Clinical manifestations and treatment options in patients with cirrhosis and diabetes mellitus.

BACKGROUND: Diabetes is frequently diagnosed in patients with cirrhosis and represents an important risk factor for morbidity and mortality. Pharmacological therapy is limited due to hepatotoxicity and the risk of hypoglycemia. Investigations on medical practice in this patient population, frequency of diabetes-associated complications and the impact of quality of metabolic control are rare. AIMS AND METHODS: A retrospective analysis was performed to compare the effects of hypoglycemic treatment, the achieved glycemic control under therapy, the prevalence of typical cirrhosis-related or microangiopathic complications, and cardiovascular comorbidities between a group of diabetic patients with cirrhosis (n = 87) and a nondiabetic cirrhotic population (n = 198). RESULTS: The prevalence of diabetes in our cohort was 30.5%. Of all diabetic patients, 39.1% received therapy which might potentially result in serious side effects in patients with end-stage liver disease. The rate of ongoing alcohol abuse (28.7%) and noncompliance under medication (41.4%) was high. Only 28.7% of all diabetic subjects showed satisfactory (as defined by HbA1c ≤ 6.5%) glycemic control under therapy. Patients achieving satisfactory control experienced a lower rate of certain cirrhosis-related complications such as hepatic encephalopathy (HE) and hepatocellular carcinoma (HCC), arterial hypertension, and hypercholesterolemia. HE was significantly more frequent in diabetic than nondiabetic cirrhotic patients.

Accuracy of anorectal manometry in patients with fecal incontinence.

BACKGROUND/AIM: Patients with fecal incontinence (FI) have lower anal resting (MRP) and squeeze (MSP) pressure and an impaired sensitivity compared to healthy people. However, whether anorectal manometry (ARM) can separate precisely between health and disease is discussed controversially. The aim was to evaluate the accuracy of ARM in a huge cohort of patients and controls. METHODS: ARM was obtained in 144 controls and in 559 FI patients. MRP, MSP, and balloon volume at first perception (BVP) and urge sensation (BVU) were determined. Receiver operating curve analysis was used to determine optimal cut-offs and sensitivity, specificity and accuracy calculated. RESULTS: FI patients showed lower MRP, MSP, BVU (p < 0.001) and a higher BVP (p = 0.007). Deterioration of the ARM parameter increased with FI severity. ARM demonstrated an excellent sensitivity (91.4%) and accuracy (85.8%), but only a moderate specificity (62.5%). The sensitivity of ARM rose with FI severity. The pressure data showed higher sensitivity and accuracy than the sensory data despite comparable specificity. CONCLUSIONS: Sensitivity and accuracy of single ARM parameters is only moderate for the pressure data and poor for the sensory data. In contrast, ARM demonstrated an excellent sensitivity, a moderate specificity, and a convincing accuracy justifying its use in clinical routine.

[Laxative use and satisfaction of chronically constipated women - a survey of female patients and gastroenterologists in Germany]. / Laxanziengebrauch und Zufriedenheit chronisch obstipierter Frauen - eine Umfrage bei Patientinnen und Gastroenterologen in Deutschland.

OBJECTIVE: Data were collected concerning the patient satisfaction in the treatment of chronic constipation with laxatives. METHOD: An internet-based survey of female patients with chronic constipation and an online enquiry addressed to gastroenterologists in Germany were carried out. RESULTS: 492 female patients and 104 physicians participated in the survey. Only 20 % of the patients were currently consuming laxatives. Around one-third of those not using laxatives have had unsatisfactory experiences. Only 32 % of the participants currently taking laxatives were totally satisfied with their drugs. As a general rule several different preparations were tried. The laxatives most closely associated with satisfied patients were bisacodyl and sodium picosulfate, followed by macrogol. The main reasons for dissatisfaction were an insufficient relief of the constipation and a bloated feeling. The majority of the participants expressed an interest in new drugs for the treatment of constipation. The participating physicians stated that they saw several female patients per week who were not satisfied with their constipation treatment, but probably overestimate the proportion. CONCLUSION: The present survey shows that the majority of women suffering from constipation do not take laxatives and also that about half of them were not satisfied with the agents tried. Only about one-third of the chronic users were totally satisfied. Thus, there is a clear need for new laxatives.

