An overview of intermittent inotropic therapy for severe congestive heart failure.

Congestive heart failure (CHF) is a major problem in the field of medicine in the U.S. Over 4 million people in the U.S. have CHF with 400,000 new cases per year. This diagnosis creates 6 million hospital days with a Medicare cost of billions of dollars. There are limited options for patients >65 years of age who have resistant heart failure on maximum medical therapy. There is considerable debate surrounding intermittent inotropic therapy. This paper is a review of the literature regarding this form of therapy; 20 studies are described. All but one of these studies disclose beneficial effects. The major criticism of these studies is that they are small and not randomized or placebo controlled. Larger well controlled studies are needed to determine the effect and safety of this treatment. Researchers must develop and evaluate all forms of therapy fairly to help decrease hospitalizations, decrease mortality, and improve quality of life.

Value of reversed saphenous vein in minimally invasive direct coronary artery bypass graft procedures.

BACKGROUND: Minimally invasive direct coronary artery bypass graft procedures are gaining acceptance for revision as well as primary coronary revascularization. When suitable, the left and right internal mammary arteries are preferred as bypass conduits; in other cases, the greater saphenous vein, used for standard coronary artery bypass graft procedures, may be useful to revascularize coronary artery branches during minimally invasive direct coronary artery bypass graft procedures. METHODS: We used the greater saphenous vein on three occasions during minimally invasive direct coronary artery bypass graft procedures (1) to revascularize the left anterior descending coronary artery by anastomosis to the left axillary artery in the infraclavicular region, (2) as an extension to the left internal mammary artery to reach the left anterior descending coronary artery, and (3) as a bridge from the splenic artery to bypass the distal right coronary artery. RESULTS: Postoperatively, all 3 patients had relief from symptoms of coronary artery insufficiency and none has been readmitted to the hospital with symptoms. Angiography or thallium studies were not performed to confirm graft patency because all patients were elderly and the risks of these procedures were considered to outweigh their potential benefit. CONCLUSIONS: The greater saphenous vein is a potential bypass conduit for use in minimally invasive direct coronary artery bypass graft procedures as well as for coronary artery bypass graft procedures.

Gastric electrical dysrhythmias and delayed gastric emptying in gastroesophageal reflux disease.

OBJECTIVE: Deranged gastric motility and delayed gastric emptying are commonly implicated in the pathophysiology of gastroesophageal reflux disease. We measured gastric electrical activity and gastric emptying time of a solid-liquid meal by electrogastrography and antral ultrasound, respectively, in 42 patients with gastroesophageal reflux disease (age 7.4 +/- 1.6 yr). METHODS: Based on endoscopy and histology of the esophageal mucosa, reflux disease was moderate in 20 patients and severe in 22. Electrogastrography was measured by placing two Ag-AgCl electrodes on the epigastric skin, signals were digitized and fed into a personal computer, and data were obtained by running spectrum analysis. The electrogastrographic variables calculated were: 1) percent of electrical dysrhythmias and normal electrical rhythm (bradygastria or 0.5-2.0 cycles/min, tachygastria or 4.0-9.0 cycles/min; normal rhythm is 2.0-4.0 cycles/min); 2) fed:fasting ratio of dominant electrogastrographic power; 3) fed:fasting ratio of the dominant frequency instability coefficient. Gastric emptying time and electrical activity results were compared with those measured in 15 controls (7.1 +/- 1.7 yr). RESULTS: Dysrhythmic episodes were more common in both groups of patients than in controls (p < 0.01); furthermore, gastric emptying time was significantly more delayed in patients than in controls (p < 0.01). Children with severe gastroesophageal reflux were distinguished from those with moderate disease for post-feeding gastric electrical abnormalities consisting of reduced electrogastrographic dominant power and increased frequency variability (p < 0.01), as well as for a more prolonged gastric emptying time (p < 0.05). Prevalence of both normal electrical rhythm and dysrhythmias did not discriminate the two groups of patients. In patients and in controls, a significant inverse correlation between fed electrogastrographic power and gastric emptying time was found (r -0.88, p < 0.01). CONCLUSIONS: Fed gastric electrical abnormalities consisting of reduced dominant power and increased variability of the electrical dominant frequency are detected in patients with severe gastroesophageal reflux disease and are associated with delayed gastric emptying. Gastric electrical dysrhythmias may be included among the pathogenetic components of gastroesophageal reflux disease.

