Association of fructose consumption with prevalence of functional gastrointestinal disorders manifestations: results from Hellenic National Nutrition and Health Survey (HNNHS).

The study aimed to assess the total prevalence of functional gastrointestinal disorders (FGID), and separately, irritable bowel syndrome (IBS) among adults and to determine their potential association with fructose consumption. Data from the Hellenic National Nutrition and Health Survey were included (3798 adults; 58·9 % females). Information regarding FGID symptomatology was assessed using self-reported physician diagnosis questionnaires the reliability of which were screened using the ROME III, in a sample of the population. Fructose intake was estimated from 24 h recalls, and the MedDiet score was used to assess adherence to the Mediterranean diet. The prevalence of FGID symptomatology was 20·2 %, while 8·2 % had IBS (representing 40·2 % of total FGID). The likelihood of FGID was 28 % higher (95 %CI: 1·03-1·6) and of IBS 49 % (95 %CI: 1·08-2·05) in individuals with higher fructose intake than with lower intake (3rd tertile compared with 1st). When area of residence was accounted for, individuals residing in the Greek islands had a significantly lower probability of FGID and IBS compared with those residing in Mainland and the main Metropolitan areas, with Islanders also achieving a higher MedDiet score and lower added sugar intake, comparatively to inhabitants of the main metropolitan areas. FGID and IBS symptomatology was most prominent among individuals with higher fructose consumption, and this was most conspicuous in areas with a lower Mediterranean diet adherence, suggesting that the dietary source of fructose rather than total fructose should be examined in relation to FGID.

Consensus statement of the Hellenic and Cypriot Gastric Cancer Study Group on the diagnosis, staging and management of gastric cancer.

Gastric Cancer epidemics have changed over recent decades, declining in incidence, shifting from distal to proximal location, transforming from intestinal to diffuse histology. Novel chemotherapeutic agents combined with modern surgical operations hardly changed overall disease related survival. This may be attributed to a substantial inherent geographical variation of disease genetics, but also to a failure to standardize and implement treatment protocols in clinical practice. To overcome these drawbacks in Greece and Cyprus, a Gastric Cancer Study Group under the auspices of the Hellenic Society of Medical Oncology (HeSMO) and Gastrointestinal Cancer Study Group (GIC-SG) merged their efforts to produce a consensus considering ethnic parameters of healthcare system and the international proposals as well. Utilizing structured meetings of experts, a consensus was reached. To achieve further consensus, statements were subjected to the Delphi methodology by invited multidisciplinary national and international experts. Sentences were considered of high or low consensus if they were voted by ≥ 80%, or < 80%, respectively; those obtaining a low consensus level after both voting rounds were rejected. Forty-five statements were developed and voted by 71 experts. The median rate of abstention per statement was 9.9% (range: 0-53.5%). At the end of the process, one statement was rejected, another revised, and all the remaining achieved a high consensus. Forty-four recommendations covering all aspects of the management of gastric cancer and concise treatment algorithms are proposed by the Hellenic and Cypriot Gastric Cancer Study Group. The importance of centralization, care by a multidisciplinary team, adherence to guidelines, and individualization are emphasized.

Consensus statement of the Hellenic and Cypriot Oesophageal Cancer Study Group on the diagnosis, staging and management of oesophageal cancer.

In spite of recent advances in the diagnosis and management of oesophageal cancer, the overall survival of the disease worldwide remains disappointingly low. In Greece and Cyprus, this may be partly due to a failure of health care providers to implement standardised treatment protocols in clinical practice. Development of clinical practice guidelines was undertaken as a joint project between the Hellenic Society of Medical Oncology (HeSMO) and Gastro-Intestinal Cancer Study Group (GIC-SG) in an effort to provide guidance for Greek and Cypriot clinicians in all aspects of the management of oesophageal cancer. A study group was formed comprising clinicians from different disciplines with a special interest in the management of oesophageal cancer. Following extensive review of the literature, the members of the group met in person and consensus statements were developed, which were later subjected to the Delphi survey process by invited national and international experts. Statements that achieved a rate of voting consensus > 80% were adopted. Those that reached a voting consensus of < 80% were revised or rejected. In total, 46 sentences were developed and subjected to the voting process. Of those, 45 sentences achieved a rate of consensus > 80% during the first voting round. One sentence that did not reach a satisfactory rate of consensus was revised by the members of the study group and subsequently incorporated to the final statement. Forty-six recommendations covering all aspects of the management of oesophageal cancer and concise treatment algorithms are proposed by the Hellenic and Cypriot Oesophageal Cancer Study Group. In particular, centralisation of services, care by multidisciplinary teams and adherence to clinical guidelines are strongly recommended.

