General interest in functional gastrointestinal disorders is increasing among Japanese doctors as well as patients. This increase can be attributed to a number of factors, including recent increased interest in quality of life and advances in our understanding of the pathophysiology of gastrointestinal disease. Japan recently became the world’s first country to list “functional dyspepsia” as a disease name for national insurance billing purposes. However, recognition and understanding of functional dyspepsia (FD) remain poor, and no standard treatment strategy has yet been established. Accordingly, the Japanese Society of Gastroenterology (JSGE) developed an evidence-based clinical practice guideline for FD, consisting of five sections: concept, definition, and epidemiology; pathophysiology; diagnosis; treatment; and prognosis and complications. This article summarizes the Japanese guideline, with particular focus on the treatment section. Once a patient is diagnosed with FD, the doctor should carefully explain the pathophysiology and benign nature of this condition, establish a good doctor–patient relationship, and then provide advice for daily living (diet and lifestyle modifications, explanations, and reassurance). The proposed pharmacological treatment is divided into two steps: initial treatment including an acid inhibitory drug (H2RA or PPI) or prokinetics, (strong recommendation); second-line treatment including anxiolytics, antidepressants, and Japanese traditional medicine (weak recommendation). H. pylori eradication, strongly recommended with a high evidence level, is positioned separately from other treatment flows. Conditions that do not respond to these treatment regimens are regarded as refractory FD. Patients will be further examined for other organic disorders or will be referred to specialists using other approaches such as psychosomatic treatment.

/pdf/evidence-based-clinical-practice-guidelines-for-functional-49tguck9dn.pdf

Evidence-based clinical practice guidelines for functional dyspepsia

Functional dyspepsia (FD) is a disorder that presents with chronic dyspepsia, which is not only very common but also highly affects quality of life of the patients. In Japan, FD became a disease name for national insurance in 2013, and has been gradually recognized, though still not satisfactory. Following the revision policy of Japanese Society of Gastroenterology (JSGE), the first version of FD guideline was revised this time.Like previously, the guideline was created by the GRADE (grading of recommendations assessment, development and evaluation) system, but this time, the questions were classified to background questions (BQs, 24 already clarified issues), future research questions (FRQs, 9 issues cannot be addressed with insufficient evidence), and 7 clinical questions that are mainly associated with treatment.These revised guidelines have two major features. The first is the new position of endoscopy in the flow of FD diagnosis. While endoscopy was required to all cases for diagnosis of FD, the revised guidelines specify the necessity of endoscopy only in cases where organic disease is suspected. The second feature is that the drug treatment options have been changed to reflect the latest evidence. The first-line treatment includes gastric acid-secretion inhibitors, acetylcholinesterase (AChE) inhibitors (acotiamide, a prokinetic agent), and Japanese herbal medicine (rikkunshito). The second-line treatment includes anxiolytics /antidepressant, prokinetics other than acotiamide (dopamine receptor antagonists, 5-HT4 receptor agonists), and Japanese herbal medicines other than rikkunshito. The patients not responding to these treatment regimens are regarded as refractory FD. 

https://link.springer.com/content/pdf/10.1007/s00535-021-01843-7.pdf

Evidence-based clinical practice guidelines for functional dyspepsia 2021

Background and Aim
The prevalence of gastroesophageal reflux disease (GERD) in adults is increasing in Japan as well as worldwide likely due to increasing obesity and the decreasing rate of Helicobacter pylori infection. However, data regarding the prevalence of GERD in children and adolescents in Japan are lacking. We investigated the prevalence of GERD in children, adults, and elderly living in the same community.

Methods
We surveyed employees of Shimane University Hospital and a related facility and their families using the Gastroesophageal Reflux Disease Questionnaire (GerdQ) and Izumo Scale instruments with demographic information (age, sex, body height, and body weight) and information regarding concurrent medication being taken for GERD. The presence of GERD was defined as a GerdQ score of ≥ 8.

Results
A total of 1859 subjects (771 males, 1088 females; 6–96 years old) were eligible for assessment. The prevalence of GERD in those under 20 years old was 4.4%, which was approximately one third of the rate in adults (11.6%). GERD prevalence was closely associated with obesity in adults, but not in subjects under 20 years old. GERD and other gastrointestinal symptoms frequently overlapped in both adults and younger subjects.

Conclusion
We found that the prevalence of GERD in subjects under 20 years of age was lower than that in adults and not associated with obesity. Nevertheless, it is important to be aware of symptoms such as heartburn and/or regurgitation when children and adolescents seek routine clinical care.

