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ABSTRACT: Scott, KM, Kreisel, BR, Florkiewicz, EM, Crowell, MS, Morris, JB, McHenry, PA, and Benedict, TM. The effect of cautionary versus resiliency spine education on maximum deadlift performance and back beliefs: A randomized control trial. J Strength Cond Res 38(7): e341-e348, 2024-The purpose of this study was to determine the effect of cautionary information about the spine vs. a message of spine resiliency on maximum deadlift (MDL) performance and beliefs regarding the vulnerability of the spine. This cluster randomized control trial involved 903 military new cadets (n = 903) during their mandatory fitness test in cadet basic training (mean age 18.3 years, body mass index 23.8 kg·m-2, 22% female). Subjects were cluster randomized to 3 groups. The cautionary group received a message warning them to protect their backs while deadlifting, the resiliency group received a message encouraging confidence while deadlifting, and the control group received the standardized Army deadlift education only. The outcome measures were MDL weight lifted and perceived spine vulnerability. Significance was set at alpha ≤0.05. There were no between-group differences in weight lifted (p=0.40). Most subjects believed that the spine is vulnerable to injury. Three times as many subjects who received the resiliency education improved their beliefs about the vulnerability of their spines compared with those receiving the cautionary education (p<0.001). This study demonstrated the potential for brief resiliency education to positively influence beliefs about spine vulnerability, whereas cautionary education did not impair performance.
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Personal Militar , Humanos , Femenino , Masculino , Personal Militar/psicología , Adolescente , Adulto Joven , Levantamiento de Peso/fisiología , Levantamiento de Peso/psicología , Traumatismos de la Espalda/prevención & control , Columna Vertebral/fisiología , AdultoRESUMEN
CONTEXT: Recently, blood flow restriction (BFR) training has gained popularity as an alternative to high-load resistance training for improving muscle strength and hypertrophy. Previous BFR studies have reported positive treatment effects; however, clinical benefits to using BFR following meniscal repair or chondral surgery are unknown. The purpose of this study was to determine the effect of resistance exercises with BFR training versus exercises alone on self-reported knee function, thigh circumference, and knee flexor/extensor strength postmeniscal or cartilage surgery. DESIGN: Single-blinded randomized controlled trial in an outpatient military hospital setting. Twenty participants were randomized into 2 groups: BFR group (n = 11) and control group (n = 9). METHODS: Participants completed 12 weeks of postoperative thigh strengthening. The BFR group performed each exercise with the addition of BFR. Both groups continued with the prescribed exercises without BFR from 12 weeks until discharged from therapy. Thigh circumference and self-reported knee function were measured at 1, 6, 12, and 24 weeks postoperatively along with knee extensor and flexor strength at 12 and 24 weeks. Change scores between time points were calculated for knee function. Limb symmetry indices (LSI) were computed for thigh circumference and knee strength variables. RESULTS: Seventeen participants were included in the final analyses (BFR = 8 and control = 9) due to COVID-19 restrictions. There were no interactions or main effects for group. Time main effects were established for change in knee function scores, thigh circumference LSI, and knee extensor strength LSI. However, knee flexor strength LSI had no main effect for time. CONCLUSION: The outcomes of this trial suggest that resistance exercises with and without BFR training may result in similar changes to function, thigh atrophy, and knee extensor strength postmeniscus repair/chondral restoration, though further study with larger sample sizes is needed.
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COVID-19 , Personal Militar , Entrenamiento de Fuerza , Terapia de Restricción del Flujo Sanguíneo , Humanos , Fuerza Muscular , Músculo Esquelético , Atrofia Muscular , Flujo Sanguíneo Regional , SARS-CoV-2RESUMEN
OBJECTIVE: Number of reflux episodes, an adjunctive metric on pH-impedance monitoring, is incompletely studied. We aimed to determine if number of reflux episodes associates with therapeutic outcome in regurgitation predominant gastro-oesophageal reflux disease (GERD). DESIGN: We performed post hoc analysis of postintervention pH-impedance data from adult patients with moderate/severe regurgitation despite QD proton pump inhibitor (PPI), randomised to either two times a day PPI or magnetic sphincter augmentation (MSA) in 2:1 allocation. After 6 and 12 months, symptom response was defined by improvement in Foregut Symptom Questionnaire (FSQ) regurgitation score to none or minimal, ≥50% reduction in GERD health-related quality of life (HRQL) score and satisfaction with therapy. Univariate and multivariate analyses were performed to determine predictors of symptom improvement. RESULTS: Of 152 randomised patients, 123 (age 46.9±1.2 year, 43% female) had complete data. Symptom and satisfaction scores significantly improved after MSA compared with two times a day PPI. Both acid exposure time (13.4%±0.7% to 1.3±0.2%, p<0.001) and reflux episodes (86±4 to 48±4, p<0.001) declined with therapy. Reduction to <40 reflux episodes was significantly more frequent in those with symptom response by FSQ regurgitation score, GERD HRQL score and satisfaction with therapy (p≤0.03 for each); <35 episodes performed better on receiver operating characteristic analysis. On multivariate analysis, improvement in regurgitation score remained independently predictive of satisfaction with therapy (p<0.001 for each). In patients crossing over to MSA, >80 episodes pretreatment predicted improvement. CONCLUSIONS: Reduction of reflux episodes on pH-impedance to physiological levels associates with improved outcomes, while pathological levels predict improvement with MSA in regurgitation predominant GERD. TRAIL REGISTRATION NUMBER: ClinicalTrials.gov: NCT02505945.
