Esophageal motility patterns are altered in older adult patients. / Los patrones de motilidad esofágica están alterados en pacientes adultos mayores.

INTRODUCTION AND AIMS: Since the 1960s, several studies have shown the effect of aging on esophageal motility, with inconsistent results. The aim of the present study was to evaluate the manometric results in older adult patients (=60 years of age) with an esophageal disorder and compare them with adults under 60 years of age. MATERIALS AND METHODS: A cross-sectional, retrospective study was conducted that included a sample of 1,175 patients (936 older adults and 239 non-older adults). The patients were evaluated and compared with respect to (i) sex, (ii) main complaint for which esophageal manometry was indicated, (iii) comorbidities, (iv) current medications, (v) smoking, and (vi) manometry results. RESULTS: Patient age ranged from 19 to 92 years (women made up 76.5% of the older adults and 72.8% of the non-older adults). Normal lower esophageal sphincter relaxation and normal peristalsis were more frequent in the non-older patient group (91.1% vs. 84.8% and 87.4% vs. 76%, respectively). The manometry results for the non-older adults vs. the older adults, respectively, were: achalasia (2.9% vs. 5.9%); hypercontractile disorder (9.2% vs. 10.4%); hypocontractile disorder (38.5% vs. 47.6%); and normal values (49.4% vs. 36.1%). After excluding the variables that could change esophageal motility, the results revealed significant differences between the two study groups. CONCLUSIONS: Esophageal manometry demonstrated statistically significant differences between the older adult and non-older adult study population evaluated.

Randomised clinical trial: daily pantoprazole magnesium 40 mg vs. esomeprazole 40 mg for gastro-oesophageal reflux disease, assessed by endoscopy and symptoms.

BACKGROUND: Pantoprazole magnesium (pantoprazole-Mg) may display extended inhibition of the proton pump with the potential for improved clinical efficacy in gastro-oesophageal reflux disease (GERD). AIM: To compare the efficacy of pantoprazole-Mg and esomeprazole in GERD. METHODS: Gastro-oesophageal reflux disease (Los Angeles grades A-D) patients were randomised to 4 weeks of treatment with pantoprazole-Mg (n = 290) or esomeprazole (n = 288), both 40 mg once daily, in this multicentre (14 Brazilian sites in 9 cities), double-blind study, with an additional 4 weeks' treatment in nonresponding patients. Severity of oesophagitis (at endoscopy) and GERD-related symptoms (ReQuest-GI) were assessed. The primary end point was the proportion of patients in complete remission (ReQuest-GI score <1.73 plus endoscopic healing) at week 4. RESULTS: Complete remission occurred in 61% of patients in each treatment group at 4 weeks (primary endpoint) and in 81% and 79% of patients in the pantoprazole-Mg and esomeprazole groups at 8 weeks, with no significant differences. Mucosal healing rates were high and not significantly different. At 8 weeks, symptom relief with pantoprazole-Mg was significantly greater than that with esomeprazole (91.6% vs. 86.0%, P = 0.0370) because of continued improvement in symptoms with pantoprazole-Mg from week 4 to week 8 (P = 0.0206). CONCLUSIONS: Pantoprazole-Mg 40 mg was at least as effective as esomeprazole 40 mg for complete remission and the mucosal healing rate was high. Symptom relief with pantoprazole-Mg continued to improve from 4 to 8 weeks and was greater than that with esomeprazole at week 8, suggesting an extended period of treatment effect (ClinicalTrials.gov identifier: NCT01132638).

Low levels of adherence with proton pump inhibitor therapy contribute to therapeutic failure in gastroesophageal reflux disease.

To assess adherence to proton pump inhibitor (PPI) treatment and associated variables in patients with gastroesophageal reflux disease (GERD). Cross-sectional and prospective comprising 240 consecutive adult patients, diagnosed with GERD for whom continuous use of standard or double dose of omeprazole had been prescribed. Patients were ranked as ne-GERD (162: 67.5%) or e-GERD classified according to the Los Angeles classification as A (48:20.0%), B (21:8.6%), C (1:0.5%), D (1:0.5%), and Barrett's esophagus (7:2.9%). The Morisky questionnaire was applied to assess adherence to therapy and a GERD questionnaire to assess symptoms and their impact. Adherence was correlated with demographics, cotherapies, comorbidities, treatment duration, symptoms scores, endoscopic findings, and patient awareness of their disease. 126 patients (52.5%) exhibited high level of adherence and 114 (47.5%) low level. Youngers (P= 0.002) or married (O.R. 2.41, P= 0.03 vs. widowers) patients had lower levels of adherence; symptomatic patients exhibited lower adherence (P= 0.02). All other variables studied had no influence on adherence. Patients with GERD attending a tertiary referral hospital in São Paulo exhibited a high rate of low adherence to the prescribed PPI therapy that may play a role in the therapy failure. Age <60 years, marital status and being symptomatic were risk factors for low adherence.

