RESUMO
Gastro-oesophageal reflux disease (GORD), a highly prevalent disease, is defined by troublesome symptoms and/or oesophageal lesions caused by reflux of gastric content. A diagnostic gold standard does not exist. A reliable diagnosis may be difficult in individual cases. Patients' history, endoscopic findings and pH-impedance monitoring contribute to the evaluation of gastro-oesophageal reflux and its consequences. High-resolution manometry may add important information on the pathophysiology of the disease and may help to rule out motility disorders as the leading cause of the symptoms. Proton pump inhibitors (PPI) are the drugs of first choice. In patients with insufficient PPI response, optimization of PPI therapy and/or combination with drugs having another mechanism of action are the available options. If PPIs are not sufficiently effective, not tolerated, or not wished antireflux procedures may be offered in specialized centers taking pathophysiological data into account.
Assuntos
Refluxo Gastroesofágico/tratamento farmacológico , Inibidores da Bomba de Prótons/uso terapêutico , Esofagite Péptica , Refluxo Gastroesofágico/diagnóstico , Humanos , ManometriaRESUMO
BACKGROUND: The symptoms of gastroesophageal reflux disease (GERD) are very common. Despite the fact that 40% of patients continue to suffer under conservative treatment, only approximately 1% of affected patients are operated on in Germany. Until recently, antireflux surgery was performed nearly exclusively in the form of a Nissen fundoplication or a Toupet hemifundoplication. These methods are still considered the gold standard. A new surgical minimally invasive procedure is described which treats reflux symptoms through electrical neuromodulation of the lower esophageal sphincter (LES). METHOD: An electrical neuromodulator for the LES (EndoStim®, EndoStim BV, Nijmegen, The Netherlands) is implanted into the abdominal wall as a pulse generator (IPG) and connected via an electrode cable to a pair of electrodes on the lower esophageal sphincter. In our own setting, patients are selected for this procedure after extensive functional diagnostics in the context of an interdisciplinary expert conference. The patient selection, patient education, required surgical training, surgical technique, postoperative phase as well as the results, complications and side effects are described. CONCLUSION: Electrical neuromodulation is a technique that successfully provides patients with GERD with control of their reflux symptoms. The technique requires interdisciplinary patient selection, comprehensive patient education, and comprehensive surgical training. The method is not free of postoperative problems. The electrical neuromodulation of the LES should therefore be used especially in centers with high expertise in reflux therapy.
Assuntos
Terapia por Estimulação Elétrica , Refluxo Gastroesofágico , Esfíncter Esofágico Inferior , Fundoplicatura , Refluxo Gastroesofágico/terapia , Alemanha , Humanos , Laparoscopia , Resultado do TratamentoRESUMO
BACKGROUND: Non-cardiac chest pain is very common and gastroenterological diseases are one of the most important causes. The frequency distribution of the underlying causes depends on the sector of the healthcare system in which it is ascertained. In individual cases it must always be taken into consideration that detection of coronary heart disease, for example, does not exclude another origin of chest pain. OBJECTIVE: This article provides a systematic review of gastroenterological diseases that can cause chest pain. Furthermore, a management algorithm was developed. MATERIAL AND METHODS: This article is based on a selective search of the literature. RESULTS AND DISCUSSION: The most frequent cause is gastroesophageal reflux disease, which is also known as reflux-chest pain syndrome. If there are no clinical alarm signals, treatment is carried out with a proton pump inhibitor either as a diagnostic test or as a probatory therapy. If this initial management does not lead to satisfactory symptom control, extended diagnostics are indicated. In individual cases this concerns the detection or exclusion of a reflux disease, of motility disorders and structural damage to the esophagus as well as diseases of the upper abdominal organs, which can evoke chest pain. After exclusion of these morphologically and/or functionally defined diseases, a so-called functional chest pain is present. The essential mechanisms are altered pain processing, esophageal hypersensitivity and mental comorbidities. The treatment of functional chest pain often proves to be difficult.