Efficacy of three different dosages of esomeprazole in the long-term management of reflux disease: a prospective, randomized study, using the wireless Bravo pH system.

OBJECTIVES: Gastroesophageal reflux disease (GERD) is a chronic condition that usually requires long-term maintenance therapy with proton-pump inhibitors (PPIs). In clinical practice, patients receive PPIs at the lowest dose to control symptoms. However, it is not known whether this approach adequately controls acidic esophageal reflux. We sought to investigate the efficacy of three different dosages of esomeprazole in patients receiving maintenance therapy for GERD, using the Bravo pH system. METHODS: Patients with a previous history of erosive esophagitis A or B (LA classification) that was healed at the time of enrollment or endoscopy-negative reflux disease (ENRD), documented with an abnormal pH study, were randomized to receive maintenance therapy with esomeprazole 40 mg twice daily (group A), once daily (group B), or every other day (group C). Intraesophageal pH was monitored for two consecutive days using the Bravo wireless system, 30 days after randomization. The parameters subjected to analysis were percent of total time pH<4 and the De Meester score. RESULTS: The pH results from 73 patients (group A=24, group B=24, group C=25 patients) were subjected to final analysis. On the first day of the study, the mean (+/-s.d.) percent of total time pH <4 and the De Meester score were group A: 0.9(1.2) and 4.1(4.0); group B: 1.5(1.6) and 7.0(6.9); group C: 1.3(1.0) and 6.0(3.3), respectively (P=0.262 and 0.134, respectively). On the second day of the study, the corresponding values were group A: 0.7(1.0) and 3.9(5.9); group B: 1.5(1.8) and 6.4(6.6); group C: 7.0(4.4) and 29.4(19.4), respectively. The difference was statistically significant (P<0.0001 and <0.0001, respectively). Further analysis showed that patients not receiving PPI had a significantly higher mean percent of total time pH<4 and De Meester score as compared with patients on PPI once or twice daily (P<0.001 and <0.001 respectively). CONCLUSIONS: The administration of esomeprazole 40 mg every other day does not control acidic esophageal reflux on the day off PPI. Esomeprazole 40 mg once daily effectively controls reflux of acid in patients with history of mild esophagitis or ENRD, whereas doubling the dose does not seem to confer any further advantage.

Prevalence and axial length of hiatus hernia in patients, with nonerosive reflux disease: a prospective study.

BACKGROUND AND AIMS: The relationship between hiatus hernia and reflux esophagitis is well established. However, there are conflicting reports regarding its effect on the development of nonerosive reflux disease (NERD). Our aim was to investigate the prevalence and axial length of hiatus hernia in patients with NERD, compared with patients with reflux esophagitis, Barrett esophagus, and controls. METHODS: Axial hernia length of the diaphragmatic hiatus was measured prospectively at endoscopy in controls and patients with typical reflux symptoms occurring at least weekly during the last month relieved by antacids. RESULTS: A final diagnosis of hiatus hernia was established in 21.2% of 249 controls, 60.4% of 346 patients with NERD, 78.1% of 251 patients with reflux esophagitis, and 88.2% of 17 patients with Barrett esophagus. Patients aged >59 years were most likely to have a hiatus hernia. There was an increased prevalence in patients with NERD as compared with controls (P<0.0001), and decreased prevalence as compared with those with reflux esophagitis and Barrett esophagus (P<0.0001 and 0.02, respectively). Axial length of hiatus hernia >3 cm was found more frequently in patients with reflux esophagitis and Barrett esophagus as compared with patients with NERD (P<0.0001 and 0.0052, respectively). There was no statistical significant difference between controls and patients with NERD regarding the prevalence of hiatus hernia >3 cm (P=0.0904). CONCLUSIONS: A small (<3 cm) hiatus hernia may contribute to the development of NERD, whereas an axial length >3 cm is associated with a more severe disease.

