Dyspepsia: Difference between revisions
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==Classification== | ==Classification== | ||
Dyspepsia has been proposed to have symptomatic subgroups:<ref name="pmid8224642">{{cite journal |author=Talley NJ, Weaver AL, Tesmer DL, Zinsmeister AR |title=Lack of discriminant value of dyspepsia subgroups in patients referred for upper endoscopy |journal=Gastroenterology |volume=105 |issue=5 |pages=1378–86 |year=1993 |pmid=8224642 |doi=}}</ref> | Dyspepsia has been proposed to have symptomatic subgroups:<ref name="pmid11731396">{{cite journal |author=Talley NJ, Phung N, Kalantar JS |title=ABC of the upper gastrointestingal tract: Indigestion: When is it functional? |journal=BMJ |volume=323 |issue=7324 |pages=1294–7 |year=2001 |pmid=11731396 |doi=}}</ref><ref name="pmid8224642">{{cite journal |author=Talley NJ, Weaver AL, Tesmer DL, Zinsmeister AR |title=Lack of discriminant value of dyspepsia subgroups in patients referred for upper endoscopy |journal=Gastroenterology |volume=105 |issue=5 |pages=1378–86 |year=1993 |pmid=8224642 |doi=}}</ref> | ||
* ulcerlike | * ulcerlike | ||
* dysmotilitylike | * dysmotilitylike | ||
| Line 8: | Line 8: | ||
* nonspecific | * nonspecific | ||
However, there is not a strong correlation of symptom type and measures of abnormal motility or hypersensitivity.<ref name="pmid8224642"/><ref name="pmid16472585">{{cite journal |author=Karamanolis G, Caenepeel P, Arts J, Tack J |title=Association of the predominant symptom with clinical characteristics and pathophysiological mechanisms in functional dyspepsia |journal=Gastroenterology |volume=130 |issue=2 |pages=296–303 |year=2006 |pmid=16472585 |doi=10.1053/j.gastro.2005.10.019}}</ref> | However, there is not a strong correlation of symptom type and measures of abnormal motility or hypersensitivity.<ref name="pmid8224642"/><ref name="pmid16472585">{{cite journal |author=Karamanolis G, Caenepeel P, Arts J, Tack J |title=Association of the predominant symptom with clinical characteristics and pathophysiological mechanisms in functional dyspepsia |journal=Gastroenterology |volume=130 |issue=2 |pages=296–303 |year=2006 |pmid=16472585 |doi=10.1053/j.gastro.2005.10.019}}</ref> | ||
A '''cluster analysis''' identified 4 groups:<ref name="pmid12671886">{{cite journal |author=Fischler B, Tack J, De Gucht V, ''et al'' |title=Heterogeneity of symptom pattern, psychosocial factors, and pathophysiological mechanisms in severe functional dyspepsia |journal=Gastroenterology |volume=124 |issue=4 |pages=903–10 |year=2003 |pmid=12671886 |doi=10.1053/gast.2003.50155}}</ref> | |||
* Factor 1 is "characterized by nausea, vomiting, early satiety, and weight loss" | |||
* Factor 2 by "postprandial fullness and bloating. Both factor 1 and 2 are associated with delayed emptying, but only factor 1 is associated with younger age, female sex, and sickness behavior". | |||
* Factor 3 is "characterized by pain symptoms and associated with gastric hypersensitivity and several psychosocial dimensions including medically unexplained symptoms and health-related quality of life dimensions". | |||
* Factor 4 is "characterized by belching, is also associated with hypersensitivity, but is unrelated to psychosocial dimensions." | |||
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====Possible causes of NUD==== | ====Possible causes of NUD==== | ||
The implied lack of organic disease may actually be incorrect as there may be physiological abnormalities that are too subtle for commonly used tests. For example, some patients may have gastric motor function or visceral sensitivity.<ref name="pmid16472585">{{cite journal |author=Karamanolis G, Caenepeel P, Arts J, Tack J |title=Association of the predominant symptom with clinical characteristics and pathophysiological mechanisms in functional dyspepsia |journal=Gastroenterology |volume=130 |issue=2 |pages=296–303 |year=2006 |pmid=16472585 |doi=10.1053/j.gastro.2005.10.019}}</ref> | The implied lack of organic disease may actually be incorrect as there may be physiological abnormalities that are too subtle for commonly used tests. For example, some patients may have gastric motor function or visceral sensitivity.<ref name="pmid16472585">{{cite journal |author=Karamanolis G, Caenepeel P, Arts J, Tack J |title=Association of the predominant symptom with clinical characteristics and pathophysiological mechanisms in functional dyspepsia |journal=Gastroenterology |volume=130 |issue=2 |pages=296–303 |year=2006 |pmid=16472585 |doi=10.1053/j.gastro.2005.10.019}}</ref><ref name="pmid12671886"/> | ||
