illustrated with full-color drawings and photographs. 4 figures. 3 tables. 19 references.
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Indigestion. Bethesda, MD: National Digestive Diseases Information Clearinghouse. 2008. 6 p.
This fact sheet familiarizes readers with indigestion, also known as dyspepsia, a term used to describe one or more symptoms including a feeling of fullness during a meal, uncomfortable fullness after a meal, and burning or pain in the upper abdomen. The fact sheet answers common questions about indigestion, including its causes, symptoms, diagnosis, and treatment. Indigestion can be caused by a condition in the digestive tract such as gastroesophageal reflux disease (GERD), peptic ulcer disease, cancer, or diseases of the pancreas or bile ducts. Sometimes a person has indigestion for which a cause cannot be found. This type of indigestion is called functional dyspepsia. Indigestion and heartburn are different conditions, but a person can have symptoms of both. The doctor may order x rays; blood, breath, and stool tests; and an upper endoscopy with biopsies to diagnose indigestion. Some people may experience relief from indigestion by making a few lifestyle changes and decreasing stress. The doctor may prescribe antacids, H2 receptor antagonists (H2RAs), proton pump inhibitors (PPIs), prokinetics, or antibiotics to treat the symptoms of indigestion. The fact sheet includes a brief description of current research in this area. Readers are referred to online publications and resource organizations, including the American Gastroenterological Association at 301–654–2055 or www.gastro.org and the International Foundation for Functional Gastrointestinal Disorders at 1–888–964–2001 or www.iffgd.org. The document concludes with a summary of the activities of the National Digestive Diseases Information Clearinghouse (NDDIC), a service of the National Institute of Diabetes and Digestive and Kidney Diseases. 1 figure.
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Irritable Bowel Syndrome (IBS), Heartburn, Dyspepsia: What’s the Difference? Digestive Health Matters. 17(1): 8-11. Spring 2008.
This article helps readers understand the differences among irritable bowel syndrome (IBS), heartburn, and dyspepsia. IBS is characterized by discomfort or pain anywhere in the abdomen that is relieved by having a bowel movement or that occurs with a change to looser or firmer stools. Dyspepsia is characterized by discomfort or pain, but only in the upper abdomen. Dyspepsia is sometimes associated with eating, but not with having a bowel movement. Heartburn is characterized by discomfort or pain, often described as burning pain in the lower chest behind the breastbone. Heartburn typically occurs after certain meals or when bending over or lying down. The author notes that the symptoms of each of these functional gastrointestinal (GI) disorders can be chronic, often beginning in youth and occurring periodically over a person’s lifetime. Because the management approach to each of these disorders is different, accurate diagnosis is important before undergoing a treatment plan. The article includes one table of warning symptoms, that is, those problems that require immediate medical attention. The author concludes that the distinction of these three disorders from one another depends on the location of the pain or discomfort, the presence or absence of a relationship to having a bowel movement, and the response to acid-suppressing drugs. 1 figure. 3 tables. 2 references.
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Managing the Functional Gastrointestinal Disorders. IN: Drossman, D., ed. Understanding the Irritable Gut: The Functional Gastrointestinal Disorders. McLean, VA: Degnon Associates, Inc. 2008. pp 95-176.
This section of five chapters is from a book that helps doctors and patients better understand functional gastrointestinal disorders (FGIDs), with text based on information developed by the Rome Foundation to identify, classify, and treat these disorders. The section begins with Chapter 13, which offers general treatment measures suitable for any FGIDs, including common-sense advice about diagnosis, diet, lifestyle, and the management of stress. Chapter 14 addresses the successful therapeutic relationship that is essential to achieve the maximum therapeutic benefit for patients with an FGID. The author notes that a strong placebo benefit accompanies most FGID treatments, and many symptoms tend to improve naturally. Therefore, it is important that specific treatments be proven beneficial and safe. Chapter 15 describes randomized clinical trials (RCTs) that can be used to test treatments and provide the foundation for evidence-based medicine. Treatment options for specific FGIDs are reviewed in Chapter 16, including suggestions for functional heartburn, functional chest pain of presumed esophageal origin, functional dysphagia, globus, functional dyspepsia, dyspepsia subtypes, belching disorders, nausea and vomiting disorders, rumination syndrome in adults, irritable bowel syndrome, functional bloating, functional constipation, functional abdominal pain syndrome (FAPS), functional gallbladder and Sphincter of Oddi disorders, functional fecal incontinence, functional anorectal pain, and functional defecation disorders. Some of the more complex of these treatments are discussed in detail in Chapter 17. Each chapter includes black-and-white and color illustrations and concludes with a brief list of recommended sources for more information.
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Treating Functional Dyspepsia: What Are Your Options?. Digestive Health Matters. 17(1): 12-13. Spring 2008.
This article outlines the treatment options that are used for functional dyspepsia, a common disorder characterized by symptoms including upper abdominal pain or discomfort and possibly symptoms of burning, pressure, or fullness often related to meals. The symptoms of dyspepsia can be caused by peptic ulcer or gastritis but are more often diagnosed as functional dyspepsia (FD). FD is a group of symptoms thought to originate in the stomach and upper small intestine but in the absence of any structural or metabolic disease. The article briefly reviews of the possible causes of FD and outlines treatment options including diet, eradication of Helicobacter pylori (H. pylori) infections, acid-lowering medications, prokinetic and antiemetic agents, and centrally acting therapies such as tricyclic antidepressants and hypnotherapy. The article concludes with a brief description of a research study on FD. Readers are referred to the National Institutes of Health (NIH) website at www.nih.gov/news/pr/sep2007/niddk-05.htm for more information and Vickie Silvernail at 507–284–2812.