Antroduodenal motor effects of intravenous erythromycin in children with abnormalities of gastrointestinal motility.

BACKGROUND: The macrolide antibiotic erythromycin (EM) affects gastrointestinal motor activity by acting as agonist of motilin receptors located on the smooth muscle cells of the gastroduodenal tract. We studied the effect of intravenous EM on fasting antroduodenal motility in controls and children with gastrointestinal dysmotility. METHODS: EM lactobionate (rate, 3.0 mg/kg/h) was infused intravenously while antroduodenal manometry was recorded in 10 controls, in 7 patients with functional dyspepsia and in 6 patients with gut pseudo-obstruction. The mean (SD) age (years) was 5.7 (1.4), 6.5 (2.4), and 6.7 (3.2), respectively. Manometry was performed by means of a four- or six-lumen catheter introduced through the nose and perfused with a low compliance pneumohydraulic system. Five controls received EM and five received saline. RESULTS: EM, infused 5 minutes after passage of an activity front (AF), induced in controls a premature antroduodenal AF occurring 15.4 +/- 3.2 minutes after starting infusion; no motor changes were seen after saline; duration and propagation velocity of EM-induced AFs did not differ from spontaneous AFs. In patients with functional dyspepsia EM induced various patterns such as premature antroduodenal AFs, antral phase III-like pattern with short duodenal bursts or prolonged phasic antral waves and no duodenal activity. In patients with neurogenic pseudo-obstruction rare or absent antral activity with incoordinated or absent duodenal activity was induced; no contractions were elicited in two patients with myogenic pseudo-obstruction. CONCLUSIONS: It is confirmed that EM, given at subtherapeutic doses, is a powerful prokinetic agent that can have clinical applications in patients with gastrointestinal dysmotility; however, the effect of the drug seems to be influenced by the nature of the underlying disorder.

Effects of omeprazole on mechanisms of gastroesophageal reflux in childhood.

Prolonged recordings of esophageal motility have shown that dynamic changes of lower esophageal sphincter (LES) pressure such as transient LES relaxation and LES pressure drifts are the most common mechanisms underlying gastroesophageal reflux (GER). The coexistence of a delayed gastric emptying has also been reported in a high proportion of patients with reflux disease. However, not much information is available on the effects of antireflux therapy on the pathogenetic mechanisms of GER. The purpose of this study was to determine in a group of children with severe reflux disease the effect of omeprazole therapy on motor changes of LES underlying GER as well as on gastric emptying time. Twenty-two children (median age: 6.6 years) with GER disease, refractory to combined ranitidine and cisapride administration, entered into an eight-week omeprazole course. Ten subjects with moderate GER disease served as controls (median age: 6.0 years). Before and after omeprazole administration, the following variables were assessed: esophagitis grading, fasting and fed simultaneous prolonged recording of distal esophageal sphincter pressure (with a sleeve catheter) and intraesophageal pH, LES and esophageal peristalsis amplitude, and gastric emptying time of a mixed solid-liquid meal (measured with gastric ultrasound). As compared to controls, patients showed a higher rate of transient LES relaxation and LES pressure drift (P < 0.01), a reduced amplitude of basal sphincter pressure (P < 0.01) and peristalsis (P < 0.05), and a more prolonged gastric emptying time (P < 0.05). After ending omeprazole, there was no significant change in any of the motor abnormalities of the esophagus and in gastric emptying time despite a marked improvement of symptoms and esophagitis in all patients. Sixteen patients were symptomatic when reevaluated on a clinical basis two months after ending therapy. We conclude that in children with severe GER disease, an abnormally high rate of both transient LES relaxation and LES pressure drift and slow gastric emptying are not affected by omperazole treatment, even though esophageal mucosal damage is markedly improved or cured. These abnormalities represent a primary motor disorder and can be implicated in the refractoriness of reflux disease.

