Shorter preparation to procedure interval for colonoscopy improves quality of bowel cleansing.

BACKGROUND: The timing of bowel preparation for colonoscopy influences the quality of bowel cleansing and the success of the procedure. AIM: We aimed to determine whether the interval between the end of bowel preparation and the start of colonoscopy influences preparation quality. METHODS: We retrospectively analysed 1785 colonoscopies performed between January 2010 and January 2011. The quality of bowel cleansing was compared between those who had a less than 8-h interval between the end of bowel preparation to the start of the procedure versus those who had a greater than 8-h interval. Univariate and multivariate logistic regression analyses evaluated quality of bowel cleansing, preparation to procedure time, age, gender, hospital inpatient or outpatient status, indication for colonoscopy, caecal intubation rate, and segmental polyp detection. RESULTS: Fifty-three per cent of the cohort was male. Eighty-nine per cent were outpatients. Bowel cleansing was reported as satisfactory/good in 87% and poor in 13%. A <8-h preparation to procedure time was associated with a higher rate of satisfactory/good cleansing than a >8-h interval (odds ratio (OR) 1.3, P = 0.04). In a multivariate analysis, female gender (OR 1.4, P = 0.02), outpatient status (OR 3.1 P = 0.001) and indication for procedure (P < 0.01) were significant predictors of adequate bowel preparation. Adequate bowel preparation was associated with a significant increase in caecal intubation rates (OR 5.3, P = 0.001). CONCLUSIONS: A shorter (<8 h) interval between end of bowel preparation and start of colonoscopy yielded better bowel cleansing than a longer (>8 h) interval. Adequate bowel preparation led to improved caecal intubation rates.

Delivery of radiofrequency energy to the lower oesophageal sphincter and gastric cardia inhibits transient lower oesophageal sphincter relaxations and gastro-oesophageal reflux in patients with reflux disease.

BACKGROUND AND AIMS: Radiofrequency energy (RFe) treatment to the lower oesophageal sphincter (LOS) and gastric cardia is a new luminally delivered therapy proposed as an alternative treatment for gastro-oesophageal reflux disease (GORD). However, it is unclear how RFe achieves its antireflux effect. This study investigated the effects of RFe on mechanisms of spontaneous reflux in patients with GORD. METHODS: Twenty patients with GORD underwent endoscopy, symptom evaluation, and combined postprandial oesophageal manometry and pH monitoring before and six months after RFe, and 24 hour ambulatory pH monitoring before and at six and 12 months after treatment. RESULTS: RFe reduced the rate of postprandial transient LOS relaxations from 6.8 (5.7-8.1) (median (interquartile range) per hour to 5.2 (4.2-5.8) per hour (p<0.01), and increased mean basal LOS pressure from 5.2 (SEM 0.3) mm Hg to 8.0 (SEM 0.4) mm Hg (p<0.01). The number of reflux events was reduced from 10 (2-15.3)/3 hours to 5 (3.5-8.5)/3 hours (p<0.05) and there was an associated significant reduction in acid exposure time from 5.4% (0.4-14.7) to 3.9% (0.4-6.6) (p<0.05). RFe significantly reduced ambulatory oesophageal acid exposure from 10.6% (7.8-13.0) to 6.8% (3.1-9.1) (p<0.01) at six months and 6.3% (4.7-10.9) (p<0.05) at 12 months. All patients required acid suppressant medication for symptom control before RFe. Six months after treatment, 15 patients (75%) were in symptomatic remission and 13 (65%) at 12 months. CONCLUSIONS: RFe has significant effects on LOS function that are associated with improvement in the antireflux barrier. Uncontrolled clinical data also suggest a beneficial effect in the control of reflux symptoms in these patients.

Effect of cisapride on secondary peristalsis in patients with gastroesophageal reflux disease.