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Understanding the Irritable Gut: The Functional Gastrointestinal Disorders. McLean, VA: Degnon Associates, Inc. 2008. 240 p.
This book helps doctors and patients better understand functional gastrointestinal disorders (FGIDs), with text based on information developed by the Rome Foundation to identify, classify, and treat these disorders. The book includes 17 chapters in three sections: About the Functional Gastrointestinal Disorders, the Nature and Diagnosis of the Functional Gastrointestinal Disorders, and Managing the Functional Gastrointestinal Disorders. Chapter 1 explains FGIDs and how their symptoms can be used to classify them into individual syndromes. Chapter 2 explains that FGIDs are extremely common throughout the world and that, although never fatal, they can trouble patients periodically throughout their lives. Chapter 3 outlines the anatomy and normal functioning of the gastrointestinal tract, and the gut's nervous system and its interaction with the brain. Chapter 4 briefly summarizes what is known about gut malfunctioning and other influences that may be responsible for functional gut symptoms. The chapters in the second section cover the diagnosis of FGIDs, functional constipation, functional diarrhea, functional dyspepsia, functional esophageal disorders, functional anorectal disorders, and less common FGIDs. The final section begins with a chapter about the general treatment measures that are suitable for any FGIDs, including common-sense advice about diagnosis, diet, lifestyle, and the management of stress. The final chapters cover the importance of a successful therapeutic relationship, the role of randomized clinical trials, and treatment options for specific FGIDs. An appendix presents the Rome criteria for the diagnoses of FGIDs. A second appendix describes some of the tests commonly used in the investigation of FGIDs. The book provides a detailed glossary of related terms and a subject index.
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Functional Dyspepsia: Mechanisms of Symptom Generation and Appropriate Management of Patients. Gastroenterology Clinics of North America. 36(3): 649-664. September 2007.
This article on the symptoms and patient management of functional dyspepsia is from a special issue of Gastroenterology Clinics of North America that focuses on gastrointestinal (GI) motility. The author notes that, with the exception of predominant heartburn, the management of upper abdominal symptoms not caused by an organic disorder remains a challenge. Topics include mechanisms in functional dyspepsia, the association between symptoms and pathophysiology in dyspepsia, and treatment strategies. Research studies have demonstrated that suppressing acid secretion and eradicating Helicobacter pylori, the use of prokinetics, and the use of antidepressants have inconsistent effects on the treatment of functional dyspepsia. This inconsistency may be due to the heterogeneity of patients, and/or the contribution of multiple mechanisms to each patient’s symptoms. The author concludes that to achieve greater treatment effectiveness it may be necessary to target treatments to a specific pathophysiology, such as impaired gastric emptying. 5 figures. 2 tables. 87 references.
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Gastrointestinal Motility Disorders. Gastroenterology Clinics of North America. 36(3): 1-774. September 2007.
This issue of Gastroenterology Clinics of North America focuses on gastrointestinal (GI) motility disorders. The issue includes 14 articles: the classification, prevalence, and epidemiology of GI motility and functional GI disorders; neurogastroenterology and enteric sciences; evolving concepts in the cellular control of GI motility; laboratory tests used to evaluate GI motility; new technologies used for evaluation of esophageal motility disorders, including impedance, high-resolution manometry, and intraluminal ultrasound; the presentation, evaluation, and treatment of esophageal motor and sensory disorders; the presentation, evaluation, and treatment of the different manifestations of gastroesophageal reflux disease (GERD); the gastroesophageal antireflux barrier; the symptoms, evaluation, and treatment of gastroparesis; the mechanisms of symptom generation and appropriate management of patients with functional dyspepsia; the symptoms, evaluation, and treatment of irritable bowel syndrome; the evaluation and treatment of colonic and anorectal motility disorders, including constipation; the use of GI electrical stimulation for the treatment of GI disorders, including gastroparesis, obesity, fecal incontinence, and constipation; the role of bacteria in GI motility disorders; and GI motility disorders in adolescent patients, including the transition to adult health care settings. Some articles include full-color illustrations and all conclude with a list of references for further reading. A subject index concludes the issue.
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Overview of Neurogastroenterology-Gastrointestinal Motility and Functional GI Disorders: Classification, Prevalence, and Epidemiology Gastroenterology Clinics of North America. 36(3): 485-498. September 2007.
This article on neurogastroenterology, notably for gastrointestinal (GI) motility and functional GI disorders, is from a special issue of Gastroenterology Clinics of North America that focuses on GI motility. The authors note that the classification of GI motility and functional GI disorders is in a state of transition. Functional GI disorders are classified by their presenting symptoms, and the epidemiology of these conditions is based on symptom surveys. In contrast, GI motility disorders are classified by results of GI motility testing; the epidemiology of these conditions is often derived from tertiary care centers. This article reviews the epidemiology of these common disorders from the esophagus to the anorectum. Women are more likely to report globus, irritable bowel syndrome (IBS), bloating, constipation, chronic functional abdominal pain, sphincter of Oddi dysfunction, fecal incontinence, and pelvic floor dysfunction. However, for functional esophageal symptoms and dyspepsia, women and men report similar rates. Studies providing these data do not include diagnostic tests and measure symptom reporting rather than providing true estimates of the prevalence of the functional GI disorders. The authors conclude that, eventually, with increasingly sophisticated methods of studying the brain-gut axis, the classification of functional disorders will likely shift from symptoms to a classification based on pathophysiology. 2 tables. 62 references.
