Geriatric consultation can aid in complex treatment decisions for elderly cancer patients.

Treatment decisions for elderly cancer patients can be challenging. A geriatric assessment may identify unknown medical conditions, give insight on patients' ability to tolerate treatment and guide treatment decisions. Our aim was to study the value of a geriatric consultation in oncological decision-making. Data on cancer patients referred for geriatric consultation for clinical optimisation or due to uncertainty regarding their optimal treatment strategy were prospectively analysed. Outcome of geriatric evaluations, non-oncological interventions and suggested adaptations of oncological treatment proposals were evaluated. Seventy-two patients were referred for consultation, over half of which in a curative treatment setting. Prevalence of geriatric syndromes was 93%, previously undiagnosed conditions were identified in 49% of patients and non-oncological interventions were initiated in 56%. Time was spent discussing patients' priorities (53% of consultations), expectations on treatment (50%) and advance care planning (14%). For 82% of patients, suggestions were made regarding the optimal treatment decision: a more intensive treatment was recommended in 39%, a less intensive therapy for 42% and in 19% only supportive care was suggested. The results demonstrate that a geriatric consultation can aid in complex treatment decisions and may allow for a reduction in over- and undertreatment of elderly cancer patients.

Does carditis have two different etiologies?

Carditis has become the subject of much study and discussion, although its etiology is still controversial. We wished to study the prevalence and possible pathogenetic mechanisms of carditis in a well-defined group of patients. In 664 patients biopsies were taken distal to the squamocolumnar junction (SCJ) and from the endoscopically defined cardia (2 cm below proximal margin of gastric folds). Specimens were stained with hematoxylin and eosin, Alcian blue, and modified Giemsa. Type of mucosa, inflammatory and metaplastic changes, and presence of Helicobacter pylori (Hp) were graded. Most of the patients had a normal appearing SCJ on endoscopy; 19.3% had short columnar segments (1-3 cm). In the first group cardiac/mixed mucosa was found in 71.9% of SCJ biopsies, and carditis (90.6%) was associated with Hp. In the second group, cardiac/mixed mucosa was present in 80.5%. There was a trend for an association between carditis (87.4%) and reflux esophagitis and hiatal hernia. Biopsies from the endoscopically defined cardia rarely contained cardiac/mixed mucosa (12.6%). These findings suggest two etiologies for carditis. In a normal-appearing SCJ carditis is associated with Hp, whereas in an irregular SCJ with short columnar segments/tongues carditis is associated with features of gastroesophageal reflux.

Prolonged measurement of lower oesophageal sphincter function in patients with intestinal metaplasia at the oesophagogastric junction.

BACKGROUND AND AIMS: It has been shown that gastro-oesophageal reflux plays a role in the pathogenesis of intestinal metaplasia (IM) limited to the oesophagogastric junction (OGJ), similar to the pathogenesis of IM in long segments of columnar lined oesophagus. The aim of this study was to examine lower oesophageal sphincter (LOS) function by means of prolonged recording in patients with IM limited to a normal appearing OGJ. PATIENTS AND METHODS: Eighteen patients with IM at the OGJ (five females, 13 males; mean age 55.4 years) and 22 patients without IM (nine females, 13 males; mean age 53.9 years) underwent conventional stationary oesophageal manometry. Thereafter, seven hour water perfused manometry with simultaneous pH measurement (probe 5 cm proximal to the LOS) was performed. Swallowing was monitored with a pharyngeal sidehole and LOS pressure was recorded with a Dent sleeve. Patients were studied in the fasted state (three hours) and after a standardised meal (four hours). LOS pressure was analysed using customised software, and the incidence of reflux episodes (pH <4 for at least five seconds) and transient LOS relaxations (TLOSRs) were examined. TLOSRs were judged to be accompanied by reflux if a decrease of 1 pH unit occurred during relaxation. RESULTS: Patients with IM at the OGJ had a higher prevalence of postprandial acid reflux compared with patients without IM. No differences were observed in LOS pressure (pre- and postprandially) or in the prevalence of TLOSRs. However, in the postprandial phase, the rate of TLOSRs accompanied by acid reflux was increased in patients with IM. CONCLUSION: Patients with IM at the OGJ have a higher prevalence of postprandial acid reflux. This is not associated with a higher prevalence of TLOSRs or a decreased LOS pressure but with a higher rate of TLOSRs accompanied by reflux.

