A randomized open-label trial of on-demand rabeprazole vs ranitidine for patients with non-erosive reflux disease.

AIM: To compare the efficacy of the proton-pump inhibitor, rabeprazole, with that of the H2-receptor antagonist, ranitidine, as on-demand therapy for relieving symptoms associated with non-erosive reflux disease (NERD). METHODS: This is a single center, prospective, randomized, open-label trial of on-demand therapy with rabeprazole (group A) vs ranitidine (group B) for 4 wk. Eighty-three patients who presented to the American University of Beirut Medical Center with persistent gastroesophageal reflux disease (GERD) symptoms and a normal upper gastrointestinal endoscopy were eligible for the study. Patients in group A (n = 44) were allowed a maximum rabeprazole dose of 20 mg twice daily, while those in group B (n = 39) were allowed a maximum ranitidine dose of 300 mg twice daily. Efficacy was assessed by patient evaluation of global symptom relief, scores of the SF-36 quality of life (QoL) questionnaires, total number of pills used, and number of medication-free days. RESULTS: Among the 83 patients who were enrolled in the study, 76 patients (40 in the rabeprazole group and 36 in the ranitidine group) completed the 4-wk trial. Baseline characteristics were comparable between both groups. After 4 wk, there was no significant difference in the subjective global symptom relief between the rabeprazole and the ranitidine groups (71.4% vs 65.4%, respectively; P = 0.9). There were no statistically significant differences between mean cumulative scores of the SF-36 QoL questionnaire for the two study groups (rabeprazole 22.40 ± 27.53 vs ranitidine 17.28 ± 37.06; P = 0.582). There was no significant difference in the mean number of pills used (rabeprazole 35.70 ± 29.75 vs ranitidine 32.86 ± 26.98; P = 0.66). There was also no statistically significant difference in the mean number of medication-free days between both groups. CONCLUSION: Rabeprazole has a comparable efficacy compared to ranitidine when given on-demand for the treatment of NERD. Both medications were associated with improved quality of life.

Posterior lingual lidocaine: a novel method to improve tolerance in upper gastrointestinal endoscopy.

AIM: To evaluate the effect of posterior lingual lidocaine swab on patient tolerance to esophagogastroduodenoscopy, the ease of performance of the procedure, and to determine if such use will reduce the need for intravenous sedation. METHODS: Eighty patients undergoing diagnostic esophagogastroduodenoscopy in a tertiary care medical center were randomized to either lidocaine swab or spray. Intravenous meperidine and midazolam were given as needed during the procedure. RESULTS: Patients in the lidocaine swab group (SWG) tolerated the procedure better than those in the spray group (SPG) with a median tolerability score of 2 (1, 4) compared to 4 (2, 5) (P < 0.01). The endoscopists encountered less difficulty performing the procedures in the SWG with lower median difficulty scores of 1 (1, 5) compared to 4 (1, 5) in the SPG (P < 0.01). In addition, the need for intravenous sedation was also lower in the SWG compared to the SPG with fewer patients requiring intravenous sedation (13/40 patients vs 38/40 patients, respectively, P < 0.01). The patients in the SWG were more satisfied with the mode of local anesthesia they received as compared to the SPG. In addition, the endoscopists were happier with the use of lidocaine swab. CONCLUSION: The use of a posterior lingual lidocaine swab in esophagogastroduodenoscopy improves patient comfort and tolerance and endoscopist satisfaction and decreases the need for intravenous sedation.

Endoscopic ultrasound-guided celiac plexus neurolysis.

Endoscopic celiac plexus neurolysis (CPN) has become the procedure of choice for the management of patients with pancreatic cancer and abdominal pain unresponsive to medical treatment. It is necessary to differentiate between CPN and endoscopic celiac plexus block performed in patients with benign disease. In this review we describe the technique of this procedure with special emphasis on technical details.

An overview of the pathogenesis and natural history of post-transplant T-cell lymphoma (corrected and republished article originally printed in Leukemia & Lymphoma, June 2007; 48(6): 1237 - 1241).

Post-transplantation lymphoproliferative disorders (PTLDs) are well recognized complications of solid organ transplantation. The vast majority of early PTLDs are B-cell non-Hodgkin lymphomas. PTLDs of T-cell origin occur much less frequently and account for only a minority of cases. T-cell PTLDs have been reported to occur primarily at extranodal sites, commonly affecting bone marrow or splenic tissues. The small bowel is an uncommon site of origin of these tumors with only seven cases of primary intestinal post-transplant T-cell lymphomas reported in the literature. We hereby report a new case of primary intestinal post-transplant T-cell lymphoma, arising 18 years following renal transplantation, along with a literature review of all published cases.

Disease progression following imatinib failure in gastrointestinal stromal tumors: role of surgical therapy.

