RESUMO
INTRODUCTION: Laparoscopic antireflux surgery (LARS) in children primarily aims to decrease reflux events and reduce reflux symptoms in children with therapy-resistant gastroesophageal reflux disease (GERD). The aim was to objectively assess the effect and efficacy of LARS in pediatric GERD patients and to identify parameters associated with failure of LARS. METHODS: Twenty-five children with GERD [12 males, median age 6 (2-18) years] were included prospectively. Reflux-specific questionnaires, stationary manometry, 24-h multichannel intraluminal impedance pH monitoring (MII-pH monitoring) and a 13C-labeled Na-octanoate breath test were used for clinical assessment before and 3 months after LARS. RESULTS: After LARS, three of 25 patients had persisting/recurrent reflux symptoms (one also had persistent pathological acid exposure on MII-pH monitoring). New-onset dysphagia was present in three patients after LARS. Total acid exposure time (AET) (8.5-0.8 %; p < 0.0001) and total number of reflux episodes (p < 0.001) significantly decreased and lower esophageal sphincter (LES) resting pressure significantly increased (10-24 mmHg, p < 0.0001) after LARS. LES relaxation, peristaltic contractions and gastric emptying time did not change. The total number of reflux episodes on MII-pH monitoring before LARS was a significant predictor for the effect of the procedure on reflux reduction (p < 0.0001). CONCLUSIONS: In children with therapy-resistant GERD, LARS significantly reduces reflux symptoms, total acid exposure time (AET) and number of acidic as well as weakly acidic reflux episodes. LES resting pressure increases after LARS, but esophageal function and gastric emptying are not affected. LARS showed better reflux reduction in children with a higher number of reflux episodes on preoperative MII-pH monitoring.
Assuntos
Fundoplicatura , Refluxo Gastroesofágico/cirurgia , Laparoscopia , Adolescente , Criança , Pré-Escolar , Transtornos de Deglutição/etiologia , Esfíncter Esofágico Inferior/fisiologia , Monitoramento do pH Esofágico , Feminino , Fundoplicatura/efeitos adversos , Humanos , Lactente , Masculino , Manometria , Complicações Pós-Operatórias , Pressão , Estudos ProspectivosRESUMO
OBJECTIVES: Vagus nerve injury is a feared complication of antireflux surgery (ARS) that may negatively affect reflux control. The aim of the present prospective study was to evaluate short-term and long-term impact of vagus nerve injury, evaluated by pancreatic polypeptide response to insulin-induced hypoglycemia (PP-IH), on the outcome of ARS. METHODS: In the period from 1990 until 2000, 125 patients with gastroesophageal reflux disease (GERD) underwent ARS at a single center. Before and 6 months after surgery, vagus nerve integrity testing (PP-IH), 24-h pH-monitoring, gastric emptying, and reflux-associated symptoms were evaluated. In 2014, 14-25 years after surgery, 110 patients were contacted again for evaluation of long-term symptomatic outcome using two validated questionnaires (Gastrointestinal Symptom Rating Scale (GSRS) and GERD-Health Related Quality of Life (HRQL)). RESULTS: Short-term follow-up: vagus nerve injury (PP peak ≤47 pmol/l) was observed in 23 patients (18%) 6 months after fundoplication. In both groups, a comparable decrease in reflux parameters and symptoms was observed at 6-month follow-up. Postoperative gastric emptying was significantly delayed in the vagus nerve injury group compared with the vagus nerve intact group. Long-term follow-up: patients with vagus nerve injury showed significantly less effective reflux control and a higher re-operation rate. CONCLUSIONS: Vagus nerve injury occurs in up to 20% of patients after ARS. Reflux control 6 months after surgery was not affected by vagus nerve injury. However, long-term follow-up showed a negative effect on reflux symptom control and re-operation rate in patients with vagus nerve injury.