[Diagnosis of oesophageal reflux by PH, impedance, and bilirubin measurement: recommendations of the German Society of Neurogastroenterology and of the working group for neurogastroenterology of the German Society for Digestive and Metabolic Diseases]. / Ösophageale Refluxdiagnostik - pH-Metrie, Impedanzmessung, Bilirubin-Messung: Empfehlungen der Deutschen Gesellschaft für Neurogastroenterologie und Motilität und der Arbeitsgruppe Neurogastroenterologie der Deutschen Gesellschaft für Verdauungs- und Stoffwechselkrankheiten.

The current recommendations on indications, technical performance, and interpretation of diagnostic techniques for oesophageal reflux update the German recommandations about 24 hour pH measurement of 2003. The recommendations encompass conventional pH measurement, wireless pH measurement, pH and impedance measurements, and bilirubin measurement (duodenogastro-oesophageal reflux).

Influence of gender and age on anorectal function: normal values from anorectal manometry in a large caucasian population.

INTRODUCTION: In the literature, data on the effects of gender and age on the pressure data of anorectal manometry differ. Possible reasons are investigation of only small numbers of healthy people and comparison of only 2 groups with large age differences. In addition, data about the influence of gender or age on anorectal sensation are sparse. Therefore, the aim of the present study was to determine the influence of gender and age on anorectal manometry in a large healthy female and male cohort spanning a great age range. METHODS: Anorectal manometry was performed in 72 women and 74 men with a median age of 64 years in both groups (ranges: women 22-90 years; men 23-88 years). We determined mean anal resting and squeeze pressure as well as minimal rectal balloon volume for perception and for urge/desire to defecate. The Mann-Whitney U test was used to analyze for gender differences, regression analysis to search for age influences. RESULTS: Squeeze pressure (p = 0.007) and perception threshold (p < 0.001) are significantly lower in females, while the mean resting pressure and urge threshold are similar in females and males. Mean resting pressure (women p < 0.0001; men p = 0.03) and mean squeeze pressure decrease (women p < 0.0001; men p = 0.004) with age. An age-related increase in sensory thresholds (= decreased rectal sensitivity) is only seen in females (perception threshold p = 0.01; urge threshold p = 0.04). CONCLUSION: Most of the parameters measured by anorectal manometry (anal canal pressure, sensory thresholds) are influenced by gender and age. Therefore, the results of anorectal manometry must be interpreted in relation to sex- and age-adapted normal values.

[Summary of the annual meeting of the German Society for Neurogastroenterology and Motility]. / Deutsche Gesellschaft für Neurogastroenterologie und Motilität e. V. - Zusammenfassung der Jahrestagung 2009.

The annual meeting of the German Society for Neurogastroenterology and Motility was held at Castle Hohenkammer from 27 (th) to 29 (th) of March 2009. A "Young Investigator Meeting" took place on Friday communicating basics about scientific work. During the two-day main symposium, basic researchers and clinical scientists from Germany, but also from Europe, USA, Australia and Egypt presented their results on studies of the function of the enteric nerve system, gastrointestinal motility, and functional disturbances of the GI tract. Basic researchers as well as clinical scientists discussed the study results. Both days included a review lecture: E. Muth (USA) talked about "The effects of stress on the GI system and its relevance for functional gastrointestinal disorders" and B. Niesler (Heidelberg) about "Serotonin receptors and irritable bowel syndrome - what are the causal relations?"

[Performance and interpretation of esophageal manometry: recommendations of the German Societies for Neurogastroenterology and Motility (DGNM), for Digestive and Metabolic Diseases (DGVS) and for General and Visceral Surgery (DGAV)]. / Durchführung und Interpretation der Osophagusmanometrie: Empfehlungen der Deutschen Gesellschaften für Neurogastroenterologie und Motilität (DGNM), für Verdauungs- und Stoffwechselerkrankungen (DGVS) und für Allgemein- und Viszeralchirurgie (DGAV).

