Severe oesophageal disease and its associations with systemic sclerosis.

OBJECTIVES: Severe oesophageal disease in patients with systemic sclerosis (SSc), referred as scleroderma oesophagus, is characterised by ineffective or absent peristalsis along with hypotensive oesophagogastric junction (hEGJ). The associations between scleroderma oesophagus and different clinical and laboratory manifestations of SSc is still controversial. In this study we aimed to assess associations between scleroderma oesophagus, diagnosed by high resolution manometry (HRM), and other manifestations of disease. METHODS: Fifty-four consecutive SSc patients (49 women, mean age 50.6±11.6) with oesophageal symptoms underwent clinical interview, medical records review and HRM. HRMs were analysed according to the Chicago Classification in order to provide oesophageal motility diagnosis; EGJ <9 mmHg was considered hypotensive. Demographic characteristics, patient-reported symptoms, SSc subtypes, pulmonary fibrosis, cutaneous ulcers, and anti-Scl-70 positivity were compared between SSc patients with or without scleroderma oesophagus. Comparison was also performed in computed tomography (CT) findings of oesophageal lumen in 26 patients with available data. Oesophageal dilatation was deemed present when the diameter was >9 mm. RESULTS: Absent contractility was present in 37 (68.5%) patients; among these patients hEGJP was found in 32, thus 32/54 (59.2%) patients had classic scleroderma oesophagus. There were no associations with gender, age, oesophageal symptoms, skin involvement extent, anti-Scl-70, pulmonary fibrosis and cutaneous ulcers. Notably, oesophageal dilation on chest CT was more frequent in patients with scleroderma oesophagus compared to those without (77% vs. 7%, p=0.04, respectively). CONCLUSIONS: Scleroderma oesophagus diagnosed by HRM was present in less than 2/3 of symptomatic patients with SSc and associated only with oesophageal dilation in CT. Although further studies are needed, oesophageal dilation on chest CT may be a non-invasive alternative for evaluation of SSc patients with oesophageal symptoms.

The evolution of Helicobacter pylori antibiotics resistance over 10 years in Greece.

BACKGROUND: Increasingly, over time, antibiotic resistance is considered a problem for the efficacy of H. pylori eradication treatment. The aim of our study was to evaluate the changes in clarithromycin and levofloxacin resistance of H. pylori strains in Greek patients in two different time periods (in 2000 and in 2010). METHODS: Gastric biopsies of consecutive H. pylori-positive patients were investigated retrospectively. Mutations in H. pylori 23S rRNA and gyrA genes associated with resistance to clarithromycin and quinolones, respectively, were determined by allelic specific polymerase chain reaction. RESULTS: In the first time period (2000), H. pylori resistance patterns were evaluated in 50 and in the second period (2010) in 57 patients. During the first time period 30 and 0% of patients were infected with clarithromycin- or quinolone-resistant strains, respectively. In the second time period (2010), the percentage of patients infected with clarythromycin or quinolone resistance strains increased to 42 and 5.3%, respectively. CONCLUSIONS: Our study showed an increase in the prevalence of both clarithromycin and quinolones resistance of H. pylori. Although the resistance rate to quinolones increased over the years, it is relatively low justifying its use for the eradication of H. pylori infections.

Esophageal manifestation in patients with scleroderma.

The esophagus is the most commonly affected part of the gastrointestinal system in patients with systemic sclerosis (SSc). Esophageal involvement may lead to a significant reduction in patient quality of life. The exact pathophysiology is complex and not yet fully elucidated. Ultimately, esophageal smooth muscle becomes atrophied and replaced by fibrous tissue leading to severe motility disturbance of the distal esophagus. Symptoms are mainly attributed to gastroesophageal reflux disease and to esophageal dysmotility. Compelling evidence has correlated esophageal involvement to the severity of pulmonary disease. No formed guidelines exist about the diagnostic modalities used to assess esophageal disease in patients with SSc, though upper gastrointestinal endoscopy is the first and most important modality used as it can reveal alterations commonly observed in patients with SSc. Further exploration can be made by high resolution manometry and pH-impedance study. Proton pump inhibitors remain the mainstay of treatment, while prokinetic agents are commonly used as add-on therapy in patients with symptoms attributed to gastroesophageal reflux disease not responding to standard therapy as well as to motility disturbances. Gastroesophageal reflux disease symptoms in patients with SSc are frequently difficult to manage, and new therapeutic modalities are emerging. The role of surgical treatment is restricted and should only be preserved for resistant cases.

Serum zonulin levels in patients with liver cirrhosis: Prognostic implications.