Assuntos
Refluxo Gastroesofágico/cirurgia , Complicações Pós-Operatórias/diagnóstico , Traumatismos do Nervo Vago/diagnóstico , Adulto , Idoso , Monitoramento do pH Esofágico , Feminino , Fundoplicatura , Esvaziamento Gástrico , Humanos , Masculino , Manometria , Pessoa de Meia-Idade , Estudos Prospectivos , Qualidade de Vida , Fatores de Risco , Inquéritos e Questionários , Resultado do TratamentoRESUMO
BACKGROUND: Gastric peroral endoscopic pyloromyotomy (G-POEM) is a promising therapeutic modality for refractory gastroparesis (GP). However, as characteristics of suitable patients for G-POEM remain unclear, antro-duodenal manometry (ADM) has been suggested to provide objective parameters for patient selection. The aim of the present study was to identify ADM parameters as predictors for treatment response after G-POEM in refractory GP. METHODS: Refractory GP patients who underwent a G-POEM between 2017 and 2022 were included. The following ADM parameters were mainly scored: antral hypomotility, pylorospasm, and the presence of neuropathic enteric patterns. Treatment response was defined as a GCSI-score decrease of ≥1 point 12 months after G-POEM. Explorative analyses were performed on potential predictors of response using logistic regression analysis. KEY RESULTS: Sixty patients (52 women, mean age 52 ± 14 years.) with refractory GP (33 idiopathic, 16 diabetic, 11 postsurgical) were included. Clinical response data were available for 52 patients. In 8 out of 60 patients, it was not feasible to advance the catheter beyond the pylorus. Abnormal ADM was found in 46/60 patients (77%). Antral hypomotility and pylorospasm were found in respectively 33% and 12% of patients. At least one neuropathic enteric dysmotility pattern was found in 58% of patients. No differences were found when comparing baseline ADM parameters between clinical response groups at 12 months follow-up. Following explorative analyses, no ADM parameters were identified to predict clinical response 12 months after G-POEM. CONCLUSIONS AND INFERENCES: No ADM parameters were identified as predictors of clinical response after G-POEM in refractory GP patients. Additionally, a high percentage of abnormal ADM tracings was found, in particular with relation to enteric dysmotility, while only a low percentage of patients showed antral hypomotility or pylorospasm.
RESUMO
BACKGROUND: Pneumatic balloon dilatation (PD) is a regular treatment modality for achalasia. The reported success rates of PD vary. Recurrent symptoms often require repeated PD or surgery. OBJECTIVE: To identify predicting factors for symptom recurrence requiring repeated treatment. METHODS: Between 1974 and 2006, 336 patients were treated with PD and included in this longitudinal cohort study. The median follow-up was 129 months (range 1-378). Recurrence of achalasia was defined as symptom recurrence in combination with increased lower oesophageal sphincter (LOS) pressure on manometry, requiring repeated treatment. Patient characteristics, results of timed barium oesophagram and manometry as well as baseline PD characteristics were evaluated as predictors of disease recurrence with Kaplan-Meier curves and Cox regression analysis. RESULTS: 111 patients had symptom recurrence requiring repeated treatment. Symptoms recurred after a mean follow-up of 51 months (range 1-348). High recurrence percentages were found in patients younger than 21 years in whom the 5 and 10-year risks of recurrence were 64% and 72%, respectively. These risks were respectively 28% and 36% in patients with classic achalasia, respectively 48% and 60% in patients without complete obliteration of the balloon's waist during PD and respectively 25% and 33% in patients with a LOS pressure greater than 10 mm Hg at 3 months post-dilatation. These four predictors remained statistically significant in a multivariable Cox analysis. CONCLUSION: Although PD is an effective primary treatment in patients with primary achalasia, patients are at risk of recurrent disease, with this risk increasing during long-term follow-up. Young age at presentation, classic achalasia, high LOS pressure 3 months after PD and incomplete obliteration of the balloon's waist during PD are the most important predicting factors for the need for repeated treatment during follow-up. Patients who meet one or more of these characteristics may be considered earlier for alternative treatment, such as surgery.
Assuntos
Cateterismo/métodos , Acalasia Esofágica/terapia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Cateterismo/efeitos adversos , Criança , Pré-Escolar , Métodos Epidemiológicos , Acalasia Esofágica/fisiopatologia , Esôfago/fisiopatologia , Feminino , Humanos , Masculino , Manometria/métodos , Pessoa de Meia-Idade , Prognóstico , Recidiva , Resultado do Tratamento , Adulto JovemRESUMO
Nausea is a common presenting symptom in medical care with a broad differential diagnosis. In this teaching article we provide practical information on many aspects of nausea including pathophysiology and differential diagnosis, history and physical examination, and diagnostic tests and treatment. This was done by means of answering several questions from the daily practice of general practitioners, specialists in internal medicine and surgeons. In a patient with nausea a provisional diagnosis can be made based on medical history, careful history-taking and age. Diagnostic testing is only performed on clinical suspicion and depends on the provisional diagnosis and presence of alarm symptoms. Tailored medical treatment of nausea is based on the provisional diagnosis and on the mechanism of action of the intended antiemetic agent.
