Utility of mean nocturnal baseline impedance and post-reflux swallow-induced peristaltic wave index in clinical pH-impedance reflux study.

BACKGROUND AND AIMS: Analysis of mean nocturnal baseline impedance (MNBI) and post-reflux swallow-induced peristaltic wave index (PSPWi) have been proposed to increase the diagnostic yield of pH-impedance studies in reflux disease. However, routine use of these indices in clinical studies is yet to be established, particularly with PSPWi, which requires laborious manual analysis. Our study aimed to assess the utility of MNBI and PSPWi and their potential for future incorporation into clinical practice. METHODS: pH-impedance recordings from consecutive patients referred to the Motility Laboratory at Royal Adelaide Hospital for evaluation of gastro-oesophageal reflux disease (GORD) were prospectively collected and manually analysed. Baseline demographic characteristics, symptoms, acid exposure time (AET), number of reflux episodes, and MNBI and PSPWi were collected. RESULTS: Eighty-nine patients were included in the study (age 50 ± 17 years, 35 males). MNBI and PSPWi inversely correlated with AET (R = -0.678, P < 0.0001 and R = -0.460, P < 0.0001 respectively) and with reflux episodes (R = -0.391, P = 0.0002 and R = -0.305, P = 0.0037 respectively). In patients with a negative pH study, but with typical reflux symptoms, 4/30 (13%) had pathologic MNBI and PSPWi. There was a positive correlation between MNBI and PSPWi values (R = 0.525, P < 0.0001). Performing analysis of PSPWi was substantially more laborious than MNBI. CONCLUSION: MNBI and PSPWi are both useful adjuncts in the diagnosis of reflux disease, although in our cohort MNBI showed stronger correlation with AET with less time to analyse. The role of these indices remains to be further explored, particularly in patients with inconclusive AET and in those with positive compared to negative symptom association.

Clinical utility of purgative bowel preparation before capsule endoscopy: a multicenter, blinded, randomized controlled trial.

BACKGROUND AND AIMS: Optimal bowel preparation before capsule endoscopy (CE) is currently unknown. In this multicenter, blinded, randomized controlled trial, we assessed clinical effectiveness of 2 types of purgative regimen and a control arm of clear fluid only. METHODS: Patients with suspected small intestinal bleeding were randomized into 3 arms: arm A, clear fluids only for 18 hours before CE and simethicone 200 mg in 150 mL water immediately before CE; arm B, same as A + 2 L of polyethylene glycol (PEG) 12 hours before CE; and arm C, same as A + 1 L PEG + sodium ascorbate 3 hours before CE. To assess diagnostic yield, lesions were classified either as highly relevant (P2) or less relevant (P0 or P1) lesions. Small-bowel visualization quality (SBVQ) was assessed using the Brotz score. Patient tolerability was assessed using the visual analog scale (0-10, with lower scores indicating better tolerability). RESULTS: Two hundred twenty-nine patients completed the study. The mean age was 58.7 years (95% confidence interval, 29.3-87.9), and 47.2% were men. There was no significant difference in diagnosis of P2 lesions in arms A, B, and C (48.7%, 48.0%, and 45.9%, respectively; P = .94). Overall SBVQ and distal SBVQ were similar across the 3 arms (P = .94 and P = .68, respectively). Patients reported better tolerability in arm A (mean score, 1.5) compared with arms B and C (mean score, 3.5 and 2.6, respectively; P < .001). CONCLUSIONS: The use of a purgative bowel preparation before CE does not improve diagnostic yield or small-bowel visualization and is associated with lower patient tolerance. (Clinical trial registration number: ACTRN 12614000883617.).

Distal esophageal wall thickness correlates with dysphagia in adult patients with eosinophilic esophagitis.

