General practitioners' management of symptomatic uncomplicated diverticular disease of the colon by using rifaximin, a non-adsorbable antibiotic.

OBJECTIVE: Symptomatic uncomplicated diverticular disease of the colon (SUDD) is generally managed by gastroenterologists rather than General Practitioners (GPs). The aim of this study was to assess the efficacy of the treatment of SUDD with rifaximin, a non-absorbable antibiotic, in a primary care setting by GPs. PATIENTS AND METHODS: This retrospective, observational study investigated the use of rifaximin at a dose of 400 mg b.i.d. for 5, 7 or 10 days monthly, up to 3 months. The symptoms were reported by the patients using a visual analogic scale (VAS) of 0-10. RESULTS: 286 SUDD patients were enrolled (44.4% of men, average age 70.92±10.98). Respectively, 15 (5.2%) patients received the treatment for 5 days, 205 (71.7%) for 7 days and 66 (23.1%) for 10 days. After three months, a significant reduction of VAS score was observed in almost all symptoms assessed: 135 (47.2%) patients reported no abdominal pain (p<0.001) and 23 (8.1%) reported no symptom. Adverse events related to the treatment were recorded in 3 (1.04%) patients, all of them mild and not requiring interruption of the treatment. Acute diverticulitis occurred in 9 (3.1%) patients, but only 2 of them [0.7% (n=2)] underwent surgery due to complicated diverticulitis. Analysis within the different treatment groups (5, 7 and 10 days) shows that rifaximin treatment is effective in reducing the severity of symptoms in almost all groups except for the constipation in the 5-day group. CONCLUSIONS: Rifaximin can be effectively used by GPs in real-life for the management of SUDD.

Type 2 diabetes treatment and progression of chronic kidney disease in Italian family practice.

AIMS: Progressive chronic kidney disease represents a dreadful complication of type 2 diabetes mellitus (T2DM). We tested the pattern of use and the renal effects of old glucose-lowering drugs in T2DM patients cared for by Italian general practitioners (GPs). METHODS: Data of 2606 T2DM patients were extracted from the databases of GPs, who do not have access to the most recent glucose-lowering drugs in Italy. The rate of kidney function decline was calculated by CKD-EPIcr, based on two consecutive creatinine values. RESULTS: Metformin was used in 55% of cases, either alone or with sulfonylureas/repaglinide, across the whole spectrum of CKD (from 66% in stage G1 to only 8% in G4). Sulfonylurea use peaked at 21-22% in stage G2-G3a, whereas repaglinide use significantly increased from 8% in G1 to 22% in G4. The median rate of CKD decline was - 1.64 mL/min/1.73 m2 per year; it was higher in G1 (- 3.22 per year) and progressively lower with CKD severity. 826 cases (31.7%) were classified as fast progressors (eGFR decline more negative than - 5 mL/min/1.73 m2 per year). The risk of fast progressing CKD was associated with increasing BMI, albuminuria, and sulfonylurea use, alone (OR, 1.47; 95% confidence interval, 1.16-1.85), or in association with metformin (OR, 1.40; 95% CI 1.04-1.88). No associations were demonstrated for metformin, cardiovascular and lipid lowering drug use. CONCLUSION: In the setting of Italian family practice, sulfonylurea use is associated with progressive CKD in patients with T2DM. Metformin, at doses progressively reduced according to CKD stages, as recommended by guidelines, is not associated with fast progression.

Management of chronic constipation in general practice.

BACKGROUND: Chronic constipation is often diagnosed and treated by general practitioners (GPs). The aim of the study was to evaluate the management of constipation by a cohort of Italian GPs. METHODS: Over the course of 1 month, 41 GPs recorded tests and therapies suggested to patients complaining of chronic constipation. They were classified according to the Rome III criteria as constipated irritable bowel syndrome (C-IBS), functional constipation (FC), or "self-perceived constipation" (SPC) (not consistent with the Rome criteria). RESULTS: The most frequently prescribed tests for the 229 patients (147 FC, 50 C-IBS, 32 SPC) were routine blood tests (59.3 %), abdominal ultrasounds (37.2 %), thyroid function (36.7 %), fecal occult blood tests (36.7 %), and tumor markers (35 %). Patient sex and age, GP age, and whether the diagnosis was new influenced the GP's request, but FC, C-IBS, or SPC status did not. Dietary suggestions (81.9 %), fiber supplements (59.7 %), reassurance (50.9 %), and laxatives (30.5 %) were the most frequently prescribed treatments. Antispasmodics were more frequently suggested for C-IBS patients; dietary suggestions, fiber, and enemas were more frequently prescribed in SPC patients. Patient and GP age and whether the diagnosis was new influenced the GP's choice of treatment. CONCLUSIONS: The Rome III criteria do not influence diagnostic strategies and only slightly influence therapeutic strategies of GPs. Other factors (age, gender, new or old diagnosis) have more influence on GPs choice of investigations and treatment.