Dietary habits, ethanol and tobacco consumption as predictive factors in the development of esophageal carcinoma in patients with head and neck neoplasms.

Patients with primary head and neck cancers have a higher risk of developing esophageal cancer. The aim of this study was to investigate esophageal cancer prevalence, its risk factors (ethanol and tobacco consumption) and dietary habits in patients with head and neck cancer. Three hundred and twenty-six adults with primary head and neck cancer were followed by a retrospective observational study in a general university hospital in Sao Paulo, Brazil. Flexible videoendoscopy with lugol chromoscopy was the method used to investigate esophageal cancer prevalence. All subjects were interviewed face-to-face, revealing detailed information about their tobacco and alcohol use, as well as their dietary habits. Thirty-six patients with esophageal cancer were diagnosed and the overall prevalence rate was 11.04%. Patients who developed second esophageal tumors had the following characteristics: earlier age of initial ethanol consumption (P < 0.05), longer duration period of ethanol consumption (P < 0.05) and higher weekly consumption rate (P < 0.05). There was an increased risk of esophageal carcinoma in those patients who both smoked and drank (P < 0.05). There was no association between carcinoma of the esophagus and dietary habits in patients who developed esophageal neoplasms, compared with those who did not. Prevalence rate of esophageal neoplasms was 11.04% in patients with head and neck carcinoma, whose ethanol consumption was associated with esophageal cancer. There was an increased risk between ethanol and tobacco consumption and esophageal carcinoma development. On the other hand, there was no association regarding dietary habits between patients who developed esophageal cancer and those who did not.

Reduction of abdominal pressure in patients with ascites reduces gastroesophageal reflux.

The effect of the reduction of intra-abdominal pressure on the lower esophageal sphincter pressure (LESP) and the 24-hour pH monitoring were studied in 16 patients with ascites before and after paracentesis. LESP did not change (P > 0.05) with the reduction of intra-abdominal pressure (before paracentesis: 17.48 mmHg and postparacentesis: 18.67 mmHg). The results were divided into two groups according to the achieved reduction in intra-abdominal pressure group A were those in who the reduction was greater than 70% and B consisted of those a reduction of less than 70%. LESP did not change even when results for each group were considered separately (P > 0.05): group A (before: 15.60 mmHg; after: 18.09 mmHg); group B (before: 23.09 mmHg; after: 20.40 mmHg). However the 24-h pH monitoring showed pathological reflux in patients with ascites that was reduced with the paracentesis (P < 0.05; total number of reflux episodes before paracentesis was 520.26, and after, 136.26). All pH-monitoring parameters were statistically different (P < 0.05) before and after the reduction of intra-abdominal pressure for group A but not for group B. LESP does not change significantly (P > 0.05) when the intra-abdominal pressure is significantly reduced (P < 0.05). Patients with ascites showed gastroesophageal reflux. Intra-abdominal pressure reduction greater than 70% lead to a significant reduction in gastroesophageal reflux.

Intrasphincteric botulinum toxin injection in the treatment of chagasic achalasia.

According to the WHO, 16-18 million people in Central and South America are infected by Trypanosoma cruzi. Chagasic achalasia affects between 7.1% and 10.6% of the population. The aim of this study was to evaluate the effects of Botox injections in the clinical response and esophageal function of patients with dysphagia due to chagasic achalasia. In total, 24 symptomatic patients with chagasic achalasia were randomly chosen to receive Botulinum Toxin (BT) or saline injected by endoscopy in the lower esophageal sphincter (LES). Patients were monitored with a clinical score of dysphagia and an objective assessment (esophagograms, scintillography, manometry, and nutritional assessment) for a period of 6 months. Clinical improvement of dysphagia was statistically significant (P < 0.001) in patients receiving BT when compared with the placebo. There was no significant difference in the placebo group regarding clinical score, LES basal pressure and esophageal emptying time. Esophageal emptying time in the toxin group was significantly lower than in the placebo (P=0.04) after 90 days. There were non-significant increases in esophageal emptying of 25.36% and 17.39%, respectively, at 90 and 180 days, in the BT group (P=0.266). Gender, age, and baseline LES pressure did not influence the response to BT. Our data strongly suggests that intrasphincteric injection of BT in LES is clinically effective in the treatment of chagasic achalasia.