OBJECTIVE: Improvement of esophageal acid clearance appears to be an important effect of cisapride in the treatment of reflux disease. The mechanism underlying this effect is not clear. Esophageal peristalsis is a major component of the acid clearance process. In normal subjects secondary peristalsis is an important mechanism of esophageal acid clearance during sleep, and this response appears to be impaired in patients with reflux esophagitis. The effects of cisapride on secondary peristalsis are not known. The aim of this study was to investigate the effects of cisapride on the triggering and characteristics of secondary peristalsis in patients with reflux esophagitis. METHODS: In 17 patients with reflux esophagitis and impaired secondary peristalsis cisapride, 10 mg q.i.d., or placebo were administered in a randomized double blind, crossover design for 4 days separated by a 4-7 day washout period. On the fourth day of treatment, primary peristalsis and secondary peristalsis in response to 10- and 20-ml air boluses were assessed. RESULTS: Secondary peristaltic success and amplitude were greater with the 20-ml bolus than with the 10-ml bolus. However, cisapride had no effect on either secondary peristaltic success or amplitude. Cisapride also had no effect on primary peristalsis or basal LES pressure. CONCLUSIONS: The improvement in esophageal acid clearance by cisapride is not explainable by improvement in secondary peristalsis.

Biliary manometry, bacterial characteristics, bile composition, and histologic changes fifteen to seventeen years after endoscopic sphincterotomy.

AIM: To evaluate the function of the biliary sphincter 15 to 17 years after endoscopic sphincterotomy and to investigate if loss of sphincter function is associated with bacterial colonization, changes in bile composition, or inflammation of the biliary system. METHODS: Eight patients who had undergone endoscopic sphincterotomy for bile duct stones 15 to 17 years previously underwent ERCP with biliary manometry, bile sampling, and biopsy. Manometry was performed using a perfused triple-lumen manometry catheter and a station pull-through technique. Bile samples were cultured and analyzed for biliary lipids, bile salts, bacterial beta-glucuronidase, and phospholipase A2. Biopsy specimens were taken from the proximal common heptic duct for histologic examination. RESULTS: Manometry demonstrated absent basal sphincter pressure and no choledochoduodenal pressure gradient in all patients. Phasic contractions were observed in two patients. Cholangiography showed stones in one patient. Positive cultures were obtained in three patients, including the patient with stones. All bile samples showed a high content of biliary lipids and cholesterol. Some samples contained considerable amounts of hydrophobic bile salts. Five samples contained very high levels of phospholipase A2 activity. Significant bacterial beta-glucuronidase activity was found in one patient, the patient with stones. Biopsy specimens of the proximal common hepatic duct in three patients showed chronic inflammation with fibrosis and reactive epithelial changes. CONCLUSIONS: After endoscopic sphincterotomy for bile duct stones, the function of the biliary sphincter is permanently lost. This is associated with bacterial colonization, presence of cytotoxic components in the bile, and chronic inflammation of the biliary system.

Motor events underlying gastro-oesophageal reflux in ambulant patients with reflux oesophagitis.

Information on the mechanism of gastro-oesophageal reflux in patients with reflux disease is limited largely to studies in resting recumbent subjects. Evidence exists that both posture and physical activity may influence reflux. The aim of this study was to investigate reflux mechanisms in ambulant patients with reflux oesophagitis. Concurrent ambulatory oesophageal manometry and pH monitoring were performed in 11 ambulant patients with erosive oesophagitis. Lower oesophageal sphincter (LOS) pressure was monitored with a perfused sleeve sensor. Recordings were made for 90 min before and 180 min after a meal. At set times patients sat in a chair or walked. LOS pressure was < or = 2 mmHg at the time of reflux for 98% of reflux episodes. Transient LOS relaxation was the most common pattern overall and the predominant pattern in seven patients, whilst persistently absent basal LOS pressure was the most common pattern in four patients. The pattern of LOS pressure was not altered by the presence of hiatus hernia or by walking. Straining occurred at the onset of 31% of acid reflux episodes but often followed the development of an oesophageal common cavity. The occurrence of straining was not influenced by walking. In ambulant patients with reflux oesophagitis: (1) LOS pressure is almost always absent at the time of reflux, usually because of transient LOS relaxation, (2) persistently absent basal LOS pressure is an important mechanism of reflux in a few patients, (3) straining may help to induce acid reflux in a variable proportion of occasions and may in some instances be a response to gas reflux, and (4) walking does not influence the occurrence of reflux or its mechanisms.