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Esfínter Esofágico Inferior/cirugía , Monitorización del pH Esofágico , Reflujo Gastroesofágico/complicaciones , Reflujo Gastroesofágico/terapia , Inhibidores de la Bomba de Protones/uso terapéutico , Adulto , Impedancia Eléctrica , Femenino , Reflujo Gastroesofágico/diagnóstico , Humanos , Magnetoterapia , Masculino , Persona de Mediana Edad , Satisfacción del Paciente , Calidad de Vida , Encuestas y Cuestionarios , Evaluación de Síntomas , Resultado del TratamientoRESUMEN
BACKGROUND & AIMS: Irritable bowel syndrome (IBS) is a common chronic functional bowel disorder for which patients take significant risks to ameliorate symptoms. Unfortunately, there is no cure for IBS. We assessed the willingness of patients with IBS to take medication risks and the costs they would pay to improve symptoms. METHODS: We mailed a survey on medication risk to patients with IBS who met the Rome IV criteria. The survey collected data on patient demographics, symptoms, medication use, prior medication-averse events, and pain catastrophization. A standard gamble evaluated respondents' willingness to take medication risks, and a willingness-to-pay set of questions quantified maximal spending on a hypothetical medication to treat IBS. RESULTS: Among respondents (n = 215; 81.8% female; mean age, 57 y) the average duration of IBS symptoms was 17.7 years. Patients whose predominant symptom was severe diarrhea (diarrhea-predominant IBS) reported accepting a mean 10.2% ± 15.7% risk of sudden death for a 99% chance of cure. Pain catastrophizing scale scores were not associated with an increased likelihood of taking medication risks. Patients with IBS would be willing to pay an average amount of $73 per month (if annual income was <$75,000) and $197 per month (if annual income was >$75,000) for a medication that would resolve their pain. CONCLUSIONS: In a survey of 215 patients with IBS, we found that patients with diarrhea-predominant IBS are willing to take extraordinary risks to improve their symptoms, whereas patients with IBS and pain catastrophization are not. Clinician understanding of patients' willingness to take medication risks might help them guide their patients through complex therapeutic options.
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Síndrome del Colon Irritable , Diarrea/tratamiento farmacológico , Femenino , Humanos , Síndrome del Colon Irritable/tratamiento farmacológico , Masculino , Persona de Mediana Edad , Encuestas y CuestionariosRESUMEN
Disorders of gastric motor and sensory function affect 10%-20% of the world's population and adversely impact nutrition, quality of life, work productivity, and health care costs. Classifying these disorders can be challenging given the heterogeneity of symptom presentation, the presence of symptoms unexplained by endoscopic, radiographic and/or laboratory evaluation, and overlap with other luminal gastrointestinal disorders. Accurately diagnosing these highly prevalent disorders relies upon an understanding of epidemiology and risk factors, the ability to take a careful clinical history focused on symptoms, and the presence of predisposing medical, surgical, and psychological conditions. A variety of diagnostic studies are now available to assess gastric motor function and identify maladaptive relaxation, accommodation, and abnormal sensation. FDA-approved treatment options are limited and thus many patients undergo a series of empirical treatment trials that target individual symptoms, often without much benefit. This article provides updated recommendations for identifying and classifying the most common gastric motor and sensory disorders using currently accepted diagnostic tests, and provides a brief supplemental overview on treatment options. "Things sweet to taste prove in digestion sour." -Shakespeare, Richard II, 1595.
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Digestión/fisiología , Vaciamiento Gástrico/fisiología , Enfermedades Gastrointestinales/epidemiología , Calidad de Vida , Trastornos de la Sensación/epidemiología , Enfermedades Gastrointestinales/complicaciones , Enfermedades Gastrointestinales/fisiopatología , Salud Global , Humanos , Incidencia , Trastornos de la Sensación/complicaciones , Trastornos de la Sensación/fisiopatologíaRESUMEN
INTRODUCTION: Systemic sclerosis or scleroderma (SSc) is a chronic autoimmune disease that renders the esophagus prone to significant gastroesophageal reflux due to impaired esophageal clearance and reduced lower esophageal sphincter pressure. The reported prevalence of Barrett's esophagus (BE) in women with SSc varies from 2% to 37% and is derived from older studies with small sample sizes. We aimed to assess the prevalence of BE in a large cohort of women with SSc. METHODS: Women with SSc referred from the Mayo Clinic Arizona Rheumatology Clinic who completed esophagogastroduodenoscopy between 2002 and 2020 were included. Demographic and high-resolution manometry data were evaluated. The diagnosis of scleroderma was confirmed by an expert rheumatologist. The BE diagnosis was confirmed by an expert gastrointestinal pathologist. RESULTS: There were 235 women with SSc who underwent EGD. High-resolution manometry (HRM) was completed in 172 patients. Women with SSc with BE were significantly more likely to have scleroderma esophagus (absent contractility with hypotensive lower esophageal sphincter) on HRM than women with SSc without BE (P = 0.018). There were 30 patients with SSc (12.8%) with histologically proven BE. Dysplasia was found in 13 (43.3%): 4 with indefinite, 7 with low grade, and 2 with adenocarcinoma. The incidence of any dysplasia was 5.3% per year (0.9% per year for adenocarcinoma). DISCUSSION: This the largest study on prevalence of BE in women with SSc, yielding a prevalence of 12.8%. Women with SSc with BE were significantly more likely to have absent contractility with hypotensive lower esophageal sphincter findings on HRM. The high prevalence and incidence of dysplasia found suggest that women with SSc should be included in the screening recommendations for BE.
