Mucosal morphology in Barrett's esophagus: interobserver agreement and role of narrow band imaging.

BACKGROUND AND STUDY AIMS: We have recently proposed a classification of mucosal morphology in Barrett's esophagus based on three criteria: regularity of mucosal pattern, regularity of vascular pattern, and presence of abnormal blood vessels. We aimed to evaluate the interobserver agreement with the proposed mucosal morphology classification and to assess the additional value of narrow band imaging (NBI) over high resolution white light endoscopy (HR-WLE). PATIENTS AND METHODS: Five international experts in the field of Barrett's imaging and seven community endoscopists with no expertise in this field independently evaluated magnified still images from 50 areas, obtained with HR-WLE and NBI, in Barrett's esophagus patients. Visual analogue scales (VAS) were used for scoring imaging quality. Interobserver agreement for mucosal morphology and yield for identifying early neoplasia were assessed. RESULTS: Imaging qualities of NBI were rated more highly than HR-WLE, when evaluated separately as well as in a side-by-side comparison. The interobserver agreement ranged from 0.40 to 0.56 and did not significantly differ between expert and non-expert endoscopists. The overall yield for correctly identifying images of early neoplasia was 81 % for HR-WLE, 72 % for NBI and 83 % for HR-WLE + NBI, with no significant difference between experts and non-experts. CONCLUSION: Interobserver agreement for the classification of mucosal morphology was moderate. Although NBI was rated more highly than HR-WLE for imaging quality, this did not result in improved interobserver agreement or increased yield for identifying early neoplasia in Barrett's esophagus. This applied to non-expert as well as expert endoscopists.

The effect of a lactose-restricted diet in patients with a positive lactose tolerance test, earlier diagnosed as irritable bowel syndrome: a 5-year follow-up study.

DESIGN AND METHODS: Prospectively, the effect of a lactose-restricted diet was evaluated among irritable bowel syndrome patients with lactose malabsorption. Lactose malabsorption was defined by a positive hydrogen breath test and a positive blood-glucose test. An analysis of symptoms was completed before, during, 6 weeks after and 5 years after starting the diet. In addition, the number of visits made by the patients to the outpatient clinic was scored during 6 years. RESULTS: In 17 out of 70 irritable bowel syndrome patients (24.3%), lactose malabsorption was detected. There was no difference in the symptom score between patients with a positive lactose tolerance test and patients with a negative lactose tolerance test. After 6 weeks of the lactose-restricted diet, symptoms were markedly improved in lactose malabsorption-positive patients (P < 0.001). After 5 years, one patient was lost for follow-up, and 14 out of the remaining 16 lactose malabsorption patients (87.5%) still had no complaints during the lactose-restricted diet. Two patients chose not to follow the diet continuously and accepted the discomfort caused by lactose intake. Only two out of 16 patients (12.5%) no longer experienced any benefit from lactose restriction. In the 5 years before their diagnosis of lactose malabsorption, these 16 patients visited the outpatient clinic a total of 192 times (mean 2.4 visits per year per person; range 1-7 visits). In the 5 years after diagnosis, they visited the outpatient clinic a total of 45 times (mean 0.6 visits per year per person; range 0-6 visits; P < 0.0001). CONCLUSIONS: In a large majority of irritable bowel syndrome patients with lactose malabsorption, which was previously clinically unrecognized, a lactose-restricted diet improved symptoms markedly both in the short term and the long term. Furthermore, visits by all patients to the outpatient clinic were reduced by 75%. We conclude that diet therapy is extremely cost- and time-saving. Therefore, it is strongly recommended that lactose malabsorption, which is easily treatable, is excluded before diagnosing irritable bowel syndrome.

The prevalence of constipation in institutionalized people with intellectual disability.