Assuntos
Antieméticos/uso terapêutico , Diagnóstico Diferencial , Técnicas e Procedimentos Diagnósticos , Náusea/diagnóstico , Náusea/tratamento farmacológico , Escolaridade , Clínicos Gerais , Humanos , Medicina Interna , Anamnese , Exame Físico , EspecializaçãoRESUMO
BACKGROUND: Functional dyspepsia (FD) is a common functional gastrointestinal disorder with incompletely understood pathophysiology and heterogeneous symptom presentation. Assessment of treatment efficacy in FD is a methodological challenge as response to treatment must be assessed primarily by measuring subjective symptoms. Therefore, the use of patient-reported outcome measures (PROMs) is recommended by regulatory authorities to assess gastrointestinal symptoms in clinical trials for FD. In the last decades, a multitude of outcome measures has been developed. However, currently no PROM has been approved by the regulatory authorities, and no consensus has been reached with regard to the most relevant outcome measure in FD. PURPOSE: This systematic review discusses the available disease-specific outcome measures for assessment of FD symptoms with psychometric validation properties, strengths, and limitations. Moreover, recommendations for use of current available outcome measures are provided, and potential areas of future research are discussed.
RESUMO
BACKGROUND: Frequent belching is a common symptom in patients with functional dyspepsia with a reported incidence up to 80%. We hypothesized that patients with functional dyspepsia possibly have a higher frequency of belching than healthy subjects secondary to frequent air swallowing. AIM: To assess air swallowing, belching, acid and non-acid reflux patterns of patients with functional dyspepsia. METHODS: Combined 24-h oesophageal impedance and pH monitoring was performed in 10 functional dyspepsia patients and 10 controls. Analysis of the impedance-pH signals included incidence of air swallows, belching, acid and non-acid reflux. RESULTS: The incidence of air swallows in functional dyspepsia patients were significantly higher compared with controls (153 +/- 15 vs. 79 +/- 10, P < 0.001), while the incidence of liquid-only swallows were not significantly increased. The proportions of gas-containing reflux episodes (belches) and non-acid reflux episodes in functional dyspepsia patients were significantly higher when compared with controls (66.4 vs. 44.4%, P = 0.04 and 70.1 vs. 45.9%, P = 0.009, respectively). CONCLUSION: Patients with functional dyspepsia swallow air more frequently than controls and this is associated with an increased incidence of non-acid gaseous gastro-oesophageal reflux.
Assuntos
Aerofagia/complicações , Dispepsia/etiologia , Eructação/etiologia , Refluxo Gastroesofágico/complicações , Adulto , Aerofagia/fisiopatologia , Dispepsia/fisiopatologia , Eructação/fisiopatologia , Feminino , Ácido Gástrico/metabolismo , Determinação da Acidez Gástrica , Esvaziamento Gástrico/fisiologia , Refluxo Gastroesofágico/fisiopatologia , Humanos , Concentração de Íons de Hidrogênio , Masculino , Manometria , Pessoa de Meia-IdadeRESUMO
BACKGROUND: In the evaluation of several endoscopic antireflux procedures, a discrepancy in the degree of improvement between symptoms and objective reflux parameters as measured by pH-metry has been reported. AIM: To assess the additional value of impedance monitoring in the evaluation of endoscopic gastroplication for gastro-oesophageal reflux disease. METHODS: Eighteen patients with gastro-oesophageal reflux disease were treated with three endoscopic gastroplications, and underwent 24 h pH-impedance monitoring before and 3 months after treatment. RESULTS: Total reflux exposure time as assessed by pH-metry and impedance monitoring was significantly decreased after treatment (P = 0.047 and <0.001, respectively). When assessed with impedance monitoring, the mean number of reflux episodes was significantly decreased after the procedure (82 vs. 56, pre vs. post, P < 0.001). Furthermore, the mean numbers of liquid and acid reflux episodes in patients with symptomatic improvement were significantly reduced after treatment (P = 0.04 and 0.02, respectively). After treatment, mean volume clearance time (s) and mean number of proximal reflux episodes were significantly decreased (P < 0.001 and 0.002, respectively). CONCLUSIONS: Impedance monitoring can identify the specific effect of endoscopic gastroplication on the different types of reflux episodes with regard to gas-liquid composition and pH, as well as on volume clearance and the proximal extent of the refluxate.