Assuntos
Dor no Peito/diagnóstico , Dor no Peito/prevenção & controle , Esofagite/diagnóstico , Esofagite/terapia , Refluxo Gastroesofágico/diagnóstico , Refluxo Gastroesofágico/terapia , Algoritmos , Dor no Peito/etiologia , Diagnóstico Diferencial , Esofagite/complicações , Medicina Baseada em Evidências , Refluxo Gastroesofágico/complicações , Humanos , Resultado do TratamentoRESUMO
Barrett's esophagus is an endoscopically visible metaplasia of the columnar epithelium in the esophagus with histological detection of a specialized intestinal metaplasia. The circumferential and longitudinal extent are described endoscopically using the Prague classification. Barrett's esophagus mostly occurs as the result of gastroesophageal reflux disease. The risk of developing esophageal adenocarcinoma is increased but the absolute risk is low with 0.10-0.15 % per year. According to guideline recommendations, screening for Barrett's esophagus as well as endoscopic and biopsy surveillance should be limited to high risk groups. On detection of intraepithelial neoplasia (IEN) endoscopic therapy is indicated, whereby a second opinion must be obtained from a specialized pathologist for low-grade IEN. The influence of proton pump inhibitors on the progression to carcinoma is controversially discussed and a preventive anti-reflux operation is not indicated.
Assuntos
Esôfago de Barrett/diagnóstico , Esôfago de Barrett/terapia , Esofagoscopia/métodos , Esofagoscopia/normas , Refluxo Gastroesofágico/diagnóstico , Refluxo Gastroesofágico/prevenção & controle , Esôfago de Barrett/complicações , Medicina Baseada em Evidências , Refluxo Gastroesofágico/etiologia , Alemanha , Humanos , Guias de Prática Clínica como Assunto , Resultado do TratamentoRESUMO
Purpose: The acceptance and realization of clinical guidelines in daily routine practice is unknown. The aim of this study was to evaluate the behaviour of private gastroenterologists in Germany with respect to the diagnostic and therapeutic management of H. pylori infection in times of increasing antibiotic resistance. Methods: Between 12/2014 and 02/2015 a standardized questionnaire with 19 multiple choice questions were sent to 1507 private gastroenterologists in Germany. The data were electronically captured and analyzed using SurveyMonkey. Results: The response rate was 36â% (540 questionnaires). 65â% of responders prescribe first line therapy by themselves and mainly use standard triple therapies. In patients with intolerance to penicillin, 81â% prescribe Italian triple therapy and 19â% prescribe bismuth quadruple therapy. Risk factors for primary clarithromycin resistance (migrational background, previous macrolide exposure) are routinely assessed by only a minority of responders (22â% and 17â%, respectively). Forty-one percent of responders perform eradication control by themselves mainly using a 13C urea breath test (54â%). In second line therapy, 42â% are prescribing bismuth quadruple therapy and 24â% fluoroquinolone triple therapy. After second line therapy, 58â% of responders are performing eradication control by themselves. Of those, 70â% always take biopsies for antibiotic susceptibility testing. Conclusions: The results of our survey suggest that most private gastroenterologists in Germany adhere to current guidelines for H. pylori management; however, some relevant deviations seem to exist. Our data might be useful for further developments of clinical guidelines and their communication among the medical community.