Constipation is a common problem in people with intellectual disability (ID). Laxatives are frequently prescribed with disappointing results. The prevalence of constipation was investigated in a random population of 215 people with ID (IQ < 50) and constipation was correlated with clinical symptoms. All subjects were scored for bowel habits. Constipation was defined as having a bowel movement less than three times a week or the necessity of using laxatives more than three times a week. Further possible accompanying factors were evaluated. The control subjects were defined as individuals who did not use laxatives. Subjects with constipation were defined as patients and were compared to subjects without constipation (controls). One hundred and forty-nine out of 215 cases (69.3%) showed constipation. Constipation was significantly correlated with non-ambulancy, cerebral palsy, the use of anticonvulsive medication or benzodiazepines, H2-receptor antagonists or proton pump inhibitors, food refusal, and an IQ < 35. Fifty-eight per cent of the patients used bisacodyl or magnesium oxide, 39% lactulose, 13% sodiumlaurylsulphoacetate/sodium citrate/sorbitol and only 10% were given sodium phosphate enemas. Faecal soiling was found in 15% of subjects, while manual evacuation of faeces was performed in nearly 7% of cases. Constipation was randomly demonstrated in almost 70% of the population with ID. Subjects with the above-mentioned accompanying factors are especially at risk for constipation. Contrary to the general population, constipation in people with ID is associated with little use of phosphate enemas, microlax, a low incidence of faecal soiling and manual evacuation of faeces, suggesting an aetiology without distal faecal impaction. The regimen and effect of therapy has to be studied to define adequate treatment schedules.

Gastroesophageal reflux disease in intellectually disabled individuals: how often, how serious, how manageable?

Gastroesophageal reflux disease (GERD) is an important and frequently occurring problem among intellectually disabled individuals (IDI). Early suspicion and recognition of the presence of GERD in IDI is the cornerstone of adequate management of these patients. The prevalence of GERD among institutionalized IDI with an IQ < 50 is about 50%, with 70% of these reflux patients having endoscopically established reflux esophagitis. In case of symptoms as hematemesis, rumination, or dental erosions, there is an increased risk for GERD. GERD has also been shown to be associated with cerebral palsy, an IQ < 35, scoliosis, and the use of anticonvulsant drugs or benzodiazepines. To establish the diagnosis, 24-h pH measurement or endoscopy should be used in all those intellectually disabled individuals in whom GERD clinically is suspected. The efficacy of proton-pump inhibitors (PPIs) in IDI with GERD is indisputable. In IDI, adults as well as children, PPIs are highly effective, independent of the severity of esophagitis. Marked improvement of symptoms and quality of life can be noticed after medical treatment, thereby decreasing the need for surgery in this complicated group of patients.

[Gastroesophageal reflux disease in mentally retarded persons: prevalence, diagnosis and treatment]. / Gastro-oesofageale refluxziekte bij verstandelijk gehandicapten: prevalentie, diagnostiek en behandeling.

The prevalence of gastroesophageal reflux disease among institutionalised intellectually disabled individuals with an IQ < 50 is high: about 50% have an deviant 24-hour pH measurement and 70% of them have refluxoesophagitis. Intellectually disabled individuals have an increased risk of gastroesophageal reflux disease in case of cerebral palsy, IQ < 35, scoliosis, use of anticonvulsant drugs or benzodiazepines, not being ambulant, and in case of symptoms such as haematemesis, rumination or dental erosions. To establish the diagnosis is difficult because of the aspecific symptoms. Reflux disease is only diagnosed at a late stage. 24-hour pH measurement should be used in all those intellectually disabled individuals in whom gastroesophageal reflux disease is clinically suspected. For the treatment of gastro-oesophageal reflux disease in adults as well as children, proton pump inhibitors are highly effective, independent of the severity of oesophagitis. Marked improvement of symptoms and quality of life can be noticed after treatment.

The prevalence of gastroesophageal reflux disease in institutionalized intellectually disabled individuals.

OBJECTIVE: The prevalence of gastroesophageal reflux disease (GERD) was randomly investigated among Dutch and Belgian intellectually disabled individuals. METHODS: In six institutes including 1607 residents, 435 persons with IQ <50 underwent 24-h esophageal pH-metry and were scored for possible predisposing factors and characteristic reflux symptoms. In 49 (11.2%) cases the test failed because of technical reasons. A pathological pH test was defined as a pH <4 for >4.5% of the measured time. Subjects with a pathological pH test (patients) were compared with those with a normal pH test (controls). RESULTS: Of the remaining individuals, 51.8% (200/386) showed a normal pH test, whereas 186 showed a pathological pH test (median duration pH <4: 14.2%, range: 4.5-78.4%). As possible predisposing factors scoliosis, cerebral palsy, use of anticonvulsant drugs or other benzodiazepines, and IQ <35 were found, whereas symptoms such as vomiting, hematemesis, rumination, and depressive symptoms were indicative for reflux. At endoscopy reflux esophagitis was diagnosed in 129 of the 186 patients (69.4%). In 61 (47.3%) of 129 patients, grade I, 43 (33.3%) grade II, 25 (19.4%) grade III/IV (Savary-Miller) were found. Barrett's esophagus was found in 18 (14.0%) and peptic strictures in five (3.9%) cases. CONCLUSIONS: An abnormal 24-h pH-metry and symptoms suggestive for GERD were documented frequently in a large cohort of institutionalized intellectually disabled individuals. Further endoscopical evaluation confirmed the diagnosis of reflux esophagitis in the majority of these individuals.