Gastrointestinal stromal tumors (GISTs) represent the most common mesenchymal neoplasms of the GI tract. The optimal management of GISTs has been evolving rapidly over the past 5 years and depends on proper histopathologic and radiologic diagnosis as well as appropriate multidisciplinary medical and surgical treatments. Complete surgical resection of primary localized GIST with negative margins remains the best therapeutic option today. In the setting of locally advanced or metastatic disease, imatinib mesylate has emerged as the initial treatment of choice, administered either as cytoreductive or as definitive treatment. Surgery or ablative modalities in this setting are becoming increasingly employed, particularly when all disease becomes amenable to gross resection or destruction, or to manage complications arising from the disease following imatinib failure. We report on the surgical management of an unusual and clinically significant complication following progression of disease secondary to imatinib resistance. The role of surgical therapy in the management of GIST complications following resistance to imatinib and the integration of surgical and molecular therapy of locally advanced or metastatic GISTs are discussed.

The value of EUS in predicting the response of gastric mucosa-associated lymphoid tissue lymphoma to Helicobacter pylori eradication.

BACKGROUND: Gastric mucosa-associated lymphoid tissue (MALT) lymphoma is associated with Helicobacter pylori infection, and regression of the tumor has been described after its eradication. OBJECTIVE: To determine the value of EUS, in addition to other clinical/endoscopic features, in predicting the response of low-grade MALT lymphoma to H pylori eradication. DESIGN: A retrospective, single-center study. SETTING AND PATIENTS: Twenty-two patients with primary gastric MALT lymphoma were identified through a retrospective review of charts of patients seen at the American University of Beirut Medical Center. Only 19 patients with histopathologically confirmed gastric MALT lymphoma and H pylori infection who had EUS staging were included in the study. MAIN OUTCOME MEASUREMENTS: Regression of the gastric MALT lymphoma as determined by follow-up endoscopy and mucosal biopsies. RESULTS: Patients with disease restricted to the gastric mucosa had a significantly higher rate of complete remission after H pylori eradication compared with patients who had disease infiltrating into the gastric submucosa (77.8% vs 12.5%, P value .007). There was no statistical difference in terms of the mean follow-up time to achieve such response (P value .212). Age, sex, location of the tumor within the stomach, and endoscopic appearance did not correlate with the probability of complete remission of the MALT lymphoma. LIMITATIONS: The limitations include a retrospective design and a relatively small sample population. CONCLUSION: EUS determination of the invasion depth of gastric MALT lymphoma helps predict a complete response to H pylori eradication.

Heterozygous prothrombin 20210G/A mutation, associated with hyperhomocysteinemia, and homozygous methylenetetrahydrofolate reductase 677C/T mutation, in a patient with portal and mesenteric venous thrombosis.

We herein report a 34-year-old man who was investigated for severe abdominal pain. Portal vein thrombosis (PVT) and mesenteric vein thrombosis (MVT) were diagnosed. An association with two predisposing factors for thrombosis was noted: (1) heterozygous factor II 20210G/A mutation and (2) homozygous methylenetetrahydrofolate reductase (MTHFR) 677C/T mutation with hyperhomocysteinemia. Our case is of particular interest because the patient reported herein, is homozygote for the MTHFR 677C/T mutation, while the only two other cases reported in the literature with similar gene mutations, were heterozygotes for the mutation.

A randomized single-blind trial of whole versus split-dose polyethylene glycol-electrolyte solution for colonoscopy preparation.

BACKGROUND: Colonoscopy preparation regimens are often poorly tolerated because they require use of large-volume bowel preparation solution and diet restrictions for adequate cleansing. This study evaluated the efficacy and tolerability of a split-dose polyethylene glycol-electrolyte solution plus bisacodyl and a regular diet. METHODS: A total of 187 patients (104 men, 83 women; age range 18-91 years) were randomly assigned to receive either 3 L of polyethylene glycol-electrolyte solution (n = 96; Group A) with a liquid diet on the day before colonoscopy, or 2 L of polyethylene glycol-electrolyte solution, one tablet of bisacodyl, and a minimally restricted diet on the day before colonoscopy, and then 1 L of the same solution on the day of colonoscopy (n = 91; Group B). Acceptability, adverse events, and willingness to retake the preparation were assessed by questionnaire. The quality of the preparation was graded by an endoscopist, blinded to the type of preparation, by using a previously described scale (excellent to poor). RESULTS: There were 96 patients in Group A and 91 in Group B. Colon cleansing was significantly better in Group B with regard to the overall quality of the preparation (p lt; 0.05). Compliance was significantly higher in Group B as evidenced by the lower number of patients who discontinued the preparation (4 vs. 15; p = 0.02) because of side effects such as nausea or vomiting. The degree of discomfort, adverse events, and willingness to retake the preparation were not significantly different between the groups. CONCLUSIONS: Colonic preparation with split-dose polyethylene glycol-electrolyte provided better quality colon cleansing and higher compliance, with less dietary restrictions, than preparation with whole-dose polyethylene glycol-electrolyte.