Needle-knife sphincterotomy as a precut procedure: a retrospective evaluation of efficacy and complications.

BACKGROUND AND STUDY AIMS: Precut sphincterotomy remains a controversial means of gaining biliary access during endoscopic retrograde cholangiopancreatography (ERCP). This report is a retrospective evaluation of the use of needle-knife sphincterotomy as a precut procedure to achieve biliary access during ERCP. PATIENTS AND METHODS: From November 1992 to August 1993, a total of 1071 ERCPs were performed at our institution. During this time, precut sphincterotomy was carried out in 180 patients, with complete follow-up obtained in 178 patients. The follow-up concentrated on the efficacy of the procedure and short-term complications. RESULTS: Cannulation of the common bile duct was achieved immediately after precut sphincterotomy in 88% of the patients, and during a second ERCP in an additional 11% of patients (total success rate 99%). There were no precut-related deaths. The complication rate of precut sphincterotomy was 21 in 178 (12%). Complications included bleeding in ten patients (5.5%), perforation in four patients (3%), pancreatitis in one patient (0.5%), and fever of unknown origin in six (3%) patients. All complications were managed conservatively. CONCLUSIONS: Precut sphincterotomy is a safe and highly effective method of gaining biliary access in patients in whom deep cannulation proves difficult or impossible and biliary access is considered essential.

Integrity and characteristics of secondary oesophageal peristalsis in patients with gastro-oesophageal reflux disease.

Secondary peristalsis contributes to oesophageal acid clearance. The aim of the study was to evaluate the integrity and characteristics of secondary peristalsis in patients with gastro-oesophageal reflux disease. Studies were performed in 22 patients with reflux disease and 20 age matched controls. Oesophageal motility was recorded at 3 cm intervals along the oesophageal body. Primary peristalsis was tested with 5 ml water swallows. Secondary peristalsis was stimulated with 10 ml boluses of air and water injected in the mid-oesophagus and by 5 second distensions with a 3 cm balloon at the same level. It was found that primary peristalsis was normal in 19 of 20 control subjects and in 14 of 22 patients with reflux disease. In patients with reflux disease, intact secondary peristalsis was triggered infrequently by air and water distension (median success rate of 0% for both stimuli) and occurred significantly less frequently than in control subjects (50% and 30% respectively). The frequency of balloon induced secondary peristalsis, however, was similar in the two groups (0% controls, 20% reflux disease). The major pattern of failure of secondary peristalsis was the complete absence of any oesophageal secondary peristaltic response. The amplitudes of the intact secondary peristaltic responses were not significantly different for the two groups. Peristaltic velocity for air and balloon induced secondary peristalsis was also similar in control subjects and patients with reflux disease whereas water induced secondary peristalsis was slower in the reflux patients. In conclusion, patients with reflux disease exhibit a pronounced defect in the triggering of secondary peristalsis.

Pancreatic and ampullary carcinoma.