Non-ulcer dyspepsia, when of acute onset, may be due to gastric dysmotor dysfunction following gastrointestinal infections.<ref name="pmid12055579">{{cite journal |author=Tack J, Demedts I, Dehondt G, ''et al'' |title=Clinical and pathophysiological characteristics of acute-onset functional dyspepsia |journal=Gastroenterology |volume=122 |issue=7 |pages=1738–47 |year=2002 |pmid=12055579 |doi=}}</ref> | Non-ulcer dyspepsia, when of acute onset, may be due to gastric dysmotor dysfunction following gastrointestinal infections.<ref name="pmid12055579">{{cite journal |author=Tack J, Demedts I, Dehondt G, ''et al'' |title=Clinical and pathophysiological characteristics of acute-onset functional dyspepsia |journal=Gastroenterology |volume=122 |issue=7 |pages=1738–47 |year=2002 |pmid=12055579 |doi=}}</ref> | ||
Revision as of 04:21, 12 October 2007
Dyspepsia (from the Greek "δυς-" (Dys-), meaning hard or difficult, and "πέψη" (Pepse), meaning digestion) is chronic or recurrent pain or discomfort centered in the upper abdomen [1] Discomfort, in this context, includes mild pain, upper abdominal fullness and feeling full earlier than expected with eating. It can be accompanied by bloating, belching, nausea or heartburn. It may be called indigestion. Heartburn is excluded from the definition of dyspesia in ICD 10, as it usually has a different cause and management pathway. When a patient has dyspepsia, but underlying disease is found, the patient is said to have non-ulcer dyspepsia or functional dyspepsia or idopathic dyspepsia.
Classification
Dyspepsia has been proposed to have symptomatic subgroups:[2][3]
- ulcerlike
- dysmotilitylike
- refluxlike
- nonspecific
However, there is not a strong correlation of symptom type and measures of abnormal motility or hypersensitivity.[3][4]
A cluster analysis identified 4 groups:[5]
- Factor 1 is "characterized by nausea, vomiting, early satiety, and weight loss"
- Factor 2 by "postprandial fullness and bloating. Both factor 1 and 2 are associated with delayed emptying, but only factor 1 is associated with younger age, female sex, and sickness behavior".
- Factor 3 is "characterized by pain symptoms and associated with gastric hypersensitivity and several psychosocial dimensions including medically unexplained symptoms and health-related quality of life dimensions".
- Factor 4 is "characterized by belching, is also associated with hypersensitivity, but is unrelated to psychosocial dimensions."
Cause/etiology
Several studies provide prevalences of underlying causes based on findings at esophagogastroduodenoscopy (EGD).[3][6][7]
| Patients referred to gastroenterologists for dyspesia[3] | Primary care patients with dyspepsia[6] | Volunteers without dyspepsia[7] | |
|---|---|---|---|
| Normal | |||
| Macroscopically normal by EGD |
60% | 54% | 66% |
| Histologically normal by biopsy at EGD |
35% | ||
| Esophagus | |||
| Macroscopic esophagitis by EGD |
14% | 12% | 22% |
| Hiatal hernia >2 cm by UGI | 40% | 26% | |
| Hiatal hernia by EGD | 3% | 3% | |
| Stomach/duodenum | |||
| Peptic ulcer disease (PUD) | 20% | 8% | 4% |
| Gastritis/duodenitis | 14% | 20% | 9-16% |
| Other | |||
| Malignancy | 3% | 0% | 0% |
Non-ulcer dyspepsia (NUD)
When organic disease is excluded by esophagogastroduodenoscopy and other tests, the patient is considered to have non-ulcer dyspepsia (NUD). This is also called functional dyspepsia.
Possible causes of NUD
The implied lack of organic disease may actually be incorrect as there may be physiological abnormalities that are too subtle for commonly used tests. For example, some patients may have gastric motor function or visceral sensitivity.[4][5]
Non-ulcer dyspepsia, when of acute onset, may be due to gastric dysmotor dysfunction following gastrointestinal infections.[8]
H. pylori
The role of H. pylori is not clear.
