Traditional vs wireless intragastric pH monitoring: are the two techniques comparable?

BACKGROUND: Few data are available comparing intragastric pH measured with the traditional catheter-based and the more recent wireless system (Bravo), and also comparing intraesophageal and intragastric pH during reflux events. Aims of our study were to elucidate these points. METHODS: Eleven subjects with functional dyspepsia underwent placement of a Bravo capsule 9 cm below the squamo-columnar junction (SCJ) and of a dual-electrode catheter, so that the distal electrode was located 9 cm below and the proximal one 6 cm above the SCJ. KEY RESULTS: The wireless system showed lower intragastric pH than the traditional catheter in the postprandial period (median 2.2 wireless vs 2.7 catheter, P < 0.05) but not in the whole 24 h. Moreover, during the 24 h, minimum intraesophageal pH during reflux events was lower than the simultaneous pH in the gastric body recorded using the catheter (2.2 vs 2.4, P < 0.01) and in the postprandial period lower than the one recorded using both techniques (2.3 vs 2.8 wireless and 3.2 catheter, P < 0.001). CONCLUSIONS & INFERENCES: (i) after meals, in the 1st 2 h postprandial pH in the gastric body is significantly lower when measured with the wireless capsule than with the traditional catheter, presumably because of less buffering by food in proximity of the mucosa, (ii) during reflux events intraesophageal pH is lower than pH in the gastric body, in accordance with the notion of greater intragastric acidity in the subcardial region.

Role of symptoms, trend of liver tests, and endotherapy in management of post-cholecystectomy biliary leak.

AIM: Biliary leaks are widely reported complications of cholecystectomy, but standard management remains undecided. The objective of our study was to report the role of symptoms, biochemical tests, and ERCP in patients with a leak. MATERIALS AND METHODS: Twenty-one patients (8 M, 26-77 years) with suspected post-cholecystectomy biliary leak were retrospectively studied. Symptoms and liver tests (LTs) after surgery were monitored. Trends of LTs were considered positive if increases at >48 h were seen. ERCP was performed in all patients. Findings at endoscopy and treatments were reported. Outcome results were obtained for all patients. RESULTS: Seventeen of 21 patients had persistent biliary leak at ERCP, because of direct injury (n = 10), accessory duct (n = 4), or cystic duct stump (n = 3). Eleven of 17 patients (six without symptoms), had distal obstruction because of surgical injury (n = 8), stone (n = 2), or cholangiocarcinoma (n = 1) and underwent stenting (n = 4), naso-biliary drainage, NBD (n = 3), or surgery (n = 4). Among the six patients without obstruction (four without symptoms), stenting was performed in two and NBD in four. The four patients without apparent leak underwent NBD. Impairment of LTs was present in ten out of eleven (91%) patients with obstruction versus six of ten (60%) without obstruction. No complications occurred after ERCP. During a median follow-up of 33 months (cholangiocarcinoma excluded) all but one remained asymptomatic. CONCLUSIONS: Symptoms and trend of LTs were not predictive of biliary obstruction in patients with a leak after cholecystectomy. Both endotherapy and surgery had favorable outcomes.

A pneumatic dilation strategy in achalasia: prospective outcome and effects on oesophageal motor function in the long term.

BACKGROUND: Long-term follow-up studies of achalasia after pneumatic dilation, mostly retrospective, have shown variable results. AIM: To examine the outcome of achalasia after pneumatic dilation using a prospective follow-up programme. METHODS: One or two dilations (first dilation treatment) in 77 patients to achieve stable (>1 year) remission and patients followed up with yearly clinical and manometric assessments. Endoscopy, pH monitoring and barium swallow were also performed. RESULTS: A total of 69 patients achieved stable remission and were followed up for 5.6 years (3-10.7) [median (IQ range)], whereas six patients underwent cardiomyotomy and two experienced a perforation. Twelve of the 69 patients relapsed after 2.6 years (1.7-5.1): nine of 12 underwent one to two further dilations. Six-year remission rate (by Kaplan-Meyer estimates) was 82% after first dilation treatment and 96% after all dilations. Continuous antisecretory treatment was clinically needed in 16%, oesophagitis present in 7% and reflux pathological in 28% of the patients. Beneficial effects of dilation on oesophageal motility and on diameter of the oesophageal body at barium swallow were maintained during follow-up. CONCLUSIONS: A management strategy including sessions of pneumatic dilation until stable remission and a standardized follow-up is highly successful in the long term. Gastro-oesophageal reflux is clinically relevant in a minority of patients.