Omeprazole: therapy of choice in intellectually disabled children.

OBJECTIVE: To study extensively the therapeutic approach of gastroesophageal reflux disease in intellectually disabled children. DESIGN: We studied the effect of omeprazole sodium on healing and symptom relief in 52 institutionalized intellectually disabled children (male-female, 21:31; mean age, 15.4 years; range, 4-19 years). INTERVENTION: Endoscopically proven esophagitis (grades I-IV, Savary-Miller classification) was treated with omeprazole sodium, 40 mg/d (20 mg/d for children weighing <20 kg) as healing dose for 3 months, and 20 mg/d (10 mg/d for children weighing <20 kg) as maintenance dose for another 3 months. After 3 and 6 months, results of treatment were evaluated using symptom scoring and/or endoscopy. For patients with relapse, the dose was increased. RESULTS: At first endoscopy, 19 patients (36%) of 52 showed grade I esophagitis; 20 (38%), grade II; 6 (12%), grade III; and 7 (13%), grade IV. In 44 (86%) of 51 patients, treatment was effective in healing esophagitis and keeping patients in remission, independent of the severity of esophagitis. In 7 patients (14%), a symptomatic relapse was observed after decreasing the dose. However, these patients became symptom free again after increasing the dose and showed healing on endoscopy at the end of the study. One child did not finish the study for reasons not related to therapy. Marked improvement of persistent vomiting, regurgitation, food refusal, iron deficiency anemia, and signs of depression was seen at the end. CONCLUSIONS: Omeprazole is highly effective for all grades of esophagitis in intellectually disabled children, without adverse effects. The dose needed to maintain the remission can be titrated according to the reflux symptoms. One disadvantage of medical therapy is that it is open ended, in contrast to operation, but surgery in this population has high mortality and complication rates.

Gallbladder contents and fasting gallbladder volumes during and after pregnancy.

BACKGROUND: A high risk of developing sludge or gallstones has been associated with pregnancy. The aim of this study was to relate the prevalence of sludge and gallstones during and shortly after pregnancy to fasting gallbladder volume as an indicator of gallbladder motility. METHODS: The population included 114 apparently healthy pregnant women from the Outpatient Clinic of Obstetrics of a large regional hospital and from the practices of regional midwives. Ultrasonography of the gallbladder was performed at weeks 15, 25, and 35 of gestation and at week 3 and month 6 postpartum. RESULTS: At gestational week 15, 3 women had gallstones and 10 had sludge (mean volume, 33.8 ml), and 99 women had a normal gallbladder (mean volume, 30.5 ml). At week 25, 1 woman with a normal gallbladder formed gallstones and underwent cholecystectomy shortly after, and 22 women had sludge, of whom 13 had a normal gallbladder at first examination (mean volume, 33.2 ml). In 88 women with normal gallbladders (of whom 2 had sludge at week 15) mean volume was 31.9 ml. At week 35, 2 women had gallstones, and 21 had sludge (mean volume, 30.5 ml). In the remaining 79 women the gallbladders were clear (mean volume, 29.5 ml). Eight women developed sludge and two women gallstones in normal gallbladders at week 25. Seven women with sludge at week 25 had a normal gallbladder at week 35. Three weeks postpartum only 10 of 100 women had sludge (mean volume, 29.1 ml). Of these 10, 9 women had a normal gallbladder at week 35. Twenty of 21 women with sludge at week 35 had normal gallbladders week 3 postpartum. Gallstones found at week 35 had disappeared. In the women with a normal gallbladder the mean volume was decreased to 19.7 ml (P < 0.0001). Six months postpartum, sludge was found in 6 (mean volume, 18.4 ml) of 93 women (mean volume, 20.3 ml), of whom 5 had a normal gallbladder at week 3 postpartum. Only 61 women showed a normal gallbladder at each examination of the study. No differences in patient characteristics were found between women with normal gallbladders and those with sludge or gallstones. CONCLUSIONS: Fasting gallbladder volume was increased in all pregnant women. This could not explain the formation of sludge or gallstones during gestation. Decrement of gallbladder volumes after delivery was faster in normal, clear gallbladders. More than a prerequisite, increased fasting gallbladder volume seemed to be a permissive factor of pregnancy-associated gallstone formation.

