Thailand Dyspepsia Guidelines: 2018.

The management of dyspepsia in limited-resource areas has not been established. In 2017, key opinion leaders throughout Thailand gathered to review and evaluate the current clinical evidence regarding dyspepsia and to develop consensus statements, rationales, levels of evidence, and grades of recommendation for dyspepsia management in daily clinical practice based on the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. This guideline is mainly focused on the following 4 topics: (1) evaluation of patients with dyspepsia, (2) management, (3) special issues (overlapping gastroesophageal reflux disease/irritable bowel syndrome and non-steroidal anti-inflammatory drug/aspirin use), and (4) long-term follow-up and management to provide guidance for physicians in Thailand and other limited-resource areas managing such patients.

Normal Values of High-Resolution Manometry in Supine and Upright Positions in a Thai Population.

BACKGROUND: Although cut-off values used in high-resolution manometry (HRM) to diagnose esophageal motility disorders are based on representative samples of the US population and assume a supine position, differences in population and body positioning can reportedly affect results. AIMS: To establish normal HRM values for Thai people in both supine and upright positions. METHODS: Forty-one healthy subjects were recruited, each of whom underwent solid-state HRM with ten 5-mL swallows of water in both the supine and upright positions. Measuring parameters according to the Chicago classification criteria (CC v3.0) were included, for which the mean, median and 5th and 95th percentiles (PCTLs) were calculated. RESULTS: The results corresponded with the CC v3.0 criteria, except for the mean, and 5th PCTL of the distal contractile integral (DCI), which were lower for this population. In the upright position, the mean and median values for DCI, intrabolus pressure and integrated relaxation pressure were significantly decreased, whereas the length of the transitional zone was significantly increased. The limitations of this study include: (1) the relatively low number of participants, (2) the limited recruitment of participants only at Ramathibodi Hospital and (3) the limited recruitment of only young and middle-aged participants. CONCLUSIONS: We established normal values for the HRM parameters in a representative sample of the Thai population. Our supine results still prove that the use of the CC v3.0 is preferable. HRM testing in patients measured in the upright position should be analyzed based on the normative values obtained from upright swallow studies.

Normal Solid Gastric Emptying Values Measured by Scintigraphy Using Asian-style Meal:A Multicenter Study in Healthy Volunteers.

BACKGROUND/AIMS: To report gastric emptying scintigraphy, normal values should be established for a specific protocol. The aim of this study was to provide normal gastric emptying values and determine factors affecting gastric emptying using Asian rice-based meal in healthy volunteers. METHODS: One hundred and ninety-two healthy volunteers were included at 7 tertiary care centers across Thailand. Gastric emptying scintigraphy was acquired in 45 degree left anterior oblique view immediately after ingestion of a 267 kcal steamed-rice with technetium-99m labeled-microwaved egg meal with 100 mL water for up to 4 hours. RESULTS: One hundred and eighty-nine volunteers (99 females, age 43 ± 14 years) completed the study. The medians (5-95th percentiles) of lag time, gastric emptying half time (GE T1/2) and percent gastric retentions at 2 and 4 hours for all volunteers were 18.6 (0.5-39.1) minutes, 68.7 (45.1-107.8) minutes, 16.3% (2.7-49.8%) and 1.1% (0.2-8.8%), respectively. Female volunteers had significantly slower gastric emptying compared to male (GE T1/2, 74 [48-115] minutes vs. 63 (41-96) minutes; P < 0.05). Female volunteers who were in luteal phase of menstrual cycle had significantly slower gastric emptying compared to those in follicular phase or menopausal status (GE T1/2, 85 [66-102] mintes vs. 69 [50-120] minutes or 72 [47-109] minutes, P < 0.05). All of smoking volunteers were male. Smoker male volunteers had significantly faster gastric emptying compared to non-smoker males (GE T1/2, 56 [44-80] minutes vs. 67 [44-100] minutes, P < 0.05). Age, body mass index and alcohol consumption habits did not affect gastric emptying values. CONCLUSIONS: A steamed-rice with microwaved egg meal was well tolerated by healthy volunteers. Gender, menstrual status and smoking status were found to affect solid gastric emptying.

The study of allergic skin test in patients with globus pharyngeus: a preliminary report.

