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  1. Lee YY, Chua AS
    J Neurogastroenterol Motil, 2013 Jul;19(3):295-300.
    PMID: 23875095 DOI: 10.5056/jnm.2013.19.3.295
    Despite being a large ethnic group within the South-East Asia, there is a paucity of reported literatures on dyspepsia in the Malay population. Recent population-based studies indicate that uninvestigated dyspepsia, based on the Rome II criteria, is reported in 12.8% and 11.6% of Malays in the urban and rural communities respectively. Organic causes of dyspepsia including upper gastrointestinal tract cancers, its precancerous lesions, and erosive diseases are uncommon which is largely due to an exceptionally low prevalence of Helicobacter pylori infection in this population. On the other hand, functional dyspepsia and irritable bowel syndrome are relatively common in the Malays than expected. Within a primary care setting, functional dyspepsia, based on the Rome III criteria, is reported in 11.9% of Malays, of which epigastric pain syndrome is found to be more common. Married Malay females are more likely to have functional dyspepsia and psychosocial alarm symptoms. Also based on the Rome III criteria, irritable bowel syndrome, commonly overlapped with functional dyspepsia, is reported in 10.9% of Malays within a community-based setting. Rather than psychosocial symptoms, red flags are most likely to be reported among the Malays with irritable bowel syndrome despite having a low yield for organic diseases. Based upon the above observations, "proton pump inhibitor test" is probably preferable than the "test and treat H. pylori" strategy in the initial management of dyspepsia among the Malays.
  2. Lee YY, Chua AS
    J Neurogastroenterol Motil, 2012 Jul;18(3):239-45.
    PMID: 22837871 DOI: 10.5056/jnm.2012.18.3.239
    The diagnosis of functional dyspepsia (FD) is challenging since it depends largely on symptoms which are often heterogeneous and overlapping. This is particularly so in Asia with many different cultures and languages. Symptom-based diagnosis of FD based on Rome III criteria has not been fully validated and it may not be suitable in some Asian populations. Clinicians often assume that investigations in FD are not rewarding and physiological tests are often not available unless in the research setting. Investigation of alarm features and role of Helicobacter pylori in FD remain controversial but experts agreed that both should be tested. Physiological tests including gastric accommodation and chemical hypersensitivity tests are underutilized in Asia and available studies were few. While experts do not recommend routine clinical use of gastric accommodation tests but they agree that these tests can be advocated if clinically indicated. Empiric therapeutic trial is not currently a diagnostic option. The pathogenesis of FD is still poorly understood and there is a substantial placebo response. As a conclusion, a diagnosis of FD is challenging especially so in the context of Asia and despite the limitations of available physiological tests experts agreed that these tests can be advocated if and when clinically indicated.
  3. Mahadeva S, Yadav H, Everett SM, Goh KL
    J Neurogastroenterol Motil, 2012 Jan;18(1):43-57.
    PMID: 22323987 DOI: 10.5056/jnm.2012.18.1.43
    BACKGROUND/AIMS:
    The economic impact of dyspepsia in regions with a diverse healthcare system remains uncertain. This study aimed to estimate the costs of dyspepsia in a rural and urban population in Malaysia.

    METHODS:
    Economic evaluation was performed based on the cost-of-illness method. Resource utilization and quality of life data over a specific time frame, were collected to determine direct, indirect and intangible costs related to dyspepsia.

    RESULTS:
    The prevalences of dyspepsia in the rural (n = 2,000) and urban (n = 2,039) populations were 14.6% and 24.3% respectively. Differences in socioeconomic status and healthcare utilisation between both populations were considerable. The cost of dyspepsia per 1,000 population per year was estimated at USD14,816.10 and USD59,282.20 in the rural and urban populations respectively. The cost per quality adjusted life year for dyspepsia in rural and urban adults was USD16.30 and USD69.75, respectively.

    CONCLUSIONS:
    The economic impact of dyspepsia is greater in an urban compared to a rural setting. Differences in socioeconomic status and healthcare utilisation between populations are thought to contribute to this difference.