Single-session, graded esophageal dilation without fluoroscopy in outpatients with lower esophageal (Schatzki's) rings: a prospective, long-term follow-up study.

BACKGROUND: Distal esophageal (Schatzki's) ring is a frequent cause of dysphagia. Bougienage is generally effective but relapses are common. The aim of this study was to evaluate the safety and long-term efficacy of single-session graded esophageal dilation with Savary dilators, without fluoroscopic guidance, in outpatients who presented with Schatzki's ring. METHODS: The study was performed on 44 consecutive patients with symptomatic Schatzki's ring, detected endoscopically and/or radiologically. Graded esophageal dilation was performed as an outpatient procedure in a single session with Savary dilators, without fluoroscopic guidance. After appropriate assessment with esophageal manometry and 24 h ambulatory pHmetry, patients with documented gastroesophageal reflux disease (GERD) were treated with omeprazole continuously. All results, including clinical follow up and technical aspects of bougienage, were recorded prospectively. The necessity for re-dilation after documentation of the ring with endoscopy and/or radiology was considered as a relapse of the ring. RESULTS: In four (9%) patients a second session was necessary to ensure complete symptom relief. Two (4.5%) patients developed post-dilation bacteremia and were managed with antibiotics as outpatients. Patients with (n = 14) or without (n = 30) GERD were comparable with respect to sex, age, body mass index, smoke and ethanol consumption, diameter of the esophageal lumen at the level of the ring, resting lower esophageal sphincter pressure, duration of dysphagia, need for taking antacids during the follow-up period, and duration of follow-up. There was no recurrence of the ring in patients with GERD during a mean follow-up period of 43.8 +/- 9.3 months (range 27-62 months); however, in patients without GERD, during a mean follow-up period of 40.6 +/- 12.2 months (range 10-58 months), 32% of patients relapsed after a mean 19.9 +/- 10.6 months (P = 0.04). CONCLUSIONS: Single-session graded esophageal dilation with large caliber Savary dilators without fluoroscopic guidance can be safely used for the symptomatic relief in patients with lower esophageal (Schatzki's) rings. GERD should be treated if present in order to prevent a symptomatic recurrence of the ring.

Prospective comparison of secretin-stimulated magnetic resonance cholangiopancreatography with manometry in the diagnosis of sphincter of Oddi dysfunction types II and III.

BACKGROUND: In sphincter of Oddi dysfunction (SOD), sphincter of Oddi manometry (SOM) predicts the response to sphincterotomy, but is invasive and associated with complications. AIM: To evaluate the role of secretin-stimulated magnetic resonance cholangiopancreatography (ss-MRCP) in predicting the results of SOM in patients with suspected type II or III SOD. METHODS: MRCP was performed at baseline and at 1, 3, 5 and 7 min after intravenous secretin. SOD was diagnosed when the mean basal sphincter pressure at SOM was >40 mm Hg. Long-term outcome after SOM, with or without endoscopic sphincterotomy, was assessed using an 11-point (0-10) Likert scale. RESULTS: Of 47 patients (male/female 9/38; mean age 46 years; range 27-69 years) referred for SOM, 27 (57%) had SOD and underwent biliary and/or pancreatic sphincterotomy. ss-MRCP was abnormal in 10/16 (63%) type II and 0/11 type III SOD cases. The diagnostic accuracy of ss-MRCP for SOD types II and III was 73% and 46%, respectively. During a mean follow-up of 31.6 (range 17-44) months, patients with normal SOM and SOD type II experienced a significant reduction in symptoms (mean Likert score 8 vs 4; p = 0.03, and 9 vs 1.6; p = 0.0002, respectively), whereas in patients with SOD type III, there was no improvement in pain scores. All patients with SOD and an abnormal ss-MRCP (n = 12) reported long-term symptom improvement (mean Likert score 9.2 v 1.2, p<0.001). CONCLUSIONS: ss-MRCP is insensitive in predicting abnormal manometry in patients with suspected type III SOD, but is useful in selecting patients with suspected SOD II who are most likely to benefit from endotherapy.

Endoscopic ultrasonography versus other diagnostic modalities in the diagnosis of choledocholithiasis.