Prevalence of gastroesophageal reflux disease in children, adults, and elderly in the same community.

Background/Aims
Small intestinal bacterial overgrowth (SIBO) is considered to be involved in the pathogenesis of functional gastrointestinal disorders (FGID). However, the prevalence and clinical conditions of SIBO in patients with FGID remain to be fully elucidated. Here, we examined the frequency of SIBO in patients with refractory FGID.

Small Intestinal Bacterial Overgrowth in Patients with Refractory Functional Gastrointestinal Disorders

Objective To clarify the clinical characteristics of patients diagnosed with chronic gastritis in Japan, a large scale clinical survey of patients with chronic upper gastrointestinal symptoms was conducted. Patients diagnosed with functional dyspepsia (FD) according to the ROME III criteria were selected from among patients with chronic gastritis and the clinical characteristics of patients with FD and those with chronic gastritis were compared. Patients and Methods Patients with upper abdominal symptoms and diagnosed with chronic gastritis were enrolled in the study. Their main complaints, duration of symptoms, clinical characteristics, mental state, and results of endoscopic examinations, if available, were prospectively surveyed. Quality of life (QOL) impairment caused by abdominal symptoms was also surveyed using the Izumo QOL scale. Results A total of 9,125 patients with a clinical diagnosis of chronic gastritis were enrolled in the survey. Of those, approximately 60% had more than 2 symptoms and QOL impairment was greater in cases with multiple symptoms. Endoscopic examinations were performed in 2,946 cases (32.3% of enrolled patients), during which gastric and/or esophageal carcinoma was found in only 0.2%, though organic diseases were found in 6.2%. Endoscopic examinations were not done for patients with high risks of organic diseases. Of patients with organic diseases excluded by an endoscopic examination, only 362 (12.3% of patients who underwent an endoscopy) were diagnosed with FD according to the ROME III criteria, mainly because of short symptom duration. There were no remarkable differences in regard to clinical characteristics, including symptoms and mental state, between patients with chronic gastritis and those with FD. Conclusion Clinical characteristics of patients with chronic gastritis were similar to those with FD, except for shorter symptom duration.

/pdf/characteristics-of-japanese-patients-with-chronic-gastritis-14h3vfvnp5.pdf

Characteristics of Japanese patients with chronic gastritis and comparison with functional dyspepsia defined by ROME III criteria: based on the large-scale survey, FUTURE study.

Objective Quality of life (QOL) impairment of patients who visit an outpatient clinic for abdominal symptoms has not been clarified. We investigated symptom-related QOL impairment that led patients to seek medical care. Patients and Methods Abdominal symptom-related QOL was determined using the Izumo scale instrument in 172 patients who visited a clinic for their abdominal symptoms and in 961 healthy subjects who attended an annual health check. Results QOL was more strongly impaired in the patients with abdominal symptoms than in subjects who attended health checks. Patients with heartburn consulted physicians even when QOL impairment was minimal, while those with epigastric fullness tended to consult a physician only when QOL impairment was significant. Conclusion Abdominal symptom-related QOL impairment is considered to lead patients to seek medical care, though different symptoms have varying levels of influence.

Abdominal symptom-related QOL in individuals visiting an outpatient clinic and those attending an annual health check.

The characteristics of symptoms reported by patients with various organic and functional upper gastroduodenal diseases have not been fully studied. We used a questionnaire-based survey to investigate abdominal symptoms of patients with reflux esophagitis, nonerosive reflux disease (NERD), peptic ulcers, and functional dyspepsia (FD). Seven hundred thirty-seven patients with those conditions responded to a questionnaire asking about the possible presence of nine kinds of upper abdominal symptoms. The mean number of symptoms reported was 3.2 ± 1.7, and patients with organic diseases tended to have a larger number. Approximately 60% of patients with NERD complained of heartburn and 30% of at least one dyspeptic symptom; more than 50% of patients with FD noted dyspeptic symptoms and 20% complained of reflux symptoms. We found a large overlap in the abdominal symptoms of NERD and FD patients, including the most troublesome symptoms. In summary, our questionnaire-based study showed that symptom-based classification of NERD and FD is not easy because of symptom overlap. Possible overlap of NERD and FD should always be considered.

Variety of symptoms reported by patients with upper gastrointestinal diseases

A case report of adenosquamous cell carcinoma of papilla vater

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Abdominal symptom-related QOL in individuals visiting an outpatient clinic and those attending an annual health check.

Variety of symptoms reported by patients with upper gastrointestinal diseases

A case report of adenosquamous cell carcinoma of papilla vater