Surgery should be the first therapeutic modality considered in patients with pancreatic and ampullary carcinoma. Surgery is the only potentially curative therapy and offers the best form of palliation in patients with impending or overt duodenal obstruction. Patients with clearly unresectable tumors or those considered unfit for surgery should be offered palliative therapy, preferably endoscopically. The difficulty, however, arises in patients who undergo laparotomy and who subsequently are found to have unresectable tumors. The problem of stent occlusion and frequent associated hospital visits has been an argument to proceed to palliative double bypass surgery. Against this is the low mortality and shorter hospital stay of nonsurgical endoscopic palliative therapy. Direct comparisons of surgery versus endoscopic therapy have shown that both are equally effective in the initial relief of jaundice (Table 6). Surgery has a higher initial mortality and complication rate, but more long-term complications and hospital visits were seen in the endoscopic group, suggesting that it offered a poorer long-term palliation. There was no significant difference in the survival of the patients in the two groups. Patient choice is a major factor in the final decision, but current recommendations probably should be that patients with a poor short-term survival outlook should be offered nonsurgical palliative therapy and those with a longer life expectancy may best be handled with surgery. Predicting patient survival, of course, remains a major difficulty. A recent publication of the laparoscopic formation of a cholecystojejunostomy for palliation of malignant biliary obstruction also offers a promising approach that requires further evaluation.

Mechanisms of gastroesophageal reflux in ambulant healthy human subjects.

BACKGROUND/AIMS: Investigation of the motor events underlying gastroesophageal reflux has largely been confined to resting, recumbent subjects. The motor events associated with reflux during physical activity remain unknown. The aim of this study was to investigate the patterns of lower esophageal sphincter (LES) function underlying reflux in healthy subjects and the effect of exercise and physical activity on reflux mechanisms. METHODS: LES pressure was recorded with a perfused sleeve sensor in 10 healthy subjects; intraluminal transducers recorded pressure in the stomach, esophagus, and pharynx, and pH was recorded 5 cm above the LES. Signals were stored in a portable data-logger. Recordings were made for 24 hours, including moderate physical activity, periods of rest and sleep, standardized meals, and standardized exercise. RESULTS: Most reflux episodes (81 of 123; 66%) occurred in the 3 hours after food intake; only 2 episodes occurred during exercise. LES pressure was < or = 3 cm H2O in 79% of reflux episodes. Transient LES relaxation was the mechanism of reflux in 82% of episodes, irrespective of activity or body position, whereas swallow-related LES relaxations accounted for 13% and persistently absent LES pressure accounted for 1%. Straining occurred in only 20% of episodes. CONCLUSIONS: In ambulant healthy subjects, accurate continuous recording of LES function is possible, reflux usually occurs during transient LES relaxations, and straining is not a major factor in the induction of reflux.

Secondary oesophageal peristalsis in patients with non-obstructive dysphagia.

Secondary peristalsis was investigated in 30 patients with non-obstructive dysphagia and 20 age matched controls. Oesophageal motility was recorded at 3 cm intervals along the oesophageal body. Primary peristalsis was tested with 5 ml water swallows. Secondary peristalsis was stimulated with 10 ml boluses of air and water injected in the mid-oesophagus and by distensions (5 seconds duration) with a 3 cm balloon at the same level. Primary peristalsis was normal in 19 of the 20 control subjects and in nine of the 30 patients with dysphagia; 11 patients had diffuse spasm and 10 had non-specific abnormalities of primary peristalsis. Secondary peristalsis was triggered significantly less frequently by air and water distension in dysphagia patients (median success rate of 10% for the air boluses and 0% for the water boluses) than in control subjects (50% and 30% respectively, p < 0.005), and was abnormal in six of nine patients with normal primary peristalsis, nine of 11 patients with diffuse spasm and eight of 10 patients with non-specific motor abnormalities. The median frequency of balloon induced secondary peristalsis, however, was not significantly different in the two groups (0% controls, 40% non-obstructive dysphagia, p = 0.22). For each stimulus, there were no significant differences in the response rate in the three subgroups of patients. The major pattern of failure of secondary peristalsis in response to the air and water boluses was the complete absence of any oesophageal response. The amplitude of complete secondary peristalsis triggered by the water boluses and the balloon was greater in the patients with dysphagia (p = 0.03) than in normal subjects, while the amplitude of the secondary peristaltic responses triggered by the air boluses was similar in the two groups. Secondary peristaltic velocity was also similar in normal subjects and patients with non-obstructive dysphagia. Patients with non-obstructive dysphagia show a noticeable defect in the triggering of secondary peristalsis which may make an important contribution to the delayed oesophageal bolus transit and dysphagia seen in this condition.