Until recently, endoscopic retrograde cholangiopancreatography (ERCP) has been considered the gold standard for the diagnosis of and therapy in patients with suspected choledocholithiasis. However, the non-negligible complication rate of diagnostic and therapeutic ERCP has led investigators to identify different noninvasive diagnostic modalities. Endoscopic ultrasonography has been proved to be of great sensitivity (up to 97%) in the diagnosis of even tiny stones that can be easily masked by contrast medium during ERCP, without any procedure-related complications and with a negative predictive value reaching 100%, meaning that it can accurately and safely identify patients with choledocholithiasis, thereby avoiding inappropriate instrumental exploration of the common bile duct.

Refractory heartburn to proton pump inhibitors: epidemiology, etiology and management.

Patients with refractory heartburn to proton pump inhibitors (PPIs) represent a distinctive group which is difficult to manage. In a systematic review of the relative literature we found that approximately 20% of patients with erosive esophagitis and 15-25% of patients with normal endoscopy and abnormal 24-hour esophageal pH monitoring continue to report heartburn despite treatment with standard dose PPIs. Furthermore, approximately 30-40% of patients with normal endoscopy and 24-hour pH studies and 15-20% of patients with Barrett's esophagus have refractory heartburn to double dose PPIs. In such cases, compliance to therapy, duodeno-gastroesophageal reflux, gastro-esophageal motility disorders and eradication of Helicobacter pylori infection may contribute to symptoms. Based on the available evidence, we suggested an algorithm for the evaluation and management of these patients.

Endoscopic therapy for gastroesophageal reflux disease: a systematic review.

The high prevalence of gastroesophageal reflux disease (GERD) in Western societies has accelerated the need for new modalities of treatment. Currently, medical and surgical therapies are widely accepted among patients and physicians. The minimally invasive treatment revolution, however, has stimulated several new endoscopic techniques for GERD. Up to now, the data is limited and further studies are necessary to compare the advantages and disadvantages of the various endoscopic techniques to medical and laparoscopic management of GERD. This systematic review reports the efficacy and durability of various endoscopic therapies for GERD whilst the potential for widespread use of these techniques is also discussed. Despite the limited number of studies and remarkable differences between various trials, strict criteria were used for the pooled data presented and an effort was made to avoid bias by including only studies that used off-antisecretory medication scoring as baseline and intent to treat.

Eosinophilic esophagitis in adults: a systematic review.

BACKGROUND/AIMS: Eosinophilic esophagitis (EE) is an increasingly recognized condition both in children and adults. The aim of the present study was to review the available evidence regarding EE in adults. METHODS: PubMed, MEDLINE and medical textbooks were searched in May-June 2005 for English-language articles published between January 1978 and June 2005 containing relevant terms. The abstracts of two major conferences from 2000 to June 2005 were also reviewed. The presence of more than 15 eosinophils per high power field on esophageal biopsies was required to establish the diagnosis. RESULTS: Twenty-four studies with 325 patients (male/female ratio: 3/1) were found that met the review criteria. Presenting symptoms included dysphagia (93%), food impaction (62%) and heartburn (23.6%). An allergic history and peripheral eosinophilia was noted in 51.6 and 30.8% of patients, respectively. Esophageal manometry presented evidence of a motility disorder in 40% of cases. Endoscopic findings included mucosal fragility/oedema, rings, strictures, whitish pinpoint exudates and small-calibre esophagus in 59.3, 49.2, 39.7, 15.7 and 5.3% of cases, respectively, whereas 8.8% of patients had a normal endoscopy. Bougienage was performed in 64 patients, with limited efficacy and an increased complication rate. The administration of corticosteroids resulted in symptomatic improvement in more than 95% of cases. CONCLUSIONS: An allergic history and peripheral eosinophilia is less common in adults than among children with EE. An esophageal motility disorder should be a novel indication for biopsies in adults with long-lasting dysphagia. A trial with corticosteroids before bougienage may reduce active inflammation and the complication rate.

Long-term acid suppressive therapy may prevent the relapse of lower esophageal (Schatzki's) rings: a prospective, randomized, placebo-controlled study.