Cardiac rehabilitation/exercise in patients with implantable cardioverter defibrillators.

There have been no specific exercise or daily activity guidelines determined for patients with automatic implantable cardioverter defibrillators. Two patients, one with a Ventritex Cadence Model V-100 defibrillator and one with a CPI Ventak Model 1550 defibrillator were enrolled in monitored cardiac rehabilitation. One patient had symptoms of syncope and cardiodefibrillation during a vigorous short walk prior to cardiac rehabilitation and became fearful of any activity. Stress testing on this patient was terminated early because his atrial fibrillation rate approached the defibrillization rate. A low dose of beta blockade was added to his regimen. He underwent repeat stress testing and was placed in cardiac rehabilitation. This patient had no further shocks, and it was assumed that his shock was due to high atrial fibrillation rates. The second patient experienced recurrent shocks on amiodarone, propafenone, and mexiletine with presyncope. However, stress testing did not disclose abnormalities. The patient was fearful of any activity and was placed in cardiac rehabilitation. During an average of 26 sessions of cardiac rehabilitation, no symptoms have been noted, and the patients have returned to a more normal lifestyle. Specific exercise and lifestyle criteria should be given to patients with cardioverter defibrillators. Stress testing with monitored exercise can develop such a program. Larger numbers of patients need to be studied.

Ultrasound measurement of gastric emptying time in patients with cystic fibrosis and effect of ranitidine on delayed gastric emptying.

Intestinal dysmotility is commonly reported in patients with cystic fibrosis (CF); however, gastric motor activity has rarely been investigated. We measured with real-time ultrasonography the antral distention and gastric emptying time of a solid-liquid meal in 29 patients with CF (age range, 5 to 17 years). A significantly prolonged gastric emptying time was present in 26 patients compared with 13 healthy control subjects (age range, 5 to 16 years); an exaggerated antral distention in the fed period was also detected. The patients with CF and delayed gastric emptying were randomly allocated to receive cisapride or ranitidine for 4 weeks. Twelve patients treated with ranitidine and 11 with cisapride completed the trial. There was a marked decrease in gastric emptying time, antral distention, and dyspeptic symptomatic score in patients receiving ranitidine but not in patients treated with cisapride. We conclude that gastric dysmotility is commonly detected in patients with CF and that H2 receptor blockers are more effective than prokinetics in improving dyspeptic symptoms and gastric emptying and distention.

Intraepithelial cells with irregular nuclear contours as a marker of esophagitis in children with gastroesophageal reflux disease.

The diagnostic usefulness of intraepithelial cells with irregular nuclear contours (CINC) (squiggle cells) in esophageal biopsies was investigated in 76 children (range age: 6 months-12 years) with gastroesophageal reflux disease. A further 20 subjects (range age: 10 months-11 years) served as controls. Based on the microscopic changes of the esophagus, according to traditional histological criteria, four groups of patients were identified; esophagitis was severe in 27, moderate in 20, mild in 21, and 8 patients had no clear-cut evidence of microscopic esophagitis. Data are given as mean +/- SD. Intraepithelial CINC had an immunohistochemical profile consistent with T lymphocytes. Patients with severe esophagitis had a CINC density (number per high-power filed) (9.0 +/- 3.5) significantly higher than patients with mild esophagitis (7.0 +/- 3.0) and those without evidence of microscopic esophagitis (6.5 +/- 1.9) (P < 0.05), but not different from those with moderate esophagitis (8.0 +/- 3.6); in all patients groups the CINC density was higher than in controls (2.2 +/- 0.3) (P < 0.01). The percentage of reflux at 24-hr intraesophageal pH monitoring was higher in severe esophagitis patients (11.4 +/- 6.0) as compared to the other groups (moderate: 7.8 +/- 6.3; mild: 6.5 +/- 3.6; no microscopic esophagitis: 6.3 +/- 2.0; P < 0.05). There was no correlation between CINC density and the amount of intraesophageal acid exposure in all patients. Furthermore, 27 of our patients had a normal intraesophageal acid exposure at the prolonged pH test (24-hr % of reflux < or = 4.5): the CINC density was significantly higher in them than in the controls.(ABSTRACT TRUNCATED AT 250 WORDS)

Upper gastrointestinal motor abnormalities in children with active celiac disease.