    KEYWORDS:
    Asia; Dyspepsia; Health; Population; Quality-adjusted life years
  4. Lee YY, Erdogan A, Rao SS
    J Neurogastroenterol Motil, 2014 Apr 30;20(2):265-70.
    PMID: 24840380 DOI: 10.5056/jnm.2014.20.2.265
    Assessment of transit through the gastrointestinal tract provides useful information regarding gut physiology and patho-physiology. Although several methods are available, each has distinct advantages and limitations. Recently, an ingestible wire-less motility capsule (WMC), similar to capsule video endoscopy, has become available that offers a less-invasive, standardized, radiation-free and office-based test. The capsule has 3 sensors for measurement of pH, pressure and temperature, and collec-tively the information provided by these sensors is used to measure gastric emptying time, small bowel transit time, colonic transit time and whole gut transit time. Current approved indications for the test include the evaluation of gastric emptying in gastroparesis, colonic transit in constipation and evaluation of generalised dysmotility. Rare capsule retention and malfunc-tion are known limitations and some patients may experience difficulty with swallowing the capsule. The use of WMC has been validated for the assessment of gastrointestinal transit. The normal range for transit time includes the following: gastric empty-ing (2-5 hours), small bowel transit (2-6 hours), colonic transit (10-59 hours) and whole gut transit (10-73 hours). Besides avoiding the use of multiple endoscopic, radiologic and functional gastrointestinal tests, WMC can provide new diagnoses, leads to a change in management decision and help to direct further focused work-ups in patients with suspected disordered motility. In conclusion, WMC represents a significant advance in the assessment of segmental and whole gut transit and mo-tility, and could prove to be an indispensable diagnostic tool for gastrointestinal physicians worldwide.
  5. Gwee KA, Bergmans P, Kim J, Coudsy B, Sim A, Chen M, et al.
    J Neurogastroenterol Motil, 2017 Apr 30;23(2):262-272.
    PMID: 27764907 DOI: 10.5056/jnm16095
    Background/Aims: There is a need for a simple and practical tool adapted for the diagnosis of chronic constipation (CC) in the Asian population. This study compared the Asian Neurogastroenterology and Motility Association (ANMA) CC tool and Rome III criteria for the diagnosis of CC in Asian subjects.
    Methods: This multicenter, cross-sectional study included subjects presenting at outpatient gastrointestinal clinics across Asia. Subjects with CC alert symptoms completed a combination Diagnosis Questionnaire to obtain a diagnosis based on 4 different diagnostic methods: self-defined, investigator's judgment, ANMA CC tool, and Rome III criteria. The primary endpoint was the level of agreement/disagreement between the ANMA CC diagnostic tool and Rome III criteria for the diagnosis of CC.
    Results: The primary analysis comprised of 449 subjects, 414 of whom had a positive diagnosis according to the ANMA CC tool. Rome III positive/ANMA positive and Rome III negative/ANMA negative diagnoses were reported in 76.8% and 7.8% of subjects, respectively, resulting in an overall percentage agreement of 84.6% between the 2 diagnostic methods. The overall percentage disagreement between these 2 diagnostic methods was 15.4%. A higher level of agreement was seen between the ANMA CC tool and self-defined (374 subjects [90.3%]) or investigator's judgment criteria (388 subjects [93.7%]) compared with the Rome III criteria.
    Conclusion: This study demonstrates that the ANMA CC tool can be a useful for Asian patients with CC.
    Study site in Malaysia: Gastroenterology clinic, University Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia
  6. Ata-Lawenko RM, Lee YY
    J Neurogastroenterol Motil, 2017 Apr 30;23(2):164-170.
    PMID: 28013295 DOI: 10.5056/jnm16171
    Gastrointestinal sphincters play a vital role in gut function and motility by separating the gut into functional segments. Traditionally, function of sphincters including the esophagogastric junction is studied using endoscopy and manometry. However, due to its dynamic biomechanical properties, data on distensibility and compliance may provide a more accurate representation of the sphincter function. The endolumenal functional lumen imaging probe (EndoFLIP) system uses a multi-detector impedance planimetry system to provide data on tissue distensibility and geometric changes in the sphincter as measured through resistance to volumetric distention with real-time images. With the advent of EndoFLIP studies, esophagogastric junction dysfunction and other disorders of the stomach and bowels may be better evaluated. It may be utilized as a tool in predicting effectiveness of endoscopic and surgical treatments as well as patient outcomes.
  7. Chuah KH, Mahadeva S
    J Neurogastroenterol Motil, 2018 Oct 01;24(4):536-543.
    PMID: 30153722 DOI: 10.5056/jnm18064
    Culture forms an integral aspect of environmental factors which influences disease presentation and clinical outcomes in functionalgastrointestinal disorders (FGIDs). In this review, the role of culture in FGIDs in the East is briefly explored with regards to symptompresentation and diagnostic issues, lifestyle and cultural habits, epidemiology, and healthcare seeking behavior. In both functionaldyspepsia and irritable bowel syndrome, symptom presentation and disease sub-typing in Asians are known to differ from their Western counterparts, possibly relating to cultural dietary practices and from cultural perception of symptoms. Dietary patterns, together with defecating practices are explored as factors contributing to a lower prevalence of constipation in the East. An urban-rural difference in the prevalence of FGIDs in Asia is attributed to a change in dietary patterns in rapidly developing urban communities, together with an increased level of psychological morbidity. Lastly, cultural attitudes towards traditional/local remedies, variation in healthcare systems, anxiety regarding organic disease, and religious practices have been shown to influence healthcare seeking behavior among FGID patients in the East.
  8. Lee YY, Erdogan A, Yu S, Dewitt A, Rao SSC
    J Neurogastroenterol Motil, 2018 Jul 30;24(3):460-468.
    PMID: 29879762 DOI: 10.5056/jnm17081
    Background/Aims: Whether high-resolution anorectal pressure topography (HRPT), having better fidelity and spatio-temporal resolution is comparable to waveform manometry (WM) in the diagnosis and characterization of defecatory disorders (DD) is not known.