BACKGROUND: Globus pharyngeus is the lump sensation in the throat associated with various conditions including somatoform disorder and gastroesophageal reflux disease. However, many patients with unrelated causes were found to respond to anti-allergic treatment. OBJECTIVE: Determine the results of allergic skin test in globus pharyngeus patients who had unidentified causes. MATERIAL AND METHOD: Fifty-four globus pharyngeus patients were enrolled and referred for complete physical examination, screening psychological status, videostroboscopy, and reflux finding score assessment. All patients including 38 controlled subjects underwent skin prick test and/or intradermal test. The globus patients who had positive test were recommended to have anti allergic treatment. Barium swallowing study, ambulatory double-probe pH monitoring, or plain film cervical spine was done in patients with negative skin tests and in non-response to medication. RESULTS: There was statistically significant difference of positive skin test results between globus and the control group (77.8% vs. 28.6% OR = 13.12, p < 0.001). In positive skin test-globus group, globus symptom was improved in 64.3% after allergic treatment, which 85.2% had moderate and excellent improvement. In patients with negative skin test and non-response group show various conditions including gastroesophageal reflux disease (18.52%), abnormal esophageal manometry (40.74%), and myofascial pain syndrome (3.71%). CONCLUSION: Due to high prevalence of positive skin test in globus pharyngeus patients, this symptom should be considered as one of the atypical allergic manifestations.

Vocal cord dysfunction concurrent with a nutcracker esophagus and the role of gastroesophageal reflux disease.

BACKGROUND: Psychological disorders were originally thought to be the sole cause of vocal cord dysfunction (VCD). Subsequently, other organic diseases, including structural laryngeal abnormalities, have also been reported to be associated with VCD. OBJECTIVES: To describe the first patient with VCD concurrent with a nutcracker esophagus and to establish the association between VCD and gastroesophageal reflux disease (GERD) by using the Bernstein test. METHODS: Symptom assessments, neuropsychiatric evaluations, fiberoptic laryngoscopy, pulmonary function tests, allergic skin prick tests, radiographs of the chest and sinuses, esophageal manometry (including 24-hour ambulatory esophageal pH monitoring), and the Bernstein test were performed. RESULTS: A 36-year-old woman had dyspnea, hoarseness, chest pain, and wheezes without relief for a decade. Neuropsychiatric evaluations disclosed mild depression. Fiberoptic laryngoscopy showed posterior laryngitis and paradoxical vocal cord adduction with audible inspiratory stridor. Pulmonary function tests showed attenuation of the inspiratory limb with notching in both flow-volume loops and a mid-vital capacity expiratory to inspiratory flow ratio of 4. All the symptoms except chest pain were improved dramatically by speech therapy and empirical treatment for GERD. Esophageal manometry revealed a nutcracker esophagus; 24-hour ambulatory esophageal pH monitoring demonstrated multiple short reflux episodes. The Bernstein test was conducted, and all the manifestations were reproduced with 0.1 N hydrochloric acid but not with isotonic sodium chloride infusion. CONCLUSIONS: This is the first human case report confirming that GERD can trigger an acute attack of VCD and may induce chest pain as a nutcracker esophagus in patients with VCD. It strengthens this association and expands our knowledge of diverse manifestations of this clinical entity.

Validation of Rome II criteria for functional gastrointestinal disorders by factor analysis of symptoms in Asian patient sample.

BACKGROUND: It has been unclear as to whether the Rome II criteria could be applied to patients in the Asia region with functional gastrointestinal (GI) diseases. The aim of the present study was to determine if symptoms of Asian patients with functional gastrointestinal disorders formed groups which corresponded to the Rome II diagnostic criteria. METHODS: A modified English version of Talley's bowel disease questionnaire was developed in collaboration with various research teams in accordance with the Rome II criteria. This instrument was translated into the local languages of the following nine Asian regions: China, Hong Kong, Indonesia, Korea, Malaysia, Singapore, Taiwan, Thailand and Vietnam. From September to December 2001, newly enrolled outpatients attending 14 GI or medical clinics in these regions were invited to complete the questionnaire. From these respondents, patients with functional gastrointestinal disorders fulfilling the '12 weeks out of 12 months' criteria were separated for further analysis. Principal component factor analysis with varimax rotation was used to identify symptom clusters or factors. These factors were compared with the existing classification of functional GI diseases derived from the Rome II criteria. RESULTS: Factor analysis of symptoms from 1012 functional GI patients supported the Rome II classification of the following groups of functional GI disorders: diarrhea-predominant irritable bowel syndrome, functional constipation, functional dyspepsia, functional abdominal pain syndrome, functional heartburn, and functional vomiting. Functional diarrhea was combined with functional anorectal disorders, and globus merged with functional dysphagia into one factor. Some of the functional dyspepsia, abdominal bloating and belching symptoms were loaded into one factor. CONCLUSIONS: Factor analysis of symptoms from a sample of Asian patients with functional GI disorders partially supported the use of the Rome II classification.