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Appendix A: Rome III Diagnostic Criteria for Functional Gastrointestinal Disorders. IN: Drossman, D.A., ed. Rome III: The Functional Gastrointestinal Disorders. 3rd ed. McLean, VA: Degnon Associates, Inc. 2006. pp. 885-898.
This appendix is from a lengthy reference book that presents the Rome III criteria for functional gastrointestinal disorders (FGIDs), a classification system based on the assumption and premise that for each disorder there are identifiable symptom clusters that emerge across clinical and population groups. This appendix consists of a chart of the diagnostic criteria for all of the FGIDs, categorized in eight groups: functional esophageal disorders, functional gastroduodenal disorders, functional bowel disorders, functional abdominal pain syndrome, functional gallbladder and sphincter of Oddi disorders, functional anorectal disorders, FGIDs in infants and toddlers, and FGIDs in children and adolescents. Specific disorders include functional chest pain, functional heartburn, functional dysphagia, belching disorders, functional globus, functional dyspepsia, postprandial distress syndrome, epigastric pain syndrome, chronic idiopathic nausea, rumination syndrome, functional vomiting, cyclic vomiting, aerophagia, irritable bowel syndrome, functional constipation, functional diarrhea, functional bloating, unspecified functional bowel disorder, functional abdominal pain, functional biliary pain, functional fecal incontinence, functional anorectal pain, proctalgia fugax, levator ani syndrome, and functional defecation disorder. For each disorder, the chart lists the symptoms, frequency, and duration required for diagnosis.
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Appendix B: Comparison Table of Rome II and Rome III Adult Diagnostic Criteria. IN: Drossman, D.A., ed. Rome III: The Functional Gastrointestinal Disorders. 3rd ed. McLean, VA: Degnon Associates, Inc. 2006. pp. 899-916.
This appendix is from a lengthy reference book that presents the Rome III criteria for functional gastrointestinal disorders (FGIDs), a classification system based on the assumption and premise that for each disorder there are identifiable symptom clusters that emerge across clinical and population groups. This appendix consists of a chart that compares the Rome III diagnostic criteria for all of the FGIDs to the supplanted Rome II diagnostic criteria. The appendix summarizes the changes in six categories: functional esophageal disorders, functional gastroduodenal disorders, functional bowel disorders, functional abdominal pain syndrome, functional gallbladder and sphincter of Oddi disorders, and functional anorectal disorders. Specific disorders include functional chest pain, functional heartburn, functional dysphagia, belching disorders, functional globus, functional dyspepsia, postprandial distress syndrome, epigastric pain syndrome, chronic idiopathic nausea, rumination syndrome, functional vomiting, cyclic vomiting, aerophagia, irritable bowel syndrome, functional constipation, functional diarrhea, functional bloating, unspecified functional bowel disorder, functional abdominal pain, functional biliary pain, functional fecal incontinence, functional anorectal pain, proctalgia fugax, levator ani syndrome, and functional defecation disorder. For each disorder, the chart lists the symptoms, frequency, and duration required for diagnosis.
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Childhood Functional Gastrointestinal Disorders: Child - Adolescent. IN: Drossman, D.A., ed. Rome III: The Functional Gastrointestinal Disorders. 3rd ed. McLean, VA: Degnon Associates, Inc. 2006. pp. 723-777.
This chapter on functional gastrointestinal disorders (FGIDs) in children and adolescents is from a lengthy reference book that presents the Rome III criteria for FGIDs, a classification system based on the assumption and premise that for each disorder there are identifiable symptom clusters that emerge across clinical and population groups. The authors of this chapter define childhood and adolescence as ranging from 4 to 18 years of age and note that some of the pediatric FGIDs, such as cyclic vomiting and functional abdominal pain, overlap in age presentation with the neonatal and toddler group. Disorders covered include adolescent rumination syndrome, cyclic vomiting syndrome, aerophagia, functional dyspepsia, irritable bowel syndrome (IBS), abdominal migraine, childhood functional abdominal pain, functional constipation, and nonretentive fecal incontinence. The chapter covers definitions, diagnostic criteria, reasons for changes from previous criteria, clinical evaluation, physiological factors, and treatment strategies for each of these disorders. The chapter concludes with a list of recommendations for future research in these disorders. 2 tables. 200 references.
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Design of Treatment Trials for Functional Gastrointestinal Disorders. IN: Drossman, D.A., ed. Rome III: The Functional Gastrointestinal Disorders. 3rd ed. McLean, VA: Degnon Associates, Inc. 2006. pp. 779-834.
This chapter on the design of treatment trials for functional gastrointestinal disorders (FGIDs) is from a lengthy reference book that presents the Rome III criteria for FGIDs, a classification system based on the assumption and premise that for each disorder there are identifiable symptom clusters that emerge across clinical and population groups. The authors of this chapter report on their review of the literature about trial design for FGIDs, in an effort to further develop guidelines to assist researchers in conducting treatment trials for the FGIDs. The chapter follows the basic structure of a randomized clinical trial: research question, study design, inclusion and exclusion criteria, treatment intervention, outcome measures and their validation, statistical issues, and interpretation of results. In each section, recommendations are made, with supporting evidence noted. The authors focus on examples of studies of irritable bowel syndrome (IBS) and functional dyspepsia, as these disorders have been studied most extensively. The chapter concludes with a list of recommendations for additional research in this area. 1 figure. 4 tables. 209 references.