The general practitioner's approach to irritable bowel syndrome: from intention to practice.

BACKGROUND: Although general practitioners play a critical role in the management of irritable bowel syndrome because they deal with the most patients, guidelines are developed mainly by specialists. AIMS: To evaluate the clinical features of irritable bowel patients and the general practitioners' approach to irritable bowel syndrome in Italy. SUBJECTS AND METHODS: A questionnaire focusing on the management of this syndrome was completed by 28 general practitioners. Clinical features and diagnostic and treatment measures taken in 229 patients were analysed. RESULTS: Only 35.7% of the general practitioners were familiar with the Rome II criteria. Changes in bowel habits and abdominal pain/discomfort were the most common symptoms. Constipation (74.2%) was more frequent as the main symptom than diarrhoea. Routine blood tests (76.4%) and abdominal ultrasound (42.2%) were requested more frequently than colonoscopy (31.1%). At least one specialist consultation was recommended in 63.3% of patients. Drugs (mainly antispasmodics) were prescribed more frequently for diarrhoea (91.4%) than for constipation (55.7%). CONCLUSIONS: General practitioners are little acquainted with the Rome II criteria. Diagnostic tests and specialist consultations are often recommended; antispasmodics are the most frequently prescribed drug. Guidelines should be developed together by general practitioners and gastroenterologists to effectively manage patients at a lower cost.

Predictors of gastroparesis in out-patients with secondary and idiopathic upper gastrointestinal symptoms.

BACKGROUND: Delayed gastric emptying occurs frequently in patients with upper gastrointestinal symptoms associated with functional or organic diseases. AIMS: To evaluate whether: (i) the prevalence of delayed gastric emptying is influenced by the presence of organic disease; (ii) demographic or clinical factors predict modestly or markedly (gastroparesis) delayed emptying. PATIENTS: A total of 327 consecutive out-patients with upper gastrointestinal symptoms. METHODS: Routine diagnostic work-up and evaluation of demographic factors, gastrointestinal symptom evaluation and scintigraphic gastric emptying of solids were performed. RESULTS: Organic diseases were detected in 227/327 (65%) patients: 33% had delayed emptying and 20% gastroparesis. Female gender (OR: 2.1; 95% C.I.: 1.3-3.4). overweight (0.5; 0.3-0.9), relevant postprandial fullness (1.8; 1.1-3.2) and relevant epigastric bloating (1.8; 1.1-2.9), but not the presence of organic diseases, were associated with delayed emptying. Female gender (3.9; 1.3-11.9) and relevant postprandial fullness (4.1; 1.7-10.2) were associated with gastroparesis. CONCLUSIONS: (i) There is a high prevalence of delayed gastric emptying and gastroparesis in out-patients with upper gastrointestinal symptoms, which is not influenced by the presence of organic disease; (ii) female gender, low body weight, relevant fullness and bloating are associated with delayed emptying; female gender and relevant postprandial fullness predict gastroparesis.

Gastric emptying in myotonic dystrophic patients.

BACKGROUND: Myotonic dystrophy is often associated with digestive symptoms that can precede the clinical appearance of skeletal muscle involvement. Although motility disorders may be observed in these patients at any level of the gastrointestinal tract, upper gastrointestinal symptoms have up to now usually been considered to be due to oesophageal rather than gastric dysmotility. AIMS: To evaluate: a) gastric emptying in myotonic dystrophic patients without dyspeptic symptoms, and b) relationship between gastric emptying and severity and duration of the disease. PATIENTS AND METHODS: Gastric emptying was evaluated in 11 non-dyspeptic dystrophic patients and in 22 healthy volunteers by means of computerised ultrasound scan, assessing the variation in the antral area over time after ingestion of a meal. RESULTS: The final emptying time was higher in patients than in healthy volunteers (373' +/- 35' vs 270' +/- 47'; p < 0.001). Basal and maximal post-prandial antral areas were similar in the two groups. There was a significant correlation between gastric emptying and the duration of the disease (rs = 0.62; p = 0.04). No relationship was found between gastric emptying and severity of the disease. CONCLUSIONS: Gastric emptying may be abnormally delayed in myotonic dystrophy patients, even in absence of dyspeptic symptoms. This delay is correlated with duration but not with severity of the disease. However there is no difference in either basal or maximal postprandial antral areas between myotonic dystrophy patients and healthy volunteers.

Review article: Helicobacter pylori, mucosal inflammation and symptom perception--new insights into an old hypothesis.