Esophageal manometry examines the pressure profiles of the tubular esophagus and of the esophageal sphincters during resting conditions and in response to swallowing. It is regarded as the reference method for detection of esophageal motility disturbances but, up to date, performance of the procedure is not standardized among centers. This review depicts the recommendations of the German Societies for Neurogastroenterology and Motility, for Digestive and Metabolic Disturbances and for General and Visceral Surgery on indications, performance and analysis of conventional esophageal manometry. In addition to concise recommendations we give detailed background information so that the article can serve as a practical guideline for inexperienced investigators as well as an exensive review for the experienced one. Moreover, recommendations on the use of newer and/or supplementary diagnostic techniques, that is long-term and high resolution manometry as well as esophageal impedance measurements are also given.

An expert consensus definition of failure of a treatment to provide adequate relief (F-PAR) for chronic constipation - an international Delphi survey.

BACKGROUND: As treatments for constipation become increasingly available, it is important to know when to progress along the treatment algorithm if the patient is not better. AIM: To establish the definition of failure of a treatment to provide adequate relief (F-PAR) to support this management and referral process in patients with chronic constipation. METHODS: We conducted an international Delphi Survey among gastroenterologists and general practitioners with a special interest in chronic constipation. An initial questionnaire based on recognised rating scales was developed following a focus group. Data were collected from two subsequent rounds of questionnaires completed by all authors. Likert scales were used to establish a consensus on a shorter list of more severe symptoms. RESULTS: The initial focus group yielded a first round questionnaire with 84 statements. There was good consensus on symptom severity and a clear severity response curve, allowing 67 of the symptom-severity pairings to be eliminated. Subsequently, a clear consensus was established on further reduction to eight symptom statements in the final definition, condensed by the steering committee into five diagnostic statements (after replicate statements had been removed). CONCLUSIONS: We present an international consensus on chronic constipation, of five symptoms and their severities, any of which would be sufficient to provide clinical evidence of treatment failure. We also provide data representing an expert calibration of commonly used rating scales, thus allowing results of clinical trials expressed in terms of those scales to be converted into estimates of rates of provision of adequate relief.

White wine and beer induce gastro-oesophageal reflux in patients with reflux disease.

BACKGROUND: An induction of gastro-oesophageal reflux has been reported after ingestion of alcoholic beverages in healthy volunteers. However, it is unknown whether reflux in gastro-oesophageal reflux disease patients will be enhanced by the ingestion of alcoholic beverages. AIM: To investigate the effects of wine and beer on postprandial reflux in reflux patients. METHODS: Twenty-five patients (reflux oesophagitis 15, non-erosive reflux disease 10; 18 men and seven women) drank 300-mL white wine (n = 17), 500-mL beer (n = 8), or identical amounts of tap water (controls) together with a standardized meal in a randomized order. pH-measurement was carried out during three postprandial hours by pH-metry and the percentage of time pH < 4 was calculated. RESULTS: Both alcoholic beverages increased reflux compared with water [wine 23% (median), water 12%, P < 0.01; beer 25%, water 11%, P < 0.05]. Between wine and beer, no difference in reflux induction was obtained. The reflux induction was seen in patients with (23%, P < 0.01) and without reflux oesophagitis (22%, P < 0.05) and in both sexes (women 23%, men 25%, P < 0.05 each). CONCLUSIONS: Ingestion of commonly consumed alcoholic beverages such as wine and beer induces gastro-oesophageal reflux in gastro-oesophageal reflux disease patients. Therefore, these patients should be advised to avoid the intake of large amounts (> or = 300 mL) of these beverages.

The effect of decaffeination of coffee on gastro-oesophageal reflux in patients with reflux disease.