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Development and Validation of the Rome III Diagnostic Questionnaire. IN: Drossman, D.A., ed. Rome III: The Functional Gastrointestinal Disorders. 3rd ed. McLean, VA: Degnon Associates, Inc. 2006. pp. 835-854.
This chapter on the development and validation of the Rome III diagnostic questionnaire is from a lengthy reference book that presents the Rome III criteria for functional gastrointestinal disorders (FGIDs), a classification system based on the assumption and premise that for each disorder there are identifiable symptom clusters that emerge across clinical and population groups. The authors of this chapter describe two survey studies that were commissioned by the Rome Foundation. The first study compared four different response scales that have been used to elicit symptom reports, with the goal of identifying the optimal scale for use in the Rome III questionnaire. The second study investigated the reliability, sensitivity, and specificity of the Rome III modular diagnostic questionnaire that was subsequently developed by the Rome Foundation. The disorders considered FGIDs include functional chest pain, functional heartburn, functional dysphagia, functional globus, functional dyspepsia, postprandial distress syndrome, epigastric pain syndrome, chronic idiopathic nausea, rumination, functional vomiting, cyclic vomiting, aerophagia, irritable bowel syndrome, functional constipation, functional diarrhea, functional bloating, unspecified functional bowel disorder, functional abdominal pain, functional biliary pain, functional fecal incontinence, functional anorectal pain, proctalgia fugax, and functional defecation disorder. The authors conclude that the Rome III diagnostic questionnaire is a valid and reliable instrument for making provisional diagnoses of all FGIDs except unspecified functional bowel disorder. This instrument can be used for clinical, epidemiological, or research purposes, but users must recognize that laboratory diagnostic tests and clinical judgment are required to confirm some diagnoses. 9 tables.
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Dietary Supplements: Herbs and Vitamins. IN: Buchman, A., ed. Clinical Nutrition in Gastrointestinal Disease. Thorofare, NJ: Slack Incorporated. 2006. pp 109-122.
This chapter about the use of herbs and vitamins as dietary supplements is from a comprehensive textbook that compiles available data, clinical experience, and research on the role of nutrition in the management of patients with disorders that affect the gastrointestinal (GI) tract. The author encourages gastroenterologists to familiarize themselves with dietary supplements because many patients in the developed world use dietary supplements as a matter of course and most of them neglect to inform their physicians about their use of dietary supplements. The author defines the use of dietary supplement as a product intended to supplement the diet to enhance health, a category that includes vitamins, minerals, amino acids, herbs, and other botanicals. This chapter focuses on the use of herbals and vitamins, covering regulation, quality, and effectiveness; the safety, use for the GI tract, and reasons for efficacy of herbals; and the use of multivitamins, vitamin A, vitamin D and calcium, vitamin E or tocopherol, vitamin K, thiamine, folate and folic acid, vitamin B12 or cobalamin, and vitamin C. Specific disorders covered in the section on herbals include irritable bowel syndrome (IBS), dyspepsia, diarrhea, nausea and vomiting, inflammatory bowel disease, and liver disease. The author concludes that vitamin supplements are appropriate for recognized deficiencies, but there is no evidence to state conclusively that they are useful for the prevention of many chronic diseases. Vitamins should not be a substitute for a healthy lifestyle and diet. Readers are encouraged to remind their patients that “natural” supplements are not necessarily better and that using large amounts of herbal or natural products can be detrimental to health. One sidebar lists advice to provide to patients who wish to continue herbal supplements. 4 tables. 114 references.
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Functional Gastroduodenal Disorders. IN: Drossman, D.A., ed. Rome III: The Functional Gastrointestinal Disorders. 3rd ed. McLean, VA: Degnon Associates, Inc. 2006. pp. 419-486.
This chapter on functional gastroduodenal disorders is from a lengthy reference book that presents the Rome III criteria for functional gastrointestinal disorders (FGIDs), a classification system based on the assumption and premise that for each disorder there are identifiable symptom clusters that emerge across clinical and population groups. The authors of this chapter use a classification that separates functional gastroduodenal disorders into functional dyspepsia, belching disorders, functional nausea and vomiting disorders, and the rumination syndrome. In each of these categories, the authors provide a definition and discuss epidemiology, symptoms, nomenclature and classification, clinical evaluation, physiological features, and treatment strategies. Specific topics include heartburn, the overlap of dyspepsia with gastroesophageal reflux disease and irritable bowel syndrome (IBS), gastrointestinal dysmotility, hypersensitivity, drug therapy, aerophagia, chronic idiopathic nausea, functional vomiting, and cyclic vomiting syndrome. The chapter concludes with a list of recommendations for future research in functional esophageal disorders. 8 figures. 4 tables. 305 references.
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Latest on Complementary and Alternative Medicine for GI Disorders. Digestive Health and Nutrition. 8(1): 22-25. March- April 2006.
Many people with digestive disorders are frustrated by the options that traditional medicine offers and may turn to alternatives to cope with their symptoms. Up to 62 percent of Americans use some form of complementary and alternative medicine (CAM) in their lives. However, most forms of CAM still need well-designed studies to confirm their success and safety. This article is designed to help readers with chronic gastrointestinal (GI) disorders who are seeking forms of CAM to help manage their discomfort. The author outlines mind-body medicine (hypnotherapy, relaxation), which is often used for patients with functional GI disorders such as irritable bowel syndrome (IBS) and dyspepsia, constipation, vomiting, nausea, or abdominal pain; biologically-based therapies, including botanicals, vitamins and minerals, probiotics, and which are often used for the treatment of Crohn’s disease, ulcerative colitis, and dyspepsia; and energy-based therapies such as healing touch and acupuncture, which are often used for nausea and vomiting, IBS, dysphagia, gastric dysmotility, and acid reflux. Readers are encouraged to educate themselves about any CAM therapy they are considering and to work in tandem with their traditional health care providers. 3 figures. 1 reference.
