DESIGN AND SIMULATION

67 4.5.4 P.C.V OF DYSPEPTICS AND NON-DYSPEPTICS

Table 20 showing the P.C.V of dyspeptics and non-dyspeptics

P.C.V Dyspeptics Non-dyspeptics

ᵪ

≥ 30 % 159 (88.3%) 214 (97.3%) 12.57 0.0004

< 30 % 21 (11.7%) 6 (2.7%)

Total 180 (100%) 220 (100%)

Among the 400 participants that had their Packed Cell Volume result, 180 were dyspeptics while, 220 were not dyspeptic. Among the 180 that were dyspeptic, 159 (88.3%) were not anaemic while, 21 (11.7%) were anaemic. This difference was statistically significant ( P value < 0.05 ).

68 CHAPTER FIVE

DISCUSSION

The prevalence of dyspepsia in this study was found to be 44.7% with more females 119 (63.6%) being affected than males 68 (36.4%). This is in contrast to a prevalence of 26% obtained in a study by Holcombe in rural Northeastern Nigeria ³¹. The difference could be attributed to the fact that his study was a community based study that spanned over six months as against this hospital based study that spanned over two months. The higher prevalence in this study could also be accounted for by the poor security situation in the Niger Delta region and the financial stress encountered in an expensive town like Port Harcourt, which could predispose to stress which is a known cause of dyspepsia compared with the serene nature of a rural area where their own study was conducted. A prevalence of 45% was found in another study in Northern Nigeria³² higher than the prevalence in the study by Holcombe six months earlier in a similar environment³¹ but similar to the prevalence (44.7%) in this study. This could be explained by the fact that variation in the prevalence rates of dyspepsia has been partially related to difference in defining dyspepsia in the study population and also on the period of time patients are under surveillance⁴⁸.

69 In Italy, Cupella and co-workers noted a 61% prevalence of dyspepsia¹⁴⁶. However, their sample size of 102 was small compared to this study that had a sample size of 418.

The prevalence of Helicobacter pylori infection among dyspeptics in this study was found to be 40.7%. This is higher than the prevalence of 26.3% observed in a study at Abakaliki, South Eastern Nigeria¹⁴⁷. This shows that 59.3% of participants in this study were not infected with Helicobacter pylori and that symptoms of dyspepsia in these patients may not be ascribed to infection with the bacterium suggesting the involvement of other aetiological factors.

In this study, infection with Helicobacter pylori was assessed serologically. It is likely that the prevalence may be higher if biopsy based methods such as culture, histological examination, assays for urease activity and molecular typing by polymerase chain reaction (PCR) amplification methods for the identification of Helicobacter pylori specific genes had been used¹⁴⁸. Additionally, only a minority of patients infected with Helicobacter pylori will ever suffer serious consequences from their infection¹⁴⁹ and by extrapolation, represents those presenting with dyspepsia. Hence the value reported might be an underestimation of the actual prevalence in the general population. It has been found that the prevalence of peptic ulcer is higher in the general population and very much higher in patients with Helicobacter pylori infection than in those with Helicobacter pylori negative results. Also malignancy has been associated with Helicobacter pylori positivity¹⁴⁹, suggesting that 40.7% of patients in this study were at risk of ulcer diseases or malignancy. For dyspeptic patients without Helicobacter infections, gastric dysmotility, modification of gastric output or psychological factors may be responsible for the symptoms of dyspepsia.

HELICOBACTER PYLORI AS A RISK FACTOR OF DYSPEPSIA: Helicobacter pylori is a known risk factor of dyspepsia even though in this study, the association between it and dyspepsia was not statistically significant. This is not surprising since only 15% of infected people will

70 present with any form of disease. This compares with a study in Maiduguri, Northern Nigeria where Holcombe and Omotara in a serological survey of 268 patients noted that 85% of them had IgG antibodies to Helicobacter pylori and about a quarter of them had dyspepsia in the preceding six months¹⁵⁰. It could also be because in this study, serology was used to assess Helicobacter pylori infection which is not as sensitive and specific as urea breath test or Polymerase Chain Reaction( P.C.R) which has a sensitivity and specificity of 100%.

In a recent, randomized, placebo-controlled trial in a developed country, eradication of Helicobacter pylori infection proved successful in a subset of patients with dyspepsia⁹¹. However, these findings were not confirmed in another trial of similar design⁹².This disparity suggests either that the relationship between H. pylori and dyspepsia is weak or that dyspepsia is a heterogeneous disorder. A study done in the UK investigating the association of Helicobacter pylori infection with dyspepsia among 8047 subjects who were tested for Helicobacter pylori, showed that those who were infected had more dyspeptic symptoms [44%] than those who were Helicobacter pylori negative [36%]⁶². A cross-sectional study by Mc Coll, Morrison and Woodward showed an association between H. Pylori and dyspepsia⁹⁹. This association does not necessarily mean that H.