Association with other diseases
Psychiatric diagnoses
Psychiatric diagnoses are more prevalent among patients with normal endoscopies than abnormal endoscopies.[9]
Irritable bowel
There is much overlap among patients with non-ulcer dyspepsia and irritable bowel syndrome.[10]
Diagnosis
History and physical examination
The history and physical examination cannot reliably detect when organic disease underlies dypspepsia.[11]
Alarm features or red flags that may indicate serious underlying diseases are:[12]
- Age older than 55 years with new-onset dyspepsia
- Family history of upper gastrointestinal cancer
- Unintended weight loss
- Gastrointestinal bleeding
- Progressive dysphagia
- Odynophagia
- Unexplained iron-deficiency anemia
- Persistent vomiting
- Palpable mass or lymphadenopathy
- Jaundice
Although the value of these findings is hard to establish[13], one study found that the best predictions of abnormal investigations were:[14]
- History of an previous ulcer
- Age 50 or more
- Pain better with food or milk (presumably identifies duodenal pathology)
- Pain occurs < one hour after eating (presumably identifies gastric pathology)
Regarding gastric cancer, helpful findings are anemia and persistence of symptoms.[15]
Identifying a psychiatric disorder may reduce the chance than a serious organic disorder is present.[9]
On physical examination, pallor of conjunctiva, nail-bed or palmar crease, or the absence of nail-bed blanching are predictive of significant anemia (hemoglobin less than 12 gm/dl).[16]
Laboratory tests
Complete blood count
One study found that by using "H. pylori serology and a hemoglobin reading in the evaluation of dyspeptic patients under 45 years of age, the need for endoscopy can be reduced by 55%."[17]
In adults, 60% of patients with iron deficiency anemia may have underlying gastrointestinal disorders leading to chronic blood loss.[18]
H. pylori testing
Clinical practice guidelines by the American Gastroenterological Association state "H. pylori testing is optimally performed by a 13C-urea breath test or stool antigen test."[19]
Several studies indicate the need to test dyspeptic patients for H. pylori.[17][20][21][22] One study found that by using "H. pylori serology and a hemoglobin reading in the evaluation of dyspeptic patients under 45 years of age, the need for endoscopy can be reduced by 55%."[17]
The accuracy of the breath test for detecting peptic ulcer disease is:[23]
- sensitivity 93%
- specificity 60%
Although not as well studied, testing for H. pylori followed by endoscopy for positive tests may be reasonable.[24][25] This strategy allows identification of patients with GERD and also may reduce discontinuing antibiotics due to adverse drug reactions.[26]
For patients with negative H. pylori testing, endoscopy is not needed if they are less than 45 years old and without alarm symptoms.[27]
Radiology
UGI as historic significance as good before EGD.[28]
Esophagogastroduodenoscopy (EGD)
Direct visualization by esophagogastroduodenoscopy(EGD) is very sensitive, but may not detect all possible underlying causes of dyspepsia. For example, gastroesophageal reflux disease that does not cause macroscopic esophagitis will be missed by esophagogastroduodenoscopy.[29]
Treatment
In order to treat underlying peptic ulcer, clinical practice guidelines by the American Gastroenterological Association recommend:[19]
- "Patients 55 years of age or younger without alarm features should receive Helicobacter pylori test and treat followed by acid suppression if symptoms remain"
Regarding the treatment of non-ulcer dyspepsia, the value of simple reassurance is suggested by the response to placebo ranging from 40%[30] to 70%.[31]
Smaller meals
Acid suppression
A meta-analysis of randomized controlled trials by the Cochrane Collaboration concluded "there is evidence that anti-secretory therapy may be effective in NUD" with a number needed to treat for PPIs of 10.[32] Subsequent randomized controlled trials have had conflicting results reporting both benefit[33] and no benefit.[31]
Prokinetic drugs
Prokinetic drugs include:[34]
- Serotonin-3 (5-HT3) receptor agonists (cisapride, mosapride)
- Dopamine receptor antagonists (domperidone, metoclopramide, itopride)
- Opiate agonists (trimebutine). Trimebutine also has antiserotonergic activity.