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Milk Alkali Syndrome and the Dynamics of Calcium Homeostasis. Clinical Journal of the American Society of Nephrology. 1(4): 641-654. July 2006.
This review article covers the pathophysiology of the milk alkali syndrome in light of recent advances in the understanding of calcium homeostasis. The authors focus on the role of the calcium-sensing receptor (CaSR) and epithelial calcium channels that are present in various tissues such as the parathyroid gland, kidney, and intestine. The authors stress that a thorough understanding of the pathophysiology of the milk alkali syndrome, including its generation and maintenance, requires knowledge of intestinal calcium absorption, bone influx and efflux of calcium, and renal calcium excretion, as well as how these processes change with age. The authors note the clinical relevance of this problem, as milk alkali syndrome is the third most common cause of admissions for hypercalcemia. The article includes two case reports that illustrate how the milk alkali syndrome can be seen in patients who self-treat for dyspepsia. 4 figures. 1 table. 134 references.
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Motility and Functional Disorders of the Stomach: Diagnosis and Management of Functional Dyspepsia and Gastroparesis. Practical Gastroenterology. 30(12): 23-48. December 2006.
This article discusses gastrointestinal (GI) motility and functional disorders of the stomach, including the diagnosis and management of functional dyspepsia and gastroparesis. Functional dyspepsia is characterized by a group of primarily postprandial symptoms, including fullness, early satiety, and bloating. Some patients will present with a predominant symptom of epigastric pain. Gastroparesis is a symptomatic chronic disorder characterized by delayed gastric emptying without mechanical obstruction. Functional dyspepsia has multiple mechanisms, including impaired gastric accommodation, gastric hypersensitivity, and delayed gastric emptying. Gastroparesis can be caused by diabetes or prior gastric surgery, but the underlying cause is unknown in many patients. The authors discuss the underlying mechanisms, clinical features, diagnostic evaluation, and treatment for functional dyspepsia and gastroparesis. The long-term prognosis for patients with functional dyspepsia is good, but symptoms remain chronic in the majority of patients. Treatment with gastric acid suppressants, such as proton pump inhibitors, is a good approach. In patients with refractory symptoms, prokinetic agents, Helicobacter pylori eradication, and psychological intervention should be considered. Dietary modification and prokinetic medications can be effective in the approximately 40 percent of patients diagnosed with gastroparesis of unknown cause. 1 figure. 5 tables. 83 references.
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Pathophysiology and Management of Diabetic Gastropathy. IN: Opara, E., ed. Nutrition and Diabetes: Pathophysiology and Management. Boca Raton, FL: CRC Press. 2006. pp 427-448.
This chapter about the pathophysiology and management of diabetic gastropathy is from a textbook that highlights the link between the problems of obesity and diabetes mellitus. The authors caution that the clinical presentation of diabetic gastropathy is not specific and may overlap with structural disorders and functional dyspepsia. The most common symptoms are nausea, vomiting, bloating, early satiety, postprandial fullness, and upper abdominal discomfort. After an introduction, the authors review the physiological basis for gastric smooth-muscle activity, the pathophysiology of diabetic gastropathy, symptoms, the evaluation of gastric emptying, diagnostic tests used to confirm problems with gastric emptying, and treatment strategies in diabetic gastropathy. Diagnostic methods discussed include upper gastrointestinal (GI) x-ray series, scintigraphic assessment, tracer methods, ultrasonography, magnetic resonance imaging (MRI), and electrogastrography (EGG). Treatment strategies include dietary and supportive therapy, glycemic control optimization, and drug therapy, including metoclopramide, erythromycin, cisapride, domperidone, and tegaserod. A brief section considers the problem of refractory gastropathy. 1 figure. 3 tables. 157 references.
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Gastro-Oesophageal Reflux Disease: The Health Economic Implications. Alimentary Pharmacology and Therapeutics. 22 (Supl 1): 20-31. August 2005.
For the vast majority of patients with gastroesophageal reflux disease (GERD), appropriate care involves the management of symptoms with lifestyle advice and drugs. However, there are some controversies about the appropriate use of endoscopy, whether drugs should be stepped up or down according to potency, how longs drugs should be used, the role of lifestyle advice, and the role of patients’ lifestyle choices. This article explores the economics of GERD, focusing on its cost burden to the United Kingdom. The authors assess published economic models for their strengths and weaknesses and examine current recommendations for GERD management from a socioeconomic perspective. Drugs prescribed predominantly for dyspepsia cost the UK National Health Service a projected 625 million pounds in 2004, which represents 7 percent of the primary care prescribing budget. When general practitioners consultations, endoscopies, over-the-counter drugs, and sickness absences are included, the UK cost rises to 1.5 billion pounds: approximately half of this cost can be ascribed to GERD. The authors conclude that emphasis upon regular review and stepping down treatment (while maintaining adequate symptom relief) is both clinically appropriate and resource efficient. The authors conclude that if effective and cost-effective interventions emerge for Barrett’s esophagus and esophageal cancer, this may substantially alter primary care management by providing a basis for the more aggressive investigation of patients with GERD. 2 figures. 3 tables. 58 references.
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Helicobacter Pylori: Findings in Native American Population. IHS Primary Care Provider. 30(3): 1-5. March 2005.