Efficacy and tolerability of pantoprazole versus ranitidine in the treatment of reflux esophagitis and the influence of Helicobacter pylori infection on healing rate.

Patients with reflux esophagitis (grade II or III, Savary-Miller, intention-to-treat, n=256, age range 19-82 years) were randomly assigned to a double-blind, double-dummy treatment with either pantoprazole 40 mg once daily or ranitidine 150 mg twice daily. After 4 weeks, each patient was clinically and endoscopically assessed. Failure to heal required a further 4 weeks of treatment and a new evaluation thereafter. After 4 weeks, healing of lesions was confirmed in 63% (69 out of 109) of patients receiving pantoprazole and in 22% (25 out of 113) receiving ranitidine (P < 0.001, per protocol population). After 8 weeks, the cumulative healing rates were 88% and 46%, respectively (P < 0.001). Complete freedom from esophagitis-related symptoms (acid eructation, heartburn, pain while swallowing) was greater in the pantoprazole than in ranitidine group after 2 and 4 weeks (74% vs. 47%; 87% vs. 52%, respectively, P < 0.001). After 4 weeks, the healing rate was 76% in Helicobacter pylori (Hp)-positive vs. 45% in Hp-negative patients treated with pantoprazole (P < 0.01). The Hp status did not influence healing rates in patients treated with ranitidine. The most frequent adverse events in the pantoprazole group were diarrhea and somnolence (2-3% of patients), and in the ranitidine group, headache, diarrhea, dizziness, increase of liver enzymes and pruritus (2-4% of patients). In conclusion, pantoprazole was more effective than ranitidine in the healing rate and relief from reflux esophagitis-associated symptoms, and Hp infection was associated with higher healing rate during therapy with pantoprazole but not with ranitidine.

[Gastroesophageal reflux disease: comparison between patients with and without esophagitis, concerning age, gender and symptoms]. / Doença do refluxo gastroesofágico: comparação entre as formas com e sem esofagite, em relação aos dados demográficos e às manifestações sintomáticas.

BACKGROUND: Patients with gastroesophageal reflux disease may or may not have endoscopic esophagitis; there are few studies comparing these groups among themselves. OBJECTIVES: This study was designed in order to evaluate differences between patients with gastroesophageal reflux disease with and without esophagitis. PATIENTS/METHODS: A hundred and twenty-two patients with gastroesophageal reflux disease characterized by esophageal endoscopy and pHmetry were included, 90 with and 32 without esophagitis. Assessment involved an anamnesis, including the following data: age, sex, heartburn, dysphasia, non-cardiac chest pain and respiratory symptoms. Heartburn was analyzed in more detail, its duration, intensity and periodicity being determined. RESULTS: No statistical significant difference was observed between the groups, regarding age, sex or presence of symptoms. However, in the group with esophagitis, heartburn classified as severe or very severe was more frequent. CONCLUSIONS: 1. The groups of patients with or without esophagitis analyzed were very similar concerning age, gender and presence of symptoms. However, regarding the heartburn's intensity, it was more intense in the group with esophagitis. 2. Among patients with gastroesophageal reflux disease, there is a large number of cases without esophagitis (26.2%) and that prolonged pH-monitoring is fundamental in its identification; 3. A better definition of reflux disease, esophagitis and pathological reflux is needed, in order to allow better diagnostic accuracy and comparisons in different studies on this subject.

Randomized, double-blind trial comparing indinavir alone, zidovudine alone and indinavir plus zidovudine in antiretroviral therapy-naive HIV-infected individuals with CD4 cell counts between 50 and 250/mm3.

