Since the publication of the 2007 dyspepsia guidelines of the Asociación Mexicana de Gastroenterología, there have been significant advances in the knowledge of this disease. A systematic search of the literature in PubMed (01/2007 to 06/2016) was carried out to review and update the 2007 guidelines and to provide new evidence-based recommendations. All high-quality articles in Spanish and English were included. Statements were formulated and voted upon using the Delphi method. The level of evidence and strength of recommendation of each statement were established according to the GRADE system. Thirty-one statements were formulated, voted upon, and graded. New definition, classification, epidemiology, and pathophysiology data were provided and include the following information: Endoscopy should be carried out in cases of uninvestigated dyspepsia when there are alarm symptoms or no response to treatment. Gastric and duodenal biopsies can confirm Helicobacter pylori infection and rule out celiac disease, respectively. Establishing a strong doctor-patient relationship, as well as dietary and lifestyle changes, are useful initial measures. H2-blockers, proton-pump inhibitors, prokinetics, and antidepressants are effective pharmacologic therapies. H.pylori eradication may be effective in a subgroup of patients. There is no evidence that complementary and alternative therapies are beneficial, with the exception of Iberogast and rikkunshito, nor is there evidence on the usefulness of prebiotics, probiotics, or psychologic therapies. The new consensus statements on dyspepsia provide guidelines based on up-to-date evidence. A discussion, level of evidence, and strength of recommendation are presented for each statement.
Background In contrast to the well-characterized Celiac Disease (CD), the clinical scenarios encompassed by the non-celiac self-reported wheat sensitivity (NCSRWS) might be related to different antigens that trigger distinct immune-inflammatory reactions. Although an increased number of intestinal intraepithelial lymphocytes is observed at the inception of both diseases, the subsequent immunopathogenic pathways seem to be different. We aimed to describe the cytokine profile observed in the duodenal mucosa of patients with NCSRWS. Methods In a blind, cross-sectional study, we included duodenal biopsies from 15 consecutive untreated patients with active CD, 9 individuals with NCSRWS and 10 subjects with dyspepsia without CD and food intolerances. Immunohistochemistry and flow-cytometry were used to determine the presence of pro-inflammatory cytokine expressing monocytes and monocyte-derived dendritic cells involved in innate immune activation, cytokine-driven polarization and maintenance of Th1 and Th17/Th 22, and anti-inflammatory/profibrogenic cytokines. Results The percentage of cells expressing all tested cytokines in the lamina propria and the epithelium was higher in CD patients than in the control group. Cytokines that induce and maintain Th1 and Th17 polarization were higher in CD than in NCSRWS and controls, also were higher in NCSRWS compared to controls. Similar differences were detected in the expression of IL-4 and TGF-1, while IL-10-expressing cells were lower in NCSRWS patients than in controls and CD subjects. Conclusions NCSRWS patients exhibit components of both, innate and adaptive immune mechanisms but to a lesser extent compared to CD.
Background In contrast to the well characterized Celiac Disease (CD), the clinical scenarios encompassed in non-celiac gluten sensitivity (NCGS) might be related to different antigens that trigger distinct immune-inflammatory reactions. Although an increased number of intestinal intraepithelial lymphocytes is observed at the inception of both diseases, subsequent immunopathogenic pathways seems to be different. Aims To compare the immunological profile in the duodenal mucosa of patients with CD, self-reported gluten intolerant subjects and gluten tolerant patients with functional dyspepsia (GT-FD). Methods In a blind, cross-sectional study, duodenal biopsies from 15 consecutive untreated patients with active CD, 9 NCGS individuals and 10 GT-FD subjects were studied by flow-cytometry and immunohistochemistry. We determined the presence of pro-inflammatory cytokine expressing monocytes and monocyte-derived dendritic cells involved in innate immune activation, cytokine-driven polarization and maintenance of Th1 and Th17/Th22, and anti-inflammatory/profibrogenic cytokines. Results CD patients presented a higher percentage of cells expressing all tested cytokines in lamina propria and epithelium than GT-FD group. Cytokines that induce and maintain Th1 and Th17 polarization were higher in CD compared to NCGS and GT-FD cases; and higher in NCGS compared to GT-FD. Similar differences in the expression of IL-4 and TGF- β1 were detected, while IL-10-expressing cells were lower in NCGS patients compared to CD and GT-FD subjects. Conclusions NCGS patients exhibit components of both, innate and adaptive immune mechanisms but to a lesser extent compared to CD. The clinical characteristics and HLA status of our NCGS group resemble that described in subjects with irritable bowel syndrome sensible to gluten and probably represents a distinct phenotype of this syndrome.
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