Stimulation and characteristics of secondary oesophageal peristalsis in normal subjects.

The study evaluates the triggering and characteristics of secondary oesophageal peristalsis in 25 healthy volunteers. Secondary peristalsis was stimulated by rapid intraoesophageal injection of boluses of air and water, and by a five second oesophageal distension with a balloon. Air and water boluses triggered secondary peristalsis that started in the proximal oesophagus regardless of injection site. Response rates were volume dependent with 83% of the 20 ml air boluses triggering secondary peristalsis compared with 2% for the 2 ml water bolus (p < 0.0001). Response rates for air and water were similar for equal bolus volumes and were not influenced by the site of injection. In contrast, balloon distension usually induced a synchronous contraction above the balloon, with secondary peristalsis starting below the balloon after deflation. The peristaltic response rate to balloon distension was also volume dependent and the middle balloon was more effective in triggering secondary peristalsis than either the upper or lower balloons (p < 0.001). Secondary peristaltic amplitude was less than that of primary peristalsis (p < 0.001). Secondary peristaltic velocity with a water bolus was slower (p = 0.001) than that of primary peristalsis. Intravenous atropine significantly reduced secondary peristaltic responses to all stimuli. There was also a significant reduction in pressure wave amplitude for air stimulated secondary peristalsis while those for the water responses were similar. Secondary peristaltic velocity with air and water boluses was not changed by atropine. The reproducibility of testing secondary peristalsis was examined six volunteers and did not show any significant differences on separate test days in response rate and peristaltic amplitude or velocity. It is concluded that in normal subjects, secondary peristalsis can be more reliably triggered by intraoesophageal air or water infusion than balloon distension. Secondary peristaltic amplitude and velocity are stimulus but not site or volume dependent and propagation is partially mediated by cholinergic nerves.

Can the response to interferon treatment be predicted in patients with chronic active hepatitis C?

Twenty-one of 40 patients with chronic non-A, non-B hepatitis (37 anti-HCV positive) were randomised to receive interferon alpha 2b (3 million units subcutaneously thrice weekly for 24 weeks) and then to be observed for six months. Among the other 19 patients (controls) randomised to be observed without treatment for 12 months, eight have subsequently been treated with interferon for six months. One treated patient and three controls were lost to follow-up. A return to normal serum alanine aminotransferase levels which lasted until the end of the treatment period occurred in 18 (64%) of the 28 patients given interferon (and in 13 of 21 (62%) randomised to treatment), but only in one of the 16 untreated controls (p less than 0.001). Multivariant analysis indicated that, compared with the ten nonresponders, the 18 patients who responded to interferon were more likely to have acquired infection by intravenous drug abuse than by blood transfusion (p less than 0.05), and were more likely to have histologically less severe chronic liver disease (p less than 0.01). Thus, all 13 patients with less severe liver disease histologically responded to interferon, but only five of 15 patients with cirrhosis or bridging fibrosis responded. Among 17 responders followed for more than four months, five (28%) are still in remission a median of 13 months (range four months to 24 months) after stopping interferon. The characteristics which favoured a response during treatment also appeared to distinguish those who experienced sustained post-treatment remission.(ABSTRACT TRUNCATED AT 250 WORDS)

Recurrent acute fatty liver of pregnancy associated with a fatty-acid oxidation defect in the offspring.