BACKGROUND: Thickening of the esophageal wall in patients with eosinophilic esophagitis (EoE) and gastro-esophageal reflux disease (GERD) has been shown in studies using endoscopic ultrasound (EUS). We hypothesise that transmural inflammation in EoE results in prominent esophageal wall thickening compared with the mucosal inflammation in GERD. The aim of this study was to compare the relationship among dysphagia, endoscopic appearance, wall thickness, histology, and motility in EoE and GORD. METHODS: EoE and GERD patients were prospectively studied between February 2012 and April 2021. Patients were studied on 2 separate occasions with endoscopy, EUS and mucosal biopsies, followed by high-resolution manometry. Epidemiology and dysphagia data were obtained. RESULTS: A total of 45 patients (31 EoE, 14 GERD) were included. There were no significant differences in age, sex, duration of disease and presence of esophageal motility disorders. EoE patients had a higher dysphagia score (P < 0.001), EREFS score (P < 0.001) and peak eosinophil count (P < 0.001) compared with GERD patients. Thickness of the submucosa in the distal esophagus in EoE was significantly higher than GERD (P = 0.003) and positively correlated with duration of disease (P = 0.01, R = 0.67). Positive correlation was also found between dysphagia score and distal total esophageal wall thickness (P = 0.03, R = 0.39) in EoE patients. No correlation was found between these variables in GERD patients. CONCLUSION: Distal esophageal wall thickness positively correlates with dysphagia score in EoE but not GERD. This appears to be related to the composition of the submucosa which can be identified using EUS.

Pudendal nerve injury impairs anorectal function and health related quality of life measures ≥2 years after 3D conformal radiotherapy for prostate cancer.

PURPOSE: To compare GI symptoms, measures of generic and disease specific health related quality of life (HRQoL), anorectal and pudendal nerve function and anal sphincter morphology between (i) patients ≥2 years after 3D conformal radiotherapy (3D-CRT)±high dose rate (HDR) brachytherapy for carcinoma of the prostate and aged matched patients before radiotherapy and (ii) symptomatic and asymptomatic patients ≥2 years after 3D-CRT ± HDR brachytherapy. MATERIAL AND METHODS: Methodology included: (i) modified LENT-SOMA scales for GI symptoms, (ii) EORTC QLQ-C30 and EORTC QLQ-PR25 questionnaires for generic and disease specific HRQoL, (iii) anorectal manometry and terminal motor latency for anorectal and pudendal nerve function and (iv) endorectal ultrasound for anal sphincter morphology. GI symptoms, parameters of HRQoL, anorectal and pudendal nerve function and anal sphincter morphology were compared using Mann-Whitney's U, unpaired t and χ2 tests. RESULTS: Impairment of HRQoL bowel symptoms in the patients ≥2 years after 3D-CRT ± HDR brachytherapy was associated with worse anorectal motor and sensory function, internal and external anal sphincter morphology and 5× greater prevalence of pudendal nerve dysfunction compared with age matched patients before radiotherapy. Symptomatic patients had worse (i) HRQoL measures including global quality of life and bowel and urinary symptom scores, (ii) rectal bleeding, fecal urgency and incontinence scores and (iii) a 2× higher prevalence of pudendal nerve dysfunction compared with asymptomatic patients. Rectal and anal (i) V 40 Gy >65%, (ii) Dmax >60 Gy, (iii) pudendal nerve Dmax >60 Gy and (iv) Anal V 60 Gy >40% were associated with a greater prevalence of pudendal nerve dysfunction. CONCLUSIONS: 3D-CRT ± HDR brachytherapy for prostate carcinoma, impairs late functional measures including HRQoL, anorectal and pudendal nerve function. Rectal, anal and pudendal nerve radiation dose constraints are proposed for reducing the prevalence of pudendal nerve dysfunction.

Efficacy of the CathRite system to guide bedside placement of peripherally inserted central venous catheters in critically ill patients: a pilot study.

OBJECTIVES: To assess the efficacy of the CathRite system as a tool to guide clinicians in placement of peripherally inserted central catheters (PICCs) into the superior vena cava (SVC) in critically ill patients. DESIGN: Prospective, randomised, parallel controlled trial. PARTICIPANTS AND SETTING: three8 critically ill patients (mean APACHE II score, 16.6) in a mixed medical and surgical intensive care unit from 200four to 2006. INTERVENTIONS: Participants were randomised to receive PICC placement using either the CathRite system or a standard "blind" technique (control). Peripheral vein cannulation was performed for both groups under ultrasound monitoring, and the PICC was placed using the modified Seldinger technique, with position confirmed using standard chest x-ray. MAIN OUTCOME MEASURES: Proportion of PICCs guided into the SVC; placement into the lower third of the SVC; and time to complete placement. RESULTS: There was no significant difference between groups in sex distribution or age (CathRite: 12 men, 7 women; mean age +/- SEM, 61.1 +/- 3.4 years; control: 15 men, 4 women; 55.9 +/- 4.7 years). The PICC was successfully guided into the SVC in 19 patients (100%) in the CathRite group, compared with 14 (74%) in the control group (P < 0.05). Placement of catheters into the lower third of the SVC was achieved in 14 patients (74%) in the CathRite group, compared with eight (42%) in the control group (P < 0.05). Time to completion of catheter insertion was 31.4 +/- 16.2 minutes in the CathRite group compared with 24.6 +/- 14.5 minutes in the control group (P = 0.18). CONCLUSIONS: The CathRite system enabled placement of PICCs into the SVC from peripheral insertion sites and avoided ectopic placements that occurred with the blind technique.