This article reports on a retrospective study of Native American patients who received care at a community hospital over the course of 38 months for symptoms suggesting upper gastrointestinal (GI) pathology. The patients were assessed for Helicobacter pylori infection by one or more of three methods: serologic testing, esophagogastroduodenoscopy (EGD) with biopsy followed by a rapid urease test (RUT), or biopsy with histological examination. The study included a total of 154 consecutive EGDs in 145 patients. Ninety-two patients were female (63.44 percent) and 53 patients were male (36.55 percent); the age range was 15 to 95 years. The authors note that with the prevalence of H. pylori infection being strongly correlated with the socioeconomic environment and given that the local conditions have been compared to those of a third-world country, H. pylori might be expected to be found in 80 percent of more of the community members. The 72 percent rate found in this study may reflect the fact that some patients undergoing endoscopy have had treatment with histamine receptor blockers and proton pump inhibitors, or in some cases antibiotics, unrelated to dyspepsia in the weeks and months prior to endoscopy. The authors found no correlation between the presence of H. pylori and the presence of running water in the home. The lack of association between H. pylori positivity and blood group O, or H. pylori and anemia is similar to earlier studies. Of the patients in this study, about 12 percent were found to have intestinal metaplasia, and one patient was diagnosed with in situ adenocarcinoma. The authors stress that endoscopy with histology cannot be replaced by other tests in detecting the most serious pathology related to H. pylori. 4 tables. 33 references.
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How Valuable are Proton-Pump Inhibitors in Establishing a Diagnosis of Gastro-Oesophageal Reflux Disease?. Alimentary Pharmacology and Therapeutics. 22 (Supl 1): 64-69. August 2005.
Diagnostic studies used to confirm gastroesophageal reflux disease (GERD) have limitations, so a trial of acid suppression with a proton pump inhibitor (PPI) is often used in clinical practice as a diagnostic test for GERD. If the patient experiences significant improvement in symptoms when taking the PPI, the diagnosis of GERD is made. This article reviews several studies that have evaluated the administration of PPIs as a diagnostic test for GERD. The author notes that a recent meta-analysis found that response to a PPI had limited value as a diagnostic test. Likelihood ratios for a positive test ranged from 0.45 to 1.86. The positive predictive value of the test ranged from 0.17 to 0.90 and the negative predictive value from 0.17 to 1, depending on the gold standard against which comparisons were made. The gold standard can be endoscopy, 24 hour pH testing, or symptoms scores. These results may be explained by the inadequacy of the gold standard against which the PPI test is compared or by the inability of acid suppression to differentiate between GERD, peptic ulcer disease, or dyspepsia. In addition, symptom improvement is difficult to assess with short-term trials of therapy. The author concludes that although a trial of acid suppression may have pragmatic value in clinical practice, the PPI test is not an accurate test for the diagnosis of GERD. 1 table. 26 references.
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NSAID-Induced GI Toxicity: Progress with Gastroprotection. Bethesda, MD: American College of Gastroenterology. 2005. (PowerPoint presentation)
This CD-ROM offers a PowerPoint presentation of 46 slides on nonsteroidal anti-inflammatory drug (NSAID)-induced gastrointestinal toxicity. Topics include the role of gastroprotection in preventing ulcers, identifying the population most at risk of NSAID-induced ulcers, the different types of NSAID-induced gastrointestinal (GI) toxicity, the incidence of dyspepsia and ulcers, the bleeding risk associated with nonaspirin over-the-counter (OTC) NSAIDs, the economic consequences of NSAID-induced GI toxicity, mortality rates of selected related disorders, normal gastric protective mechanisms, the combination of aspirin and NSAIDs, management of NSAID-induced GI toxicity, misoprostol, lansoprazole, proton pump inhibitors (PPIs), celecoxib, diclofenac, omeprazole, non-NSAID analgesics, acetaminophen, COX-2 selective inhibitors, and Helicobacter pylori. The program concludes by reminding readers that peptic ulcers occur in up to 50 percent of NSAID users and certain factors increase the risk of ulcer development. Ulcers and other complications can occur in asymptomatic patients. GI toxicity can be prevented in at-risk patients by using misoprostol, antisecretory drug therapy (PPIs), and alternative analgesics. The program includes patient care algorithms. 46 figures.
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Quality of Life in Acute and Maintenance Treatment of Non-Erosive and Mild Erosive Gastro-Esophageal Reflux Disease. Alimentary Pharmacology and Therapeutics. 22(4): 349-356. August15, 2005.
This article reports on a large, multicenter, randomized, open label study that assessed quality of life in patients with gastroesophageal reflux disease (GERD). The authors evaluated the economic and clinical consequences of two different maintenance treatment modalities, administered to 6,017 GERD patients at 451 gastroenterological centers in Italy. Adult GERD patients received, at enrollment, an acute treatment of esomeprazole 40 milligrams per day for 4 weeks and, if successfully treated, were randomized into two maintenance treatment strategies: esomeprazole 20 milligrams per day or esomeprazole on demand for 6 months. Burden of GERD, including quality of life, was measured. Comparisons with the Italian general population suggested that symptomatic GERD patients experience a worse quality of life than the general population. At the end of the 4 week treatment with esomeprazole all quality of life (QOL) dimensions showed a statistically significant and clinically meaningful improvement. Satisfaction level towards treatment was reported high in the total enrolled population after the acute treatment. A statistically significant difference in QOL scores was registered at the end of the maintenance phase in favor of the continuous regimen, however the size of this difference was very small in all dimensions. The continuous treatment strategy was preferred in the areas of reflux and dyspepsia scores and patients’ satisfaction. 4 figures. 1 table. 43 references.