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Trastornos de Deglución/epidemiología , Esclerodermia Sistémica/epidemiología , Adulto , Anciano , Esófago de Barrett , Comorbilidad , Femenino , Humanos , Incidencia , Manometría , PrevalenciaRESUMEN
INTRODUCTION: Uncontrolled results suggest that diaphragmatic breathing (DB) is effective in gastroesophageal reflux disease (GERD) but the mechanism of action and rigor of proof is lacking. This study aimed to determine the effects of DB on reflux, lower esophageal sphincter (LES), and gastric pressures in patients with upright GERD and controls. METHODS: Adult patients with pH proven upright GERD were studied. During a high-resolution impedance manometry, study patients received a standardized pH neutral refluxogenic meal followed by LES challenge maneuvers (Valsalva and abdominal hollowing) while randomized to DB or sham. After that, patients underwent 48 hours of pH-impedance monitoring, with 50% randomization to postprandial DB during the second day. RESULTS: On examining 23 patients and 10 controls, postprandial gastric pressure was found to be significantly higher in patients compared with that in controls (12 vs 7 mm Hg, P = 0.018). Valsalva maneuver produced reflux in 65.2% of patients compared with 44.4% of controls (P = 0.035). LES increased during the inspiratory portion of DB (42.2 vs 23.1 mm Hg, P < 0.001) in patients and healthy persons. Postprandial DB reduced the number of postprandial reflux events in patients (0.36 vs 2.60, P < 0.001) and healthy subjects (0.00 vs 1.75, P < 0.001) compared with observation. During 48-hour ambulatory study, DB reduced the reflux episodes on day 2 compared with observation on day 1 in both the patient and control groups (P = 0.049). In patients, comparing DB with sham, total acid exposure on day 2 was not different (10.2 ± 7.9 vs 9.4 ± 6.2, P = 0.804). In patients randomized to DB, esophageal acid exposure in a 2-hour window after the standardized meal on day 1 vs day 2 reduced from 11.8% ±6.4 to 5.2% ± 5.1, P = 0.015. DISCUSSION: In patients with upright GERD, DB reduces the number of postprandial reflux events pressure by increasing the difference between LES and gastric pressure. These data further encourage studying DB as therapy for GERD.
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Ejercicios Respiratorios/métodos , Esfínter Esofágico Inferior/fisiopatología , Reflujo Gastroesofágico/terapia , Estómago/fisiopatología , Adulto , Anciano , Estudios de Casos y Controles , Monitorización del pH Esofágico , Femenino , Reflujo Gastroesofágico/fisiopatología , Humanos , Masculino , Manometría , Persona de Mediana Edad , Periodo Posprandial , Presión , Sedestación , Posición Supina , Maniobra de ValsalvaRESUMEN
BACKGROUND: Gastroparesis is a heterogeneous disorder. Patient characteristics and treatment responsiveness may differ based on the extent of delay in gastric emptying. AIMS: Characterize gastroparesis patients based on the degree of delay in gastric emptying, and assess the relationship of patient demographics, symptoms and response to therapy based on the extent of delay. METHODS: 1333 solid-phase 4-h scintigraphic gastric emptying scans were reviewed. Delayed emptying was categorized on percent retention at 4 h: mild (10-19%), moderate (20-29%), and severe (≥ 30%). Analyses were performed with regard to demographics, symptoms, esophagogastroduodenoscopy findings, medication use, and emergency department (ED) visits/hospitalizations. RESULTS: 284 patients had delayed gastric emptying: mild (42.6%), moderate (19.3%), and severe (37.3%). 79.5% were women, the mean age was 45 years (± 15), and mean symptom duration was 4.6 years (± 6.5). The main categories of gastroparesis were idiopathic and diabetes mellitus. The most commonly prescribed medications were metoclopramide, domperidone and erythromycin. Opiate use (n = 69) was associated with an increased degree of delayed gastric emptying (p = 0.03) with 50% of opiate users having very delayed gastric emptying. One-way analysis revealed that severely delayed gastric emptying correlated with both increased hospitalizations and ED visits. CONCLUSIONS: Severe delay in gastric emptying is a risk factor for increased hospitalizations and ED visits. Opiate use correlates with increased severity of gastric emptying. Identifying at-risk patients, stopping opioids, and instituting a programmatic care plan for patients with severely delayed gastric emptying may reduce ED visits, hospitalizations, and healthcare costs.
