Gastroesophageal reflux in patients with morbid obesity: a role of obstructive sleep apnea syndrome?

BACKGROUND: Obesity is a risk factor for gastroesophageal reflux disease (GERD) and for obstructive sleep apnea (OSA). Our aim was to evaluate in morbidly obese patients the prevalence of OSA and GERD and their possible relationship. METHODS: Morbidly obese patients [body mass index (BMI) >40 or >35 kg/m(2) in association with comorbidities] selected for bariatric surgery were prospectively included. Every patient underwent a 24-h pH monitoring, esophageal manometry, and nocturnal polysomnographic recording. RESULTS: Sixty-eight patients [59 women and 9 men, age 39.1 +/- 11.1 years; BMI 46.5 +/- 6.4 kg/m(2) (mean +/- SD)] were included. Fifty-six percent of patients had an abnormal Demester score, 44% had abnormal time spent at pH <4, and 80.9% had OSA [apnea hypopnea index (AHI) >10] and 39.7% had both conditions. The lower esophageal sphincter (LES) pressure was lower in patients with GERD (11.6 +/- 3.4 vs 13.4 +/- 3.6 mm Hg, respectively; P = 0.039). There was a relationship between AHI and BMI (r = 0.337; P = 0.005). Patients with OSA were older (40.5 +/- 10.9 vs 33.5 +/- 10.4 years; P = 0.039). GERD tended to be more frequent in patients with OSA (49.1% vs 23.1%, respectively; P = 0.089). There was no significant relationship between pH-metric data and AHI in either the 24-h total recording time or the nocturnal recording time. In multivariate analysis, GERD was significantly associated with a low LES pressure (P = 0.031) and with OSA (P = 0.045) but not with gender, age, and BMI. CONCLUSION: In this population of morbidly obese patients, OSA and GERD were frequent, associated in about 40% of patients. GERD was significantly associated with LES hypotonia and OSA independently of BMI.

An open-label study of rabeprazole in patients with Zollinger-Ellison syndrome or idiopathic gastric acid hypersecretion.

BACKGROUND: Omeprazole and lansoprazole are both of proven efficacy in the treatment of Zollinger-Ellison syndrome and idiopathic gastric acid hypersecretion. Rabeprazole, which has a similar mechanism of action, has not previously been studied in these diseases. AIM: To determine the dose of rabeprazole that decreased basal acid output to safe levels in patients with Zollinger-Ellison syndrome or idiopathic gastric acid hypersecretion. METHODS: Patients with Zollinger-Ellison syndrome or idiopathic gastric acid hypersecretion were given rabeprazole 60 mg once daily for uncomplicated disease or 40 mg twice daily for complicated disease. Doses were titrated according to response and continued for 2 years. Efficacy was assessed primarily by measuring basal acid output. RESULTS: All patients had basal acid output before the next dose controlled to <10 mmol/h either at the starting dose or after minor dose titration. Control of acid output was maintained for 2 years. Consistent with this, most patients reported few gastrointestinal symptoms. Gastric biopsy showed no enterochromaffin-like cell dysplasia or neoplasia. CONCLUSIONS: Rabeprazole was an effective and well-tolerated treatment for Zollinger-Ellison syndrome or idiopathic gastric acid hypersecretion, which reliably reduced gastric acid output to safe levels. Although a dose of 60 mg once daily was appropriate for most patients in this study, doses may need adjustment according to individual response.

[Factors of gastroesophageal acid reflux in severe obesity]. / Facteurs de reflux gastro-oesophagien acide dans l'obésité sévère.

OBJECTIVE: To study in morbid obesity the relationship between the degree of gastro-oesophageal reflux (GER) and the excess of body weight, or the related factors such as the energy intake or the fat distribution (waist-hip ratio). METHODS: In 20 morbid obese subjects (body weight: 125 +/- 32 kg) consulting in a weight-loss programme, anthropometric measurements, 3-hr oesophageal pHmetry, double isotope labelled meal for studying gastric emptying, study of gastric acid and pepsin secretions using PEG 4,000 as marker, and upper endoscopy were performed. RESULTS: Nine out of the 20 patients had more than 10 GER per 3-hr period. Seven patients had at least one GER symptom per day. In 6 patients, pH was under 4 for more than 10% of the time. The total number of GER and the number of GER of more than 5 min duration were correlated to the body mass index (P = 0.016 and P < 0.05 respectively). The number of GER was also correlated to the android type of overweight (P < 0.03). These relationships persisted when sex, age, smoking, and obesity complications (such as diabetes) were taken into account. There was a positive correlation between the number of GER and energy and lipid intake (energy intake: 3,119 +/- 1,082 kcal/day; P < 0.003 for both). The degree of GER was positively related to basal acid output (P = 0.049), and to sham feeding-stimulated acid output (P = 0.05); it was negatively related to gastric emptying half time, but was not correlated with basal or stimulated pepsin output. A relationship was found between body mass index (BMI) and gastric emptying half time for solid (P = 0.002) and liquid phases (P = 0.001). CONCLUSION: GER seems to be common in long lasting morbid obesity. The number of refluxes increased with waist/hip ratio, BMI and energy or fat intake. GER was also increased by decreased gastric emptying rate, which was in part determined by BMI. The real prevalence of GER in morbid obeses must be determined by a large prospective study.

