Breathing Exercises in Gastroesophageal Reflux Disease: A Systematic Review.

The pathogenesis of gastroesophageal reflux disease (GERD) is multifactorial. The severity of abnormal reflux burden corresponds to the dysfunction of the antireflux barrier and inability to clear refluxate. The crural diaphragm is one of the main components of the esophagogastric junction and plays an important role in preventing gastroesophageal reflux. The diaphragm, as a skeletal muscle, is partially under voluntary control and its dysfunction can be improved via breathing exercises. Thus, diaphragmatic breathing training (DBT) has the potential to alleviate symptoms in selected patients with GERD. High-resolution esophageal manometry (HRM) is a useful method for the assessment of antireflux barrier function and can therefore elucidate the mechanisms responsible for gastroesophageal reflux. We hypothesize that HRM can help define patient phenotypes that may benefit most from DBT, and that HRM can even help in the management of respiratory physiotherapy in patients with GERD. This systematic review aimed to evaluate the current data supporting physiotherapeutic practices in the treatment of GERD and to illustrate how HRM may guide treatment strategies focused on respiratory physiotherapy.

Characterization of esophageal motor activity, gastroesophageal reflux, and evaluation of prokinetic effectiveness in mechanically ventilated critically ill patients: a high-resolution impedance manometry study.

BACKGROUND: Motility disorders of upper gastrointestinal tract are common in critical illness and associated with significant clinical consequences. However, detailed quantitative and qualitative analyses of esophageal motor functions are lacking. Therefore, we aimed to characterize the key features of esophageal motility functions using high-resolution impedance manometry (HRIM) and to evaluate an objective link between esophageal motor patterns, gastric emptying, and gastroesophageal reflux. We also studied the prokinetic effects of metoclopramide. METHODS: We prospectively performed HRIM for 16 critically ill hemodynamically stable patients. Patients were included if they had low gastric volume (LGV; < 100 mL/24 h, n = 8) or high gastric volume (HGV; > 500 mL/24 h, n = 8). The HRIM data were collected for 5 h with intravenous metoclopramide administration (10 mg) after the first 2 h. RESULTS: The findings were grossly abnormal for all critically ill patients. The esophageal contraction vigor was markedly increased, indicating prevailing hypercontractile esophagus. Ineffective propulsive force was observed for 73% of esophageal activities. Panesophageal pressurization was the most common pressurization pattern (64%). Gastroesophageal reflux predominantly occurred with transient lower esophageal sphincter relaxation. The common features of the LGV group were a hyperreactive pattern, esophagogastric outflow obstruction, and frequent reflux. Ineffective motility with reduced lower esophageal sphincter tone, and paradoxically fewer reflux episodes, was common in the HGV group. Metoclopramide administration reduced the number of esophageal activities but did not affect the number of reflux episodes in either group. CONCLUSION: All critically ill patients had major esophageal motility abnormalities, and motility patterns varied according to gastric emptying status. Well-preserved gastric emptying and maintained esophagogastric barrier functions did not eliminate reflux. Metoclopramide failed to reduce the number of reflux episodes regardless of gastric emptying status. Trial registration ISRCTN, ISRCTN14399966. Registered 3.9.2020, retrospectively registered. https://www.isrctn.com/ISRCTN14399966 .

Diagnosis of gastrointestinal motility disorders.

Gastrointestinal motility and the effects on luminal contents that are brought about by it can be studied in several ways. In clinical practice, manometry remains one of the most important investigational techniques, in particular for oesophageal and anorectal disorders. Radiographic examination of bolus transit through the gastrointestinal tract also continues to be a valuable tool. Scintigraphy still is the standard for assessment of gastric emptying, but 13C breath tests are an alternative. Many other techniques are used mainly in the context of scientific research but some of these may become incorporated in the diagnostic armamentarium. Key words: breath tests - conventional manometry - high-resolution manometry - radiodiagnostic methods - scintigraphy.

[Percutaneous endoscopic gastrostomy: analysis of practice at the endoscopic center of tertiary medical care]. / Perkutánní endoskopická gastrostomie: analýza praxe v endoskopickém centru terciární lékarské péce.