Although from the clinical point of view a GI motor disorder can be suspected in celiac disease, objective evidence for this is still lacking. We therefore conducted a study on children with active celiac disease to detect possible GI motor abnormalities in this disease. Fourteen children (age range, 1-13 years) were studied; they underwent fasting and fed manometric recordings in the gastroduodenojejunal area. Four patients were restudied after a 6-month gluten-free diet. Data were compared with those obtained in eight control children. As compared with controls, celiac disease patients showed a shorter duration of activity fronts (p < 0.01) and a significant (p < 0.01) reduction of the postprandial antral motility index; furthermore, > 90% of the patients displayed marked fasting and/or fed motor abnormalities, suggesting a neuropathic disorder. Interestingly, gut dysmotilities disappeared in the four subjects reassessed after the gluten-free diet. It is concluded that celiac disease frequently affects the motor behavior of the gut and that its effects may be reversed by appropriate diet.

Real-time ultrasound reveals gastric motor abnormalities in children investigated for dyspeptic symptoms.

Real-time ultrasonography (US) of the gastric antrum after ingestion of a mixed solid-liquid meal was performed in 60 patients (median age, 8.2 years; range, 3-17) being investigated for symptoms suggesting upper intestinal dysfunction (vomiting, regurgitation, abdominal pain, early satiety, and anorexia) and in 13 controls (median age, 5 years; range, 3-15). The diagnostic work-up allowed identification of 14 patients with esophagitis (group A) and 26 with Helicobacter pylori (HP) gastritis (group B); median age in group A was 9 years (range, 3-15) and in group B was 9.5 years (range, 3-17). Group A patients had significantly more prolonged gastric-emptying times (median, 180 min; range, 110-270) than did controls (median, 150 min; range, 110-180; p < 0.01); however, group A times were not significantly longer than those of group B patients (median, 160 min; range, 90-265). In the remaining 20 patients (group C; median age, 7.1 years; range, 3-15) without a specific diagnosis, markedly delayed gastric emptying was detected (median, 237 min; range, 165-270; p < 0.01 vs. group B patients and vs. controls; p < 0.05 vs. group A patients); in this group, GI manometry revealed findings of deranged motility of the gut. Distension of the antral area (percentage of increase vs. baseline values) 60 and 90 min after feeding was higher in group C (60 min: median, 185%; range, 70-614%; 90 min: median, 175%; range, 60-400%) than in both controls (60 min: median, 80%; range 26-148%; 90 min: median 90%; range 20-253%; p < 0.01) and HP patients (60 min: median, 120%; range, 35-311%; 90 min: median, 98%; range, 23-400%; p < 0.05); there was no significant difference versus esophagitis patients. The latter differed from controls only for the 60-min postfeeding antral distension (p < 0.01), whereas HP patients did not differ from controls. In group C patients, symptomatic dyspeptic score correlated with both 60- and 90-min fed antral distension (r = 0.61 and r = 0.64, respectively; p < 0.05), but no correlation was found with gastric-emptying time. In group A patients, histologic score of esophagitis correlated with 60-min postfeeding antral distension (r = 0.56; p < 0.05), whereas poor correlation was found with 90-min postfeeding antral distension and with gastric-emptying time. However, the latter significantly correlated with 90-min fed antral distension in esophagitis patients (r = 0.70; p < 0.01). We conclude that US imaging of the antral area of the stomach reveals abnormalities of gastric motility in most children referred for dyspeptic symptoms; this technique should be included among the investigative tools in the diagnostic approach to these patients.

Simultaneous prolonged recordings of proximal and distal intraesophageal pH in children with gastroesophageal reflux disease and respiratory symptoms.