The Cochrane Collaboration concluded "trials evaluating prokinetic therapy are difficult to interpret as the...[positive] result could have been due to publication bias.".[32] More recently, a randomized controlled trial of itopride found that 100 mg three times per day benefited 17% of patients (number needed to treat is 6).[30]
Tricylic antidepressants
A meta-analysis found that patients needed to be treated to improve 1 patient (number needed to treat is 3).[35]
Eradication of H. pylori
The Cochrane Collaboration concluded "small but statistically significant effect in ''H. pylori'' positive non-ulcer dyspepsia. The number needed to treat was 14. An economic model suggests this modest benefit may still be cost-effective but more research is needed."[36]
Psychological interventions
It is unclear if any form of psychological interventions is beneficial[37]
Prevention
Users of nonsteroidal anti-inflammatory (NSAID) medications
For patients starting long-term NSAIDs, screening for H. pylori with a breath test among patients with prior ulcer or dyspepsia and and treating positive patients reduced subsequent rate of ulcers.[38]
For patients who must take NSAIDs, proton pump inhibitors may be effective in preventing dyspepsia.[39]
Asymptomatic adults
Community screening for H. pylori may be beneficial.[40]
References
- ↑ N. Talley, et al., "Guidelines for the management of dyspepsia", American Journal of Gastroenterology 100 (2005), pp. 2324-2337.
- ↑ Talley NJ, Phung N, Kalantar JS (2001). "ABC of the upper gastrointestingal tract: Indigestion: When is it functional?". BMJ 323 (7324): 1294–7. PMID 11731396. [e]
- ↑ 3.0 3.1 3.2 3.3 Talley NJ, Weaver AL, Tesmer DL, Zinsmeister AR (1993). "Lack of discriminant value of dyspepsia subgroups in patients referred for upper endoscopy". Gastroenterology 105 (5): 1378–86. PMID 8224642. [e]
- ↑ 4.0 4.1 Karamanolis G, Caenepeel P, Arts J, Tack J (2006). "Association of the predominant symptom with clinical characteristics and pathophysiological mechanisms in functional dyspepsia". Gastroenterology 130 (2): 296–303. DOI:10.1053/j.gastro.2005.10.019. PMID 16472585. Research Blogging.
- ↑ 5.0 5.1 Fischler B, Tack J, De Gucht V, et al (2003). "Heterogeneity of symptom pattern, psychosocial factors, and pathophysiological mechanisms in severe functional dyspepsia". Gastroenterology 124 (4): 903–10. DOI:10.1053/gast.2003.50155. PMID 12671886. Research Blogging.
- ↑ 6.0 6.1 Williams B, Luckas M, Ellingham JH, Dain A, Wicks AC (1988). "Do young patients with dyspepsia need investigation?". Lancet 2 (8624): 1349–51. PMID 2904061. [e]
- ↑ 7.0 7.1 Johnsen R, Bernersen B, Straume B, Førde OH, Bostad L, Burhol PG (1991). "Prevalences of endoscopic and histological findings in subjects with and without dyspepsia". BMJ 302 (6779): 749–52. PMID 2021764. [e] Fulltext
- ↑ Tack J, Demedts I, Dehondt G, et al (2002). "Clinical and pathophysiological characteristics of acute-onset functional dyspepsia". Gastroenterology 122 (7): 1738–47. PMID 12055579. [e]
- ↑ 9.0 9.1 O'Malley PG, Wong PW, Kroenke K, Roy MJ, Wong RK (1998). "The value of screening for psychiatric disorders prior to upper endoscopy". Journal of psychosomatic research 44 (2): 279–87. PMID 9532557. [e]
- ↑ Agréus L, Svärdsudd K, Nyrén O, Tibblin G (1995). "Irritable bowel syndrome and dyspepsia in the general population: overlap and lack of stability over time". Gastroenterology 109 (3): 671–80. PMID 7657095. [e]
- ↑ Moayyedi P, Talley NJ, Fennerty MB, Vakil N (2006). "Can the clinical history distinguish between organic and functional dyspepsia?". JAMA 295 (13): 1566–76. DOI:10.1001/jama.295.13.1566. PMID 16595759. Research Blogging.
- ↑ Talley NJ, Vakil NB, Moayyedi P (2005). "American gastroenterological association technical review on the evaluation of dyspepsia". Gastroenterology 129 (5): 1756–80. DOI:10.1053/j.gastro.2005.09.020. PMID 16285971. Research Blogging.
