Patient response to marketing minimally invasive surgery for heartburn.

BACKGROUND: Over 40% of Americans suffer from "heartburn" at least once a month. This and other manifestations of gastroesophageal reflux (GERD) are often treated with neglect by both patients and their primary care physicians. Diagnostic evaluation is all too often sought only in late stages of the disease. We studied the response to a media campaign promoting minimally invasive surgery as a cure for longstanding heartburn. METHODS: The information was publicized on 14 TV and six radio stations over 4 weeks. Patients were referred to an 800-number and data on the following topics were obtained using a standardized questionnaire: demographics, reflux symptoms, previous specialist referral, diagnostic evaluation and treatment, insurance information, and reasons for and expectations in calling. All questionnaires were screened for likelihood of GERD (high, medium, low). A return call was placed to triage patients (surgical or medical appointment, information only, no contact). RESULTS: We received calls from 1,389 potential patients. Based on symptoms, medical therapy, and previous evaluation, 891 (64%) were judged to likely have GERD and assigned high-priority status. Of the patients providing insurance information, 32% were enrolled in an HMO; 29% commercial; 16% Medicare; 14% employer based; and 9% had no insurance. Six hundred ninety-eight high-priority patients were contacted. Of these, 402 (58%) wanted information only; 228 (33%) desired surgical and 68 (%) medical appointments. Two hundred fifteen patients (16% of callers) were seen by a surgical or medical consultant. One hundred thirty-five underwent diagnostic studies, of which 77 (57%) had pathologic esophageal acid exposure. Eighty-three patients have undergone surgery to date-60 laparoscopic and 14 open antireflux procedures; nine had other surgical procedures. CONCLUSIONS: Surprisingly, 64% of patients responding to a marketing campaign for heartburn have typical symptoms of GERD, have consulted one or more physicians and/or received medical treatment. More than half the patients tested (77/135) were found to have a positive 24-h pH study, and 78% (60/77) of these elected antireflux surgery to control their reflux symptoms.

Enflurane-associated hepatitis.

A 57-yr-old female with no previous history of liver disease was exposed to enflurane during three separate surgeries over a 12-mo period. After the second and third exposures, she developed systemic symptoms and abnormal liver tests similar to those seen in halothane hepatitis. A liver biopsy obtained after the third exposure was compatible with drug-induced hepatitis. This is the first reported case of enflurane-associated hepatitis.

Successful treatment of vigorous achalasia associated with gastric lymphoma.

A 61-year-old male was evaluated for dysphagia. Esophageal manometry revealed vigorous achalasia. Upper-gastrointestinal endoscopy revealed a probable gastric neoplasm which was confirmed at laparotomy. Histologically the tumor was a lymphoma. Antineoplastic therapy resuted in rapid and complete improvement in the patient's dysphagia. Repeat esophageal manometry was normal. It is concluded that: (1) patients presenting with achalasia or vigorous achalasia should be carefully evaluated for the presence of a gastric malignancy involving the gastric fundus and lower esophagus; (2) chemotherapy may produce a resolution of esophageal symptoms.

Cimetidine versus intensive antacid therapy for duodenal ulcer: a multicenter trial.

In a randomized double blind multicenter trial, patients treated with cimetidine (800 or 1200 mg daily) or an intensive regimen of Al-Mg antacid (210 ml daily) had similar rates of duodenal ulcer healing and pain relief. After 4 weeks of treatment, the proportion of patients with ulcer healing by endoscopy were: cimetidine (1200 mg), 21 of 33 (64 percent); cimetidine (800 mg), 19 of 32 (59 percent); and antacids, 15 of 29 (52 percent). These proportions did not differ significantly. Eighty per cent of cimetidine-treated patients became asymptomatic by week 4, as did 63 percent of antacid-treated patients (P greater than 0.1). No untoward effects were observed during cimetidine treatment. Twenty-seven per cent of antacid-treated patients reported diarrhea.

The clinical value of ascitic fluid culture and leukocyte count studies in alcoholic cirrhosis.

Because of the paucity of studies establishing the accepted leukocyte count is sterile ascites, less than 300 WBC per mm3 with 25% polymorphonuclear (PMN) leukocytes, peritoneal fluid WBC counts and bacterial cultures were studied in 63 consecutive hospitalized patients with alcoholic cirrhosis and ascities. In 58 culture-negative patients the ascitic fluid WBC count range was 28 to 1800 and 50% of counts were greater than 300 WBC per mm3. The percentage of PMN leukocytes ranged from 2 to 98%. Five patients with spontaneous bacterial peritonitis (SBP), proven by positive cultures, had an ascitic WBC count range of 300 to 6320 WBC per mm3 and a PMN leukocyte range of 20 to 76%. Physical findings did not allow clear separation of the two groups. Anaerobic organisms were not found. It is concluded: (1) differentiation of SBP from sterile ascities relies on prompt ascitic fluid bacteriology; (2) the improved survival of 40% of SBP patients in this study may be related to an increased awareness of the entity and early treatment.

Effect to gastric alkalinization on lower esophageal sphincter pressure and serum gastrin.

The purpose of this study was to measure the effect of alkaline intragastric pH on lower esophageal sphincter pressure (LESP) and on serum gastrin concentration in man. One hundred ten milliliters each of 0.1 N NaHCO3 and control solution were instilled into the stomach for 30 min in random order. Neither LESP nor serum gastrin were higher during the alkali instillation than during the control instillation. Individual subject's peak gastrin and peak LESP during the alkali period were not significantly higher than the corresponding basal values. We conclude that intragastric alkalinization did not increase total radioimmunoassayable serum gastrin concentration or LESP.

Comparative effects of metoclopramide and bethanechol on lower esophageal sphincter pressure in reflux patients.

The effects of oral metoclopramide, 10 and 20 mg, bethanechol, 25 mg, and placebo on lower esophageal sphincter pressure (LESP) were studied in 15 men with symptoms of gastroesophageal reflux and basal LESP less than 11 mm Hg. Each drug produced a significant increase in LESP when compared to placebo. Metoclopramide, 20 mg, produced a greater increase than either metoclopramide, 10 mg, or bethanechol, 25 mg. Serum gastrin concentrations were not altered by any of the drugs. Side effects were unremarkable. The LESP increasing effect of metoclopramide might be useful in treatment of gastro-esophageal reflux.