Management of abdominal bloating and distension, from subjective to objective.

Abdominal distension is a clinical occurrence that involves a measurable, objective increase in abdominal circumference, which patients report as feeling like pregnant or like having a balloon inside the abdomen. This sign is often preceded by a subjective feeling of abdominal heaviness or bloating, reported as the sensation of having a huge amount of gas trapped inside. These manifestations are highly prevalent and may reflect on their own a gut-brain axis condition, such as functional abdominal distension, or be part of other disorders such as functional dyspepsia or irritable bowel syndrome (IBS). The prevalence of abdominal distension and bloating is 3.5 %. However, when associated with other gut-brain axis disorders such as dyspepsia or IBS, prevalence grows above 50 %. The etiology and pathophysiology of abdominal bloating and distension are highly complex and represent a challenge for both the practitioner and the patient. The patient often associates these sensations with trapped gas, and attributes them to some food intolerance, hence he/she adopts a highly restrictive diet that fails to resolve distension while incurring the risk of nutritional deficiencies or secondary dysbiosis, making a directed treatment guideline necessary.

Study of gastroesophageal reflux. Interpretation of functional tests in the obese patient.

Overweight and obesity are a public health problem and in 1997 obesity was recognized as a global epidemic by the World Health Organization (WHO). Overweight and obesity affect almost 60% of adults and one in three children in Europe according to the most recent WHO report. Objectively, gastroesophageal reflux disease (GERD) is defined as the presence of characteristic esophageal mucosal damage assessed by endoscopy and/or the demonstra-tion of pathological acid exposure by reflux monitoring studies. The prevalence of GERD is increased in obese patients In overweight and obese patients, the clinical symptoms of GERD are especially present in the supine position and this correlates with more frequent episodes of nocturnal reflux in the 24-h pH monitoring, there is also an increase in the number of refluxes with content acid. In the population with symptoms, digestive endoscopy detects data of erosive esophagitis in 50% of patients, while 24-h pH-impedanciometry diagnoses 92% of patients with non-erosive reflux disease (NERD) The presence of persistent GERD in the mucosa affects esophageal motility and patients may develop ineffective esophageal motility-type disorders, so we will review the interpre-tation of the functional tests that determine motility, which is esophageal manometry, and those that determine reflux gastroesophageal, acid and non-acid, which is the pH measure-ment with or without 24-h impedanciometry.

Benefit of extending the protocol for high resolution manometry according to the version 4.0 of the Chicago criteria. A multicenter study.

BACKGROUND: The last version of the Chicago Criteria for high resolution esophageal manometry proposes an expanded protocol including complementary maneuvers to improve the diagnostic yield of the exploration. Our aim was to determine the diagnostic gain of the CCv4.0 protocol compared to the CCv3.0 protocol. METHODS: All manometry recordings performed in 4 reference centers during the first 10 months after the implementation of the new protocol were retrospectively reviewed. The time spent to complete the protocol was measured, and the changes in diagnosis resulting from the new CCv4.0 were compared to CCv3.0. KEY RESULTS: From a total of 756 HRM performed, 606 studies could be properly analyzed. The duration of the studies was 18.3 ± 4.3 min. From these, 11.3 ± 3.4 min were spent to complete the CCv3.0 protocol, and 7.4 ± 3.6 min were spent for the remaining maneuvers. A discordant diagnosis between CCv3.0 and CCv4.0 was obtained in 12% of patients: 32% of patients with ineffective esophageal motility turned to normal motility; 24% of patients with esophagogastric junction outlet obstruction (EGJOO) turned to a non-obstructive disorder; and 1% of patients with an apparently normal EGJ relaxation, turned to an obstructive disorder. EGJOO according to CCv4.0 was more prevalent in patients referred for dysphagia (11%) than those referred for GERD (4%; p = 0.003). CONCLUSIONS AND INFERENCES: Prolongation of the time spent to complete the CCv4.0 protocol leads to a change in the diagnosis of 12% of patients. Clinically relevant changes are mainly related to the evaluation of EGJOO.

From metastasis to the primary tumor: Giant liver metastasis from a pancreatic neuroendocrine tumor.

We present the case of a 37-years old male, who consulted for an extended history of intermittent nausea and vomiting. Laboratory tests showed moderate elevated bilirubin (1.30 mg/dL) and GGT (106 U/L). An abdominal CT scan performed showed a solid 18-centimetres (cm) mass located in the right liver lobe. A biopsy of the lesion was performed, revealing metastastic cells of a well-differentiated neuroendocrine tumour (NET, G3 (Ki-67: 25%). Further study was performed with MRI, and SPECT-CT, showing a 2-cm lesion in the pancreatic tail suggestive of being the primary NET. Chromogranin A levels were high (114.100 ng/ml). In our case, despite the large size of the liver metastasis a full resection of the tumours was achieved.

Suspected malignant degeneration in a Zenker's diverticulum: should we biopsy it?

We report the case of an 89-year-old female who presented with progressive weight loss, oropharyngeal dysphagia and food regurgitation.