OBJECTIVES: Distal esophageal (Schatzki's) rings are a frequent cause of dysphagia. Bougienage is generally effective, but relapses are common. The aim of this study was to evaluate the effect of long-term antisecretory therapy on the relapse rate of lower esophageal rings after successful bougienage with Savary dilators. PATIENTS AND METHODS: The study was performed on 44 consecutive patients with symptomatic Schatzki's rings, detected endoscopically, and/or radiologically. Graded esophageal dilation was performed as an outpatient procedure in a single session. After appropriate assessment with esophageal manometry and 24-h ambulatory esophageal pH monitoring, patients with documented GERD (n = 14) were treated with long-term omeprazole therapy. The remaining patients were blindly randomized to receive maintenance treatment with either omeprazole (group A-15 patients) or placebo (group B-15 patients). The necessity for redilation after documentation of the ring with endoscopy and/or radiology was considered as a relapse of the ring. The relapse rate was evaluated in all groups. RESULTS: All bougienages were performed without significant side effects. Eight patients (8 of 44, 18.2%) had one or more relapses after a mean (SD) of 19.0 (10.1) months. Patients with (n = 14) or without (n = 30) GERD were comparable with respect to sex, age, body mass index, cigarette and alcohol consumption, diameter of the esophageal lumen at the level of the ring, resting lower esophageal sphincter pressure, duration of dysphagia, need for taking antacids during the follow-up period, and duration of follow-up. There were no recurrences of Schatzki's ring in the group of patients with documented GERD (follow-up [mean +/- SD]: 43.8 +/- 9.3 months, range: 27-62). In group A (follow-up [mean +/- SD]: 37.1 +/- 17.1 months, range: 11-66), one patient relapsed after 13 months, while in group B (follow-up [mean +/- SD]: 34.3 +/- 14.6 months, range: 10-58), seven patients relapsed after a mean (SD) of 19.9 (10.6) months. The actuarial probability of relapse was higher in patients without therapy (group B) (p= 0.008). CONCLUSIONS: Our data support the hypothesis that, in patients with symptomatic Schatzki's rings, acid suppressive maintenance therapy after bougienage may prevent relapse of the ring.

Postbiopsy intramural hematoma of the duodenum in an adult with Noonan's syndrome.

Intramural duodenal hematoma is a rare complication of endoscopic biopsy. It is usually seen in children with growth failure and in patients with bleeding disorders or who are anticoagulated. It is frequently associated with acute pancreatitis. We present a case of an adult patient with Noonan's syndrome who developed postbiopsy intraduodenal hematoma. Abdominal ultrasound and computed tomography scan established the diagnosis. Conservative treatment was successful. According to a brief review of the literature, patients with Noonan's syndrome may develop hematoma after sampling of the duodenum because they present all the main predisposing factors. Additionally, pulmonic valve stenosis may be another predisposing factor, but this may warrant further investigation.

Gastric electrical activity in patients with cholelithiasis undergoing laparoscopic cholecystectomy: a prospective controlled study.

BACKGROUND: The aim of the present study was to evaluate the effect of gallstone disease (GD) and laparoscopic cholecystectomy on gastric electrical activity of slow waves, which was recorded via transcutaneous electrogastrography (EGG). METHODS: Twenty-one consecutive patients (M/F: 12/9, 52.7 +/- 15 years old) with GD and no previous history of abdominal operations or known disease affecting gastrointestinal motility were studied. The EGG was performed for 30 min prior to and 90 min after a standard meal, during a 4-6 month period prior to and after laparoscopic cholecystectomy. The percentile proportion of the three spectra of gastric slow waves frequency was studied, defined as follows: bradygastria, 1-2.1 cycles per min (c.p.m.); normogastria, 2.2-3.9 c.p.m.; and tachygastria, 4-9 c.p.m. The findings were compared to those of nine healthy subjects (M/F: 5/4, 49.5 +/- 14.8 years old). RESULTS: No statistically significant difference was found in percentile distribution of bradygastria, normogastria and tachygastria, pre- or post-prandially, neither before or after laparoscopic cholecystectomy, nor between patients and controls. CONCLUSIONS: Patients with GD do not exhibit differences in gastric electrical activity of slow waves in comparison to normal subjects and laparoscopic cholecystectomy does not alter gastric electrical activity. These findings suggest that cholelithiasis does not seem to cause dyspeptic symptoms due to gastric dysrythmias.