Relationship between pressure wave amplitude and esophageal bolus clearance assessed by combined manometry and multichannel intraluminal impedance measurement.

OBJECTIVES: Esophageal wave amplitude is an important determinant of esophageal clearance. A threshold of 30 mmHg is widely accepted as the threshold for effective clearance in the distal esophagus. However, the precise relationship between wave amplitude and clearance has received relatively little attention. The aim of this study was to assess the impact of peristaltic wave amplitude on esophageal volume clearance using multiple intraluminal impedance (MII) measurement. METHODS: Concurrent manometry and MII were performed on 42 healthy asymptomatic volunteers and 13 patients with ineffective esophageal motility. Esophageal motility was measured at four sites 5-cm apart, starting 2 cm above the lower esophageal sphincter. MII was measured at corresponding sites with electrodes incorporated into the manometric assembly. Ten 5-mL liquid (saline) boluses and ten 5-mL low impedance viscous boluses were tested in each subject. Pressure wave amplitude was determined at each site as well as peristaltic success of the responses. Bolus clearance was measured from individual recording segment and from the esophagus as a whole. RESULTS: The proportion of liquid boluses cleared at each site was directly related to wave amplitude and did not increase significantly above a threshold of 25 mmHg in the proximal esophagus, 22 mmHg in the mid-esophagus, and 30 mmHg in the distal esophagus. Corresponding wave amplitudes for total esophageal clearance were 35-40 mmHg. There was a good correlation between the wave amplitude at one site of the esophagus and those of the rest of the esophagus. For both liquid and viscous boluses, the likelihood of impaired clearance was directly related to the number of segments with hypotensive pressure waves. CONCLUSION: The findings confirm the validity of the wave amplitude threshold required for effective liquid bolus clearance and have established the amplitude threshold for clearance of viscous boluses. However, the number of hypotensive pressure waves required for the definition of ineffective motility may be too low.

Inhibition of transient lower esophageal sphincter relaxations by electrical acupoint stimulation.

Acupuncture has been shown to modulate visceral sensation and function. Traditionally, stimulation at the Neiguan (pericardial meridian) has been used to treat upper gastrointestinal symptoms. Some of the effects of acupuncture may be mediated through release of endogenous opioids and are reversed by naloxone. Gastric distension is the major trigger for transient lower esophageal sphincter (LES) relaxations (TLESRs). The aim of this study was to investigate the effect of electric stimulation at the Neiguan and naloxone on the TLESRs. In 14 healthy volunteers, electrical acupoint stimulation was applied at the Neiguan and a sham point on the hip in randomized order on the same day. In 12 healthy volunteers, the effects of naloxone (80 microg/kg iv bolus injection) and saline on electrical acupoint stimulation were compared on separate days at least 1 wk apart. Esophageal motility was measured during distension of the proximal stomach with 500 ml of air using a barostat balloon. Electric acupoint stimulation at the Neiguan decreased the rate of TLESRs by approximately 40% from a median of 6/h to 3.5/h (P < 0.02). Acupoint stimulation had no effect on basal LES pressure, the residual LES pressure during TLESRs, the duration of TLESRs, or gastrointestinal symptoms of fullness, bloating, discomfort, or nausea. The effect of acupoint stimulation was not inhibited by naloxone. Electric acupoint stimulation at the Neiguan significantly inhibits the frequency of TLESRs in response to gastric distention in healthy subjects. This effect does not appear to be mediated through mu-opioid receptors.