Efficacy of Helicobacter pylori eradication therapy for functional dyspepsia: updated systematic review and meta-analysis

ObjectiveFunctional dyspepsia (FD) is a chronic disorder that is difficult to treat. Helicobacter pylori may contribute to its pathophysiology. A Cochrane review from 2006 suggested that eradication therapy was beneficial, but there have been numerous randomised controlled trials (RCTs) published since. We evaluated impact of eradication therapy on both cure and improvement of FD, as well as whether any benefit was likely to arise from eradication of H. pylori.DesignWe searched the medical literature through October 2021 to identify RCTs examining efficacy of eradication therapy in H. pylori-positive adults with FD. The control arm received antisecretory therapy or prokinetics, with or without placebo antibiotics, or placebo alone. Follow-up was for ≥3 months. We pooled dichotomous data to obtain a relative risk (RR) of symptoms not being cured or symptoms not improving with a 95% CI. We estimated the number needed to treat (NNT).ResultsTwenty-nine RCTs recruited 6781 H. pylori-positive patients with FD. Eradication therapy was superior to control for symptom cure (RR of symptoms not being cured=0.91; 95% CI 0.88 to 0.94, NNT=14; 95% CI 11 to 21) and improvement (RR of symptoms not improving=0.84; 95% CI 0.78 to 0.91, NNT=9; 95% CI 7 to 17). There was no significant correlation between eradication rate and RR of FD improving or being cured (Pearson correlation coefficient=−0.23, p=0.907), but the effect was larger in patients with successful eradication of H. pylori than with unsuccessful eradication (RR=0.65; 95% CI 0.52 to 0.82, NNT=4.5, 95% CI 3 to 9). Adverse events (RR=2.19; 95% 1.10 to 4.37) and adverse events leading to withdrawal (RR=2.60; 95% CI 1.47 to 4.58) were more common with eradication therapy.ConclusionThere is high quality evidence to suggest that H. pylori eradication therapy leads to both cure and improvement in FD symptoms, although the benefit is modest.

Current Prospects of Herbal STW 5 Agent in Treatment of Functional Gastrointestinal Diseases

Aim. A review of current therapeutic perspectives of the herbal STW 5 medicine (Iberogast®) in functional gastrointestinal (GI) diseases.Key points. A limited remediation in most common functional GI diseases, functional dyspepsia (FD) and irritable bowel syndrome (IBS), is conditioned by their multifactorial pathogenesis. Meanwhile, most specific medicines only target selected pathogenesis components, thus warranting a multitarget agent development. Such is Iberogast® that acts at variant components of FD and IBS pathogenesis. The article reviews the Iberogast® mechanisms of action and evaluates its treatment efficacy in FD and IBS.Conclusion. The current evidence claims that Iberogast® provides an effective and safe treatment for FD and IBS.

Duodenal Dysbiosis and Relation to the Efficacy of Proton Pump Inhibitors in Functional Dyspepsia

Proton pump inhibitors (PPI) may improve symptoms in functional dyspepsia (FD) through duodenal eosinophil-reducing effects. However, the contribution of the microbiome to FD symptoms and its interaction with PPI remains elusive. Aseptic duodenal brushings and biopsies were performed before and after PPI intake (4 weeks Pantoprazole 40 mg daily, FD-starters and controls) or withdrawal (2 months, FD-stoppers) for 16S-rRNA sequencing. Between- and within-group changes in genera or diversity and associations with symptoms or duodenal factors were analyzed. In total, 30 controls, 28 FD-starters and 19 FD-stoppers were followed. Mucus-associated Porphyromonas was lower in FD-starters vs. controls and correlated with symptoms in FD and duodenal eosinophils in both groups, while Streptococcus correlated with eosinophils in controls. Although clinical and eosinophil-reducing effects of PPI therapy were unrelated to microbiota changes in FD-starters, increased Streptococcus was associated with duodenal PPI effects in controls and remained higher despite withdrawal of long-term PPI therapy in FD-stoppers. Thus, duodenal microbiome analysis demonstrated differential mucus-associated genera, with a potential role of Porphyromonas in FD pathophysiology. While beneficial effects of short-term PPI therapy were not associated with microbial changes in FD-starters, increased Streptococcus and its association with PPIeffects in controls suggest a role for duodenal dysbiosis after long-term PPI therapy.