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Efectos Colaterales y Reacciones Adversas Relacionados con Medicamentos/diagnóstico por imagen , Vaciamiento Gástrico/fisiología , Gastroparesia/diagnóstico por imagen , Gastroparesia/tratamiento farmacológico , Índice de Severidad de la Enfermedad , Adulto , Analgésicos Opioides/efectos adversos , Antieméticos/efectos adversos , Efectos Colaterales y Reacciones Adversas Relacionados con Medicamentos/metabolismo , Femenino , Gastroparesia/metabolismo , Humanos , Masculino , Persona de Mediana Edad , Cintigrafía/métodos , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
INTRODUCTION: Biliary strictures are a common complication of donation after circulatory death (DCD) liver transplantation (LT) and require multiple endoscopic retrograde cholangiopancreatography (ERCP) procedures. Three classification systems, based on cholangiograms, have been proposed for categorizing post-LT biliary strictures. We examined the interobserver agreement for each of the three classifications. METHODS: DCD LT recipients from 2012 through March 2017 undergoing ERCP for biliary strictures were included in the study. Initial cholangiograms delineating the entire biliary tree prior to endoscopic intervention were selected. One representative cholangiogram was selected from each ERCP. Five interventional endoscopists independently viewed each anonymized cholangiogram and classified the post-LT stricture according to each of the three classification systems. The Ling classification proposes four types of post-LT strictures based on their location. The Lee classification proposes four classes based on location and number of intrahepatic strictures. The binary system classifies strictures into anastomotic or non-anastomotic types. The Krippendorff's alpha reliability estimate was used to grade the strength of agreement as "poor," "fair," "moderate," "good," or "excellent" for values between 0-0.20, 0.21-0.4, 0.41-0.6, 0.61-0.08, and 0.81-1, respectively. RESULTS: One hundred DCD LT recipients (age 57.07 ± 8.8 years; 71 males) were initially evaluated. Of these, 49 patients who underwent 206 ERCP procedures for biliary strictures were included in the analysis. One hundred thirty-nine cholangiograms were selected and subsequently classified by five endoscopists. Interobserver agreement for post-LT biliary strictures was 0.354 for Ling classification (fair agreement), 0.405 for Lee classification (fair agreement), and 0.421 for the binary classification (moderate agreement). The binary classification provided the least amount of detail regarding the location and number of biliary strictures. DISCUSSION: The currently available classification systems for assessing post-LT biliary strictures have sub-optimal interobserver agreement. A better-designed classification system is needed for categorizing post-LT biliary strictures.
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Sistema Biliar/diagnóstico por imagen , Trasplante de Hígado/clasificación , Choque/clasificación , Choque/diagnóstico por imagen , Obtención de Tejidos y Órganos/clasificación , Anciano , Colangiografía/clasificación , Colangiografía/tendencias , Femenino , Humanos , Trasplante de Hígado/tendencias , Masculino , Persona de Mediana Edad , Variaciones Dependientes del Observador , Estudios Retrospectivos , Obtención de Tejidos y Órganos/tendenciasRESUMEN
BACKGROUND: Accurately diagnosing gastroparesis relies upon gastric emptying scintigraphy (GES) being performed correctly. Jointly published protocol guidelines have long been available; however, the extent to which practitioners adhere to these guidelines is unknown. AIMS: This study aimed to assess national compliance with established GES protocol guidelines. METHODS: We developed a questionnaire addressing the key protocol measures outlined in the Consensus Recommendations for Gastric Emptying Scintigraphy. Survey questions addressed patient information collection (15), patient preparation and procedure protocol (16), meal content and preparation (7), imaging (3), interpretation (4), reporting (7), and institutional demographic data (7). The anonymous questionnaire was distributed electronically to members of the Society of Nuclear Medicine and Medical Imaging (SNMMI) and non-member recipients of the SNMMI daily email newsletter. One response per medical institution was permitted. RESULTS: A total of 121 out of 872 potential medical institutions (MI) responded (13.9%); 49 (40.4%) were academic/teaching medical centers. The annual number (mean) of GES procedures was 199.9 (range 5-2000 GES/year). On average, MI performed 33.5/52 (64%) of protocol measures according to guidelines while academic medical centers performed 31.5/52 (61%) of protocol measures according to guidelines. Only 4 out of 88 MI (4.5%) performed GES while adhering to three critical measures: validated study duration; controlled blood glucose levels; and proper restriction of medications. CONCLUSIONS: Low compliance with GES protocol guidelines, even among academic medical centers, raises the likely possibility of misdiagnosis and improper management of upper gastrointestinal symptoms. These results highlight a need for increased awareness of protocol guidelines for gastric scintigraphy.