[Female dyschesia, functional associations and pelvic disorders]. / Dyschésie féminine, associations fonctionnelles et troubles de la statique pelvienne.

OBJECTIVES: Although the usual methods of exploring anorectal disorders give information on specific aspects of defecation, they do not take into account the related effect of disorders involving the pelvic contents including the genital and urinary tract. We therefore used physical examination and global imaging to demonstrate the effect of urinary and genital anomalies in female patients with dyschesia. METHODS: A prospective study was conducted in 50 consecutive female patients (age range 21-83) who consulted for dyschesia. The following protocol was used. History taking included a search for urinary and gynaecology surgery or medical treatment and the number of pregnancies and instrumental deliveries as well as a precise scoring of defecation disorders. The general physical examination included a search for signs of prolapsus or ulcerations. A rectocolpocystogram was performed in all patients. RESULTS: There were 7 patients under 40 years of age, 25 from 41 to 61 years and 18 over 61. Urinary incontinence was the most frequent functional complaint (80%). In 92% of the patients, the rectocolpocystogram revealed associated anatomic anomalies. Dynamic stimulation was associated with cervicocystoptosis (72%), hysteroptosis (50%) and rectocele (66%). CONCLUSION: Female dyschesia is a complex phenomena involving the anatomic status of the urinary, genital and anorectal tracts. Therapeutic management should be based on a complete examination including an evaluation of the pelvic contents and the perineum.

[Role of lower digestive tract endoscopy and biopsy in inflammatory bowel diseases in adults]. / Place de l'endoscopie basse et des biopsies dans les maladies inflammatoires de l'intestin de l'adulte.

The term inflammatory bowel diseases applies to two intestinal diseases (ulcerative colitis and Crohn's disease) localized to the colon. Clinical, morphological and histological data often point to one or the other of these diseases, but they are not always distinguishable, and intermediate forms classified under one name or the other are numerous. Lower digestive tract endoscopy and biopsies are determinant (1) for the diagnosis, as they provide a precise description of the lesions for each segment and evaluate their severity; (2) to monitor the course of the disease under treatment and detect precancerous lesions.

[Release of pancreatic polypeptide in response to the intragastric administration of a meal is not different in duodenal ulcer patients and normal subjects]. / La libération de polypeptide pancréatique en réponse à l-administration intra-gastrique d'un repas n'est pas différente chez des ulcéreux duodénaux et des sujets normaux.

The high basal and meal-induced acid secretions in duodenal ulcer patients has led to the concept that vagal hyperactivity is a common factor in the pathogenesis of peptic ulcer. For these reasons, since pancreatic polypeptide secretion is known to be under vagal control, we studied the pancreatic polypeptide release after intragastric administration of two protein meals (10 and 20 g protein in 400 ml) in 18 duodenal ulcer patients and in 17 normal subjects. After a 10 g protein meal was administered, gastric pH was either maintained at pH 4.5 or allowed to decrease. The 20 g protein meal induced a higher pancreatic polypeptide release than did the 10 g protein meal (p less than 0.05): the integrated pancreatic polypeptide responses were 1.07 +/- 0.5 and 3.21 +/- 0.58 nmol/l/60 min respectively in the duodenal ulcer group and 0.46 +/- 0.21 and 2.67 +/- 0.69 nmol/l/60 min respectively in the control group. On the other hand, the responses to the two protein meals in duodenal ulcer patients were not different from those obtained in normal subjects, despite the higher meal-induced acid secretions in the duodenal ulcer group. pancreatic polypeptide increase was not larger when gastric pH was fixed than when it was allowed to decrease, 0.56 +/- 0.21 and 1.7 +/- 0.63 nmol/l/60 min respectively in normal subjects and 1.07 +/- 0.5 and 1.07 +/- 0.49 nmol/l/60 min respectively in duodenal ulcer patients.(ABSTRACT TRUNCATED AT 250 WORDS)