Assuntos
Antibacterianos/uso terapêutico , Gastroenterologistas/estatística & dados numéricos , Fidelidade a Diretrizes/estatística & dados numéricos , Infecções por Helicobacter/diagnóstico por imagem , Infecções por Helicobacter/tratamento farmacológico , Helicobacter pylori , Padrões de Prática Médica/estatística & dados numéricos , Adulto , Idoso , Feminino , Alemanha/epidemiologia , Pesquisas sobre Atenção à Saúde , Infecções por Helicobacter/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Prática Privada/estatística & dados numéricosAssuntos
Infecções por Helicobacter/diagnóstico por imagem , Infecções por Helicobacter/terapia , Helicobacter pylori , Úlcera Péptica/diagnóstico por imagem , Úlcera Péptica/terapia , Guias de Prática Clínica como Assunto , Medicina Baseada em Evidências , Gastroenterologia/normas , Alemanha , Infecções por Helicobacter/virologia , Humanos , Resultado do TratamentoRESUMO
For secondary prevention of acute coronary syndrome, guidelines recommend dual antiplatelet therapy with acetylsalicylic acid and a P2Y12 receptor antagonist such as clopidogrel, prasugrel or ticagrelor for a period of 12 months. Premature discontinuation of dual antiplatelet therapy is associated with an increased risk of ischaemic events. However, antiplatelet therapy is also associated with an increased risk of bleeding that should not be under- or overestimated. To ensure an optimal care of patients receiving dual antiplatelet therapy after an acute coronary syndrome, an interdisciplinary group of experienced experts in the fields of cardiology, cardiac surgery, gastroenterology, anaesthesiology, intensive care and haemostaseology gathered bleeding-related information and developed recommendations relevant to daily clinical practice. These include the significance of bleeding events in the course of treatment, measures for bleeding prevention and the adequate care of patients with bleedings.
Assuntos
Síndrome Coronariana Aguda/complicações , Síndrome Coronariana Aguda/tratamento farmacológico , Hemorragia/etiologia , Hemorragia/terapia , Inibidores da Agregação Plaquetária/administração & dosagem , Inibidores da Agregação Plaquetária/efeitos adversos , Aspirina/administração & dosagem , Aspirina/efeitos adversos , Medicina Baseada em Evidências , Humanos , Equipe de Assistência ao Paciente/organização & administração , Antagonistas do Receptor Purinérgico P2Y/administração & dosagem , Antagonistas do Receptor Purinérgico P2Y/efeitos adversos , Resultado do TratamentoRESUMO
In the line "bismuth-containing quadruple therapy" of Table 7 (p 342), in the column "dosage" incorrectly at the three antibiotics respectively 1-1-1-1. The correct is: 3-3-3-3.
RESUMO
BACKGROUND: More and more patients are being treated with direct oral anticoagulants (DOAC). Under treatment with DOACs gastrointestinal bleeding appears to occur more frequently, particularly in the lower gastrointestinal tract, compared to treatment with vitamin K antagonists (e.g. warfarin). OBJECTIVE: A possible approach should now be elaborated in a joint effort by gastroenterologists and cardiologists. MATERIAL AND METHODS: A selective literatue search was carried out and own experiences were also included. RESULTS: The decision to perform procoagulant therapy by slowly injecting 30-50 IU prothrombin complex concentrate (PPSB) per kg body weight intravenously depends on various factors and should be assessed critically. Specific antidotes are awaiting approval. After a bleeding episode potentially controllable and reversible triggers must be excluded (e.g. drug interactions and renal impairment). The risk of recurrent bleeding and the risk of thromboembolic events have to be weighed against each other before deciding to readminister an anticoagulant and its form. Dose reduction and changing to apixaban (in reduced dosage) are options for risk reduction and vitamin K antagonists can also be considered. DISCUSSION: It is still unclear what role specific antidotes will play.