A case of a 29-year-old woman who has had two episodes both clinically and biochemically consistent with acute fatty liver of pregnancy is described. These episodes occurred in two successive pregnancies, and liver biopsy confirmed the diagnosis in the second pregnancy. Both pregnancies were managed by prompt fetal delivery; on both occasions this led to a complete biochemical resolution of the liver function abnormalities. Two healthy babies were delivered by ceasarian sections. This case is of particular importance because a rapidly progressive and devastating illness developed in both infants, leading to death at 6 1/2 and 6 months, respectively. The illness in both babies was characterized by wide-spread fatty infiltration of several vital organs and a failure of any treatment to influence the outcome of that illness. Studies suggested that the illness in the children was caused by a still ill-defined disorder of fatty acid oxidation. The biochemical disorder evidenced in this family is discussed, in an attempt to shed light on the etiology of acute fatty liver of pregnancy.

Sexuality education among black South African teenagers: what can reasonably be expected?

Incidence rates of teenage pregnancies in South Africa--especially among the black population--poses definite reason for concern. The adverse physical, psychological, social and demographic consequences do not only put the lives of the mother and infant at risk, but also threatens the quality of their lifestyle. Sexuality education is not a panacea for preventing teenage pregnancy, but within a multi-disciplinary approach evidence indicates that it has an important and ameliorative role to play in successful preventive programmes. The practical aspects of the delivery of sexuality education, particularly in comprehensive health clinics in black areas, raises questions regarding the expectations to be attached to such services. A partial answer is provided by a preliminary study conducted in two South African townships. The study highlights some of the issues impeding the effective functioning of sexuality education services in clinics. In order to address some of these problems, the author contends that sexuality education should be synonomous with effective two-way communication. This implies a high degree of co-operation between policy makers, nurses and black teenagers. This link between communication and sexuality education will be referred to as SEC (Sexuality Education as Communication). Within this framework a cognitive-behavioural approach as a four-step process to learning, holds potential to incorporate most of the requirements for SEC. The attitude and ability of the nursing staff is of crucial importance in all four steps, as the SEC model continuously emphasizes the relationship between adolescents and the nursing staff. There is almost universal agreement that the educator is the key element in good programmes.(ABSTRACT TRUNCATED AT 250 WORDS)

Chronic non-A, non-B hepatitis: lack of correlation between biochemical and morphological activity, and effects of immunosuppressive therapy on disease progression.

A study was made of 52 patients considered to probably have chronic non-A, non-B hepatitis who were seen during an eight-year period at Westmead Hospital, Sydney. The patients were followed for a median of 28 months to assess the natural history of the disease and, in a small number of patients, the effect of immunosuppressive therapy on disease progression was examined. In 94% of cases, infection appeared to have been acquired by a parenteral route; the remainder were sporadic infections. Fifty-six per cent of the patients had mild constitutional symptoms and the remainder were asymptomatic. Similarly, 54% of patients had no signs of chronic liver disease and none exhibited signs of hepatic decompensation. Liver biopsies were performed in 42 patients; chronic active hepatitis with or without cirrhosis was present in 90%. However, neither the presence of symptoms nor the degree of biochemical abnormality were predictive of disease severity as determined histologically. Among eight patients treated with corticosteroids (with or without azathioprine), six underwent follow-up liver biopsy. Quantitative analysis of inflammatory and fibrotic changes indicated significant (p less than 0.01) progression of histological severity during a median 33 months (range 7-98 months) between biopsies with cirrhosis developing in four instances. In contrast, among the seven untreated patients rebiopsied after a median of 16.0 months (range 11-37 months) there was no overall change in histological severity and only one patient developed cirrhosis. it is concluded that histological assessment is required in all patients suspected of having chronic non-A, non-B hepatitis as other means of assessment are unreliable.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of surgical lubricants on semen analysis.

The effects of a number of commercially available surgical lubricants on the motility of spermatozoa with time, have been examined with the aim of recommending a non-toxic, water soluble aid which was not visibly detrimental to spermatozoa following collection of semen for routine analysis. The results have shown that motility is impaired at concentrations above 5%, but that below this level of contamination, spermatozoal motility, and progression, as objectively determined by multiple exposure photography, was unaffected. For various practical reasons, and because it is well known, K-Y Jelly, packaged as a single sachet, is probably the lubricant of choice.