- ↑ Hammer J, Eslick GD, Howell SC, Altiparmak E, Talley NJ (2004). "Diagnostic yield of alarm features in irritable bowel syndrome and functional dyspepsia". Gut 53 (5): 666–72. PMID 15082584. [e]
- ↑ Marton KI, Sox HC, Wasson J, Duisenberg CE (1980). "The clinical value of the upper gastrointestinal tract roentgenogram series". Arch. Intern. Med. 140 (2): 191–5. PMID 7352814. [e]
- ↑ Gillen D, McColl KE (1999). "Does concern about missing malignancy justify endoscopy in uncomplicated dyspepsia in patients aged less than 55?". Am. J. Gastroenterol. 94 (1): 75–9. PMID 9934734. [e]
- ↑ Nardone DA, Roth KM, Mazur DJ, McAfee JH (1990). "Usefulness of physical examination in detecting the presence or absence of anemia". Arch. Intern. Med. 150 (1): 201–4. PMID 2297289. [e]
- ↑ 17.0 17.1 17.2 Valle PC, Breckan RK, Amin A, et al (2006). ""Test, score and scope": a selection strategy for safe reduction of upper gastrointestinal endoscopies in young dyspeptic patients referred from primary care". Scand. J. Gastroenterol. 41 (2): 161–9. DOI:10.1080/00365520500286881. PMID 16484121. Research Blogging.
- ↑ Rockey D, Cello J (1993). "Evaluation of the gastrointestinal tract in patients with iron-deficiency anemia". N Engl J Med 329 (23): 1691-5. PMID 8179652.
- ↑ 19.0 19.1 Talley NJ (2005). "American Gastroenterological Association medical position statement: evaluation of dyspepsia". Gastroenterology 129 (5): 1753–5. DOI:10.1053/j.gastro.2005.09.019. PMID 16285970. Research Blogging. National Guideline Clearinghouse
- ↑ Jarbol DE, Kragstrup J, Stovring H, Havelund T, Schaffalitzky de Muckadell OB (2006). "Proton pump inhibitor or testing for Helicobacter pylori as the first step for patients presenting with dyspepsia? A cluster-randomized trial". Am. J. Gastroenterol. 101 (6): 1200–8. DOI:10.1111/j.1572-0241.2006.00673.x. PMID 16771937. Research Blogging.
- ↑ Arents NL, Thijs JC, van Zwet AA, et al (2003). "Approach to treatment of dyspepsia in primary care: a randomized trial comparing "test-and-treat" with prompt endoscopy". Arch. Intern. Med. 163 (13): 1606–12. DOI:10.1001/archinte.163.13.1606. PMID 12860586. Research Blogging.
- ↑ Shaw IS, Valori RM, Charlett A, McNulty CA (2006). "Limited impact on endoscopy demand from a primary care based 'test and treat' dyspepsia management strategy: the results of a randomised controlled trial". The British journal of general practice : the journal of the Royal College of General Practitioners 56 (526): 369–74. PMID 16638253. [e]
- ↑ McColl KE, el-Nujumi A, Murray L, et al (1997). "The Helicobacter pylori breath test: a surrogate marker for peptic ulcer disease in dyspeptic patients". Gut 40 (3): 302–6. PMID 9135516. [e]
- ↑ Delaney B, Ford AC, Forman D, Moayyedi P, Qume M (2005). "Initial management strategies for dyspepsia". Cochrane database of systematic reviews (Online) (4): CD001961. DOI:10.1002/14651858.CD001961.pub2. PMID 16235292. Research Blogging.