The role of Helicobacter pylori and the accompanying mucosal inflammatory response in functional dyspepsia is still undefined. Human and animal studies have clearly demonstrated a link between intestinal mucosal inflammation and changes in sensory-motor function. Growing clinical and basic evidence supports the concept that a similar paradigm may occur in H. pylori-related dyspepsia. The infection may both induce gastric dysmotility and trigger neuroplastic changes in the afferent neural pathways leading to visceral hyperalgesia. A reduction of central antinociceptive control systems may also play a pathophysiological role. H. pylori eradication has provided disappointing results in terms of improvement of symptoms. This may reflect the long-term recovery of neuroplastic changes occurring in the afferent nervous system or, alternatively, the incomplete resolution of gastritis and the persistent production of inflammatory mediators by resident cells in the muscularis externa. The identification of these mechanisms may provide a better understanding of the pathophysiology of H. pylori-related dyspepsia and prompt innovative therapeutic approaches.

Helicobacter pylori infection and gastric function in patients with fundic atrophic gastritis.

In the present study we evaluated the relation among histology, H. pylori, IgG to H. pylori, gastric emptying, and acid secretion in 43 patients with fundic atrophic gastritis. On the basis of gastric acid secretion, patients were divided into three subgroups: patients with preserved acid secretion (Group 1), patients with hypochlorhydria (Group 2), and patients with achlorhydria (Group 3). Fundic glandular atrophy was more severe in hypoachlorhydric patients than in those with preserved acid secretion (P < 0.05 vs Group 2, P < 0.005 vs Group 3). H. pylori colonization was found in 94% of patients in Group 1, in 61% of patients in Group 2, and in only 8% of patients in Group 3 (P < 0.001 vs Group 1, P < 0.05 vs Group 2). Conversely, serological positivity to H. pylori was high in all three subgroups of patients (100% in Group 1, 77% in Group 2, 92% in Group 3). Gastric emptying was delayed in atrophic patients, particularly in those with hypoachlorhydria. Our data suggest that fundic atrophic gastritis represents a possible end stage of H. pylori infection, characterized by a progressive disappearance of the bacterium and a progressive deterioration of gastric functions.

Review article: the continuing dilemma of dyspepsia.

Dyspepsia drains a substantial proportion of healthcare resources in industrialized countries and an appropriate management strategy is needed. An aetiological role for Helicobacter pylori infection has been demonstrated in a number of pathological conditions associated with dyspepsia, such as peptic ulcer and gastric malignancies, but not in functional dyspepsia. Endoscopy and diagnosis-based treatment, H. pylori testing and eradication therapy, history taking and empirical therapy, are the main tools that are currently available for managing patients with upper gastrointestinal symptoms. Endoscopy identifies malignancies and organic diseases of the proximal gut and therefore provides reassurance to both doctors and patients. It should be recommended in older patients with suspicious symptoms and it has proven to be more cost-effective than empirical H2-receptor antagonists in patients with ulcer-like symptoms. Empirical eradication in all dyspeptics without suspicious symptoms is a cost-effective approach that cures the majority of peptic ulcers. Nevertheless, it does not control symptoms in the majority of patients, it may exacerbate gastro-oesophageal reflux disease, and it encourages antibiotic resistance. The realities of current clinical practice require empirical therapy in most, if not all, the dyspeptics seen by general practitioners. A detailed history taking can help to diagnose gastro-oesophageal reflux disease and to identify suspicious symptoms. Furthermore, identification of dyspepsia subgroups may provide guidance for empirical therapy. Nevertheless, even analysis of individual symptoms does not provide a sufficient diagnostic yield to differentiate functional from organic dyspepsia and appropriate investigations are needed in patients with poor response to short-term therapy or frequent relapses.

Standards for non-invasive methods for gastrointestinal motility: scintigraphy. A position statement from the Gruppo Italiano di Studio Motilità Apparato Digerente (GISMAD).

Scintigraphic techniques are well established methods to assess gastrointestinal transit patterns. The main advantages are represented by the possibility to evaluate, in a relatively non-invasive manner, the transit time of specific components of physiological meals as well as of some digestive secretions. These techniques are generally well accepted by the patients and results are largely not operator dependent. Their main limitation is the use of a radioisotope, that prevents repeated applications in all subjects and immediate exclusion of women of childbearing potential. Due to the high costs of these tests and the limited availability of Nuclear Medicine Departments, scintigraphic techniques should be reserved for well-selected patients. A review is made of the technical requirements and indications for scintigraphic tests currently available for clinical purposes (gastric emptying study, oesophageal transit time, evaluation of gastro-oesophageal reflux, intestinal and colonic transit time, evaluation of biliary motility and of duodenogastric reflux).

Gastric emptying and dyspeptic symptoms in patients with nonautoimmune fundic atrophic gastritis.