Gastroesophageal reflux disease in intellectually disabled individuals: leads for diagnosis and the effect of omeprazole therapy.

OBJECTIVES: The therapeutic approach to gastroesophageal reflux disease (GERD) in intellectually disabled individuals has not been studied extensively. So far, only low response rates to medical and surgical therapy of GERD have been reported. However, the efficacy of proton pump inhibitors, to date the most effective medical therapy for GERD, has never been evaluated in this population. Our purpose, therefore, was to study the effect of omeprazole on healing and symptom relief in the intellectually disabled. METHODS: The treatment scheme was as follows: omeprazole 40 mg was given once daily (o.d.) as a healing dose for 3 months, and omeprazole 20 mg o.d. was given as a maintenance dose for another 3 months, to intellectually disabled subjects with endoscopically proven esophagitis, grades I-IV, according to Savary-Miller classification. After 3 and 6 months, the result of this treatment was evaluated by symptom scoring and/or endoscopy. In case of relapse, the dose was increased. RESULTS: At the first endoscopy, 40 of 107 patients (37%) had grade I, 36 (34%) grade II, 18 (17%) grade III, and 13 (12%) grade IV esophagitis. In 92 of 104 patients (88%), the treatment scheme was effective in healing the esophagitis and keeping patients in remission, independent of the severity of esophagitis. In 11 of 104 (11%) patients, a symptomatic relapse was observed after the dose was decreased to 20 mg o.d. However, all of these patients became symptom free again after the dose was increased to 40 mg o.d., and all were healed endoscopically at the end of the study. One (1%) patient needed omeprazole 60 mg o.d. for healing, but in this patient, no relapse was seen while on a maintenance dose of omeprazole 40 mg o.d. Marked improvement of persistent vomiting, hematemesis, regurgitation, food refusal, iron deficiency anemia, and depressive symptoms was seen at the end of the study. CONCLUSIONS: This study indicates that omeprazole is highly effective for all grades of esophagitis in the intellectually disabled. The dose needed to maintain them in remission can be titrated according to the reflux symptoms.

The age-related incidences of oesophageal carcinoma in intellectually disabled individuals in institutes in The Netherlands.

OBJECTIVE: An increased age-related incidence of oesophageal cancer in people with intellectual disability has been suggested by studies in the Netherlands. Gastro-oesophageal reflux disease (GORD), as documented by pH testing, occurs frequently in the intellectually disabled population, being found in nearly 50% of those with an IQ less than 50, while Barrett's oesophagus is found in about 15-26%. DESIGN: We compared the age-related incidence of oesophageal cancer in institutionalized, intellectually disabled individuals in the Netherlands with the age-related incidence in the general Dutch population. METHODS: Data were provided by the Netherlands Cancer Registry. The patient's institute physician was asked to complete a questionnaire about the diagnosis, which was endoscopically and histologically confirmed. RESULTS: The incidence of oesophageal carcinoma was 20 in 168,000 person-years. The expected incidence for oesophageal cancer, based on age-related incidence in the general population, was 7.0, resulting in a standardized morbidity ratio in the population with intellectual disability of 2.9 (confidence limits, 1.8-4.1; P < 0.001). Endoscopic findings were as follows: in 18/20 intellectually disabled carcinoma patients an adenocarcinoma was found; the remaining two patients had a squamous cell carcinoma. Barrett's epithelium was observed in nine patients (45%), eight (42%) of whom showed a peptic stricture as well. In 15 (75%) cancer patients reflux oesophagitis was found, accompanied in 14 cases by a hiatal hernia. CONCLUSION: A standardized morbidity ratio for oesophageal carcinoma of 2.9 was found in the intellectually disabled population as compared to the general population. Early detection and treatment of GORD in the population with intellectual disability is of paramount importance to prevent the development of Barrett's dysplasia and carcinoma.

