الفهرس 
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Abstract
Dyspepsia is a prevalent complaint in general practice and GI clinics. FD is considered one of the most FGIDs, represents about 75% of all cases of dyspepsia, and affecting 5%‐20% of the population worldwide (Ford et al., 2015). There are numerous mechanisms implicated in the pathogenesis of FD, and H. pylori is one of the most likely causes (Sugano et al., 2015, Tally and Ford, 2015). Studies on FD in Sohag governorate are rare, moreover, there are no studies regarding the role of H. pylori infection in the causation of FD symptoms and correlation of the histopathological findings with symptomatology of FD. Therefore, this study was conducted to highlight this common health problem. The aim of this study was to study clinical, laboratory, imaging, endoscopic and histopathological features of patients with FD according to Rome IV criteria, in Sohag University Hospital. A cross sectional study was carried out among 120 consecutive adult patients with FD at the Internal Medicine Department, Sohag University Hospital, from November 2017 to May 2019. Patients with FD and older than 18 years were included in this study. On the other hand, patients whose dyspepsia had been investigated previously, had positive history of recent treatment with H2RAs, PPIs, and H. pylori eradication within 4 weeks before being enrolled in the study, had prior upper GIT surgery, chronic illnesses (Diabetes mellitus, renal, hepatic, Cardiac, thyroid, chronic respiratory diseases, Coagulopathy, and/or malignancies), presence of major psychiatric disorders, and pregnant women were excluded.
All included patients who gave an informed written consent were subjected to detailed history, complete general, systemic examination with
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special emphasis on GI manifestations, BMI determination, abdominal ultrasound, and Laboratory investigations (blood picture, fasting, random blood glucose levels, blood urea, serum creatinine, liver function tests and H. pylori antigen in stool). EGD with multiple biopsies were taken from the stomach, duodenum according to the Sydney–Houston system for grading gastritis. Histopathological examination was performed using H &E and geimsa stain.
All included patients with FD, were assigned into two groups according to the stool H. pylori antigen: group I – included 69 (57.5%) patients of FD with positive stool H. pylori antigen: group II – included 51 (42.5%) patients of FD with negative stool H. pylori antigen. The mean age of patients in group II was higher significantly than group I, (49.61±10.84, 43.43±11.57 respectively). 50.7% of group I and 56.9% of group II were females, and there was non-signifncant statistical difference among both sex. group II had more smokers (47.1%) than group I (29%) with significant statistical difference. The mean of BMI was higher in group I than group II (24.97±4.10, 22.73±2.68 respectively), with high significant statistical difference, and most of both groups were normal weight with significant statistical difference. 21.7% of group I and 5.9% of the group II had history of NSAIDs intake with significant statistical difference between two groups.
The study showed that, the proportion of PDS alone, EPS alone and PDS-EPS overlap was 45.8%, 29.2%, and 25% respectively. In group I, the most common clinical subtype was EPS, while PDS was the commonest in group II. There was significant statistical difference between both groups regarding EPS which was higher significantly in group I than group II, and PDS was higher significantly in group II than group I. In group I, the most common symptom was epigastric pain followed by postprandial fullness, early satiety, and epigastric burning (71%, 59.4%, 34.8%, and 5.8%
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respectively). On the other hand, the most common symptom in group II was postprandial fullness followed by early satiety, epigastric pain, and epigastric burning (88.2%, 47.1%, 31% and 2% respectively). There was non-significant statistical difference between both groups regarding all symptoms except for each of epigastric pain which was higher significantly in group I than group II, postprandial fullness, and GIT bleeding were higher significantly in group II than group I. Only 7.8% of group II and 1.4% of group I had family history of GI malignancy with non-significant statistical difference in both groups
All studied patients (100%) had normal EGD findings. There was non-significant statistical difference between both groups regarding all laboratory investigations except hemoglobin level and AST which were highly significant, in group I than group II.
The present study showed that, histopathological findings were present in 79 (65.8%) out of 120 studied patients (61 of group I, and 18 of group II). 88.4% of group I had histologic evidence of gastritis, while only 35.3% of group II had this histologic evidence of gastritis with high statistical significant difference. In group I, mild degree of gastritis was the commonest characterized by presence of neutrophilic infiltration within the gastric mucosa in 72.5%. On the other hand, in group II, moderate gastritis was the commonest grade and neutrophilic infiltration was present in 27.5% with high significant statistical difference. Glandular atrophy was detected in 43.5% of group I patients, and in 15.7% of group II, with high significant statistical difference. Intestinal metaplasia was detected only in a minority of patients of both groups (8.7% and 2%, respectively) with no statistical significant difference.
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The present study showed that, not all patients of group I had H. pylori bacilli in their histopathology, as well as not all patients of group II showed absence of H. pylori bacilli in their histopathology. In group I, H. pylori bacilli density was not detected in 26 (37.8%) out of 69 patients, while it was detected in 19 (37.7%) out of 51 patients of group II. The degree of H. pylori density was mild in majority of both groups with significant statistical difference, however, marked colonization was not found at all in group II patients.
Histologic duodenitis was present in 68.1% of group I patients, and 33.3% of group II patients. It was commonly mild in both groups followed by moderate and marked duodenitis that was found in only 5.8% of group I but not found at all in group II with high significant statistical difference. In both groups, the prevalence of microscopic duodenitis differ significantly in the presence or absence of gastritis, and it was not diagnosed in any patients with normal gastric histopathology. In patients with FD, microscopic gastritis and duodenitis are completely independent findings in patients of group I, but these two conditions are strongly related to each other in group II patients.
The present study showed that, in group I, there was non-significant statistical difference between FD symptoms, presence or absence of histologic gastritis, neutrophilic infiltration, and glandular atrophy except for early satiety, and epigastric burning as regards presence of histologic duodenitis. On other hand, In group II, there was non-significant statistical difference between FD symptoms, presence or absence of histologic gastritis, duodenitis, neutrophilic infiltration and glandular atrophy. In both groups, there was non-significant statistical difference between FD symptoms and presence or absence of intestinal metaplasia as well as H. pylori bacilli density.
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Conclusion: ▪ This study showed that H. pylori infection constitutes an important subset of FD. It is one of the components that can contribute to the clinical, laboratory and histopathological features of FD patients.
▪ In FD patients, the endoscopic findings of dyspepsia correlated poorly with histopathological findings.
▪ It is obvious that, FD patients with positive stool H. pylori antigen had severe clinical, laboratory and histologic parameters than the negative group and this is shown by highly significant statistical difference in most of these features.
Study limitations:
There were some limitations in this study.
1. First, H. pylori infection was confirmed only by the stool H. pylori antigen, however, its sensitivity and specificity are lower than invasive tests.
2. Second, the results of stool antigen test may be influenced by patients compliance.
Recommendations
All physicians dealing with patients with FD should be aware that, All FD patients should be underwent upper endoscopy for dyspepsia, and should be exposed for routine biopsies of the normal-appearing mucosa for histopathological examination, and detection of H. pylori infection.
▪ For FD patients having stool H. pylori negative, further studies are needed to be established the exact cause of symptoms and possible treatment.