Pylori eradication will cure dyspepsia in the population. This trial of screening and treatment for H. Pylori in the community showed that 15% of dyspepsia in infected individual could be cured by eradication therapy. This clinical effect is small, and the causes of dyspepsia in the majority of individuals remain uncertain.

NON-STEROIDAL ANTI-INFLAMMATORY DRUGS: In this study, there was no significant statistical association between the ingestion of non-steroidal anti-inflammatory drugs and dyspepsia. This could be because the ingestion of non-steroidal anti-inflammatory drugs is commonest among the elderly who have different forms of joint diseases such as osteoarthritis,

71 spondylosis, low back pain e.t.c and in this study, only 5.3% of dyspeptics were above the age of 60 (Dyspepsia was commonest in the 21-30 years age group). This corroborates the study by Rosenstock and co-workers who expressed surprise in the absence of an association between the use of NSAIDS and dyspepsia.⁶¹ They also noted that the link between dyspepsia and NSAID consumption was most pronounced in the elderly patients who presented with bleeding gastric ulcers. In this study too, the use of non-steroidal anti-inflammatory drugs was also more in those that were older than 50 years. Possible explanation for their findings could be due to invalid data on the use of NSAID at study entry, or that the impact of NSAID could be less marked in the general population who primarily suffer from uncomplicated ulcers⁶¹.

ALCOHOL: In this study, there was a significant statistical association between ingestion of alcohol and dyspepsia. This corroborates a study by Moayyedi et al on the effect of population screening and treatment for Helicobacter pylori on dyspepsia and quality of life in the community, where they opined that alcohol consumption was an important risk factor for dyspepsia, but that their overall effect on dyspepsia was likely to be small²¹. Halder and co-workers in a study on the influence of alcohol consumption on dyspepsia also noticed that alcohol consumption was associated with dyspepsia¹³⁷. They felt this association was because of the effect of alcohol on the gut.

This association between alcohol and dyspepsia may be explained by the fact that alcohol may cause direct injury to the gastric mucosa and some patients may notice that their symptom gets worse with alcohol ingestion, so avoiding it where possible is sensible. Also, alcohol causes a transient relaxation of the lower oesophageal sphincter, causing a delay in gastric emptying and thereby causing epigastric pain¹⁶.

72 However, the fact that alcohol was associated with dyspepsia in this study is in contrast to a study by Wallander and co-workers on the risk factors of dyspepsia in general practice, where they showed that alcohol consumption were unlikely to have a major role in the development of dyspepsia¹¹⁹. Holtmann and coworkers in their study on the risk factors of dyspepsia also noted that the intake of alcohol decreased the risk of developing dyspepsia¹³⁵. The prevalence of alcohol ingestion in this study was 41.6% which could be due to the proliferation of drinking bars, fast food joints and eateries in Port Harcourt. It could also be because alcoholic drinks are brewed in the Niger Delta area due to the availability of raffia palms from which raw materials are obtained.

CIGARETTE SMOKING: In this study, there was no significant statistical association between cigarette smoking and dyspepsia. This could be as a result of the few number of smokers in the study population ( the prevalence of cigarette smoking in this study was 6.9% ). It could also be because patients with dyspepsia decrease their smoking rate since it is a risk factor for acidity and gastrointestinal pain. This corroborates the study by Wallander and co-workers who showed that lifestyle factors such as smoking and alcohol consumption were unlikely to have a major role in the development of dyspepsia¹¹⁹. However, in Denmark, Kay and Jorgensen in their study on the influence of sex, age, intake of coffee and smoking on dyspepsia found out that smoking decreased the risk of having dyspepsia¹³².

INGESTION OF COFFEE: In this study, there was a significant statistical association between the ingestion of coffee and dyspepsia. This compares with a study by Rosenstock and co-workers, where they noted that a high number of dyspepsia cases were reported in patients who consumed large amounts of coffee⁶¹. This could be because coffee and other caffeine-containing beverages are associated with hypersecretion and hyperacidity. Also coffee drinking is associated with

73 controlling stress. It is possible that people under stress (also a risk factor of dyspepsia) were taking coffee, hence the association with dyspepsia.