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Protocolos Clínicos/normas , Vaciamiento Gástrico , Gastroparesia , Guías de Práctica Clínica como Asunto , Cintigrafía/métodos , Estómago/diagnóstico por imagen , Errores Diagnósticos/prevención & control , Gastroparesia/diagnóstico , Gastroparesia/epidemiología , Gastroparesia/fisiopatología , Adhesión a Directriz , Necesidades y Demandas de Servicios de Salud , Humanos , Utilización de Procedimientos y Técnicas , Garantía de la Calidad de Atención de Salud/métodos , Encuestas y Cuestionarios , Estados Unidos/epidemiologíaRESUMEN
Up to 90% of patients with systemic sclerosis (SSc) develop gastrointestinal (GI) symptoms. To evaluate whether GI symptoms and quality of life in patients with SSc demonstrate longitudinal stability. Consecutive patients with SSc (n = 100) completed the validated university of California at Los Angeles scleroderma clinical trial consortium gastrointestinal tract 2.0 (GIT) instrument and completed the same instrument approximately 5 years later. Comparison was made between patients with diffuse (dcSSc) and limited (lcSSc) subtypes and duration of disease of less than or greater than 5 years. GIT scores were calculated and analyzed for differences. 37 patients with dcSSc and 63 patients with lcSSc were included. Social functioning score significantly improved over time [0.44 (0.59)-0.31 (0.47); P = 0.003]. Total GIT scores were lower in patients with diffuse [0.51 (0.41)] compared with limited [(0.72 (0.53); P = 0.029] disease at both baseline and follow-up. Social functioning improved similarly in both dcSSc and lcSSc over time (P = 0.004). GIT Total scores increased in 27% (27/100) of patients and did not change or improved in 73% (73/100). Patients with worsening GI status had significantly increased scores on all GIT subscales. A lower body-mass index at baseline was significantly associated with worsening GIT Total score (OR 1.22; 95% CI 1.07-1.39; P < 0.001). Patients with SSc generally demonstrate longitudinal stability or improvement in their GI symptoms, but a subset of patients experience worsening of GI symptoms and negative impacts on GI-related quality of life.
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Estreñimiento/fisiopatología , Diarrea/fisiopatología , Reflujo Gastroesofágico/fisiopatología , Tracto Gastrointestinal/fisiopatología , Calidad de Vida , Esclerodermia Sistémica/fisiopatología , Interacción Social , Anciano , Estreñimiento/complicaciones , Diarrea/complicaciones , Progresión de la Enfermedad , Femenino , Reflujo Gastroesofágico/complicaciones , Humanos , Masculino , Persona de Mediana Edad , Esclerodermia Sistémica/complicacionesRESUMEN
INTRODUCTION: Normal response to multiple rapid swallows (MRS) during high-resolution esophageal manometry is deglutitive inhibition; opioids may interfere with this. The aim of this study was to evaluate the response to MRS in patients on opioids, not on opioids, and healthy controls. METHODS: Response to MRS was evaluated for complete vs impaired inhibition in 72 chronic opioid users, 100 patients not on opioids, and 24 healthy controls. RESULTS: Impaired deglutitive inhibition was significantly more frequent in chronic opioid users compared with patients not on opioids and healthy controls (54% vs 14% vs 0%; P < 0.0001). DISCUSSION: Impaired deglutitive inhibition during MRS is frequent in opioid users, supporting that opioids interfere with esophageal inhibitory signals.
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Analgésicos Opioides/administración & dosificación , Deglución/efectos de los fármacos , Adulto , Estudios de Casos y Controles , Femenino , Humanos , Masculino , Manometría , Persona de Mediana EdadRESUMEN
INTRODUCTION: Esophageal dysmotility including features of achalasia may develop because of bariatric surgery. However, the prevalence of these complications is unknown. We sought to define the prevalence of dysphagia and major esophageal motility disorders including achalasia after bariatric surgery through a large retrospective database review. METHODS: Patients with a history of laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass who underwent a diagnostic high-resolution impedance manometry (HRIM) either before or after bariatric surgery across 3 large tertiary referral sites from June 2012 through February 2019 were identified from a procedural database. HRIM studies were interpreted per the Chicago classification v3.0 by a blinded investigator (K.R.). Demographic/clinical features were collected. In addition, patients who underwent bariatric surgery from January 2014 to April 2015 were contacted and administered a validated symptom assessment survey to gauge the overall prevalence of dysphagia in a postbariatric population. RESULTS: A total of 137 patients were identified, including 97 who underwent HRIM after bariatric surgery (laparoscopic sleeve gastrectomy [n = 39, 40.1%]; Roux-en-Y gastric bypass [n = 58, 59.8%]) at a median of 5.84 years (interquartile range 2.1-12.5) postoperatively and 40 preoperative bariatric surgery candidates with medically complicated obesity. A manometric pattern consistent with achalasia was identified in 7 (7.2%) postsurgical patients compared with none in the preoperative group (P = 0.08). We further identified a separate achalasia-like pattern defined by aperistalsis and increased intragastric pressure (postobesity surgery esophageal dysfunction [POSED]) in 5 (5.2%) postsurgical patients vs none found preoperatively (P = 0.14). Achalasia or POSED was associated with postbariatric surgery (12.4% vs 0%, P = 0.02). Increasing time since surgery was independently associated with the development of achalasia (median 12.5 vs 5.8 years, P = 0.02), POSED (median 15.0 vs 5.8 years, P = 0.02) and major motility disorders (6.6 vs 4.9 years, P = 0.01). Furthermore, among 271 postbariatric surgery patients contacted for symptom assessment via survey, the prevalence of dysphagia was 13.7% at a mean 3.9 years after surgery. DISCUSSION: Postoperative dysphagia is a common long-term complication of bariatric surgery. This is potentially the consequence of a time-dependent association with the development of postoperative esophageal dysmotility, particularly achalasia and POSED. Consequently, esophageal dysmotility may be an important under-recognized complication of bariatric surgery.