Eradication of intestinal bacterial overgrowth as a treatment method for functional dyspepsia

Functional dyspepsia (FD) is one of the most common gastrointestinal functional diseases, occurring in an average of 10 % of the adult population. Recently, much attention is being paid to the infectious factor in FD pathophysiology. In addition to H. pylori infection and acute gastrointestinal infections, consideration is given to the syndrome of intestinal bacterial overgrowth (SIBO), in which the number of bacteria in the small intestine increases significantly. Objective — to establish the SIBO prevalence in patients with different FD subtypes and to establish the clinical and microbiological efficacy of rifaximin‑a (Alpha Normix®) at this pathology. Materials and methods. To refine the SIBO prevalence, 118 patients with FD were examined in three gastroenterological centers, including 45 men, 73 women aged 22 to 45 years (mean age — 35 ± 10 years). The control group consisted of 30 clinically healthy people with the mean age 33 ± 12 years. The diagnosis of FD and establishment of its subtype was performed according to Rome IV criteria. All patients underwent upper endoscopy with biopsy and H. pylori testing, which did not show any structural abnormalities. To diagnose SIBO, all patients underwent H2‑breath test with lactulose (H2‑LBT). All patients, depending on the FD subtype, received basic therapy with either a proton pump inhibitor (Omeprazole 20 mg once a day) at FD with epigastric pain syndrome (EPS) (group 1, n = 37), or prokinetic (Itopride in a dose of 50 mg three times a day) at FD with postprandial distress syndrome (PDS) (group 2, n = 36) for two weeks. Patients with positive H2‑LBT result, which predicted SIBO presence, were administered monotherapy with rifaximin‑a (Alpha Normix®) in a dose of 1200 mg/day for 10 days. The effectiveness of the treatment was assessed after 2 and 4 weeks based on the dynamics of the scores of SAGIS (Structured Assessment of Gastrointestinal Symptom) scale. Results. According to the positive H2‑LBT results, SIBO presence was recorded in 45 of 118 patients with FD (38.1 %) and 2 (6.6 %) subjects from the control group. Positive H2‑LBT result was significantly more often recorded in patients with FD‑PDS (45.4 %) compared with patients with FD‑EPS (28.8 %, p < 0.01) and all patients with FD (38.1 %). Moreover, SIBO was significantly more common in patients with postinfectious FD (50 % of patients, p < 0.01). The use of rifaximin in a dose of 1200 mg/day for 10 days was accompanied by the clinical improvement in 28 of 45 patients (62.2 %) after 4 weeks of treatment. The clinical efficacy of rifaximin in FD patients on the SAGIS scale did not differ significantly from the efficacy of PPIs and prokinetics used in FD‑EPS and FD‑PDS, respectively. After 4 weeks, in 36 of 45 patients, repeated H2‑LBT was negative, which indirectly indicated the SIBO eradication and high antibacterial efficacy of rifaximin. Rifaximin treatment was safe, and minor side effects were observed in only 3 patients (6.6 %). Conclusions. SIBO is quite often associated with FD and is observed in more than every third patient. In patients with FD‑PDS, SIBO was found significantly more often than in patients with FD‑EPS, which emphasizes the important role of slowing gastric emptying in the development of SIBO. Also, SIBO is significantly more common in patients with postinfectious FD, which emphasizes the important role of the intestinal microbiome in maintaining the stability of the structural and functional state of the gastrointestinal tract. The obtained data allow to consider SIBO as a possible pathogenetic factor of FD, at least in some patients. This requires timely diagnosis and correction of SIBO in patients with FD, in particular with the use of rifaximin‑a.