Assuntos
Impedância Elétrica , Monitoramento do pH Esofágico/normas , Esôfago/metabolismo , Refluxo Gastroesofágico/metabolismo , Adulto , Endoscopia Gastrointestinal/métodos , Feminino , Refluxo Gastroesofágico/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Operatórios/métodos , Resultado do TratamentoRESUMO
Oesophageal emptying can be assessed by radiographic and scintigraphic tests with radiation exposure or by multichannel intraluminal impedance monitoring (MII). The aim of this study was to evaluate the applicability of MII for the assessment of oesophageal emptying in achalasia patients. In 10 achalasia patients, impedance tracings were scored independently by three observers after ingestion of a 100-mL barium bolus. Bolus clearance time (BCT) and height of barium column were scored using fluoroscopic images acquired at 20-s intervals. All patients showed a low baseline impedance level in the distal oesophagus. Air trapping in the proximal oesophagus was detected in nine patients. BCT on MII was similar to that on fluoroscopy in 40-70% of the patients. Correlations between height of barium on fluoroscopy and fluid level on MII were poor to moderate at different time intervals. Concordance (Kendall's coefficient) between the three observers for assessment of fluid level on MII was 0.31 (P = 0.04) at 1 and 5 min, 0.26 (P = 0.08) at 10 and 0.44 (P = 0.01) at 15 min. We conclude that in achalasia patients, low baseline impedance levels and air entrapment in the proximal oesophagus limit the value of intraluminal impedance monitoring as a test of oesophageal emptying.
Assuntos
Acalasia Esofágica/diagnóstico , Acalasia Esofágica/fisiopatologia , Esôfago/fisiopatologia , Adulto , Feminino , Fluoroscopia , Humanos , Masculino , Pessoa de Meia-Idade , Pletismografia de ImpedânciaRESUMO
BACKGROUND: Alterations in serotonin (5-HT) metabolism have been postulated to play a role in the pathogenesis of irritable bowel syndrome (IBS). However, previous reports regarding 5-HT metabolism in IBS are contradicting. AIM: To compare platelet poor plasma (PPP) 5-HT and 5-hydroxyindole acetic acid (5-HIAA) levels and their ratio in a large cohort of IBS patients and healthy controls (HC), including IBS-subgroup analysis. METHODS: Irritable bowel syndrome patients and HC were evaluated for fasting PPP 5-HT and 5-HIAA levels. Furthermore, GI-symptom diary, GSRS, quality of life, anxiety and depression scores were assessed in the 2 weeks before blood sampling. RESULTS: One hundred and fifty four IBS patients and 137 HC were included. No differences were detected in plasma 5-HT between groups. The 5-HIAA concentrations and 5-HIAA/5-HT ratio were significantly lower in IBS compared to HC: 24.6 ± 21.9 vs. 39.0 ± 29.5 µg/L (P < 0.001) and 8.4 ± 12.2 vs. 13.5 ± 16.6 (P < 0.01), respectively. Subtype analysis for 5-HIAA showed all IBS subtypes to be significantly different from HC. The 5-HIAA/5-HT ratio was significantly lower in the IBS-M subtype vs. HC. Linear regression analysis points to an influence of gender but not of GI-symptoms, psychological scores or medication use. CONCLUSIONS: We demonstrated that fasting 5-HT plasma levels are not significantly different in IBS patients compared to controls. However, decreased 5-HIAA levels and 5-HIAA/5-HT ratio in IBS patients may reflect altered serotonin metabolism in IBS. Gender affects 5-HIAA levels in IBS patients, but no effects of drugs, such as SSRIs, or higher GI-symptom or psychological scores were found.
Assuntos
Ácido Hidroxi-Indolacético/metabolismo , Síndrome do Intestino Irritável/metabolismo , Qualidade de Vida , Serotonina/metabolismo , Adulto , Jejum , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Adulto JovemRESUMO
BACKGROUND: Laparoscopic antireflux surgery (LARS) is a well-established treatment option for children with proton pomp inhibitor (PPI)-resistant gastroesophageal reflux disease (GERD). Besides preventing reflux of gastric fluid and solid content, LARS may also impair the ability of the stomach to vent intragastric air (i.e. gastric belching) and induce gas-related complications, such as bloating and/or hyperflatulence. Furthermore, it was previously hypothesized that LARS induces a behavioral type of belching, not originating from the stomach, called supragastric belching. The aim of this study was to objectively evaluate the impact of LARS on gastric (GB) and supragastric belching (SGB) in children with GERD. METHODS: We performed a prospective, Dutch multicenter cohort study including 25 patients (12 males, median age 6 (range 2-18) years) with PPI-resistant GERD who were scheduled for LARS. Twenty-four-hour multichannel intraluminal impedance pH monitoring (MII-pH monitoring) was performed before and 3 months after fundoplication. Impedance pH tracings were analyzed for reflux episodes and GBs and SGBs. KEY RESULTS: LARS reduced acid exposure time from 8.5% (6.0-16.2%) to 0.8% (0.2-2.8%), p < 0.001. The number of GBs also significantly decreased after LARS (59 [43-77] VS 5 [2-12], p < 0.001). The number of air swallows remained unchanged after LARS. SGBs were infrequent before LARS with no change in the number of SGB observed after the procedure. Postoperative belching symptoms were associated with GBs, not with SGBs. CONCLUSION & INFERENCES: LARS significantly reduces the number of GBs in children with GERD, whereas the number of air swallows remains unchanged. Postoperative symptomatic belching is associated with GBs, but not with SGBs. These findings suggest that LARS does not induce the occurrence of SGBs in children, but longer follow-up is required.