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Stomach and Duodenum. IN: Digestive Disorders 2005. Palm Coast, FL: Medletter Associated. pp 19-24. 2005.
This chapter on the stomach and duodenum is from a White Paper on digestive disorders, including conditions that affect the esophagus, stomach, gallbladder, bile ducts, small intestine, and large intestine. This chapter covers normal anatomy of the stomach and duodenum, and the causes, symptoms, diagnosis, and treatment of gastritis, and peptic ulcer disease (PUD). Gastritis is an inflammation of the gastric mucosa, the inner lining of the stomach. The author describes the most common infection of the stomach, that caused by Helicobacter pylori bacteria. Gastritis can also be caused by medications, autoimmune reactions, or hypersensitivities or allergies. The symptoms of gastritis are indigestion and a worsening of abdominal pain after meals. Gastritis is usually diagnosed with endoscopy; infection is treated with antibiotics and with medications to suppress gastric acid production. Peptic ulcers are deep, nonhealing mucosal defects in the stomach, often caused by Helicobacter pylori infection or drug effects. People with gastric ulcers experience pain soon after eating, are frequently afraid to eat, and often lose weight. Peptic ulcers are diagnosed with an upper GI series or endoscopy; treatment includes use of medications that suppress gastric acid secretion and antibiotics to eradicate H. pylori infection. One chart summarizes the common drug therapy used for peptic ulcers. 1 table.
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Stress and the Gastrointestinal Tract. Journal of Gastroenterology and Hepatology. 20(3): 332-339. March 2005.
This review article considers the short- and long-term influence of stress on the function of the gastrointestinal tract. The authors discuss concepts of the brain-gut axis, central stress circuitry, emotional motor system, modulation of visceral sensitivity, changes in hypothalamic-pituitary-adrenal responses, brain mapping and the role of stress in both organic and functional bowel disorders. The authors find that stress increases the intestinal permeability to large antigenic molecules. Stress can thus lead to mast cell activation, degranulation, and colonic mucin depletion. A reversal of small bowel water and electrolyte absorption occurs in response to stress and is mediated cholinergically. Stress also leads to increased susceptibility to colonic inflammation. The authors discuss stress in relation to specific disorders, including gastroesophageal reflux disease (GERD), functional dyspepsia, peptic ulcer disease, inflammatory bowel disease (IBD), and irritable bowel syndrome (IBS). The authors conclude with a brief discussion of mind-directed therapies for the gut; i.e., non-drug therapy to allay stress as a component of the management of patients with functional gastrointestinal disorders. The available options include cognitive behavioral therapy (CBT), dynamic psychotherapy, hypnotherapy, and relaxation therapy. 81 references.
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Validation of a Short Questionnaire in English and French for Use in Patients with Persistent Upper Gastrointestinal Symptoms Despite Proton Pump Inhibitor Therapy: The PASS (Proton Pump Inhibitor Acid Suppression Symptom) Test. Canadian Journal of Gastroenterology. 19(6): 350-358. June 2005.
The management of persistent symptoms during acid suppression therapy in patients with gastroesophageal reflux disease or dyspepsia might be improved if patient-physician communication regarding symptoms were better facilitated. This research study was undertaken to validate the PPS Acid Suppression Symptom (PASS) test, a simple questionnaire developed to identify patients with persistent acid-related symptoms during proton pump inhibitor (PPI) therapy and document their response to a change in therapy. Content validity of this test was established in 20 English-speaking and 16 French-speaking patients. Psychometric validation in 158 English-speaking and 113 French-speaking patients revealed good to excellent test-retest reliability. After 4 weeks of therapy with esomeprazole, the PASS test score fell to zero in 30 percent of English-speaking and in 33 percent of French-speaking patients. Scores demonstrated good responsiveness relative to the Gastrointestinal Symptom Rating Scale, the Reflux Disease Questionnaire, and the Quality of Life in Reflux and Dyspepsia questionnaire. The authors conclude that the five-item PASS test is a valid tool for the evaluation of persistent acid-related symptoms in patients receiving PPI therapy. 5 figures. 3 tables. 34 references.
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What Do We Mean By GERD?: Definition and Diagnosis. Alimentary Pharmacology and Therapeutics. 22 (Supl 1): 2-10. August 2005.
Heartburn and regurgitation, with or without dysphagia (swallowing disorder), comprise the clinical syndrome of gastroesophageal reflux disease (GERD). A range of other conditions are associated with GERD, including the reflux-chest pain syndrome, exercise-induced GERD, and the extra-esophageal complications of GERD. This article considers the present understanding of GERD, its definition and diagnosis. The authors separate the diagnostic and definition requirements of general care providers and those of gastroenterologists. The authors note that, since the majority of patients with heartburn do not have mucosal breaks, expressions such as endoscopy-negative reflux disease, non-erosive reflux disease, or even reflux-like dyspepsia and functional heartburn are frequently employed despite the lack of consensus concerning their exact meaning. The primary care physician’s role is to decide, on the basis of symptoms and clinical examination, if it is likely that the patient has some serious problem which requires urgent investigation and intervention. A symptom-based diagnosis of GERD can be made in primary care with reasonable accuracy when typical symptoms dominate the presentation. The secondary care physician has to make a full evaluation of an already highly-selected patients and, as far as possible, to make a comprehensive, accurate diagnosis, using whatever investigative tools are required. The authors conclude with a brief discussion of impedance pH monitoring. 3 figures. 1 table. 48 references.