    Methods: Patients with chronic constipation (Rome III) were evaluated for DD with HRPT and WM during bearing-down "on-bed" without inflated rectal balloon and "on-commode (toilet)" with 60-mL inflated rectal balloon. Eleven healthy volunteers were also evaluated.

    Results: Ninety-three of 117 screened participants (F/M = 77/16) were included. Balloon expulsion time was abnormal (> 60 seconds) in 56% (mean 214.4 seconds). A modest correlation between HRPT and WM was observed for sphincter length (R = 0.4) and likewise agreement between dyssynergic subtypes (κ = 0.4). During bearing down, 2 or more anal pressure-segments (distal and proximal) could be appreciated and their expansion measured with HRPT but not WM. In constipated vs healthy participants, the proximal segment was more expanded (2.0 cm vs 1.0 cm, P = 0.003) and of greater pressure (94.8 mmHg vs 54.0 mmHg, P = 0.010) during bearing down on-commode but not on-bed.

    Conclusions: Because of its better resolution, HRPT may identify more structural and functional abnormalities including puborectal dysfunction (proximal expansion) than WM. Bearing down on-commode with an inflated rectal balloon may provide additional dimension in characterizing DD.

  9. Gwee KA, Gonlachanvit S, Ghoshal UC, Chua ASB, Miwa H, Wu J, et al.
    J Neurogastroenterol Motil, 2019 Jul 01;25(3):343-362.
    PMID: 31327218 DOI: 10.5056/jnm19041
    Background/Aims: There has been major progress in our understanding of the irritable bowel syndrome (IBS), and novel treatment classes have emerged. The Rome IV guidelines were published in 2016 and together with the growing body of Asian data on IBS, we felt it is timely to update the Asian IBS Consensus.

    Methods: Key opinion leaders from Asian countries were organized into 4 teams to review 4 themes: symptoms and epidemiology, pathophysiology, diagnosis and investigations, and lifestyle modifications and treatments. The consensus development process was carried out by using a modified Delphi method.

    Results: Thirty-seven statements were developed. Asian data substantiate the current global viewpoint that IBS is a disorder of gut-brain interaction. Socio-cultural and environmental factors in Asia appear to influence the greater overlap between IBS and upper gastrointestinal symptoms. New classes of treatments comprising low fermentable oligo-, di-, monosacharides, and polyols diet, probiotics, non-absorbable antibiotics, and secretagogues have good evidence base for their efficacy.

    Conclusions: Our consensus is that all patients with functional gastrointestinal disorders should be evaluated comprehensively with a view to holistic management. Physicians should be encouraged to take a positive attitude to the treatment outcomes for IBS patients.