INTRODUCTION: Percutaneous endoscopic gastrostomy (PEG) is a minimally invasive routine procedure used to provide long-term enteral nutrition in selected patients with impaired oral intake. The knowledge of clinical, technical and safety features of PEG is an important issue in clinical practice.The aim of this study was to evaluate the popu-lation of patients selected for PEG insertion, describe certain aspects of the insertion procedure, assess the service life of PEG, as well as account for the number of complications and patient mortality in the six-month period following the procedure. METHODS: We used a retrospective analysis of data from medical database. The data were collected in a single endoscopic tertiary-referral center for a period of seven and a half years. RESULTS: We evaluated 326 PEG insertions performed on 292 patients with a median age of 63 years (IQR 55-70). Mortality in the six-month period following PEG insertion was 26 %. Prevailing indications for PEG insertion were oncological (53 %) and neurological (40 %) diseases, with certain fluctuation of these numbers during the observed period according to changing demands of the two medical specialties. Local anesthesia alone was applied in 56 % of patients, 38 % underwent analgosedation and 6 % required general anesthesia. Median duration of the procedure (from insertion of endoscope to its final extraction) in 68 consecutive procedures was 6 minutes (IQR 5-8). Median interval between PEG introduction and its first replacement in 21 patients was 22 months (IQR 14-31, range 4-76). 61 patients underwent PEG extraction during the observed period, 66 % of whom had oncological disease. Periprocedural complications were seen in 5.8 % of patients, of these one patient (0.3 %) suffered a serious complication. The buried bumper syndrome was observed in four patients (1.2 %), all of whom had neurological disease. CONCLUSIONS: PEG is a relatively safe procedure and can be performed in a short time using local anesthesia or analgosedation in a majority of patients. The population of patients indicated for PEG insertion reflects primarily the current needs of neurological and oncological departments. Most patients within the observed group benefit from PEG insertion for more than six months. KEY WORDS: analgosedation - complications - mortality - percutaneous endoscopic gastrostomy.

[Celiac disease in adult patients with type 1 diabetes mellitus]. / Celiakie u pacientu s diabetes mellitus 1. typu.

OBJECTIVE: To assess the prevalence of celiac disease in adult patients with type 1 diabetes mellitus (T1DM). Influence the new started treatment of celiac disease on glycemic control and body mass index (BMI) of the patients. Prevail the anti-transglutaminase antibody (atTG) positivity one year after commencement of the therapy. METHODS: A retrospective assessment of celiac disease targeted screening in 465 adult T1DM patients at Diabetes Center, 1st Medical Department, University Hospital in Pilsen (80 % of all T1DM patients) from 1. 1. 2007 until 1. 7. 2011. Enterobiopsy was indicated in case of atTG-A (or atTG-G) positivity. In patients with newly started gluten-free diet, HbA1c and BMI within a year after diagnosis of celiac disease were compared to a year period six months after treatment commencement (3-4 visits), atTG was evaluated one year after treatment beginning. Paired T-test was used for statistical evaluation. RESULTS: The prevalence of all forms of celiac disease in the studied group was 10.5 %. Celiac disease diagnosed in childhood was found in 1.1 % patients (5/465). Positivity of atTG was newly observed in 9.5 % (44/465) patients. Three patients with atTG > 300 kIU/l refused the enterobiopsy examination. Celiac disease is highly plausible. The influence of gluten-free diet on BMI and HbA1c could not be evaluated due to the lack of compliance. 22 patients had a potential form of celiac disease (negative histology). Positive enterobiopsy was found in 19 patients (4.1 %). Another 3 patients had to be excluded from the subgroup of 22 patients (newly indicated gluten-free diet) as the HbA1c values and BMI were affected by the primary diagnosis of T1DM. Subgroup characteristics: 9 women and 7 men, mean age 38 ± 12 years, diabetes duration 21 ± 13 years, celiac disease diagnosed 20.7 ± 13 years since first diagnosis of T1DM. No statistically significant change in HbA1c (67 ± 11.4 vs 69 ± 13.9 mmol/mol) was observed in the studied period, however and a significant change of BMI from 25.4 ± 4.2 to 25.9 ± 4.3 (p < 0.01) was found. The atTG positivity prevailed in 47 % (9/19) of patients after one year. CONCLUSION: A total prevalence of the celiac disease in the group of adult T1DM patients was 10.5 %. No significant change in HbA1c occurred following treatment, a significant change of BMI was observed. The atTG positivity prevailed in 47 % of patients after one year.