Assuntos
Eructação/fisiopatologia , Eructação/cirurgia , Monitoramento do pH Esofágico/tendências , Refluxo Gastroesofágico/fisiopatologia , Refluxo Gastroesofágico/cirurgia , Laparoscopia/tendências , Adolescente , Criança , Pré-Escolar , Eructação/diagnóstico , Monitoramento do pH Esofágico/métodos , Feminino , Seguimentos , Refluxo Gastroesofágico/diagnóstico , Humanos , Laparoscopia/métodos , Masculino , Estudos ProspectivosRESUMO
Multichannel intraluminal impedance (MII) is being used increasingly to assess oesophageal bolus clearance. However, there is no good standardization of the impedance parameters that define 'effective bolus clearance'. The aim of this study was to define these important impedance parameters and to determine their normal values. Concurrent perfusion manometry and MII were performed in 42 healthy volunteers. Ten, 5-mL liquid (saline) boluses and then, 10x5-mL low impedance viscous boluses were tested in each subject in the right-lateral position. Normal values for bolus presence time (BPT) at each site and total bolus transit time (TBTT) were determined from either 'normal' peristaltic responses (amplitude>or=30 mmHg in distal oesophagus) or 'super-normal' peristaltic responses (amplitudes>or=50 mmHg at all sites). The relationship between BPT and TBTT within a response and per-individual performance was determined. A total of 840 swallows of liquids and viscous responses were analysed. BPT and TBTT of viscous swallows were longer than those for liquids. Non-peristaltic responses were significantly more likely not to clear a viscous than a liquid bolus. Within a response, the number of sites with prolonged BPT strongly predicted the incidence of prolonged TBTT. Using impedance criteria, normal oesophageal bolus clearance is defined when an individual completely clears at least 70% of liquid responses and at least 60% of viscous responses. This study provides normal values for impedance measurement of bolus clearance when combined with perfusion manometry. These values will allow standardization of impedance application in oesophageal function testing, in both research and clinical setting.
Assuntos
Esôfago/fisiologia , Manometria/métodos , Adolescente , Adulto , Idoso , Deglutição/fisiologia , Impedância Elétrica , Esfíncter Esofágico Inferior/fisiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Perfusão , Peristaltismo/fisiologia , Valores de ReferênciaRESUMO
BACKGROUND: Antireflux therapy may lead to recovery of impaired mucosal integrity in gastro-esophageal reflux disease (GERD) patients as reflected by an increase in baseline impedance. The study objective was to evaluate the effect of endoscopic fundoplication and proton pump inhibitor (PPI) PPI therapy on baseline impedance and heartburn severity in GERD patients. METHODS: Forty-seven GERD patients randomized to endoscopic fundoplication (n = 32) or PPI therapy (n = 15), and 29 healthy controls were included. Before randomization and 6 months after treatment, baseline impedance was obtained during 24-h pH-impedance monitoring. Heartburn severity was evaluated using the GERD-HRQL questionnaire. KEY RESULTS: Before treatment, baseline impedance in GERD patients was lower than in healthy controls (p < 0.001). Antireflux therapy increased baseline impedance (from 1498 [IQR 951-2472] to 2393 [IQR 1353-3027] Ω, p = 0.001), however it only led to a partial recovery when compared to healthy controls (2393 [IQR 1353-3027] vs 2983 [2335-3810] Ω, p < 0.01). The effect of both treatment options was not significantly different (p = 0.13) despite the increased number of non-acid reflux events in the PPI group. No correlation was found between baseline impedance and GERD symptoms before or after treatment. CONCLUSIONS & INFERENCES: Reduction in acid reflux by endoscopic fundoplication or PPI therapy leads to an increase in baseline impedance in GERD patients, likely to reflect recovery of mucosal integrity. The impact of non-acid reflux events on esophageal mucosal integrity may be limited as no difference in the increase in baseline impedance was observed after both treatment options. The lack of association between impedance baseline and heartburn severity indicates that other factors may contribute to heartburn perception in GERD.