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Acalasia del Esófago/epidemiología , Trastornos de la Motilidad Esofágica/epidemiología , Obesidad Mórbida/cirugía , Complicaciones Posoperatorias/epidemiología , Adulto , Anciano , Cirugía Bariátrica , Estudios Transversales , Trastornos de Deglución/epidemiología , Trastornos de Deglución/fisiopatología , Acalasia del Esófago/fisiopatología , Trastornos de la Motilidad Esofágica/fisiopatología , Femenino , Gastrectomía , Derivación Gástrica , Humanos , Masculino , Manometría , Persona de Mediana Edad , Complicaciones Posoperatorias/fisiopatología , Periodo Preoperatorio , Presión , Prevalencia , Estudios Retrospectivos , Factores de Tiempo , Adulto JovenRESUMEN
OBJECTIVES: Symptoms are inconsistently associated with esophageal motor findings on high-resolution manometry (HRM). We aimed to evaluate predictors of dysphagia severity, including esophageal hypervigilance and visceral anxiety, among patients evaluated with HRM. METHODS: Adult patients undergoing HRM at 4 academic medical centers (United States and France) were prospectively evaluated. HRM was completed and analyzed per the Chicago Classification v3.0. Validated symptom scores, including the Brief Esophageal Dysphagia Questionnaire and Esophageal Hypervigilance and Anxiety Scale, were completed at the time of HRM. RESULTS: Two hundred thirty-six patients, aged 18-85 (mean 53) years, 65% female, were included. Approximately 59 (25%) patients had a major motor disorder on HRM: 19 achalasia, 24 esophagogastric junction outflow obstruction, 12 absent contractility, and 4 jackhammer. Approximately 177 (75%) patients did not have a major motor disorder: 71 ineffective esophageal motility and 106 normal motility. Having a major motor disorder was a significant predictor of dysphagia severity (Radj = 0.049, P < 0.001), but the Esophageal Hypervigilance and Anxiety Scale score carried a predictive relationship of Brief Esophageal Dysphagia Questionnaire that was 2-fold higher than having a major motor disorder: Radj = 0.118 (P < 0.001). This finding remained when evaluated by the major motor disorder group. HRM metrics were nonsignificant. DISCUSSION: In a prospective, international multicenter study, we found that esophageal hypervigilance and visceral anxiety were the strongest predictors of dysphagia severity among patients evaluated with HRM. Thus, an assessment of esophageal hypervigilance and visceral anxiety is important to incorporate when evaluating symptom severity in clinical practice and research studies.
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Ansiedad/fisiopatología , Trastornos de Deglución/diagnóstico , Trastornos de la Motilidad Esofágica/diagnóstico , Manometría/métodos , Índice de Severidad de la Enfermedad , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Ansiedad/diagnóstico , Trastornos de Deglución/etiología , Trastornos de Deglución/psicología , Trastornos de la Motilidad Esofágica/etiología , Trastornos de la Motilidad Esofágica/psicología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Factores de Riesgo , Adulto JovenRESUMEN
GOALS AND BACKGROUND: Baseline impedance measured during high-resolution impedance manometry (HRIM) can distinguish patients with gastroesophageal reflux disease (GERD) from controls, presumably due to differences in esophageal acid exposure. The characteristics of regurgitation and reflux in rumination syndrome and GERD are very different, and thus we investigated whether baseline esophageal impedance would differ in these 2 patient groups compared with controls. STUDY: We compared 20 patients with rumination syndrome with 20 patients who had GERD and 40 controls. Baseline impedance was measured over 15 seconds during the landmark period of HRIM in all 18 impedance sensors on a HRIM catheter. RESULTS: The mean distal baseline impedance measured in ohms during HRIM was 1336 Ω [95% confidence interval (CI)=799, 1873) in patients with GERD, 1536 Ω in rumination syndrome (95% CI=1012, 2061), and 3379 Ω in controls (95% CI=2999, 3759) (P<0.0001). Proximal impedance was significantly lower in the GERD and rumination groups compared with controls; rumination syndrome (2026; 95% CI=1493, 2559 Ω), GERD (2572; 95% CI=2027, 3118 Ω), and controls (3412; 95% CI=3026, 3798 Ω) (P<0.001). CONCLUSIONS: Baseline impedance measured during HRIM in patients with rumination syndrome is significantly lower than controls and appears similar to patients with GERD both in the proximal and distal esophagus. These findings suggest that the postprandial regurgitation in rumination syndrome alters both the distal and proximal esophageal mucosal barrier.