OBJECTIVES: To characterize both proximal and distal esophageal acid exposure in children with gastroesophageal reflux-related respiratory disease and to investigate the usefulness of dual-channel intraesophageal pH monitoring in these patients. METHODS: Continuous simultaneous recording of distal and proximal esophageal pH was performed in 40 patients with gastroesophageal reflux disease and respiratory symptoms (wheezing, nocturnal cough, obstructive bronchitis) (age range 3-168 months) (group A), in 20 patients with reflux disease alone (age range 7-156 months) (group B), and in 14 controls (age range 5-108 months) (group C). RESULTS: (expressed as median +/- SD) 1) The two groups of patients did not differ with regard to distal and proximal esophageal acid exposure (percentage of reflux) during both the total recording period [distal, A: 9.2 +/- 4, B: 10.7 +/- 7 (NS), C: 1.9 +/- 1.0; and proximal, A: 4.8 +/- 3.3, B: 4.0 +/- 3.3 (NS), C: 1.0 +/- 0.7] and during nighttime [distal, A: 8.0 +/- 6.2, B: 10.4 +/- 6.1 (NS), C: 0.9 +/- 0.65; and proximal, A: 3.72 +/- 3, B: 3.6 +/- 3.0 (NS), C: 0.75 +/- 0.45]. 2) The two groups did not differ with regard to the ratio between proximal and distal esophageal acid exposure during both total and nocturnal periods of analysis. 3) No significant correlation was found between distal and proximal esophageal acid exposure during total and nocturnal recording periods. 4) In patients with reflux-related respiratory disease, the respiratory symptomatic index was significantly higher during distal esophageal acid exposure alone (47.0 +/- 28.6%) than during simultaneous reflux at the two esophageal levels (26.9 +/- 27%) (p < 0.05). Furthermore, reflux episodes associated with respiratory symptoms reached lower pH values than those in patients without symptoms at the two recording sites. CONCLUSIONS: Gastroesophageal reflux into the proximal esophagus does not discriminate between patients with reflux disease alone and those with reflux disease complicated by respiratory symptoms. Symptoms of asthma in reflux patients appear to be elicited more by a reflex mechanism than by aspiration of gastric refluxate into the airways. Intraesophageal acidification seems to be involved in eliciting respiratory symptoms related to reflux disease, and prolonged intraesophageal two-level pH measurement does not seem to be useful in the approach to patients with reflux disease associated with respiratory symptoms.

Gastric emptying and myoelectrical activity in children with nonulcer dyspepsia. Effect of cisapride.

We examined the effect of oral cisapride on gastric emptying time and myoelectrical activity using real-time ultrasonography and cutaneous electrogastrography in 10 children with nonulcer dyspepsia. A clear dominant frequency close to 3 cpm was present both at baseline and after eight weeks of cisapride. After cisapride, nine children had an increase in the normal slow wave percentage and the mean percentage of normal slow wave was significantly different (71.90 +/- 5.19% vs 79.16 +/- 5.54%; P < 0.01). Moreover, an increased stability of the dominant frequency, determined by computing the coefficient of variation before and after cisapride, was found (28.12 +/- 1.72% vs 23.61 +/- 3.47%; P < 0.01). At baseline the gastric emptying time, expressed as T1/2, was 139.76 +/- 40.04 min and at eight weeks 119.76 +/- 30.04 min (P = 0.06). As regards the relationship between EGG and gastric emptying, the proportion of children with improved normal slow wave percentage was similar to that with improved T1/2 emptying (Z = 0.57, P = 0.57). Thus, gastric electrical activity seems to be an important factor in the pathophysiology of nonulcer dyspepsia in children.

Antroduodenojejunal manometry in the diagnosis of chronic idiopathic intestinal pseudoobstruction in children.

