The dose of omeprazole required to achieve adequate intraesophageal acid suppression in patients with gastroesophageal junction specialized intestinal metaplasia and Barrett's esophagus.

BACKGROUND: The mainstay of medical therapy for Barrett's esophagus is normalization of esophageal acid exposure with proton pump inhibitors (PPIs). However, the optimal dose and whether once daily or twice daily is required for acid suppression is unknown. AIM: The purpose of this study was to assess whether adequate intra-esophageal acid suppression could be achieved with once daily versus twice daily omeprazole in patients with gastroesophageal specialized intestinal metaplasia (GEJSIM), short-segment (SSBE) and long-segment Barrett's esophagus (LSBE). METHODS: Patients with GEJSIM and Barrett's esophagus underwent upper endoscopy with 48-h wireless pH capsule while on once daily 20 mg omeprazole for at least 1 week. If intra-esophageal acid was not adequately controlled, defined as pH value <4 for greater than 4.2 % of the time during the second 24-h period, omeprazole was increased to twice daily for 1 week and upper endoscopy with wireless pH capsule was repeated. RESULTS: A total of 36 patients completed the study (10 patients had GEJSIM, 16 patients had SSBE, and 10 patients had LSBE). Normalization of intraesophageal pH was achieved in 28 patients (78 %) with once daily PPI and eight patients required twice daily PPI. There was no significant difference between the three groups in the proportion of patients requiring high dose PPI (GEJSIM 10 %, SSBE 25 %, LSBE 30 %, p = 0.526). CONCLUSIONS: The majority of patients with Barrett's esophagus were controlled with once daily low dose PPI and only a minority required twice daily dosing, regardless of the length of Barrett's mucosa.

Can quality of care for patients with cirrhosis be measured?

INTRODUCTION: The ultimate purpose of measuring quality of care is to discriminate between healthcare providers in order to motivate improvement. Recently, a set of evidence-based indicators has been proposed for measurement of processes of care for patients with cirrhosis, for example early endoscopy for variceal bleeding. The objective of this study was to determine whether these indicators can be measured in a reliable and automated fashion in routine practice. MATERIALS AND METHODS: We applied the top five indicators, based on agreement of a panel of experts, to hospitalized adults at our institution over a 3-year period. RESULTS: Only two of the indicators could be reliably measured on the basis of the published wording, and these two still required physician chart review. After applying some assumptions, the indicators were met in 46-100% of cases. None of the indicators was linked to a single physician or institution in all cases, and none occurred with sufficient frequency to discriminate quality between providers. CONCLUSION: Measuring quality of care in cirrhosis is a laudable objective, but current indicators are not yet ready for administrative use.

Esophageal motor disorders in adults with eosinophilic esophagitis.

BACKGROUND: An association between eosinophilic esophagitis (EoE) and esophageal motility disorders has been described in small studies. AIMS: The aim of this study was to describe the prevalence of esophageal motor disorders in a large cohort of adults with EoE and examine whether an association exists between esophageal dysmotility and dysphagia. METHODS: A retrospective review of esophageal manometry studies in adult EoE patients was performed. Tracings were reviewed for abnormalities including nutcracker esophagus and ineffective swallows, defined as low amplitude peristalsis (<30 mmHg) or non-propagating contractions. Ineffective esophageal motility (IEM) was categorized as mild (30-40% ineffective swallows), moderate (50-60% ineffective swallows), and severe (≥70% ineffective swallows). Dysphagia was graded on a 0-3 scale for frequency and severity. RESULTS: Seventy-five tracings from EoE patients were reviewed (85% male, mean age 41 ± 12 years). IEM was identified in 25 patients and categorized as mild (n = 13), moderate (n = 6), and severe (n = 6). Nutcracker esophagus was found in three patients. There was no significant difference in eosinophil count among the motility groups: normal 46.5 ± 3.1, mild IEM 56.9 ± 36.9, moderate IEM 45.5 ± 23.7, severe IEM 34.3 ± 12.6 (P = 0.157). CONCLUSIONS: In this cohort of EoE patients, the majority had normal esophageal motility studies, although a subset of these patients had some esophageal dysmotility. It is unlikely that esophageal dysmotility is a major contributing factor to dysphagia, although it is reasonable to consider esophageal manometry testing in EoE patients to identify potential abnormalities of the smooth muscle esophagus.

