J Neurogastroenterol Motil 2019; 25(4): 483-486  https://doi.org/10.5056/jnm19168
The Associations Among Symptoms, Quality of Life, and Gastric Emptying: An Unresolved Issue
Tae Hee Lee
Institute for Digestive Research, Soonchunhyang University Seoul Hospital, Seoul, Korea
Correspondence to: Tae Hee Lee, MD, PhD
Institute for Digestive Research, Digestive Disease Center, Soonchunhyang University Seoul Hospital, 59, Daesagwan-ro, Yongsangu, Seoul 140-743, Korea
Tel: +82-2-710-3084, Fax: +82-2-709-9696, E-mail: iman0825@schmc.ac,kr
Received: September 2, 2019; Accepted: September 19, 2019; Published online: October 30, 2019.
© The Korean Society of Neurogastroenterology and Motility. All rights reserved.

cc This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Functional dyspepsia (FD) is a chronic disorder of gastroduodenal function that is characterized by one or more of the following symptoms: epigastric pain, epigastric burning, postprandial fullness, and early satiation in the absence of any organic disease that is likely to explain the symptoms.1 A recent meta-analysis indicated that the overall pooled prevalence of dyspepsia is 21% and varies among countries and according to the definition of dyspepsia.2

Patients with dyspepsia have reduced health related quality of life (HRQOL) because of their symptoms.1 HRQOL describes patients’ perceived physical and mental health status. FD is not related to increased mortality. Therefore, HRQOL assessment is important to understand the impact of disease and treatments on patients.

Controversy exists as to whether delayed gastric emptying is related to specific symptoms or symptom severity (Table). A few studies indicated that gastric emptying may not be useful for stratifying patients with FD regardless of how the data were analyzed.36 However, postprandial fullness has been reported to be significantly related to impaired gastric emptying.712 Specifically, Stanghellini et al7 reported that female sex, relevant and severe postprandial fullness, and severe vomiting are independently associated with delayed gastric emptying of solids.

Controversy also exists over whether gastric emptying impacts on the HRQOL in patients with dyspepsia (Table). Talley et al13 reported that patients with dysmotility-like symptoms had significantly worse HRQOL than those with ulcer-like symptoms. In the population based cross-sectional endoscopic study applying the Rome III definition for FD, postprandial distress syndrome impair HRQOL in all short form-36 domain more than epigastric pain syndrome.14 These observations suggest the possibility that gastric emptying may have a significant impact on HRQOL in patients with FD.

In this issue of Journal of Neurogastroenterology and Motility, Wuestenberghs et al15 assessed association between symptoms and gastric emptying in 198 patients with dyspepsia. The main findings were that there was no association between symptoms, quality of life, and gastric emptying in their population. However, there was a significant association among symptoms, quality of life, and gastric emptying in their analysis using a different criteria (ie, T1/2 = 200 minutes). That means that patients with severely delayed gastric emptying had worse symptoms and poorer quality of life. Given this finding, the authors questioned the traditional reference value of delayed gastric emptying in the assessment of 13C breath test using octanoic acid incorporated into a solid meal. Their study also highlights the need to assess normal values for this test. This breath test, which requiring standardization and validation, is an alternative to gastric emptying scintigraphy.16 The drawbacks of this gastric emptying breath test are that the reference range depends on the protocol and mathematical analysis method used.17 Dichotomous value (ie, normal versus abnormal) based on the threshold of 166 minutes in this study potentially undermines the diagnostic utility, and can be misleading. This analysis also erroneously implies that symptoms, quality of life, and gastric emptying were unrelated. Hence, it may be preferable to compare these metrics expressed on a continuous scale. The authors indicated that among the overall population, gastric emptying correlated with symptom severity assessed by total symptom score (r = −0.215, P = 0.002), quality of life assessed by the gastrointestinal quality of life index (GIQLI; r = −0.227, P = 0.001), and anxiety and depression assessed by the hospital anxiety depression scale (r = 0.206, P = 0.004).

Impaired HRQOL in patients with FD is mainly associated with symptom severity (ie, moderate to severe symptoms).18 Putative factors related to reduced HRQOL include gender, symptom nature (ie, FD subtype), overlap with gastroesophageal reflux disease (GERD) or irritable bowel syndrome (IBS), somatization, comorbid psychiatric conditions such as anxiety and depression, health knowledge, and socioeconomic status (Figure).18 In particular, overlap conditions with IBS or GERD might be important to understand the impact on HRQOL. Specifically, a population-based study applying the Rome III showed FD overlap both with IBS and GERD had a significant impact on bodily pain.14 In addition, Wuestenberghs et al15 reported that patients with IBS present poorer quality of life (GIQLI scores of 71.9 points compared to 83.6 without overlap with IBS, P = 0.002). As mentioned above, these factors may be confounders that distort the association among gastric emptying, symptoms and HRQOL. Therefore, the unresolved issue require further large study which utilizes a validated gastric emptying test and minimizes the effects of these confounders during study design and statistical analysis.