We analyzed the antroduodenojejunal (ADJ) manometric patterns in a group of 19 consecutive children (mean age, 53 months; range, 5 months to 14 years) referred for suspected chronic idiopathic intestinal pseudoobstruction. Diagnosis was based on typical symptoms, absence of extraintestinal diseases, and structural lesions of the gut at endoscopy and radiology. Surgical full-thickness intestinal biopsies were evaluated in nine patients. Manometry of the stomach and small bowel was performed in the fasting and fed state with a multilumen perfused probe. All patients showed severe abnormalities of ADJ motor activity that were not seen in the eight controls (mean age, 38.2 months; range, 1-9 years). In 12 patients, manometric patterns suggesting neuropathic disease were detected with fasting and/or fed sustained and incoordinated duodenojejunal phasic waves, aberrant propagation and/or configuration of phase III of the inter-digestive motility complex, inability of a meal to convert a fasting into a fed pattern, and prolonged groups of fasting and fed nonpropagated phasic waves. In seven of these patients, histology revealed marked changes of the intrinsic neurons. In four cases, manometry disclosed features suggestive of a myogenic disease, including severe fasting and fed infrequent low-amplitude contractions, sometimes with some degree of propagation; in two of these cases, histology showed morphological abnormalities of smooth muscle cells of the gut wall. In three patients, manometry revealed signs suggestive of mechanical obstruction of the gut, such as repetitive post-feeding clusters and simultaneous repeated broad-based waves; in these patients, more detailed x-ray studies showed organic obstructive causes (ileal lymphoma, Hirschsprung's disease, and intestinal malrotation).(ABSTRACT TRUNCATED AT 250 WORDS)

Omeprazole and high dose ranitidine in the treatment of refractory reflux oesophagitis.

Thirty two consecutive patients (age range 6 months-13.4 years) with severe reflux oesophagitis were randomised to a therapeutic trial for eight weeks during which they received either standard doses of omeprazole (40 mg/day/1.73 m2 surface area) or high doses of ranitidine (20 mg/kg/day). Twenty five patients completed the trial (12 on omeprazole, 13 on ranitidine). At entry and at the end of the trial patients underwent symptomatic score assessment, endoscopic and histological evaluation of the oesophagus, and simultaneous oesophageal and gastric pH measurement; results are given as median (range). Both therapeutic regimens were effective in decreasing clinical score (omeprazole before 24.0 (15-33), after 9.0 (0-18); ranitidine before 19.5 (12-33), after 9.0 (6-12)), in improving the histological degree of oesophagitis (omeprazole before 8.0 (6-10), after 2.0 (0-60); ranitidine before 8.0 (8-10), after 2.0 (2-6), and in reducing oesophageal acid exposure, measured as minutes of reflux at 24 hour pH monitoring (omeprazole before 129.4 (84-217), after 44.6 (0.16-128); ranitidine before 207.3 (66-306), after 58.4 (32-128)) as well as intragastric acidity, measured as median intragastric pH (omeprazole before 2.1 (1.0-3.0), after 5.1 (2.2-7.4); ranitidine before 1.9 (1.6-4), after 3.4 (2.3-5.3)). Serum gastrin concentration was > 150 ng/l in four patients on omeprazole and in three patients on ranitidine. It is concluded that in children with refractory reflux oesophagitis high doses of ranitidine are comparable with omeprazole for the healing of oesophagitis and relief of symptoms; both drugs resulted in efficacious reduction of intragastric acidity and intra-oesophageal acid exposure.

Fasting and postprandial mechanisms of gastroesophageal reflux in children with gastroesophageal reflux disease.