The prevalence of Helicobacter pylori infection among inhabitants and healthy employees of institutes for the intellectually disabled.

OBJECTIVES: The prevalence of Helicobacter pylori infection varies in the Netherlands from 5% in children to about 50% in the elderly. In the institutionalized intellectually disabled, a high prevalence of infection has been reported. It is unknown whether there are specific risk factors to obtain H. pylori infection in this population, and whether employees of such institutes are at risk for H. pylori infection. METHODS: Therefore, we analyzed the seroprevalence of H. pylori antibodies by ELISA among 338 intellectually disabled inhabitants and 254 employees of two institutes. H. pylori-positive patients were compared with H. pylori-negative controls. The intellectually disabled and the employees were evaluated for possible risk factors. RESULTS: Of the 338 intellectually disabled, 280 (82.8%, median age 51 yr) were infected with H. pylori. This rate is significantly higher than the prevalence of H. pylori in the Dutch population. The presence of H. pylori was significantly associated with male gender, longer duration of institutionalization, an IQ < 50, rumination, and a history of upper abdominal symptoms. Of the 254 employees, 69 (27.2%) were infected, which is equal to the rate for the total Dutch population. The presence of H. pylori infection among employees was, however, significantly associated with a higher level of physical contact with the intellectually disabled, longer duration of employment, and having upper abdominal symptoms. CONCLUSIONS: Intellectually disabled persons are at high risk of developing H. pylori infection. Employees with close physical contact to the intellectually disabled population for a considerable period of time are also at increased risk. H. pylori infection should be considered a job attributable risk in this profession.

The prevalence of gastro-oesophageal reflux disease based on non-specific symptoms in institutionalized, intellectually disabled individuals.

OBJECTIVE: The prevalence of gastro-oesophageal reflux disease (GORD) in randomly selected, institutionalized, intellectually disabled individuals (IQ < 50) in The Netherlands is high. DESIGN: In this study we investigated the prevalence of GORD and reflux oesophagitis (RO) in intellectually disabled individuals specifically selected for symptoms such as: behavioural difficulties such as automutilation, food refusal, fear and restlessness, vomiting, regurgitation and rumination. Predisposing factors were also evaluated. METHODS: One hundred and ten individuals from one institute underwent a 24-h oesophageal pH test and were scored for predisposing factors and non-specific reflux symptoms. A pathological pH test was defined as a pH lower than 4 more than 4.5% of the measured time. Subjects with a pathological pH test (patients) were compared to those with a normal pH test (controls). RESULTS: In seven cases (6.4%) the test failed for technical reasons. In 57 (55.3%) cases a pathological pH test was found. RO was diagnosed in 33 (64.7%) patients. The use of anticonvulsant drugs and cerebral palsy appeared to be predisposing factors, while the non-specific reflux symptoms did not discriminate for GORD. CONCLUSION: The prevalence of GORD was equal in a randomly selected group of intellectually disabled individuals, and in this group, specifically selected on account of possible reflux symptoms. This study confirms that in this particular group, it is nearly impossible to discriminate for the diagnosis of GORD on non-specific reflux symptoms only. However, GORD may be suspected where there are certain predisposing factors, particularly cerebral palsy and use of anticonvulsant drugs.)

Dental erosions and gastro-oesophageal reflux disease in institutionalized intellectually disabled individuals.