This in contrast to a study in Denmark, where Kay and Jørgensen noted that only psychiatric vulnerability and not the ingestion of coffee significantly increased the risk of dyspepsia¹³². SOCIO-ECONOMIC STATUS: In this study, even though there was no significant statistical association between dyspepsia and socio-economic status, dyspepsia was commonest among those with low socio-economic status. This corroborates a study by Shmuely et al in Nakuru, Kenya where they observed that low socio-economic level was associated with dyspepsia in adults¹³⁹. Ito et al also noted that length of education was inversely associated with the risk of dyspepsia¹⁴⁰. A Canadian survey revealed that dyspepsia was more prevalent in adults with low socio-economic class, those who were unemployed and with lower educational levels⁴⁰. This may be because Helicobacter pylori infection is associated with low socio-economic background and the infection is a high risk for dyspepsia. Also, people with low socio-economic background are not able to have three square meals making them prone to having “ hunger pains”.

PSYCHOLOGICAL ASSOCIATIONS: Psychological distress is an unpleasant subjective state that can take the form of being lonely, hopeless, stressed, worried, irritable and afraid. In this study, there was a significant statistical association between stress and dyspepsia. It also corroborates a Danish survey, where Kay and Jorgensen noted that dyspepsia was strongly associated with adults who had ‘experience of problems’ and ‘psychological vulnerability’¹³². Another survey in Hong Kong also revealed that subjects with dyspepsia had more anxiety, compared to adults with irritable bowel syndrome, which appeared to influence health-care seeking habits⁴³. In particular, the fear of a serious event orfatal disease and the occurrence of such diseases among relativesand friends have been found to be associated with healthcare seeking behaviour in patients with

74 dyspepsia¹³¹. In Denmark, Kay and Jørgensen found that psychiatricvulnerability and experience of problems significantly increased the risk of dyspepsia¹³². The fear of daily kidnapping, killings, gunshots and heavy military presence by the joint military task force at every nook and cranny in Port Harcourt may have contributed to an increased level of stress and this could be the reason why more dyspeptics had their pain worsened. Also the increased secretion of gastric acid during stressful conditions such as worry and fear could be the reason for the association noticed between stress and dyspepsia.

DIET: In this study, 55.1% of dyspeptics had various types of food that worsened their symptom.

The commonest was beans and peppery food. This may be because, beans, peppery food and other spices is associated with hypersecretion of gastric acid. The role of diet in dyspepsia has not been studied by many, probably due to the diversity of dietary habits within individual populations. In an urban survey in India, Shah, Bhatia and Mistry managed to demonstrate that no differences in dyspeptic symptoms occurred between vegetarians [29.1%] and meat-eaters [31.2%], whilst spicy, fried or food prepared outside the home contributed insignificantly to worsening of symptoms³⁷. In Nigerian adults living in the highlands, the type of staple food consumed was strongly associated with dyspepsia, but no specific definitions of food types were given³².

GENDER: In this study, although dyspepsia was commoner in females compared to males, this difference was not statistically significant. However, females are known to be more susceptible to some kind of health conditions than males because of hormonal influence. Several studies in different populations have noted a consistent female preponderance with dyspepsia,39,42,44,132. Shmuely et al in Nakuru, Kenya observed that female sex was associated with dyspepsia in adults¹³⁹. The study by Moayyedi however noted that more males had dyspepsia than females²¹.

75 AGE: Dyspepsia was commonest in the 21-30 years age group. This is similar to a study done in Nakuru, Kenya where dyspepsia was also commonest in the 21-30 years age group. This could be because of the limited healthcare resources seen in most African countries. However, it is in contrast to the study done in Northeastern Nigeria where the prevalence of dyspepsia increased with age³¹. Peak prevalence of dyspepsia has been noted between the ages 45-54 in a Canadian survey⁴⁰. In other populations, the prevalence of dyspepsia appeared to decrease with increasing age in Taiwanese⁴² and Danish¹³² surveys. In contrast, a survey in urban Mumbai, India found that dyspepsia was more prevalent in adults above 40 years³⁷. Despite these trends, age extremities have not been identified as a predictor of dyspepsia.

BODY MASS INDEX AND DYSPEPSIA: 48.1% of dyspeptics in this study were overweight, mildly obese, moderately obesed or morbidly obese. This compares to an Australian study by Talley and Jones where they noted that a high BMI was associated with dyspepsia¹¹⁵. However, this is in contrast to the study by Kay and Jørgensen in Denmark where they noted that a high BMI was not associated with dyspepsia¹³². Tack reported that impaired gastric accommodation to a meal was found in 40% of tertiary care dyspepsia patients, and this abnormality was associated with early satiety as well as substantive weight loss¹⁵¹. Subsequently, in a study of 720 patients with dyspepsia from the same referral center in Belgium, predominant early satiety or vomiting was noted to be linked to weight loss²⁷. However, it remains unknown if specific dyspepsia symptoms are associated with weight change in the general population. Weight loss should therefore be considered a warning symptom of dyspepsia.

FAECAL OCCULT BLOOD, PCV AND DYSPEPSIA: 62.8% of the dyspeptic patients in this study had positive faecal occult blood result even though most of them were not anaemic (88.3%).