Exercise-associated hyponatremia: the influence of pre-exercise carbohydrate status combined with high volume fluid intake on sodium concentrations and fluid balance.

To evaluate the effect of hydration and carbohydrate (CHO) status on plasma sodium, fluid balance, and regulatory factors (IL-6 & ADH) during and after exercise; 10 males completed the following conditions: low CHO, euhydrated (fluid intake = sweat loss) (LCEH); low CHO, dehydrated (no fluid) (LCDH); high CHO, euhydrated (HCEH); and high CHO, dehydrated (HCDH). Each trial consisted of 90-min cycling at 60% VO(2) max in a 35°C environment followed by 3-h rehydration (RH). During RH, subjects received either 150% of sweat loss (LCDH & HCDH) or an additional 50% of sweat loss (LCEH and HCEH). Blood was analyzed for glucose, IL-6, ADH, and Na(+). Post-exercise Na(+) was greater (p < 0.001) for LCDH and HCDH (141.7 + 0.72 and 141.6 + 0.4 mM) versus LCEH and HCEH (136.4 + 0.6 and 135.9 + 0.3 mM). Post-exercise IL-6 was similar in all conditions, and post-exercise ADH was greater (p = 0.01) in dehydrated versus euhydrated conditions. The rate of urine production was greater in HCEH (7.59 + 3.0 mL/min) compared to all other conditions (3.86 + 2.2, 5.29 + 3.1, and 2.96 + 1.1 mL/min for LCDH, LCEH, and HCDH, respectively). Despite CHO and hydration manipulations, no regulatory effects of IL-6 and ADH on plasma [Na(+)] were observed. With euhydration during exercise and additional fluid consumed during recovery, a high-CHO status increased urinary output during recovery, and it decreased the frequency of hyponatremia (Na(+) < 135 mM). Therefore, a high-CHO status may provide some protection against exercise-associated hyponatremia.

Acute liver failure in a military recruit treated with valproic acid and harboring a previously unrecognized POLG-1 mutation.

Patients with mutations in the POLG-1 gene often are afflicted with drug-resistant seizures at an early age and have an increased risk of valproic acid-induced acute liver failure. Severe valproate hepatotoxicity most commonly arises in children within the first 3 months of treatment with an overall estimated incidence of 1 in 40,000 treated patients. Due to high mortality rates among transplanted children, many experts consider valproic acid-induced acute liver failure in patients with mitochondrial disorders to be a contraindication to liver transplant. We report the successful use of liver transplantation in a young man with valproic acid-associated acute liver failure harboring a previously unrecognized POLG-1 mutation.

Colonic perforation during screening CT colonography using automated CO2 insufflation in an asymptomatic adult.

CT colonography has become a potential alternative technique to optical colonoscopy for the detection of colorectal polyps and cancer. While considered safer than optical colonoscopy, CT colonography is not without risk. We report a case of colonic perforation during CT colonography using automated CO(2) insufflation and present procedural changes to help minimize the adverse effects of perforation when it occurs.

A review of irritable bowel syndrome and an update on therapeutic approaches.

BACKGROUND: Irritable bowel syndrome is a common disorder that is associated with a significant impact on both affected individuals and society. While the pathophysiology of irritable bowel syndrome remains unknown, knowledge regarding the normal and abnormal functions of the gut and its complex interactions with the body's nervous systems continue to shed light on the multifactiorial origins of irritable bowel syndrome symptoms. OBJECTIVE: This article provides an overview of the current knowledge on the therapeutic approaches to irritable bowel syndrome. METHODS: A search of the online bibliographic databases MEDLINE and EMBASE was performed in order to identify all relevant articles published between 1980 and 2008. The search was enhanced with the use of a medical librarian. Bibliographies from potentially relevant articles were manually searched. RESULTS/CONCLUSIONS: The therapeutic options for irritable bowel syndrome are rapidly evolving beyond traditional symptom-based therapies, such as fiber, antispasmodics, antidiarrheals and laxatives and are moving towards agents with organ-specific receptor selectivity directed, in many cases, at specific gastrointestinal functions.