Treatment with indinavir has been shown to result in marked decreases in viral load and increases in CD4 cell counts in HIV-infected individuals. A randomized double-blind study to evaluate the efficacy of indinavir alone (800 mg q8h), zidovidine alone (200 mg q8h) or the combination was performed to evaluate progression to AIDS. 996 antiretroviral therapy-naive patients with CD4 cell counts of 50-250/mm3 were allocated to treatment. During the trial the protocol was amended to add lamivudine to the zidovudine-containing arms. The primary endpoint was time to development of an AIDS-defining illness or death. The study was terminated after a protocol-defined interim analysis demonstrated highly significant reductions in progression to a clinical event in the indinavir-containing arms, compared to the zidovudine arm (p<0. 0001). Over a median follow-up of 52 weeks (up to 99 weeks), percent reductions in hazards for the indinavir plus zidovudine and indinavir groups compared to the zidovudine group were 70% and 61%, respectively. Significant reductions in HIV RNA and increases in CD4 cell counts were also seen in the indinavir-containing groups compared to the zidovudine group. Improvement in both CD4 cell count and HIV RNA were associated with reduced risk of disease progression. All three regimens were generally well tolerated.

Manometric findings of esophageal motor disorders in 240 Brazilian patients with non-cardiac chest pain.

Two hundred and forty Brazilian patients with chest pain and normal cardiac evaluation were submitted to computerized esophageal manometry. Endoscopic examination and/or swallow barium studies had excluded obstructive lesions. Motor disorders were found in 63% of patients; non-specific motors disorders and hypotensive lower esophageal sphincter were the most common. The finding of nutcracker esophagus in only 6% of the patients is a quite different rate from what has been previously described in the literature. Esophagitis was observed at endoscopy in 13.4% of the patients, hiatus hernia in 19.7% and peptic gastric or duodenal ulcer in 4.9%. It should be emphasized that after excluding pain as being of cardiac origin an abnormal manometry result points to the esophagus as the probable site of origin of the pain; esophageal investigation is important for establishing proper treatment for these patients.

Achalasia: a prospective study comparing the results of dilatation and myotomy.

BACKGROUND/AIMS: In a prospective and randomized clinical study, the operative method and dilatation in the initial stage of megaesophagus were evaluated. METHODOLOGY: Forty patients in the initial stage of megaesophagus, managed by forced hydrostatic dilatation of the cardia (20 patients-DILAT Group) or by esophagocardiomyotomy associated with esophagofundopexy (20 patients-Group OP) were followed-up for three years, in terms of clinical, radiographic, endoscopic, manometric and pH monitoring. RESULTS: 1) Both procedures can be performed without significant morbidity or mortality. 2) The two procedures are similar regarding ongoing suppression of dysphagia. 3) Radiologically, the methods are equivalent, since they promote significant elimination of contrast stasis and maintenance of the esophageal diameter. 4) Endoscopic follow-up did not differentiate the procedures in terms of the development of reflux esophagitis, with a rate of only 5% for each group of patients. 5) Manometry demonstrated that surgery produced a significantly greater reduction of the LESP as compared to dilatation, although the latter also determined a marked drop in the maximum basal pressure of the LES. 6) Neither procedure altered the length of the LES. 7) With prolonged esophageal pH monitoring, dilatation demonstrated a greater propensity for reflux as compared to surgery. CONCLUSION: Both methods offer benefits in the treatment of the initial stage of megaesophagus, although esophageal pH monitoring indicates that dilatation provokes a greater index of esophageal acid exposition time.

The screening sensitivity of endoscopy, acid perfusion test and 24-hour pH-monitoring to evaluate esophagitis in patients with heartburn and histological esophagitis.

The sensitivity of endoscopic examinations, acid perfusion test and 24-hour esophageal pH-monitoring, were studied in patients with heartburn. Thirty six adult patients with histological esophagitis were included in this prospective study. Endoscopy showed esophageal lesion in 18/36 (sensitivity of 50%): esophagitis grade I in 10 (55.6%) and, grade II in eight (44.4%). Acid perfusion test was positive in 10/25 (sensitivity of 40%) of the patients submitted to the test. Twenty-four-hour pH-monitoring was positive in 17/29 patients (sensitivity of 58.6%): eight (61.5%) did not have esophageal lesion at endoscopy, two (25%) had esophagitis grade I and seven (87.5%) had esophagitis grade II. In the patients submitted to 24-hour pH-monitoring, a greater number or reflux episodes in orthostatic position than in supine position (P < 0.0001) was observed. The total number of reflux episodes, the most prolonged reflux and the total pH time < 4 were statistically higher in post-prandial period than during meals (P = 0.005).