Wireless pH monitoring: better tolerability and lower impact on daily habits.

BACKGROUND: Twenty-four hours oesophageal pH monitoring is considered the reference-standard for the diagnosis of gastro-oesophageal reflux disease, but it is limited by catheter discomfort and limitations of daily habits. AIM: We evaluated tolerability and impact on food intake and daily activities of catheter-based compared to wireless pH monitoring. PATIENTS: One-hundred and thirty-three consecutive patients with suspected gastro-oesophageal reflux disease were enrolled. METHODS: Seventy-eight patients (36 M, 53+/-2 years) underwent the 24 h catheter-based and 55 patients (25 M, 44+/-3 years) the 48 h wireless pH monitoring. Discomfort at placement and during the test was evaluated by 100 mm visual analogue scales. Limitations of food intake and of daily activities were evaluated by standardized questionnaires (score 0 to 3). RESULTS: Discomfort (mean+/-standard error of the mean) at placement and during the test was 32+/-3 versus 29+/-4 (p=ns) and 37+/-3 versus 22+/-3 (p<0.001) for the catheter-based versus wireless techniques. Limitation of food intake and of daily activities (mean+/-standard error of the mean) were 0.9+/-0.1 versus 0.4+/-0.1 (p<0.05) and 1.2+/-0.1 versus 0.2+/-0.1 (p<0.0001), respectively. CONCLUSIONS: The wireless pH monitoring is better tolerated and has minor impact on daily habits compared to the traditional technique. Whether this translates into better diagnostic accuracy remains to be evaluated.

Gallstone disease and related risk factors in a large cohort of diabetic patients.

BACKGROUND AND AIM: The aim of this study of a large cohort of consecutive patients with diabetes mellitus was to investigate the still controversial questions concerning the prevalence and possible risk factors of gallstone disease in diabetics. PATIENTS AND METHODS: We enrolled 1337 consecutive patients (710 males aged 63 +/- 11 years and 627 females aged 65 +/- 11 years), of whom 1235 (92%) had type 2 and 102 (8%) had type 1 diabetes mellitus. The data were statistically analysed using multiple logistic regression analysis. RESULTS: The prevalence of gallstone disease was significantly higher in diabetics than in the general population with comparable characteristics (MICOL study) (332/1337 (24.8%) versus 4083/29684 (13.8%); z = 11.208, P = 0.0001) and this difference maintained its statistical significance even when only the North Italian centers involved in this nation-wide survey were considered (332/1337 (24.8%) versus 2469/18091 (13.6%); z = 11.225, P = 0.0001). A total of 332 diabetics (25%) had gallstone disease: 261 had stone(s) and 71 had previously undergone cholecystectomy for gallstone disease after a diagnosis of diabetes mellitus. The prevalence of gallstone disease was higher in the females (29% versus 22%, P = 0.003), and increased with age (13, 20 and 30% in patients aged < or = 40, 41-65 and > 65 years, respectively; P = 0.001), body mass index (24% in patients with a body mass index of < or = 30 and 30% in those with a body mass index of > 30 kg/m2; P = 0.001) and a positive family history of gallstone disease (31% versus 23%; P = 0.001). Gallstone disease was not significantly related to the type of diabetes, plasma total and HDL cholesterol and triglyceride levels, alcohol intake, smoking habits, physical activity, weight reduction in the last year, the use of oral contraceptives, parity or menopause. At multivariate analysis, increasing age, a higher body mass index and a positive family history maintained their statistical significance. CONCLUSIONS: In patients with type 1 or type 2 diabetes mellitus, the prevalence of gallstone disease was significantly related to age, body mass index and a family history of gallstone disease.