BACKGROUND: Patients with reflux disease often complain of heartburn after ingestion of coffee. Induction of gastro-oesophageal reflux has been demonstrated by pH-metry following the intake of coffee in healthy volunteers. The reflux was reduced when the coffee had undergone a decaffeination process. The aim of this study was to investigate the effect of decaffeination of coffee on reflux in patients with reflux disease. METHODS: Seventeen reflux patients underwent two osesophageal 3-h pH measurements. The patients received, in a double-blind study design in a randomized order, 300 mL of either regular or decaffeinated coffee together with a standardized breakfast. The fraction time oesophageal pH < 4 was calculated during the three postprandial hours. RESULTS: For regular coffee the fraction time was calculated to a median of 17.9% with a range of 0.7-56.6%. The fraction time was significantly reduced to 3.1% (0-49.9%) after ingestion of decaffeinated coffee. CONCLUSION: The amount of gastro-oesophageal reflux induced by the intake of regular coffee in patients with reflux disease can be reduce by the decaffeination of coffee.

Effects of two anticholinergic drugs, trospium chloride and biperiden, on motility and evoked potentials of the oesophagus.

BACKGROUND: Anticholinergic drugs are known to impair the motor function of the oesophagus but their effects on the oesophageal afferent pathways are unknown. AIM: To determine the effects of a peripherally-acting (trospium chloride) and a centrally-acting (biperiden) anticholinergic drug on the motility and the evoked potentials of the oesophagus. METHODS: Nine healthy volunteers were randomized to receive 1.2 mg trospium chloride (TC), 5 mg biperiden (BIP) or saline i.v. Primary peristalsis was elicited by swallowing a 5 mL water bolus and secondary peristalsis by insufflation of 20 mL air, 10 times each. Oesophageal potentials were evoked by electrical stimulation in the distal and proximal oesophagus (30 stimulations at 0.4 Hz, two runs). RESULTS: Both anticholinergic drugs reduced by a similiar amount the contraction amplitudes (TC 17 mmHg, BIP 25 mmHg, saline 67 mmHg; P < 0.01) and the rate of secondary contractions (TC 60%, BIP 70%, saline 95%; P < 0.01). In contrast, only biperiden prolonged the latencies of the evoked potentials (N1 peak, distal oesophagus: BIP 191 ms, TC 102 ms, saline 101 ms; P < 0.01; P1 peak: BIP 322 ms, TC 161 ms, saline 144 ms; P < 0.01). CONCLUSIONS: Both anticholinergic drugs depress oesophageal motility, but only the centrally-acting anticholinergic drug biperiden modifies the oesophageal evoked potentials, suggesting a central cholinergic transmission of the oesophageal afferent pathways.

Effect of caloric density of a meal on lower oesophageal sphincter motility and gastro-oesophageal reflux in healthy subjects.

BACKGROUND: Patients with gastro-oesophageal reflux disease are advised to avoid the ingestion of large meals. In healthy volunteers, a relationship between the amount of postprandial gastro-oesophageal reflux and the volume of a liquid meal has been demonstrated. AIM: To evaluate whether the amount of postprandial gastro-oesophageal reflux is also related to the calorie content of a meal, a second parameter that will be reduced by avoidance of the ingestion of large meals. METHODS: Twelve healthy volunteers (six female, 19-31 years) received two solid-liquid meals with either 842 kcal (solid 582 kcal, liquid 260 kcal) or 582 kcal (31% reduction) in a randomized order. The nutritional components (10% fat, 76% carbohydrates, 14% protein) and the volume of the meals were identical in both meals. The lower oesophageal sphincter pressure was measured continuously in the first postprandial hour with a Dent sleeve, and pH-metry was performed for 3 h postprandially with a glass electrode in the distal oesophagus. Blinded to the type of ingested meal, we calculated the mean lower oesophageal sphincter pressure, the frequency of transient lower oesophageal sphincter relaxations, the number of reflux episodes, and the fraction of time for which pH < 4. RESULTS: A similar decrease in lower oesophageal sphincter pressure was observed after ingestion of the high calorie meal (median 10.9 mmHg, range 4.8-16.7 mmHg) and low calorie meal (median 9.9 mmHg, range 3.9-18.4 mmHg). No difference in the number of transient lower oesophageal sphincter relaxations (high calorie: median 9 per hour, range 5-13 per hour; low calorie: median 7 per hour, range 0-14 per hour) and of reflux episodes (high calorie: median 12 in 3 h, range 3-22 in 3 h; low calorie: median 12 in 3 h, range 3-30 in 3 h) was registered after intake of both types of meal. Additionally, no difference was identified regarding the fraction of time for which pH < 4 between the high calorie (mean 2.3%, 0.2-23.7%) and low calorie meal (3.3%, 0.5-17.8%). CONCLUSION: Reducing the caloric density of a meal neither influences postprandial lower oesophageal sphincter pressure nor decreases gastro-oesophageal reflux in healthy volunteers. Thus, the amount of gastro-oesophageal reflux induced by ingestion of a meal seems to depend on the volume but not on the caloric density of a meal.