BACKGROUND: Increased gut permeability and bacterial translocation play an important role in liver cirrhosis. Zonulin is a recently recognized protein involved in the disintegration of the intestinal barrier. AIM: To investigate possible differences in serum zonulin levels among patients with different cirrhosis stages and their potential prognostic implications. METHODS: Consecutive cirrhotic patients who attended our liver clinic were included in the study. Serum zonulin levels, clinical, radiological and biochemical data were collected at baseline. Patients who accepted participation in a regular surveillance program were followed-up for at least 12 mo. RESULTS: We enrolled 116 cirrhotics [mean Child-Turcotte-Pugh (CTP) score: 6.2 ± 1.6; model for end-stage liver disease score: 11 ± 3.9]. The causes of cirrhosis were viral hepatitis (39%), alcohol (30%), non-alcoholic fatty liver disease (17%), and other (14%). At baseline, 53% had decompensated cirrhosis, 48% had ascites, and 32% had history of hepatic encephalopathy. Mean zonulin levels were significantly higher in patients with CTP-B class than CTP-A class (4.2 ± 2.4 ng/dL vs 3.5 ± 0.9 ng/dL, P = 0.038), with than without ascites (P = 0.006), and with than without history of encephalopathy (P = 0.011). Baseline serum zonulin levels were independently associated with the probability of decompensation at 1 year (P = 0.039), with an area under the receiving operating characteristic of 0.723 for predicting hepatic decompensation. Higher CTP score (P = 0.021) and portal vein diameter (P = 0.022) were independent predictors of mortality. CONCLUSION: Serum zonulin levels are higher in patients with more advanced chronic liver disease and have significant prognostic value in identifying patients who will develop decompensation.

The 100 most cited manuscripts in esophageal motility disorders: a bibliometric analysis.

BACKGROUND: The use of bibliometrics can help us identify the most impactful articles on a topic or scientific discipline and their influence on clinical practice. We aimed to identify the 100 most cited articles covering esophageal motility disorders and examine their key characteristics. METHODS: The Web of Science database was utilized to perform the search, using predefined search terms. The returned dataset was filtered to include full manuscripts written in the English language. After screening, we identified the 100 most cited articles and analyzed them for title, year of publication, names of authors, institution, country of the first author, number of citations and citation rate. RESULTS: The initial search returned 29,521 results. The top 100 articles received a total of 20,688 citations. The most cited paper was by Inoue et al. (665 citations) who first described peroral endoscopic myotomy (POEM) for treating achalasia. The article with the highest citation rate was the third version of the Chicago Classification system, written by Kahrilas and colleagues. Gastroenterology published most papers on the list (n=32) and accrued the highest number of citations (6,675 citations). Peter Kahrilas was the most cited author (3,650 citations) and, along with Joel Richter, authored the highest number of manuscripts (n=14). Most articles were produced in the USA (n=66) between the years 1991 and 2000 (n=32). CONCLUSIONS: By analyzing the most influential articles, this work is a reference on the articles that shaped our understanding of esophageal motility disorders, thus serving as a guide for future research.

Patients with refractory gastroesophageal reflux disease: diagnostic tools.

Patients with refractory to proton pump inhibitors (PPIs) gastroesophageal reflux disease (GERD) symptoms are approximately 40% and represent a very common problem in clinical practice. Many of these patients do not have GERD, but suffer from functional heartburn or hypersensitive esophagus. After thorough clinical evaluation and failure of escalation of PPI dose, diagnostic investigations include endoscopy, esophageal manometry, pH testing, esophageal Bilitec and esophageal impedance with pH monitoring.

Role of non-acid reflux in patients with non-erosive reflux disease.

Non-erosive reflux disease (NERD) is the most common presentation of gastroesophageal reflux disease. Although acid reflux is the most important cause of symptom generation in NERD patients, non-acid reflux is also associated with reflux symptoms. The temporal relation between symptoms and reflux episodes is of importance in evaluating the results of combined pH-impedance monitoring in NERD patients. Mucosal hypersensitivity and mechanical stimulation due to great volume of non-acid reflux are among the putative mechanisms of symptom generation.

Current management of functional dyspepsia: impact of Rome III subdivision.

Functional dyspepsia (FD) is a highly prevalent disease characterized by symptoms originating from the gastroduodenal region in the absence of underlying organic disease. The Rome III consensus made a distinction between meal-induced and meal-unrelated symptoms and proposed subdivision of FD into postprandial distress syndrome and epigastric pain syndrome. The applicability of this subdivision and the impact on management are areas of active research. So far, empirical approaches are still employed for the treatment of FD, although various therapeutic modalities for FD have been explored; acid-suppressive, prokinetic, and fundic relaxant drugs, antidepressants and psychological therapies. FD remains a challenge and presents unmet clinical needs.