Assuntos
Monitoramento do pH Esofágico , Fundoplicatura , Refluxo Gastroesofágico/tratamento farmacológico , Refluxo Gastroesofágico/cirurgia , Azia/tratamento farmacológico , Azia/cirurgia , Inibidores da Bomba de Prótons/uso terapêutico , Adulto , Idoso , Endoscopia Gastrointestinal , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: Achalasia is characterized by a functional esophagogastric junction (EGJ) obstruction. The functional luminal imaging probe (EndoFLIP) is a method to assess EGJ distensibility. In a homogeneous group of newly diagnosed achalasia patients treated with pneumatic dilation (PD), we aimed (i) to determine whether the assessment of EGJ distensibility has added value in the management of achalasia patients and (ii) to evaluate whether EGJ distensibility differs between achalasia subtypes. METHODS: Twenty-six newly diagnosed achalasia patients were treated by graded PD (30 and 35 mm) separated by 1 week. EGJ distensibility was measured with the EndoFLIP technique before and after 30 mm PD. Good clinical outcome was defined as an Eckardt score <4 at 1-year follow-up. Fifteen healthy controls underwent an EndoFLIP measurement as control group. KEY RESULTS: Newly diagnosed achalasia patients had reduced EGJ distensibility compared to healthy controls (0.9 [0.7-1.5] vs 3.4 [2.7-4.2] mm(2) /mmHg, p < 0.01), and EGJ distensibility was lower in type II compared to type I patients (0.8 [0.7-1.1] vs 1.5 [0.9-1.9] mm(2) /mmHg, p = 0.02). EGJ distensibility was increased after PD from 0.9 (0.7-1.5) to 4.2 (3.0-5.7) mm(2) /mmHg (p < 0.001). No difference was found in EGJ distensibility directly after PD between patients with good and poor clinical outcome at 1-year follow-up. CONCLUSIONS & INFERENCES: Assessment of EGJ distensibility with the EndoFLIP technique is able to demonstrate the functional EGJ obstruction in newly diagnosed achalasia patients and EGJ distensibility differs between achalasia subtypes. Although PD improves EGJ distensibility, assessment of EGJ distensibility with a limited number of distension steps provides no additional information that is useful for clinical evaluation and management of achalasia patients.
Assuntos
Acalasia Esofágica/terapia , Junção Esofagogástrica/fisiopatologia , Esofagoscopia/métodos , Resultado do Tratamento , Adulto , Gerenciamento Clínico , Acalasia Esofágica/fisiopatologia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Adulto JovemRESUMO
BACKGROUND: A previous single-centre study showed that lower oesophageal sphincter electrical stimulation therapy (LES-EST) in gastro-oesophageal reflux disease (GERD) patients improves reflux symptoms and decreases oesophageal acid exposure. AIM: To evaluate safety and efficacy of LES-EST in GERD patients with incomplete response to proton pump inhibitors (PPIs) in a prospective, international, multicentre, open-label study. METHODS: GERD patients, partially responsive to PPIs, received LES-EST. GERD health-related quality of life (GERD-HRQL), daily symptom diaries, quality of life scores, oesophageal acid exposure, and LES resting and residual pressure were measured before and after initiation of LES-EST. Stimulation sessions were optimised based on residual symptoms and oesophageal acid exposure. RESULTS: Forty-four patients were enrolled and 6-month data from 41 patients are available. Hiatal repair was performed in 16 patients. One device-related, one procedure-related and one unrelated severe adverse event were reported. GERD-HRQL improved from 31.0 (IQR 26.2-36.8) off-PPI and 16.5 (IQR 9.0-22.8) on-PPI to 4 (IQR 1-8) at 3-month and 5 (IQR 3-9) at 6-month follow-up (P < 0.0001 vs. on- and off-PPI). Oesophageal acid exposure (pH < 4.0) improved from 10.0% (IQR 7.5-12.9) to 3.8% (IQR 1.9-12.3) at 3 months (P = 0.0027) and 4.4% (IQR 2.2-7.2) at 6 months (P < 0.0001). CONCLUSIONS: These interim results show an acceptable safety record of LES-EST to date, combined with good short-term efficacy in GERD patients who are partially responsive to PPI therapy. A remarkable reduction in regurgitation symptoms, without the risk of intervention-requiring dysphagia may prove to be an advantage compared with other anti-reflux procedures. ClinicalTrials.gov Identifier: NCT01574339.