Our aim was to evaluate the relationship between gastric emptying and demographic, clinical, histological, and secretory features in patients with nonautoimmune fundic atrophic gastritis. Only 31% of 45 patients with fundic atrophic gastritis presented with achlorhydria. Scintigraphic gastric emptying of solids was delayed compared to healthy controls. Patients with achlorhydria showed gastric emptying rates lower than those with preserved acid secretion. Significant, but weak, correlations were observed between emptying rates and both peak acid output (Rs = 0.33) and serum gastrin levels (Rs = -0.36), but not with grading of mucosal atrophy. No symptom differences were observed between patients with or without achlorhydria, but a weak correlation was detected between peak acid output and the severity of epigastric pain (Rs = 0.40). In conclusion, patients with fundic atrophic gastritis present delayed gastric emptying that is weakly related to the reduction of the acid secretion and the raising of serum gastrin levels rather than to the severity of the atrophy.

Management of Helicobacter pylori-related gastrointestinal diseases by general practitioners in Italy.

AIMS: To investigate the diagnostic approach to and management of Helicobacter pylori infection at primary care level in Italy 2 years after the Maastricht consensus report. METHODS: A total of 100 randomly selected general practitioners (GPs) answered a 12-item multiple-choice questionnaire, personally delivered and collected by non-medical staff. RESULTS: In 25% of cases, GPs preferred a prompt referral of dyspeptic patients to the specialist. The favourite diagnostic test for H. pylori infection was gastroscopy with biopsies (55%), followed by standard and office-based serology (24% and 18%, respectively), and 13C urea breath test (5%). H. pylori-eradication was prescribed in patients with peptic ulcer, reflux oesophagitis and functional dyspepsia by 64%, 43% and 66% of GPs, respectively. Only 7% of GPs adopted a test-and-treat approach. Proton pump inhibitor-based triple therapies were used by almost all physicians. In peptic ulcer disease, most of GPs re-tested patients in order to confirm H. pylori eradication (50% by gastroscopy with biopsies and 30% by serology only 2 months after therapy). CONCLUSIONS: Uncertainty seems to persist among Italian GPs concerning the indications for H. pylori treatment, the use of diagnostic tests, and patient follow-up. In contrast, no doubts exist regarding the first choice eradication regimens. This survey suggests that further efforts should be made to spread scientific knowledge and guidelines on H. pylori diagnosis and management in primary care in Italy.

How should Helicobacter pylori negative patients be managed?

Dyspepsia is a digestive syndrome distinct from (although frequently overlapping with) gastro-oesophageal reflux disease (GORD) and irritable bowel syndrome (IBS), which is characterised by various combinations of painful and non-painful symptoms arising from the epigastrium. Dyspepsia can be secondary to a variety of diseases, but in most instances it is idiopathic. Helicobacter pylori infection is responsible for the majority of peptic ulcers and of other diseases potentially associated with dyspepsia. Nevertheless, a causal role for H pylori infection in symptom occurrence has not been established. Experimental data indicate that H pylori eradication does not improve symptoms in the majority of dyspeptic patients. It has been proposed recently that H pylori negative patients should be managed according to their clinical presentation. Some reports suggest that taking into consideration the most relevant or "predominant" symptom may help to identify distinct subgroups among dyspeptic patients with different underlying pathophysiological abnormalities and different responses to treatment. Well designed and conducted prospective studies are needed to verify whether treatment of H pylori negative dyspeptic patients based on the predominant symptom actually is a cost effective approach.

Predominant symptoms identify different subgroups in functional dyspepsia.

OBJECTIVE: Dyspepsia is a common syndrome that often defies diagnosis. Whether the unexplained (or "functional") dyspepsia represents a homogeneous syndrome or includes different subgroups with specific clinical features has not been clarified. The aim of this study was to investigate the relationship between symptom severity, demographic features, and gastric dysmotility in a large series of patients with functional dyspepsia. METHODS: Severity of individual digestive symptoms, demographic features, and scintigraphic gastric emptying of solids were evaluated in 483 patients with chronic unexplained dyspepsia. RESULTS: Two main subgroups were identified. The first was characterized by predominant epigastric pain, male gender (61%), and normal gastric emptying. The second subgroup was characterized by predominant nonpainful symptoms, female gender (60%), a high frequency of associated irritable bowel syndrome (30%), and delayed gastric emptying (42%). A third group included approximately one-third of patients who did not present with any predominant symptom, and was characterized by a high frequency of delayed gastric emptying (30%), overlapping irritable bowel syndrome (28%), and gastroesophageal reflux disease (41%). CONCLUSIONS: Different subgroups exist among patients with functional dyspepsia seen in a referral center. They can be identified by the predominant symptom and are characterized by different demographic, clinical, and pathophysiological features.