Assuntos
Anticoagulantes/efeitos adversos , Anticoagulantes/uso terapêutico , Cuidados Críticos/métodos , Hemorragia Gastrointestinal/induzido quimicamente , Hemorragia Gastrointestinal/tratamento farmacológico , Protrombina/administração & dosagem , Administração Oral , Substituição de Medicamentos , Humanos , Injeções Intravenosas , Protrombina/efeitos adversos , Pirazóis/efeitos adversos , Pirazóis/uso terapêutico , Piridonas/efeitos adversos , Piridonas/uso terapêutico , Recidiva , Fatores de Risco , Tromboembolia/induzido quimicamente , Tromboembolia/prevenção & controle , Vitamina K/antagonistas & inibidoresRESUMO
BACKGROUND: Proton pump inhibitors (PPIs) are the treatment of choice for reflux esophagitis (RE). The effectiveness of PPIs throughout RE management, from healing to maintenance, has not been fully studied. AIM: To compare esomeprazole with lansoprazole or pantoprazole for RE management using a management model. METHODS: Data from six studies comparing esomeprazole with lansoprazole or pantoprazole for healing (4-8 weeks) or maintenance of healing (6 months) of RE were incorporated into hypothetical management models to determine the proportion of patients in endoscopic remission after sequential healing and maintenance therapy, assuming that patients received the same PPI throughout. The number needed to treat (NNT) to achieve one more patient in remission with esomeprazole vs. other PPIs was estimated. The hypothetical model was validated using results from the EXPO study, which compared esomeprazole with pantoprazole for RE healing and maintenance. RESULTS: Overall, esomeprazole 40 mg produced higher rates of healing (life-table estimates) than lansoprazole 30 mg (82.4-92.6% vs. 77.5-88.8%; p < 0.01) or pantoprazole 40 mg (95.5% vs. 92.0%; p < 0.001) and higher rates of endoscopic and symptomatic remission at 6 months than lansoprazole (83.0-84.8% vs. 74.0-75.9%; p < 0.001; life-table estimates) or pantoprazole (70.9% vs. 59.6%; p < 0.0001; observed rates). In the hypothetical management model, the NNT for esomeprazole was 9 vs. lansoprazole and 8 vs. pantoprazole. The actual NNT for esomeprazole vs. pantoprazole in the EXPO study was 9 (95% confidence interval: 6; 16). CONCLUSIONS: In this management model, esomeprazole was more effective than either lansoprazole or pantoprazole for maintaining remission after sequential healing and 6 months' maintenance therapy for RE.
Assuntos
Esomeprazol/administração & dosagem , Esofagite Péptica/tratamento farmacológico , Lansoprazol/administração & dosagem , Inibidores da Bomba de Prótons/administração & dosagem , Administração Oral , Relação Dose-Resposta a Droga , Método Duplo-Cego , Quimioterapia Combinada , Endoscopia Gastrointestinal , Esofagite Péptica/diagnóstico , Seguimentos , Humanos , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Because of the higher risk of bleeding, guidelines recommend cessation of clopidogrel seven days prior to high-risk endoscopic procedures. However, premature cessation of clopidogrel may lead to catastrophic cardiovascular sequelae due to stent thrombosis. We aimed to assess the current clinical practice among German gastroenterologists regarding endoscopic procedures in patients under clopidogrel/dual antiplatelet therapy. METHODS: A 10-item questionnaire on endoscopic procedures in patients under clopidogrel/dual antiplatelet therapy was sent by e-mail to all 220 members of the ALGK. RESULTS: 73 (33â%) chief gastroenterologists returned completed questionnaires, 35 (48â%) of whom conduct high-volume endoscopic units performing more than 4000 procedures per annum. 62 (85â%) endoscopic units perform endoscopic biopsies under clopidogrel alone, while just in 30 (41â%) departments biopsies are carried out under dual antiplatelet therapy. In 36 (49â%) GI-units endoscopic polypectomy under clopidogrel monotherapy is performed, in contrast to only 4 (5.5â%) in the case of combined antiplatelet therapy. However, in emergency situations more than 60â% of all participants do perform endoscopic sphincterotomy in patients under clopidogrel/dual antiplatelet therapy. Percutaneous endoscopic gastrostomy is carried out in 32 endoscopic units (44â%) under clopidogrel monotherapy, but only in 4 (5.5â%) under dual antiplatelet therapy. CONCLUSION: Current guidelines on endoscopic procedures in patients under clopidogrel/dual antiplatelet therapy are mainly based on expert opinion and therefore, backed by only weak evidence. Our survey shows that in this setting the clinical decision making takes place on an individual basis, as there are no data to support the recommendations of the present guidelines.