This corroborates a study by Ugwuja and Ugwu in Abakaliki, Ebonyi state, Nigeria where 62.2%

76 of dyspeptic patients had positive faecal occult blood result¹⁵². The detection of gastrointestinal bleeding through faecal occult blood testing may have some implications for dyspeptic patients.

For example, faecal occult blood screening has been associated with reduction in colorectal cancer, possible reduction in cancer incidence through early detection and removal of colorectal adenomas¹⁵³. In primary health setting, early detection of internal bleeding through faecal occult blood testing might have important implications for early management decisions when patients first present with dyspepsia.

HYPERTENSION AND DYSPEPSIA: In this study, normal blood pressure was reported to be commoner in most dyspeptics. The relationship between cardiovascular system and dyspepsia has not been extensively studied and since no literature reviewed showed any correlation between hypertension and dyspepsia, hypertension is therefore not a co morbid condition of dyspepsia.

77 LIMITATIONS

The following limitations in the execution of this study are acknowledged.

1. The greatest limitation to this study was the paucity of local journals and literature on dyspepsia especially in outpatients in Nigeria. Majority of those seen were far older than ten years making them irrelevant to this study.

2. Oil company workers who are into private retainership arrangements with private clinics were not part of this study and they form a reasonable group of those passing through the stress of being kidnapped or their children being kidnapped because in Port Harcourt, it is mostly the oil company workers, their children or their parents that are the main targets. Hence the sample recruited may not be completely representative of Port Harcourt.

3. Inability to use urea breath test or Polymerase Chain Reaction to assess Helicobacter pylori infection that has a sensitivity and specificity of 100% and would have given better results, compared to serology that was used in this study.

4. Incomplete results by those patients that didn’t come back with their P.C.V and occult blood result could have affected the relationship P.C.V/ Occult blood and dyspepsia.

78 CONCLUSIONS

1. The prevalence of dyspepsia in the general out-patient department of the University of Port Harcourt Teaching Hospital was high. It was found to be 44.7%.

2. Dyspeptics in the general out-patient department of the University of Port Harcourt Teaching Hospital were characterized by female sex, who were stressed or worried, with a low socio-economic status and ingested NSAID’s. They also consumed alcohol, didn’t smoke cigarette, had a positive faecal occult blood result and were between the ages of 21-30 years.

3. The prevalence of Helicobacter pylori infection in the general out-patient department of the University of Port Harcourt Teaching Hospital was high. It was found to be 40.7%. It could have been higher if biopsy based methods such as culture, histological examination, assays for urease activity and molecular typing by polymerase chain reaction (PCR ) amplification methods for the identification of Helicobacter pylori specific genes had been used.

4. This study has confirmed that Uncomplicated dyspepsia was the commonest form of dyspepsia in the general out-patient department of the University of Port Harcourt Teaching Hospital within the period the study was conducted.

5. Most dyspeptics in this study had a positive faecal occult blood result and studies have shown that many diseases such as colon cancer, polyps, colitis, diverticulitis and other gastrointestinal problems can cause occult blood in stool (participants in this study were advised not to eat meat and vegetables for three days before going for stool occult blood test).

6. Most dyspeptics in this study had normal blood pressure implying that most dyspeptics in this study were not associated with hypertensive related diseases.

79 7. In this study, cigarette smoking, Helicobacter pylori infection, age and gender showed no significant statistical association with dyspepsia.

RECOMMENDATIONS

1. In primary care setting, faeacal occult blood testing is important because early detection of internal bleeding through faecal occult blood testing might have important implications for early management decisions when patients first present with dyspepsia.

2. Patients should be given a non-invasive test such as serology to establish their H. pylori status, and those found to be positive should have an eradication therapy while those who tested negative should have symptomatic treatment. Eradication therapy include the use of a proton pump inhibitor ( omeprazole 20mg twelve hourly ), amoxicillin capsules 1gm twelve hourly and metronidazole 400mg twelve hourly all for ten days to two weeks. Symptomatic treatment involves the use of antacids or a proton pump inhibitor alone.

3. In terms of Co-morbidities, further research is recommended into the relationship between dyspepsia and blood pressure.

4. Patients with dyspepsia should be asked about other physicalproblems, coexisting psychological symptoms, and stressful lifeevents, because these factors influence the severity of theillness and affect its management.

5. If careful history taking, physical examination, and screeninglaboratory tests in patients with dyspepsia do not lead to adiagnosis, it is recommended that patients who are older than 55 years, that are predisposed to early gastric cancer, or who have worrisome features should undergo endoscopy with biopsy for Helicobacter pylori. Other patients should undergo testing for Helicobacter pylori by serology. Patients who tested positive should be treated forH. pylori