  10. Goh KL, Choi MG, Hsu PI, Chun HJ, Mahachai V, Kachintorn U, et al.
    J Neurogastroenterol Motil, 2016 Jul 30;22(3):355-66.
    PMID: 26932927 DOI: 10.5056/jnm15150
    Although gastroesophageal reflux disease is not as common in Asia as in western countries, the prevalence has increased substantially during the past decade. Gastroesophageal reflux disease is associated with considerable reductions in subjective well-being and work productivity, as well as increased healthcare use. Proton pump inhibitors (PPIs) are currently the most effective treatment for gastroesophageal reflux disease. However, there are limitations associated with these drugs in terms of partial and non-response. Dexlansoprazole is the first PPI with a dual delayed release formulation designed to provide 2 separate releases of medication to extend the duration of effective plasma drug concentration. Dexlansoprazole has been shown to be effective for healing of erosive esophagitis, and to improve subjective well-being by controlling 24-hour symptoms. Dexlansoprazole has also been shown to achieve good plasma concentration regardless of administration with food, providing flexible dosing. Studies in healthy volunteers showed no clinically important effects on exposure to the active metabolite of clopidogrel or clopidogrel-induced platelet inhibition, with no dose adjustment of clopidogrel necessary when coprescribed. This review discusses the role of the new generation PPI, dexlansoprazole, in the treatment of gastroesophageal reflux disease in Asia.
  11. Lawenko RM, Lee YY
    J Neurogastroenterol Motil, 2016 Jan 31;22(1):25-30.
    PMID: 26717929 DOI: 10.5056/jnm15151
    Gastroesophageal reflux disease (GERD) is a disease predominantly seen in the West but there is a rising trend in Asia. Ambulatory 24-hour catheter-based pH monitoring has been the de facto gold standard test for GERD that correlates symptoms with acid reflux episodes. However, drawbacks such as patients' discomfort, and catheter displacement render the test as cumbersome and error-prone. The Bravo pH wireless system is designed to be user-friendly and has an added advantage of prolonged pH monitoring. The system is comparable to the catheter-based pH monitoring system in terms of diagnostic yield and symptom-reflux association. Indications include evaluation of patients with refractory GERD symptoms and prior to anti-reflux surgery. Bravo utilizes a wireless pH-sensing capsule with a complete prepackaged system, and a data processing software. The capsule may be positioned indirectly using endoscopic or manometric landmarks or under direct endoscopic guidance. Optimal threshold cut-off values are yet to be standardized but based on available studies, for the Asian population, it may be recommended for total % time pH < 4 of 5.8 over 48 hours. Cost is a limitation but capsule placement is relatively safe although technical failures may be seen in small percentage of cases.
  12. Yaakob NS, Chinkwo KA, Chetty N, Coupar IM, Irving HR
    J Neurogastroenterol Motil, 2015 Jul 30;21(3):361-9.
    PMID: 26130632 DOI: 10.5056/jnm14157
    Several disorders of the gastrointestinal tract are associated with abnormal serotonin (5-HT) signaling or metabolism where the 5-HT3 and 5-HT4 receptors are clinically relevant. The aim was to examine the distribution of 5-HT3, 5-HT4, and 5-HT7 receptors in the normal human colon and how this is associated with receptor interacting chaperone 3, G protein coupled receptor kin-ases, and protein LIN-7 homologs to extend previous observations limited to the sigmoid colon or the upper intestine.
  13. Ghoshal UC, Gwee KA, Chen M, Gong XR, Pratap N, Hou X, et al.
    J Neurogastroenterol Motil, 2015 Jan 1;21(1):83-92.
    PMID: 25537673 DOI: 10.5056/jnm14045
    The development-processes by regional socio-cultural adaptation of an Enhanced Asian Rome III questionnaire (EAR3Q), a cultural adaptation of the Rome III diagnostic questionnaire (R3DQ), and its translation-validation in Asian languages are presented. As English is not the first language for most Asians, translation-validation of EAR3Q is essential. Hence, we aimed to culturally adapt the R3DQ to develop EAR3Q and linguistically validate it to show that the EAR3Q is able to allocate diagnosis according to Rome III criteria.
  14. Lee YY, Erdogan A, Rao SS
    J Neurogastroenterol Motil, 2014 Oct 30;20(4):547-52.
    PMID: 25230902 DOI: 10.5056/jnm14056
    Management of chronic constipation with refractory symptoms can be challenging. Although new drugs and behavioral treat-ments have improved outcome, when they fail, there is little guidance on what to do next. At this juncture, typically most doc-tors may refer for surgical intervention although total colectomy is associated with morbidity including complications such as recurrent bacterial overgrowth. Recently, colonic manometry with sensory/tone/compliance assessment with a barostat study has been shown to be useful. Technical challenges aside, adequate preparation, and appropriate equipment and knowledge of co-lonic physiology are keys for a successful procedure. The test itself appears to be safe with little complications. Currently, colon-ic manometry is usually performed with a 6-8 solid state or water-perfused sensor probe, although high-resolution fiber-optic colonic manometry with better spatiotemporal resolutions may become available in the near future. For a test that has evolved over 3 decades, normal physiology and abnormal findings for common phenotypes of chronic constipation, especially slow transit constipation, have been well characterized only recently largely through the advent of prolonged 24-hour ambulatory colonic manometry studies. Even though the test has been largely restricted to specialized laboratories at the moment, emerg-ing new technologies and indications may facilitate its wider use in the near future.(J Neurogastroenterol Motil 2014;20:547-552).
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