Health & Medical hepatitis

Distinguishing Functional Dyspepsia From NERD

´╗┐Distinguishing Functional Dyspepsia From NERD

Abstract and Introduction


Background and Aim: The Frequency Scale for the Symptoms of Gastroesophageal Reflux Disease (FSSG) is the standard questionnaire used in Japan for the diagnosis of gastroesophageal reflux disease (GERD) and assessment of the response to treatment. We modified the FSSG in order to assess dyspepsia symptoms, and evaluated the modified questionnaire.
Methods: We modified the FSSG by adding two questions on interdigestive and postprandial epigastric pain. We then assessed the modified FSSG with 100 new untreated symptomatic patients presenting to hospital and in 200 subjects undergoing health checks. Endoscopic assessment of the esophagogastric junction was performed according to the modified Los Angeles classification with addition of Grade N (normal appearance) and Grade M (minimal change). Endoscopic images were assessed by five experienced endoscopists blinded to the questionnaire results.
Results: The 100 new patients included 16 with erosive GERD (>Grade A), 12 with peptic ulcer, and two with gastric cancer. Among the 70 patients with no evidence of organic disease, the modified FSSG diagnosed functional dyspepsia (FD) in 41 and non-erosive gastric disease (NERD) in 29. A significant difference was seen in the dyspepsia score between patients with FD and NERD. Subjects with endoscopic GERD undergoing health checks had significantly higher scores for all symptoms, reflux symptoms, and dyspeptic symptoms on the modified FSSG.
Conclusion: The modified FSSG can clearly distinguish FD from NERD, and is useful for the assessment of dyspeptic symptoms.


A thorough history is the mainstay for the diagnosis of functional gastrointestinal disorders (FGID). When the main symptom is heartburn, gastroesophageal reflux disease (GERD) or non-erosive reflux disease (NERD) is suspected. A number of different diagnostic questionnaires have been devised; however, many of these are not suitable for the evaluation of therapeutic efficacy. In general, the efficacy of treatments for GERD and NERD have been evaluated in terms of improvement in quality of life (QOL) rather than symptomatic improvement. Analysis of responses to QOL questionnaires can be complicated, however, and few can be considered satisfactory, even among specific QOL scales.

We previously developed the Frequency Scale for the Symptoms of GERD (FSSG) as a questionnaire targeting GERD. From 50 questions related to gastrointestinal symptoms, we extracted 12 questions to which patients with GERD most often answered "yes". We then scored the symptoms related to these questions according to their frequency. Studies supporting the objectivity of the FSSG questionnaire have shown that it has a stronger correlation with the endoscopic grade of esophagitis than the Questionnaire for the Diagnosis of Reflux Esophagitis (QUEST). In another study, the FSSG questionnaire showed similar accuracy to the SF-8, a QOL scale, in the assessment of treatment response. Other studies have shown that some patients with GERD also have acid-related dyspepsia responsive to PPI therapy. The FSSG questionnaire has been used for evaluation of the symptoms of GERD since it appeared. The FSSG questionnaire has been used not only in the field of gastroenterology, but also respiratory medicine, otorhinolaryngology, and orthopedic surgery, as well as in patients with systemic sclerosis and post-gastrectomy patients. It is therefore reasonable to conclude that the FSSG is the standard questionnaire in Japan for the diagnosis of GERD and for the assessment of therapeutic response.

Functional dyspepsia (FD) is a common condition in FGID patients complaining of upper abdominal symptoms. The Rome III criteria identifies "bothersome postprandial fullness", "early satiation", "epigastric pain", and "epigastric burning" as the four defining symptoms of FD, and broadly divide FD into postprandial distress syndrome (PDS) and epigastric pain syndrome (EPS) according to the relationship of symptoms to meals. The FSSG questionnaire has seven questions related to acid reflux symptoms and five related to dyspeptic symptoms, and although it includes two of the Rome III dyspeptic symptoms, it does not include "epigastric pain" or "epigastric burning". There has been a report on the use of the FSSG (with the addition of one question related to pain symptoms) for the diagnosis of FD. However, to use the FSSG as a questionnaire for FD, we need to determine the relationship between symptoms and meals by asking questions about postprandial and interdigestive pain symptoms. Accordingly, we modified the FSSG questionnaire by the addition of two new questions: "Do you get epigastric pain (burning) after meals?" and "Do you get epigastric pain (burning) before meals?" We then tested the new questionnaire on patients attending the Gastroenterology Outpatients Clinic and clients undergoing routine health checks to investigate its clinical usefulness.

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