In order to define the mechanisms of gastroesophageal reflux (GER) in children, we performed simultaneous intraluminal esophageal motility and pH studies in 24 children with symptomatic reflux and abnormal prolonged pH probe study, ten (group A) without endoscopic and histologic esophagitis, 14 (group B) with endoscopic and histologic esophagitis. Median (ranges) age (years) was 5.0 (6 months-10 years) and 3.0 (6 months-12 years), respectively. Recordings were done for 1 hr before and 1 hr after feeding apple juice (15 ml/kg; pH 4.0). All episodes of GER in group A patients and 77.1% in group B patients were accounted for by abrupt transient lower esophageal sphincter (LES) relaxation (TLESR); 22.9% of reflux events in group B patients occurred during gradual drifts of LES pressure (LESP) to undetectable levels. Esophageal refluxate exposure (mean percentage time with esophageal pH < 4.0), the rate of TLESR (number of episodes/hr), and the percentage of TLESRs associated with reflux significantly increased in the fed period both in group A (18.5 +/- 5.4%, 6.2 +/- 2.65, 87.1%) and in group B (29.7 +/- 6.5, 7.8 +/- 3.05, 84.9%) as compared to the fasting state (group A: 10.8 +/- 3.9, 3.9 +/- 3.17, 46.1%; group B: 16.1 +/- 2.6, 4.14 +/- 3.06, 55.17%) (p < 0.01). The rate of LESP drifts (number of episodes/hr) was also significantly higher postprandially (4.85 +/- 1.24 vs 1.8 +/- 0.9, p < 0.01); furthermore there was a postfeeding increase of the LESP drift percentage associated with reflux (79.41% vs 46.15%, p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Reversal of gastric electrical dysrhythmias by cisapride in children with functional dyspepsia. Report of three cases.

Three children (ages 5, 7.6, and 8 years), with recurrent unexplained upper abdominal symptoms such as vomiting, epigastric pain, anorexia, early satiety and without structural or mucosal abnormalities of gastrointestinal tract, underwent electrogastrography (EGG)--recording of gastric electrical activity using cutaneous electrodes positioned on the epigastric region and connected to a recording polygraph. Frequency of EGG signals was analyzed by fast Fourier transform. Significant changes of fasting and fed gastric myoelectrical activity (tachygastria, bradygastria, flatline pattern) were recorded in the three patients; furthermore, gastric emptying (GE) of a solid-liquid mixed meal, measured by ultrasonography, was significantly prolonged in them. A follow-up study was carried out after an eight-week course with oral cisapride: in all patients symptoms improved, GE time normalized, and EGG analysis showed normal electrical rhythm. It is suggested that gastric dysrhythmias can play a pathogenetic role in patients with functional gastrointestinal symptoms and that symptomatic improvement is accompanied by normalization of gastric electrical rhythm.

Electrogastrography in non-ulcer dyspepsia.

Fasting and fed gastric electrical activity was recorded by cutaneous electrodes (electrogastrography) in 14 children with unexplained recurrent symptoms of upper intestinal dysfunction, and in 10 controls. The unexplained symptoms included vomiting, epigastric pain, fullness, and early satiety. Mean (SD) age was 7.0 (3) and 7.5 (2) years, respectively. Gastric emptying time of a solid-liquid meal was also measured by real time ultrasonography in all subjects (patients and controls). In all patients radiography and endoscopy excluded structural and focal abnormalities of the gastrointestinal tract. Gastric emptying time was significantly more prolonged in patients than in controls. It was also found that there were appreciable irregularities of gastric electrical rhythm (tachygastria, bradygastria, flat line pattern, and mixed arrhythmia) in 12 fasting and 10 fed patients, whereas controls showed short and rare episodes of arrhythmia during both fasting and fed recording periods. The percentage distribution of the total electrogastrographic energy power across three frequency bands of electrical activity (low, normal, and high) showed that patients were different from controls both for reduced activity of normal frequency and for increased incidence of high and low abnormal frequencies. It is concluded that gastric electrical abnormalities are found in a high proportion of children with recurrent unexplained upper gastrointestinal symptoms. Electrogastrography can be a valuable tool in the assessment of these patients.

Disorders of oesophageal motility in children with psychomotor retardation and gastro-oesophageal reflux.

A group of 25 children affected by different degrees of psychomotor retardation (severe (n = 13); mild-moderate (n = 12)) and symptoms suggesting gastro-oesophageal reflux (GOR) underwent oesophageal manometry and oesophageal pH monitoring. Of these patients, 21 (84%) were affected by GOR. In all children with severe brain damage and GOR (12/13), oesophageal manometry showed marked motility abnormalities that persisted after cure of GOR. In patients with minor retardation and GOR (9/12), oesophageal manometry showed normal motility or a less severe degree of oesophageal motor dysfunction which improved after curing the GOR. These results suggest that oesophageal motor dysfunction is a frequent occurrence in children affected by severe psychomotor retardation and GOR.