Assuntos
Endoscopia Gastrointestinal/estatística & dados numéricos , Endoscopia Gastrointestinal/normas , Pesquisas sobre Atenção à Saúde , Inibidores da Agregação Plaquetária/uso terapêutico , Guias de Prática Clínica como Assunto , Padrões de Prática Médica/estatística & dados numéricos , Ticlopidina/análogos & derivados , Clopidogrel , Gastroenterologia/normas , Alemanha , Fidelidade a Diretrizes/estatística & dados numéricos , Humanos , Padrões de Prática Médica/normas , Ticlopidina/uso terapêuticoRESUMO
BACKGROUND: Diverticular bleeding is the most common cause of acute severe lower gastrointestinal bleeding. Diagnostic and therapeutic approaches have not been standardized. OBJECTIVE: Development of an evidence-based management algorithm. MATERIALS AND METHODS: A systematic search of the literature (PubMed 1998-2013) was carried out and a review with consideration of current guidelines is given. RESULTS: The lifetime risk of clinically relevant bleeding is estimated to be 5 % in persons with colonic diverticula. Patients with clinically suspected diverticular hemorrhage should be admitted to hospital. Diverticular bleeding will cease spontaneously in around 70-90 % of the cases. In patients with severe lower gastrointestinal tract bleeding, defined as instability of the circulation, persistent bleeding after 24 h, drop of the hemoglobin level to ≥ 2 g/dl or the necessity for transfusion, endoscopy of the upper and lower gastrointestinal tract within the first 12-24 h is recommended. In patients with active diverticular bleeding or signs of recent hemorrhage (e.g. visible vessel or adherent clot) endoscopic therapy is strongly recommended because it significantly decreases the rate of early and late rebleeding. Angiography with superselective embolization is a therapeutic option in patients where endoscopy failed. Surgery should be considered in patients with ongoing bleeding and failure of interventional treatment and in patients who suffered from recurrent severe diverticular bleeding. CONCLUSIONS: Diverticulosis coli remains the most common cause of lower gastrointestinal bleeding. Colonoscopy is recommended as first-line diagnostic and therapeutic approach. In the vast majority of patients diverticular hemorrhage can be readily managed either conventionally or by interventional therapy.
Assuntos
Doença Diverticular do Colo/cirurgia , Hemorragia Gastrointestinal/cirurgia , Perfuração Intestinal/cirurgia , Algoritmos , Angiografia , Colo/irrigação sanguínea , Colonoscopia , Doença Diverticular do Colo/diagnóstico , Embolização Terapêutica , Medicina Baseada em Evidências , Hemorragia Gastrointestinal/diagnóstico , Alemanha , Hemoglobinometria , Humanos , Perfuração Intestinal/diagnóstico , Guias de Prática Clínica como Assunto , Recidiva , Remissão Espontânea , Falha de TratamentoAssuntos
Claritromicina/uso terapêutico , Infecções por Helicobacter/tratamento farmacológico , Infecções por Helicobacter/epidemiologia , Helicobacter pylori , Lesões Pré-Cancerosas/epidemiologia , Lesões Pré-Cancerosas/prevenção & controle , Neoplasias Gástricas/epidemiologia , Neoplasias Gástricas/prevenção & controle , Estudos Transversais , Quimioterapia Combinada , Humanos , Incidência , Programas de Rastreamento , Úlcera Gástrica/epidemiologia , Úlcera Gástrica/prevenção & controleAssuntos
Anti-Inflamatórios não Esteroides/efeitos adversos , Anti-Inflamatórios não Esteroides/uso terapêutico , Antiulcerosos/uso terapêutico , Aspirina/efeitos adversos , Aspirina/uso terapêutico , Infecções por Helicobacter/tratamento farmacológico , Helicobacter pylori/efeitos dos fármacos , Omeprazol/uso terapêutico , Úlcera Péptica Hemorrágica/induzido quimicamente , Úlcera Péptica Hemorrágica/prevenção & controle , Inibidores da Bomba de Prótons/uso terapêutico , Estudos de Coortes , Quimioterapia Combinada , Infecções por Helicobacter/complicações , Humanos , Assistência de Longa Duração , Estudos Prospectivos , Prevenção SecundáriaRESUMO