Effect of decaffeination of coffee or tea on gastro-oesophageal reflux.

BACKGROUND: Coffee and tea are believed to cause gastro-oesophageal reflux; however, the effects of these beverages and of their major component, caffeine, have not been quantified. The aim of this study was to evaluate gastro-oesophageal reflux induced by coffee and tea before and after a decaffeination process, and to compare it with water and water-containing caffeine. METHODS: Three-hour ambulatory pH-metry was performed on 16 healthy volunteers, who received 300 ml of (i) regular coffee, decaffeinated coffee or tap water (n = 16), (ii) normal tea, decaffeinated tea, tap water, or coffee adapted to normal tea in caffeine concentration (n = 6), and (iii) caffeine-free and caffeine-containing water (n = 8) together with a standardized breakfast. RESULTS: Regular coffee induced a significant (P < 0.05) gastro-oesophageal reflux compared with tap water and normal tea, which were not different from each other. Decaffeination of coffee significantly (P < 0.05) diminished gastro-oesophageal reflux, whereas decaffeination of tea or addition of caffeine to water had no effect. Coffee adapted to normal tea in caffeine concentration significantly (P < 0.05) increased gastro-oesophageal reflux. CONCLUSIONS: Coffee, in contrast to tea, increases gastro-oesophageal reflux, an effect that is less pronounced after decaffeination. Caffeine does not seem to be responsible for gastro-oesophageal reflux which must be attributed to other components of coffee.

Dysmotility of the small intestine in achalasia.

During recent years there has been increasing evidence for extraoesophageal dysfunction in achalasia. The aim was to investigate whether motility of the small intestine is abnormal in achalasia. Thirteen patients (eight men, five women) aged 52 (33-85) years were studied. They had all previously undergone treatment with pneumatic balloon dilatation and were free of dysphagia when examined. Ambulatory 24-h motility was recorded in the upper jejunum under standardized caloric intake with a digital datalogger and catheter-mounted pressure transducers located beyond the ligament of Treitz. Visual analysis was performed by two observers and data underwent quantitative analysis of phasic contractile events using a computer program. Normal values were obtained from 50 healthy controls. In the fasting state, a complete loss of cyclic MMC activity (n = 2), an abnormally prolonged phase II (n = 2) and disturbances in the aboral migration of phase III (n = 5) were observed. Postprandial motor response was absent (n = 2) or frequently showed a contraction frequency below the normal range (n = 5). Further abnormalities consisted in hypomotility during phase II (n = 3) and in a reduced frequency of migrating clustered contractions in the fasting (n = 2) or postprandial state (n = 2). In addition, motor events not present in any healthy subject, giant migrating contractions (n = 5), retrograde clustered contractions (n = 6) and repetitive retrograde contractions (n = 3) were identified. Each patient exhibited findings out of the range of normal. Dysmotility of the proximal small intestine is present in achalasia.