The role of stress-related physical confinement in the pathogenesis of acute gastric hemorrhage after alcohol instillation in rats.

The combination of alcohol and stress have been considered producers of gastric hemorrhage both experimentally and in clinical observations. Since excessive alcohol intake often occurs in situations of severe emotional conflict and stress, it was decided to study the possible role of the latter in the etiology of gastric hemorrhage, up to now thought to be dependent only on alcohol. The study consists of 75 male Wistar rats divided into eight groups with seven to 14 animals each. They were submitted to fasting only, or to additional prolonged fasting, restraint-stress (physical confinement) for 17 hours and the oral administration of a single dose of 40% alcohol (1 ml/150 g of body weight). The stomachs were analyzed macroscopically and microscopically for the presence of gastric hemorrhage, and the following was observed; 1) only 10% of the rats submitted to a 25 hour fast either isolated or associated with 17 hours of physical confinement, demonstrated gastric hemorrhage; 2) after an eight hour fast, the administration of alcohol to the rats either sacrificed immediately or maintained for 17 hours, revealed gastric lesions in only 33.3% and 28.5% respectively, without significant statistical difference between the two groups (P > 0.05); 3) administration of alcohol prior to the 17 hour physical confinement revealed lesions in only 12.5% of the animals; 4) administration of alcohol to rats previously submitted to a 25 hour fast plus physical confinement for 17 hours, resulted in a significant number of hemorrhagic lesions (88.8%). This caused a statistical difference in the group compared to the others (P < 0.01). The results of this study led to the conclusion that stress (by prolonged physical confinement) was an important conditioning factor to the appearance of gastric hemorrhage when 40% alcohol was administered. It is possible that if the alcohol had been administered prior to the prolonged physical confinement its cytotoxic effect on the gastric mucosa might have been reduced.

Small bowel bacterial overgrowth in strongyloidiasis.

Small bowel bacterial growth was studied in patients with strongyloidiasis, and the results were compared to controls. We concluded that in strongyloidiasis there is small bowel bacterial overgrowth, and so it should be considered in the pathogenesis of some of the gastrointestinal manifestations and complications of strongyloidiasis.

Response of the lower esophageal sphincter to pentagastrin on patients with megaesophagus secondary to Chagas' disease.

In 12 patients with moderate chagasic megaesophagus the lower esophageal sphincter pressure was studied under basal conditions and after i. v. infusion of pentagastrin by open tips infused rapid pull through manometry. Pentagastrin was infused in graded doses of 0.5, 1.0, 2.0 and 4.0 micrograms/kg/h. Results were compared with those of 12 healthy controls. Mean basal pressure in the megaesophagus group was significantly higher (p less than 0.05) than in the control group (36.2 +/- 2.5 and 27.4 +/- 1.8 cmH2O, respectively). Following pentagastrin infusion all the values of the lower esophageal sphincter pressure were significantly higher in the chagasic group (p less than 0.05). The plateau was achieved with 0.5 micrograms/kg/h in the control group and with 1.0 micrograms/kg/h in the chagasic group (p less than 0.05). Furthermore, the patients with megaesophagus needed a higher dose of pentagastrin to achieve the maximal contraction.

Jejunal flora of patients with megaoesophagus secondary to Chagas disease.

The jejunal flora of 15 patients with megaoesophagus secondary to Chagas disease was studied and compared with that of 15 control individuals. In addition to the serological reactions for Chagas disease (immunofluorescence and complement fixation reaction), all subjects were submitted to endoscopy and X-ray of the oesophagus, gastric secretory study and investigation of the jejunal flora. The mean bacterial counts (log10) of Chagas disease patients (4.14 +/- 2.15 c.f.u./ml) was significantly higher than those of the control group (2.83 +/- 1.34 c.f.u./ml). Aerobic bacteria were isolated from 14 Chagasic patients (maximum count 10(10) c.f.u./ml) and 7 controls (maximum count 10(5) c.f.u./ml). Anaerobes were isolated from 7 patients (maximum count 10(7) c.f.u./ml) and 1 control (10 c.f.u./ml). Controls and Chagas disease patients differed significantly in the maximum acid output, but there was no statistically significant relation between bacterial counts and maximum output.