Assuntos
Terapia por Estimulação Elétrica/métodos , Esfíncter Esofágico Inferior , Refluxo Gastroesofágico/terapia , Adulto , Idoso , Terapia por Estimulação Elétrica/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Inibidores da Bomba de Prótons/uso terapêutico , Qualidade de Vida , Resultado do TratamentoRESUMO
This retrospective study was performed to assess whether type III intestinal metaplasia is an obligatory precancerous lesion of intestinal-type gastric carcinoma and to determine its possible use as a marker of enhanced cancer risk. From 48 consecutive patients with gastric cancer who underwent a gastrectomy over a 3-year period (mean age 72.0 years; 29 M/19 F), at least two sections from antrum, corpus and tumour-surrounding mucosa were obtained for the examination of presence and subtypes of intestinal metaplasia (IM). It was found that 77.1% of the carcinomas were of the intestinal type and 22.9% of the diffuse type. The intestinal-type was more often found in males (P = 0.01); the mean age at diagnosis in this type was higher than in the diffuse cancer group (P = 0.004). There was a high prevalence of total IM in both the intestinal (75.7%) and diffuse group (88.9%). Type I IM was predominant in antrum and corpus of patients from both groups. Type III IM was only found among patients with intestinal-type carcinoma. However, its prevalence was rather low (26.3%). Therefore the absence of this lesion in patients with other risk factors cannot be used as an argument for lowering the degree of surveillance and its presence seems to be sufficient indication for long-term follow-up.
Assuntos
Biomarcadores Tumorais/análise , Carcinoma/fisiopatologia , Sistema Digestório/patologia , Lesões Pré-Cancerosas/patologia , Neoplasias Gástricas/fisiopatologia , Idoso , Idoso de 80 Anos ou mais , Carcinoma/etiologia , Carcinoma/cirurgia , Feminino , Gastrectomia , Humanos , Masculino , Metaplasia , Pessoa de Meia-Idade , Prevalência , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Neoplasias Gástricas/etiologia , Neoplasias Gástricas/cirurgiaRESUMO
Three primigravidae were admitted during the first trimester of pregnancy with nausea, vomiting, ketonuria and liver enzyme elevation of varying severity. A 29-year-old woman had elevated aminotransferase values, at levels described in the literature (ASAT 112 U/l, ALAT 214 U/l). The second patient, a woman aged 26 years, had undergone in vitro fertilisation and showed higher liver enzyme elevation, including the total bilirubin level (ASAT 250 U/l, ALAT 474 U/l, total bilirubin 59.8 micromol/l). A 30-year-old woman had extremely high aminotransferase values (ASAT 705 U/l, ALAT 1674 U/l) and she is the first reported patient with ALAT values exceeding 1,000 U/l in connection with hyperemesis gravidarum. Gallstone disease, viral and drug-induced hepatitis were excluded in all of these patients. Treatment was symptomatic and the abnormal liver tests returned to normal promptly when the vomiting resolved, independent of the severity of liver enzyme elevation. The pregnancies proceeded normally and all three patients delivered healthy babies.
Assuntos
Hiperêmese Gravídica/enzimologia , Transaminases/sangue , Adulto , Feminino , Humanos , GravidezRESUMO
BACKGROUND: Irritable bowel syndrome (IBS) is a heterogenous disorder with visceral hypersensitivity as important hallmark. It is not known whether IBS patients with visceral hypersensitivity have different epidemiological and clinical characteristics compared with IBS patients without visceral hypersensitivity. Aim of our study was to compare in detail a large group of hyper- vs normosensitive IBS patients with respect to epidemiological and clinical characteristics. METHODS: IBS patients (Rome III criteria) have been recruited for a large-scale cohort study. All patients from this cohort who underwent a rectal barostat procedure were included and allocated based on those with and without visceral hypersensitivity. Patient demographics, and symptoms were collected using questionnaires (GSRS, HADS, SF-36) and a 14-day symptom diary for IBS-related symptoms. A multivariate logistic regression model was used to identify risk markers for having visceral hypersensitivity. KEY RESULTS: Ninety-five normosensitive and 93 hypersensitive IBS patients participated in this study. Hypersensitive patients had significantly higher scores for GSRS abdominal pain (p < 0.05), indigestion, reflux and constipation syndrome (all p < 0.01), and IBS symptom intensity, discomfort (both p < 0.05) and mean symptom composite score (p < 0.01). Age, female sex, and the use of SSRI medication were significantly different between the normo- and the hypersensitive IBS patients. However, after adjustment for other risk markers, only increasing age was found to be significantly associated with lower odds for having hypersensitivity (OR 0.97 [95% CI: 0.94; 0.99]). CONCLUSIONS & INFERENCES: Apart from more severe symptomatology, hypersensitive IBS patients are characterized by significantly younger age compared with normosensitive IBS patients. The study has been registered in the US National Library of Medicine (http://www.clinicaltrials.gov, NCT00702026).