OBJECTIVE: Both exogenous acids, from the diet, and endogenous acids, from stomach juice, can dissolve the enamel mineral, resulting in dental erosions. Gastric acid may reach the mouth by gastro-oesophageal reflux disease (GERD), recurrent vomiting, rumination and regurgitation. These conditions are frequently found in the intellectually disabled population. Therefore, we investigated the presence of dental erosions in combination with GERD among intellectually disabled inhabitants, with an IQ < 50, taken from three Dutch institutes. MATERIALS AND METHODS: At random 63 individuals underwent an oesophageal pH test and dental screening and possible predisposing and attributable factors were determined. An abnormal pH level was defined as a pH < 4, > 4.5% of the measured time. Subjects with dental erosions were compared to those without dental erosions. RESULTS: In 29 out of 63 (46.0%) cases evidence of dental erosions was found. In 19 of these 29 subjects with erosions (65.5%) GERD was diagnosed, compared to nine (26.5%) out of 34 subjects without erosions (P = 0.04). In the subjects with erosions mean duration of pH < 4 was 15.6% (range: 0.5-90.5) compared to 6.3% (range 0-40.4) in subjects without erosions (P = 0.02). An IQ < 35 was found to be predisposing (P < 0.001). CONCLUSION: In this population of 63 institutionalised intellectually disabled persons dental erosions were diagnosed in 46%. Sixty-five per cent of them had GERD. Individuals with longer duration of pH < 4 than 6.3% of the measured time and with an IQ < 35 were at higher risk to develop dental erosions. This study shows that dental erosions in the intellectually disabled population might be an oral manifestation of GERD.

Gastro-oesophageal reflux disease in institutionalised intellectually disabled individuals.

BACKGROUND: The prevalence of reflux oesophagitis (RO) in the normally intellectual population is about 2%, while this condition in the intellectually disabled has an estimated prevalence of 10%. METHODS: We investigated the presence of RO among 1687 intellectually disabled, with an IQ < 50, from 5 different institutes in the Netherlands. All were scored for possible associated factors and reflux symptoms, and compared with the overall population (n = 1580) from the same institutes (controls). Also, the effect of treatment on symptoms was evaluated after at least one year of therapy. RESULTS: Gastro-oesophageal reflux disease (GORD) was suspected clinically in 169 patients based on the following symptoms: vomiting, haematemesis, anaemia, rumination or behaviour problems. At endoscopy RO was diagnosed in 107 of 1687 patients (6.4%): 17 (15.9%) grade I, 34 (31.8%) gr. II, 42 (39.3%) gr. III and 14 (13.1%) gr. IV RO (Savary-Miller classification). Cerebral palsy, constipation, anticonvulsant drugs, an IQ < 35, underweight and gastrostomy feeding appeared to be possible associated factors, while as reflux symptoms persistent vomiting, haematemesis, iron deficiency anaemia, rumination, and behaviour problems were found. Concerning therapy, surgery was found to be effective in 38%, H2 receptor antagonists in 60% and the proton-pump inhibitor omeprazole in 96%. CONCLUSIONS: In this group of Dutch intellectually disabled patients with IQ < 50 RO was diagnosed in about 6% (107 of 1687), mostly severe grades of oesophagitis. Several possible associated factors were significantly present. From non-specific reflux symptoms persistent vomiting was the most indicative factor. In this population the most effective treatment of RO was long-term omeprazole therapy.

The clinical relevance of lactose malabsorption in irritable bowel syndrome.

OBJECTIVE: The prevalence of lactose malabsorption (LM) in the Caucasian population of northern Europe is estimated to be low. Irritable bowel syndrome (IBS) is a very common diagnosis, and its symptoms are nearly identical to those of LM. Therefore we investigated the prevalence of LM among IBS patients in comparison with healthy volunteers. DESIGN: A double-blind clinical trial compared with healthy controls. SETTING: One out-patient gastroenterology clinic in the Netherlands. PATIENTS: 70 Caucasian IBS patients and 35 healthy volunteers (staff members). METHODS: All 105 underwent hydrogen (H2) breath and blood glucose tests, after an oral intake of 50 grams of lactose. The IBS patients were treated with a lactose-restricted diet for 6 weeks. They completed a lactose intake score before, and a symptom score scored by six separate criteria, before, during and after treatment. RESULTS: In 17 out of 70 (24.3%) IBS patients LM was detected, in comparison with 2 out of 35 (5.7%) controls (P < 0.009). There was no difference in the pre-entry mean lactose intake and symptom score between the LM positive and negative IBS patients. The mean symptom score of the LM positive group showed a marked decrease after 6 weeks of dietary therapy (P < 0.001). CONCLUSION: A substantial number of IBS patients showed a clinically unrecognized lactose malabsorption, which could not be discriminated by symptoms and dietary history, and which can be treated with a lactose-restricted diet. Therefore LM has to be excluded before the diagnosis IBS is made.