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Epidemiology and Quality of Life in Functional Gastrointestinal Disorders. Alimentary Pharmacology and Therapeutics. 20: 31-39. November 2004.
This article reviews the epidemiology and quality of life in patients with functional gastrointestinal disorders, particularly irritable bowel syndrome (IBS), functional dyspepsia, and chronic constipation. Data shows that the prevalence of functional gastrointestinal disorders is statistically significant across the world, with a higher rate seen in woman with IBS and chronic constipation, but not those with functional dyspepsia. The author cautions, however, that differences between global and gender prevalence rates may be due to cultural factors and study methodology. IBS was found to be associated with a significant health care burden, including increased outpatient service, abdominal and pelvic surgeries, physician visits, and health care costs. Impaired health-related quality of life (HRQoL) was shown in patients with IBS, particularly in those with moderate to severe disease seen in referral settings. The HRQoL appears to improve in treatment responders, or correlates with symptom improvement. Predictors of HRQoL in patients with functional gastrointestinal disorders include psychosocial factors, such as early adverse life events, and symptoms related to visceral perception (e.g., pain and chronic stress). The author concludes that although gastrointestinal-related symptoms are obviously important, non-gastrointestinal symptoms appear to have a major, if not greater, effect on health care visits, health care costs, and HRQoL in patients with IBS. 1 figure. 1 table. 67 references.
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Gastric Adenocarcinoma. In: Kelly, K.A.; Sarr, M.G.; Hinder, R.A., eds. Mayo Clinic Gastrointestinal Surgery. St. Louis, MO: Elsevier Science. 2004. p. 75-90.
This chapter on cancer of the stomach (gastric adenocarcinoma) is from a book that focuses on the major diseases treated by gastrointestinal surgeons, from the esophagus to the anal canal. The presentation has a definite clinical orientation and a major emphasis on practical applications as they are applied at the Mayo Clinic. The author of this chapter notes that even though the incidence of gastric cancer has declined, several controversies and challenges confront the surgeon. Because the symptoms of gastric carcinoma are usually insidious, diagnosis is often made only at late stage. The 5 year survival rate is highly stage-dependent and ranges from 7 percent to 78 percent. Topics covered include epidemiology and risk factors, pathology, diagnosis and preoperative evaluation, surgical management, the operative approach used at the Mayo Clinic, adjuvant and neoadjuvant therapy, and long-term follow up. Liberal use of endoscopy in patients with dyspepsia may increase the number of patients in whom gastric cancer is diagnosed early. Even though the extent of operation is still controversial, a curative resection is essential for long-term survival. The gastric resection needs to include the tumor and a negative margin of tumor-free tissue. Postoperatively, all patients should be referred to an oncologist for consideration of adjuvant therapy. The chapter is illustrated with line drawings. 5 figures. 3 tables. 112 references.
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Gastric Emptying in Functional Gastrointestinal Disorders. Alimentary Pharmacology and Therapeutics. 20: 56–60. November 2004.
This article focuses on gastric motor physiology, examining how it may provide a basis for gastric motor dysfunction in functional gastrointestinal disorders. The author notes that although delayed gastric emptying has been described in several functional gastrointestinal disorders, and appears to be especially common in functional dyspepsia, the relationship of this finding to symptoms and basic pathophysiology is difficult to define. The interactions between delayed gastric emptying and symptoms have been hampered by the limitations of present diagnostic methods, the extent of overlap between the various functional disorders, and the sensitivity of gastric emptying to factors external to the stomach. Thus, treatment strategies aimed at simply accelerating gastric emptying may prove futile. The author concludes that caution should be used when interpreting the finding of delayed gastric emptying in a patient with functional symptoms. 1 figure. 36 references.
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Know the Warning Signs of a Heart Attack. Alexandria, VA: American Diabetes Association. 2004. 1 p.
Cardiovascular disease (CVD) is the leading cause of death among people with diabetes, accounting for at least two out of three diabetes-related deaths. A heart attack (myocardial infarction) occurs when the blood vessels that go to the heart become partially or totally blocked by fatty deposits and the blood supply is reduced or cut off. When this happens, oxygen and other needed materials are not carried to the heart and the heart muscle dies. This brief fact sheet on the warning signs of a heart attack is from a set of 26 reproducible patient education handouts on topics related to diabetes CVD. The fact sheet reminds readers that the warning signs of a heart attack can include chest pain or discomfort; pain or discomfort in the arms, back, jaw, neck or stomach; shortness of breath; sweating or lightheadedness; indigestion or nausea; and or tiredness. Readers are encouraged to call for emergency intervention right away if a heart attack is suspected; early intervention (such as getting drug therapy) can save one's life. 1 figure.
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Use of a Therapeutic Trial as a Diagnostic Test for GERD. Practical Gastroenterology. 28(12): 45-50. December 2004.
This article explores the use of a therapeutic trial of proton pump inhibitor medication (PPIs) as a diagnostic test for gastroesophageal reflux disease (GERD). Symptoms associated with GERD include heartburn, regurgitation, dyspepsia, nausea, cough, asthma, hoarseness and chest pain; however, these symptoms can also be indicative of other conditions and thus are not reliable as a definitive diagnostic tool for GERD. The author describes the physiological and pharmacological basis for a trial of therapy to diagnose GERD, the reviews PPI clinical trials of therapy to diagnose GERD. The author concludes that, in the setting of suspected GERD, there is a sound physiological and pharmacological basis for considering use of a PPI as a diagnostic test. This approach is particularly appropriate for patients with noncardiac chest pain, less so in those with more typical symptoms of GERD. 23 references.
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