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Impedancia Eléctrica , Reflujo Gastroesofágico/fisiopatología , Manometría/estadística & datos numéricos , Síndrome de Rumiación/fisiopatología , Adulto , Esófago/fisiopatología , Femenino , Humanos , Masculino , Manometría/métodos , Persona de Mediana Edad , Periodo Posprandial , Valores de Referencia , Adulto JovenRESUMEN
Distal esophageal spasm (DES) is a motility disorder characterized by premature contraction of the esophageal body during single swallows. It is thought to be due to impairment of esophageal inhibitory pathways, but studies to support this are limited. The normal response to multiple rapid swallows (MRS) is deglutitive inhibition of the esophageal body during the MRS sequence. Our aim was to compare the response to MRS in DES patients and healthy control subjects. Response to MRS during HRM was evaluated in 19 DES patients (8 with and 11 without concomitant esophagogastric junction outflow obstruction [EGJOO]) and 24 asymptomatic healthy controls. Patients with prior gastroesophageal surgery, peroral endoscopic myotomy, pneumatic dilation, esophageal botulinum toxin injection within 6 months of HRM, opioid medication use, and esophageal stricture were excluded. Response to MRS was evaluated for complete versus impaired inhibition (esophageal body contractility with distal contractile integral [DCI] > 100 mmHg-sec-cm during MRS), presence of post-MRS contraction augmentation (DCI post MRS greater than single swallow mean DCI), and integrated relaxation pressure (IRP). Impaired deglutitive inhibition during MRS was significantly more frequent in DES compared to controls (89% vs. 0%, P < 0.001), and frequency was similar for DES with versus without concomitant EGJOO (100% vs. 82%, P = 0.48). The proportion of subjects with augmentation post MRS was similar for both groups (37% vs. 38%, P = 1.00), but mean DCI post MRS was higher in DES than controls (3360.0 vs. 1238.9, P = 0.009). IRP was lower during MRS compared to single swallows in all patients, and IRP during MRS was normal in 5 of 8 patients with DES and EGJOO. Our study suggests that impaired deglutitive inhibition during MRS is present in the majority of patients with DES regardless of whether they have concomitant EGJOO, and future studies should explore the usefulness of incorporating response to MRS in the diagnosis of DES.
Asunto(s)
Trastornos de la Motilidad Esofágica , Espasmo Esofágico Difuso , Espasmo Esofágico Difuso/complicaciones , Unión Esofagogástrica , Humanos , Manometría , Estudios RetrospectivosRESUMEN
OBJECTIVE: Data regarding opioid effects on esophageal function are limited. We previously demonstrated an association between chronic opioid use and esophageal motor dysfunction characterized by esophagogastric junction outflow obstruction, distal esophageal spasm, achalasia type III, and possibly Jackhammer esophagus. Our aim was to characterize the influence of different opioids and doses on esophageal dysfunction. METHODS: Retrospective review of 225 patients prescribed oxycodone, hydrocodone, or tramadol for >3 months, who completed high-resolution manometry from 2012 to 2017. Demographic and manometric data were extracted from a prospectively maintained motility database. Frequency of opioid-induced esophageal dysfunction (OIED, defined as distal esophageal spasm, esophagogastric junction outflow obstruction, achalasia type III, or Jackhammer esophagus on high-resolution manometry, was compared among different opioids. The total 24-hour opioid doses for oxycodone, hydrocodone, and tramadol were converted to a morphine equivalent for dose effect analysis. RESULTS: OIED was present in 24% (55 of 225) of opioid users. OIED was significantly more prevalent with oxycodone or hydrocodone use compared with tramadol (31% vs 28% vs 12%, P = 0.0162), and for oxycodone alone vs oxycodone with acetaminophen (43% vs 21%, P = 0.0482). There was no difference in OIED for patients taking hydrocodone alone vs hydrocodone with acetaminophen. Patients with OIED were taking a higher median 24-hour opioid dose than those without OIED (45 vs 30 mg, P = 0.058). DISCUSSION: OIED is more prevalent in patients taking oxycodone or hydrocodone compared with tramadol. There is greater likelihood of OIED developing with higher doses. Reducing the opioid dose or changing to tramadol may reduce OIED in opioid users.
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Analgésicos Opioides/efectos adversos , Acalasia del Esófago/inducido químicamente , Espasmo Esofágico Difuso/inducido químicamente , Dolor Abdominal/tratamiento farmacológico , Adulto , Anciano , Analgésicos Opioides/administración & dosificación , Artralgia/tratamiento farmacológico , Dolor de Espalda/tratamiento farmacológico , Relación Dosis-Respuesta a Droga , Acalasia del Esófago/fisiopatología , Enfermedades del Esófago/inducido químicamente , Enfermedades del Esófago/fisiopatología , Espasmo Esofágico Difuso/fisiopatología , Unión Esofagogástrica/fisiopatología , Femenino , Humanos , Hidrocodona/administración & dosificación , Hidrocodona/efectos adversos , Masculino , Manometría , Persona de Mediana Edad , Oxicodona/administración & dosificación , Oxicodona/efectos adversos , Estudios Retrospectivos , Tramadol/administración & dosificación , Tramadol/efectos adversosRESUMEN
BACKGROUND AND AIMS: There is controversy about finding intestinal metaplasia (IM) of the gastric cardia on biopsy. The most recent American College of Gastroenterology guideline comments that IM cardia is not more common in patients with Barrett's esophagus (BE). It provides limited guidance on whether the cardia should be treated when patients with BE undergo endoscopic eradication therapy (EET) and whether the cardia should undergo biopsy after ablation. The aims of our study were to determine the frequency in the proximal stomach of (1) histologic gastric cardia mucosa and (2) IM cardia. A third aim was to explore the frequency of advanced pathology (dysplasia and adenocarcinoma) in the cardia after patients with BE have undergone EET. METHODS: Consecutive patients undergoing esophagogastroduodenoscopy between January 2008 and December 2014 who had proximal stomach biopsies were included. Patients who had histologically confirmed BE were compared with those without BE. RESULTS: Four hundred sixty-two patients, 289 with BE and 173 without BE, were included. Histologically confirmed cardiac mucosa was found in 81.6% of all patients. This was more frequent in those with versus without BE (86% vs 75%; odds ratio [OR], 2.06; 95% confidence interval [CI], 1.28-3.32; P = .003). IM cardia was more common in the BE group (17% vs 7%; OR, 2.67; 95% CI, 1.38-5.19; P = .004). Advanced pathology was more likely in the patients with BE who had undergone EET. CONCLUSIONS: Cardiac mucosa is present in most patients who undergo endoscopy for upper GI symptoms. IM cardia is more common in patients with BE than those without. Advanced histologic changes in the cardia were seen only in the subgroup of patients with BE who had undergone EET.