Assuntos
Hiperalgesia/epidemiologia , Hiperalgesia/etiologia , Síndrome do Intestino Irritável/epidemiologia , Adulto , Estudos de Coortes , Feminino , Humanos , Síndrome do Intestino Irritável/complicações , Síndrome do Intestino Irritável/diagnóstico , Masculino , Pessoa de Meia-Idade , Medição da Dor , Qualidade de Vida , Fatores de RiscoRESUMO
BACKGROUND: Irritable bowel syndrome (IBS) is characterized by heterogeneous pathophysiology and low response to treatment. Up to 60% of IBS patients suffers from visceral hypersensitivity, which is associated with symptom severity and underlying pathophysiological mechanisms. Recently, positive effects of probiotics in IBS have been reported, but overall the response was modest. We performed a study in IBS patients, characterized by visceral hypersensitivity measured with the rectal barostat, aiming to assess the effect of 6 weeks of multispecies probiotic mix on visceral pain perception. METHODS: We conducted a randomized, placebo-controlled, double-blind trial in forty Rome III IBS patients with visceral hypersensitivity. Prior to intake, patients kept a 2-week symptom diary and underwent a rectal barostat measurement. When hypersensitivity was confirmed, participation was allowed and patients received a multispecies probiotic with in vitro proven potential beneficial effects on mechanisms contributing to visceral hypersensitivity (six different probiotic strains; 10(9) cfu/g), or a placebo product of one sachet (5 g) per day for 6 weeks. At the end of the intervention period, visceroperception and symptoms were reassessed. KEY RESULTS: Thirty-five patients completed the trial. The percentage of patients with visceral hypersensitivity decreased significantly in the probiotic and placebo group (76.5% and 71.4%, respectively; N.S. between groups). Improvement in pain scores and mean symptom score did not differ between the probiotic and placebo group. CONCLUSIONS & INFERENCES: In this placebo-controlled trial in IBS patients with visceral hypersensitivity, no significant effect of a multispecies probiotic on viscerperception was observed. The study has been registered in the US National Library of Medicine (http://www.clinicaltrials.gov, NCT00702026).
Assuntos
Hiperalgesia/tratamento farmacológico , Síndrome do Intestino Irritável/tratamento farmacológico , Probióticos/uso terapêutico , Dor Visceral/tratamento farmacológico , Adulto , Método Duplo-Cego , Feminino , Humanos , Hiperalgesia/fisiopatologia , Síndrome do Intestino Irritável/fisiopatologia , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento , Dor Visceral/fisiopatologiaRESUMO
BACKGROUND: Intestinal permeability has been studied in small groups of IBS patients with contrasting findings. AIMS: To assess intestinal permeability at different sites of the GI tract in different subtypes of well-characterised IBS patients and healthy controls (HC), and to assess potential confounding factors. METHODS: IBS patients and HC underwent a multi-sugar test to assess site-specific intestinal permeability. Sucrose excretion and lactulose/rhamnose ratio in 0-5 h urine indicated gastroduodenal and small intestinal permeability, respectively. Sucralose/erythritol ratio in 0-24 h and 5-24 h urine indicated whole gut and colonic permeability, respectively. Linear regression analysis was used to assess the association between IBS groups and intestinal permeability and to adjust for age, sex, BMI, anxiety or depression, smoking, alcohol intake and use of medication. RESULTS: Ninety-one IBS patients, i.e. 37% IBS-D, 23% IBS-C, 33% IBS-M and 7% IBS-U and 94 HC were enrolled. Urinary sucrose excretion was significantly increased in the total IBS group [µmol, median (Q1;Q3): 5.26 (1.82;11.03) vs. 2.44 (0.91;5.85), P < 0.05], as well as in IBS-C and IBS-D vs. HC. However, differences attenuated when adjusting for confounders. The lactulose/rhamnose ratio was increased in IBS-D vs. HC [0.023 (0.013;0.038) vs. 0.014 (0.008;0.025), P < 0.05], which remained significant after adjustment for confounders. No difference was found in 0-24 and 5-24 h sucralose/erythritol ratio between groups. CONCLUSIONS: Small intestinal permeability is increased in patients with IBS-D compared to healthy controls, irrespective of confounding factors. Adjustment for confounders is necessary when studying intestinal permeability, especially in a heterogeneous disorder such as IBS.