- ↑ Duggan AE. Unpublished. Data reconstructed from: Delaney B et al. Initial management strategies for dyspepsia (Cochrane Review). In The Cochrane Library, Issue 4, 2005. Oxford Update Software PMID 16235292 and from Duggan AE et al. BMJ 1999;319:1236 PMID 10550087
- ↑ Heaney A, Collins JS, Watson RG, McFarland RJ, Bamford KB, Tham TC (1999). "A prospective randomised trial of a "test and treat" policy versus endoscopy based management in young Helicobacter pylori positive patients with ulcer-like dyspepsia, referred to a hospital clinic". Gut 45 (2): 186–90. PMID 10403729. [e]
- ↑ Asante MA, Mendall M, Patel P, Ballam L, Northfield TC (1998). "A randomized trial of endoscopy vs no endoscopy in the management of seronegative Helicobacter pylori dyspepsia". European journal of gastroenterology & hepatology 10 (12): 983–9. PMID 9895042. [e]
- ↑ (1985) "Endoscopy in the evaluation of dyspepsia. Health and Public Policy Committee, American College of Physicians". Ann. Intern. Med. 102 (2): 266–9. PMID 3917639. [e]
- ↑ Tefera L, Fein M, Ritter MP, et al (1997). "Can the combination of symptoms and endoscopy confirm the presence of gastroesophageal reflux disease?". The American surgeon 63 (10): 933–6. PMID 9322676. [e]
- ↑ 30.0 30.1 Holtmann G, Talley NJ, Liebregts T, Adam B, Parow C (2006). "A placebo-controlled trial of itopride in functional dyspepsia". N. Engl. J. Med. 354 (8): 832–40. DOI:10.1056/NEJMoa052639. PMID 16495395. Research Blogging.
- ↑ 31.0 31.1 Leung WK, Wu JC, Chan FK, et al (2007). "Initial treatment with lansoprazole in young dyspeptic patients with negative urea breath test result: a randomized controlled trial with 12-month follow-up". Am. J. Gastroenterol. 102 (7): 1483–8. DOI:10.1111/j.1572-0241.2007.01229.x. PMID 17593161. Research Blogging.
- ↑ 32.0 32.1 Moayyedi P, Soo S, Deeks J, Delaney B, Innes M, Forman D (2006). "Pharmacological interventions for non-ulcer dyspepsia". Cochrane database of systematic reviews (Online) (4): CD001960. DOI:10.1002/14651858.CD001960.pub3. PMID 17054151. Research Blogging.
- ↑ van Zanten SV, Armstrong D, Chiba N, et al (2006). "Esomeprazole 40 mg once a day in patients with functional dyspepsia: the randomized, placebo-controlled "ENTER" trial". Am. J. Gastroenterol. 101 (9): 2096–106. DOI:10.1111/j.1572-0241.2006.00751.x. PMID 16817845. Research Blogging.
- ↑ Hiyama T, Yoshihara M, Matsuo K, et al (2007). "Treatment of functional dyspepsia with serotonin agonists: A meta-analysis of randomized controlled trials". J. Gastroenterol. Hepatol. 22 (10): 1566–70. DOI:10.1111/j.1440-1746.2006.04723.x. PMID 17845684. Research Blogging.
- ↑ Jackson JL, O'Malley PG, Tomkins G, Balden E, Santoro J, Kroenke K (2000). "Treatment of functional gastrointestinal disorders with antidepressant medications: a meta-analysis". Am. J. Med. 108 (1): 65–72. PMID 11059442. [e]
- ↑ Moayyedi P, Soo S, Deeks J, et al (2006). "Eradication of Helicobacter pylori for non-ulcer dyspepsia". Cochrane database of systematic reviews (Online) (2): CD002096. DOI:10.1002/14651858.CD002096.pub4. PMID 16625554. Research Blogging.
- ↑ Soo S, Moayyedi P, Deeks J, Delaney B, Lewis M, Forman D (2004). "Psychological interventions for non-ulcer dyspepsia". Cochrane database of systematic reviews (Online) (1): CD002301. DOI:10.1002/14651858.CD002301.pub2. PMID 14973988. Research Blogging.
- ↑ Chan FK, To KF, Wu JC, et al (2002). "Eradication of Helicobacter pylori and risk of peptic ulcers in patients starting long-term treatment with non-steroidal anti-inflammatory drugs: a randomised trial". Lancet 359 (9300): 9–13. PMID 11809180. [e]
- ↑ Spiegel BM, Farid M, Dulai GS, Gralnek IM, Kanwal F (2006). "Comparing rates of dyspepsia with Coxibs vs NSAID+PPI: a meta-analysis". Am. J. Med. 119 (5): 448.e27–36. DOI:10.1016/j.amjmed.2005.11.020. PMID 16651060. Research Blogging.
- ↑ Ford AC, Forman D, Bailey AG, Axon AT, Moayyedi P (2005). "A community screening program for Helicobacter pylori saves money: 10-year follow-up of a randomized controlled trial". Gastroenterology 129 (6): 1910–7. DOI:10.1053/j.gastro.2005.09.016. PMID 16344059. Research Blogging.