[Biological therapy in women with inflammatory bowel disease during pregnancy]. / Biologická terapie u pacientek s idiopatickými strevními zánety v gravidite

The aim of this article is to objective review available research data regarding the safety of biological therapies during pregnancy and breastfeeding in women with inflammatory bowel disease. Biological therapies appear to be safe in pregnancy, as no increased risk of malformations has been demonstrated. Available clinical results suggest that the efficacy of infliximab and adalimumab in achieving clinical response and maintaining remission in pregnant patients might outweigh the theoretical risks of drug exposure to the fetus. If possible, anti-TNF therapy should be stopped by the end of the second trimester due to transplacental transfer and potential risk for the fetus. The use of infliximab and adalimumab is probably compatible with breastfeeding.

Clostridium difficile infection in hospitalized patients at a Czech tertiary center: analysis of epidemiology, clinical features, and risk factors of fulminant course.

OBJECTIVE: Clostridium difficile infection (CDI) has been increasing in incidence, with significant morbidity and mortality, and is subject to geographical and institutional variability. We aimed to characterize epidemiology and clinical manifestations of CDI in a Czech tertiary care center and to identify risk factors of fulminant course. METHODS: All adult patients hospitalized with primary CDI in a 3-year period were retrospectively identified. Epidemiological and clinically descriptive data were extracted from medical records. Multivariate analysis was used to identify the risk factors of fulminant course. The relationship between incidence of CDI and antibiotic consumption was evaluated. RESULTS: Overall, 183 CDI patients, median age 67 years, were enrolled. Hospital-acquired CDI was present in 85% of cases. The incidence of CDI was 1/10,000 patient-days. Hospital-acquired CDI hospital mortality was 22.4%. Severe CDI (SCDI) was identified in 15.8% of patients, with 62% mortality. SCDI patients had longer onset of symptoms to diagnosis interval compared with mild CDI (P=0.05). Multivariate analysis showed that SCDI patients were older (P=0.018), and more frequently had abnormal abdominal physical findings (P=0.001), higher inflammatory markers (P<0.001), higher creatinine (P=0.002), and lower albumin (P<0.001) than patients with mild CDI. Analysis of antibiotic consumption at departments with the highest incidence of CDI showed a trend toward higher incidence of CDI associated with penicillin use (P=0.08) and a negative correlation of CDI incidence with nitroimidazoles consumption (P=0.03). CONCLUSION: CDI is less frequent in the conditions studied compared with literary data; however, the fulminant form has a very high mortality. Delayed recognition and treatment is a crucial determinant of the severity of CDI. The association between CDI and antibiotic consumption is less clear.

Diagnosing celiac disease in patients with a history of lymphoma: factors that matter.

OBJECTIVE: The aim of this study was to identify pitfalls in establishing the diagnosis of celiac disease (CD) in patients with a history of lymphoma. METHODS: A total of 103 patients with a history of lymphoma had anti-tissue transglutaminase antibodies (atTGA) and their class A, G, and M immunoglobulin (IgA, IgG) levels determined. Patients with atTGA positivity underwent enterobiopsy and CD-associated HLA locus testing. RESULTS: The mean age of patients was 55 ( ± 13.5) years. The predominant lymphoma types included B-type non-Hodgkin's lymphoma (B-NHL, 66 %), T-type NHL (8 %), and Hodgkin's lymphoma (26 %). Serological positivity was documented in 3.9 % of cases; one patient had the diagnosis of CD confirmed by enterobiopsy. In 11 patients (10.7 %), IgA levels were decreased to a various extent; of these patients, 10 were shown to have also their IgG levels decreased. The median time from follow-up to blood collection was 58 (32-104) months. The decrease in immunoglobulin levels correlated with a more advanced stage of the tumor (Ann Arbor III-IV) at the time of diagnosis [1.4 (0.9-2.0) g/l versus 2.4 (1.5-3.0) g/l for IgA, p = 0.0001; and 9.4 (7.2-11.5) g/l versus 11.2 (10.3-12.3) g/l for IgG, p = 0.001] and older age [65 (54-72) years versus 55 (44-61) years for IgA, p = 0.04; and 69 (59-74) years versus 53 (43-61) years for IgG, p = 0.0001]. Rituximab therapy in B-NHL patients had no effect on the subsequent incidence of decreased IgA levels. CONCLUSION: Reduced IgA and IgG levels represent important factors contributing to the low detection rate of serological screening for CD in patients with a history of lymphoma.