Figures
Fig. 1. Putative factors impacting on the health related quality of life in patients with functional dyspepsia. GERD, gastroesophageal reflux disease; IBS, irritable bowel syndrome.

Tables

Literature Review on Association Among Symptoms, Quality of Life, and Gastric Emptying in Patients With Dyspepsia

Primary author Year Nation Study population Methods used Symptomsa QOL Comments
Stanghellini7 1996 Italy Rome II FD (n = 304) GES Severe postprandial fullness (OR 3.78), severe vomiting (OR 4.04) NA Female sex, relevant and severe postprandial fullness, and severe vomiting are independently associated with delayed gastric emptying of solids.
Perri8 1998 Italy Rome II FD (n = 343) 13C octanoic gas-tricemptying test Postprandial fullness, nausea, vomiting NA H. pylori status had no influence on gastric emptying
Talley3 1989 Australia Dyspeptic patients (n = 32) GES No NA Gastric emptying of solids was slightly delayed in females with dyspepsia.
Guo19 2001 US Dyspeptic patients (n = 129) GES Greater symptom score NA Extending gastric emptying scintigraphy from 2 to 4 hours detects more patients with gastroparesis.
Talley4 2001 Australia Rome II FD (n = 551)
Dsypeptic patients with DM
GES, NDI No No Symptom prevalence and severity were similar in dyspeptic patients with and without delayed gastric emptying.
Sarnelli9 2003 Belgium Rome II FD (n = 392) GES Vomiting (OR 2.65), postprandial fullness (OR 3.08) NA Demographic factors and H. pylori status do not differ between patients with normal or with delayed gastric emptying.
Talley10 2006 US Rome II FD (n = 864) GES, SF-36, NDI Postprandial fullness (OR 1.98) No Female, epigastric pain, and nausea were associated with impaired QOL.
van Lelyveld5 2008 Netherland Rome II FD (n = 60) 13C octanoic gas-tricemptying test No NA A delayed gastric emptying rate, defined as a half emptying time ≥120 min and/or a retention after 120 min ≥40%.
Cassilly20 2008 US Dyspeptic patients (n = 226) GES Nausea, vomiting NA The total or average GCSI score did not reliably predict the diagnosis of gastroparesis.
Punkkinen6 2008 Finland Dyspeptic patients with type 1 DM (n = 27) GES No NA Impaired gastric emptying of solids in paients with Type 1 diabetes is related to autonomic neuropathy.
Pathikonda11 2012 US Dyspeptic patients (n = 1449) GES Early satiety, postprandial fullness, vomiting, loss of appetite NA Gastric retention at 1 hour may miss 36% of patients found to have delayed gastric emptying at 4 hours.
Guo21 2012 China Rome III FD (n = 93) GES No NA Presence of nausea was associated with delayed gastric emptying of the proximal stomach.
Ardila-Hani22 2013 US Dyspeptic patients (n = 717) GES Vomiting, loss of appetite NA Symptoms cannot distinguish between degrees of delayed or rapid gastric emptying.
DiBaise12 2016 US Rome III FD (n = 266) GES, PAGI-QOL Nausea, vomiting, postprandial fullness, early satiety, GCSI total score Yes Patients with delayed gastric emptying had more severe gastroparetic symptom.
Tseng23 2018 US Rome III FD (n = 172) GES, PAGI-QOL, SF-12 Higher GCSI Yes Results of GES did not help to identify those with improved or worsened symptoms or QOL at follow-up
Asano24 2017 Japan Rome III FD (n = 94) GES No NA PDS type of FD.

Whether delayed gastric emptying was associated with a specific symptom pattern or overall symptom severity.

Whether quality of life was impaired by delayed gastric emptying.

QOL, quality of life; FD, functional dyspepsia; GES, gastric emptying scintigraphy; OR, odds ratio; NA, not assessed; H. pylori, Helicobacter pylori; NDI, Nepean dyspepsia index; DM, diabetes mellitus; GCSI, gastroparesis cardinal symptom index; PAGI-QOL, patient assessment of upper gastrointestinal quality of life; PDS, postprandial distress syndrome.


Footnotes

Conflicts of interest: None.

Financial support: This work was supported by the Soonchunhyang University Research Fund.

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