BACKGROUND: Gastrointestinal endoscopies are increasingly being carried out with sedation. All of the drugs used for sedation are associated with a certain risk of complications. Data currently available on sedation-associated morbidity and mortality rates are limited and in most cases have substantial methodological limitations. The aim of this study was to record severe sedation-associated complications in a large number of gastrointestinal endoscopies. METHODS: Data on severe sedation-associated complications were collected on a multicentre basis from prospectively recorded registries of complications in the participating hospitals (median documentation period 27 months, range 9 - 129 months). RESULTS: Data for 388,404 endoscopies from 15 departments were included in the study. Severe sedation-associated complications occurred in 57 patients (0.01 %). Forty-one percent of the complications and 50 % of all complications with a fatal outcome (10/20 patients) occurred during emergency endoscopies. In addition, it was found that 95 % of the complications and 100 % of all fatal complications affected patients in ASA class ≥ 3. CONCLUSIONS: Including nearly 400,000 endoscopies, this study represents the largest prospective, multicenter record of the complications of sedation worldwide. The analysis shows that sedation is carried out safely in gastrointestinal endoscopy. The morbidity and mortality rates are much lower than previously reported in the literature in similar groups of patients. Risk factors for the occurrence of serious complications include emergency examinations and patients in ASA class ≥ 3.
Assuntos
Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/mortalidade , Endoscopia Gastrointestinal/mortalidade , Hipnóticos e Sedativos/uso terapêutico , Sistema de Registros , Adulto , Idoso , Feminino , Alemanha/epidemiologia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Segurança do Paciente , Estudos Prospectivos , Fatores de Risco , Taxa de SobrevidaRESUMO
INTRODUCTION: After the S3 Guideline Sedation in Gastrointestinal Endoscopy was published, a training curriculum for a three-day course for endoscopy nurses was developed. The aim of this study was to investigate what effect the course participation had on the daily routine process and structure quality by implementing a German-wide survey in gastroenterology practices and clinics. METHODS: A questionnaire with a total of 44 individual questions on personnel, space, and equipment structure, sedation, peri- and post-interventional monitoring, as well as discharge and complication management in endoscopy departments was sent to a total of 2113 course participants (1056 Institutions). They had completed the seminar between December 2008/January 2009 and June 2010. RESULTS: The response rate was 21.2 % (224 /1056). Fifty-four percent were from clinic endoscopy departments, 46 % from practices. Overall, some form of structural change occurred in 86.8 % of the clinics and in 84.5 % of the practices. New staff was hired in 28.1 % of the clinics and 12.6 % of the practices. Rosters were changed in 11.6 % of the clinics and 7.8 % of the practices. Almost all issues improved after course participation. However, they did not reach statistic significance with the exception of the availability of peri-interventional ECG-monitoring in practices. The "performance of sedation in threesomes" increased in clinics by more than 20 % and in practices by more than 15 %. The use of the ASA-classification to assess risk increased significantly in clinics (before 24 %, after 50 %) as well as practices (before 40 %, after 60 %) by more than 20 % (p = 0.0007 and p = 0.0385, respectively). The documentation of the discharge status (e. g. using checklists) more than doubled in clinics (before 19 %, after 41.3 %) and practices (before 17.5 %, after 38.8 %) after course completion. CONCLUSION: The only nationwide endoscopy nurses' survey on structure and process quality in endoscopy so far, shows that since the publication of the S3 guideline in 2008 numerous processes and structures have improved with respect to patient safety.