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Adenocarcinoma/patología , Esófago de Barrett/patología , Cardias/patología , Mucosa Gástrica/patología , Neoplasias Gástricas/patología , Adenocarcinoma/diagnóstico por imagen , Adenocarcinoma/epidemiología , Anciano , Esófago de Barrett/diagnóstico por imagen , Esófago de Barrett/epidemiología , Esófago de Barrett/cirugía , Cardias/diagnóstico por imagen , Endoscopía del Sistema Digestivo , Femenino , Mucosa Gástrica/diagnóstico por imagen , Humanos , Masculino , Metaplasia/diagnóstico por imagen , Metaplasia/epidemiología , Metaplasia/patología , Imagen de Banda Estrecha , Neoplasias Gástricas/diagnóstico por imagen , Neoplasias Gástricas/epidemiologíaRESUMEN
GOALS: To assess the effect of unilateral versus bilateral lung transplantation (LTx) on esophageal motility and gastroesophageal reflux, and the association with the development of obstructive chronic lung allograft dysfunction (o-CLAD). BACKGROUND: We have shown that esophagogastric junction outflow obstruction, incomplete bolus transit, and proximal reflux are all independent risk factors for the development of chronic allograft failure. However, it remains unclear whether these factors are influenced by the type of surgery and how this relates to allograft failure. STUDY: Patients post-LTx (n=48, 24 female; aged 20 to 73 y) completed high-resolution impedance manometry and 24-hour pH/impedance. RESULTS: Patients who had undergone unilateral LTx were more likely to exhibit esophagogastric junction outflow obstruction (47% vs. 18%; P=0.046) and less likely to exhibit hypocontractility (0% vs. 21%; P=0.058) than those who had undergone bilateral LTx. Although the proportion of patients exhibiting gastroesophageal reflux was no different between groups (33% vs. 39%; P=0.505), those undergoing bilateral LTx were more likely to exhibit proximal reflux (8% vs. 37%; P=0.067). Univariate Cox proportion hazards regression analysis did not show a difference between unilateral versus bilateral LTx in the development of o-CLAD (hazard ratio=1.17; 95% confidence interval, 0.48-2.85; P=0.723). CONCLUSION: The type of LTx performed seems to lead to different risk factors for the development of o-CLAD. Physicians should be aware of these differences, as they may need to be taken into account when managing patient's post-LTx.
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Trastornos de la Motilidad Esofágica/epidemiología , Reflujo Gastroesofágico/epidemiología , Rechazo de Injerto/epidemiología , Trasplante de Pulmón/efectos adversos , Adulto , Anciano , Trastornos de la Motilidad Esofágica/fisiopatología , Unión Esofagogástrica/fisiopatología , Femenino , Reflujo Gastroesofágico/fisiopatología , Rechazo de Injerto/etiología , Humanos , Masculino , Manometría , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Adulto JovenRESUMEN
BACKGROUND: The GCSI questionnaire measures symptoms of gastroparesis (GP). Symptoms of FD overlap with GP. The ability of the GCSI to discriminate FD from GP is unknown. AIMS: By prospectively evaluating functional dyspepsia (FD) patients, we aimed to evaluate the ability of the Gastroparesis Cardinal Symptom Index (GCSI) to: (1) distinguish FD from GP; (2) predict symptom severity, anxiety, and depression; (3) correlate symptoms with gastric emptying. METHODS: FD patients (Rome III criteria) were identified, and upper endoscopy and gastric emptying scan (GES) data recorded. A total of 254 patients were mailed a questionnaire evaluating demographics, FD symptoms, mental well-being; the GCSI was included. RESULTS: One hundred and twenty-three patients responded; of them, 75% were women and mean age was 49 (15 SD) years. 44.7% were categorized as postprandial distress subtype (PDS), 34.1% were epigastric pain subtype (EPS), and 21.1% were mixed type. The mean GCSI score was 2.02 (1.1 SD), slightly lower than historical GP controls (2.26-2.56). Mixed EPS-PDS subtype had the lowest GCSI scores (1.79; 0.91 SD). Bloating was the highest GCSI subscore (2.70; 1.53 SD), followed by fullness (2.31; 1.39 SD) and nausea (1.08; 1.19 SD). The GCSI total score did not correlate with anxiety and depression scores or with 4-h gastric emptying. CONCLUSIONS: In this population of FD patients, GCSI scores were slightly lower than historical gastroparesis control patients, although within the reported range. These results suggest that the GCSI cannot accurately distinguish FD patients from GP patients. A more specific questionnaire is needed to aid in the diagnosis and management of these distinct gastrointestinal disorders.