Epidemiological, clinical, and histological characteristics of intestinal metaplasia at the oesophagogastric junction compared to short segments of columnar-lined oesophagus.

OBJECTIVE: Intestinal metaplasia (IM) close to the oesophagogastric junction (OGJ) has become a focus of research interest against a background of the rising incidence of malignancies in that area. Studies have focused on the presence of IM in short columnar segments (0-3 cm). Recently it has been suggested that IM at the OGJ and IM in short columnar segments may represent different entities. The objective of this current study was to determine the prevalence of IM in these areas and to assess clinical characteristics in order to test the hypothesis that IM at the OGJ and IM in short columnar segments are different entities. METHODS: Six hundred and fifty-eight patients referred for gastroscopy, in whom a columnar lining of 0-3 cm was found, participated in the study. Endoscopic oesophagitis was graded, distances to endoscopic landmarks were measured, and biopsies (antrum, corpus, 'cardia', and immediately distal to the squamocolumnar junction) were taken. Biopsies were stained with haematoxylin & eosin, Alcian Blue (pH 2.5), modified Giemsa for Helicobacter pylori (Hp), and immunohistochemistry in cases of a negative Giemsa. According to endoscopy, patients were categorized as having a normal OGJ (0-1 cm) or having a short columnar segment (1 -3 cm, tongues >1 cm). RESULTS: In this study 77.7% of patients had a normal OGJ (IM-positive 15.1%), and 22.3% had a short columnar segment (IM-positive 29.3%). In the first group, IM was correlated with Hp (P = 0.003) and antral IM (P = 0.002), in the second IM was associated with the presence of a hiatal hernia (P < 0.001) and reflux oesophagitis (P = 0.023). CONCLUSION: These findings suggest that IM at the OGJ is not the same entity as IM in short columnar segments.

Abnormal clotting parameters before therapeutic ERCP: do they predict major bleeding?

A total of 399 consecutive patients undergoing 598 ERCPs (endoscopic retrograde cholangiopancreatographies), including 88 pre-cut papillotomies and 206 conventional papillotomies, are described in a retrospective study. Clotting parameters, haemoglobin levels, indications for pre-cut and/or conventional papillotomy and the use of drugs assumed to interfere with blood clotting (anticoagulants, platelet-aggregation inhibitors, low-molecular-weight heparin) were evaluated in order to detect risk factors for ERCP-associated bleeding. The overall incidence of ERCP-associated bleeding was 18/598 (3.0%). The incidence of bleeding in the group without papillotomy was 7/346 (2.0%). This group consisted of patients who underwent only a diagnostic ERCP, patients who had undergone papillotomy previously, patients in whom a renewed attempt was made to extract biliary stones, and patients in whom removal or change of a stent was necessary. The incidence of papillotomy-associated bleeding was 11/252 (4.4%). Pre-cut papillotomy did and conventional papillotomy did not significantly increase the incidence of bleeding: 15.2% (P < 0.001) and 1.9% (P= 1.00) respectively. The incidence of ERCP-associated bleeding in the group not using any drugs interfering with blood clotting was 2.5%. The use of low-molecular-weight heparin (10.3%) during ERCP significantly increased the risk of bleeding (P= 0.01). However, the use of platelet aggregation inhibitors (2.4%) did not (P= 1.00). As the incidence of bleeding in patients with normal clotting parameters, including the patients with abnormal parameters which were well corrected (4.3%), was higher than in patients with abnormal haemostatic screens (2.7%), abnormal coagulation tests did not predict ERCP-associated bleeding.

Columnar lined oesophagus and intestinal metaplasia: current concepts.

Barrett's oesophagus is a condition where the distal oesophagus is lined with columnar epithelium. For the diagnosis intestinal metaplasia has to be found and a minimal length of 3 cm is required for the columnar-lined segment. It is well known that patients with the traditional Barrett's oesophagus have a higher risk of developing adenocarcinomas in the metaplastic segment. The clinical significance of shorter metaplastic segments and intestinal metaplasia at the gastro-oesophageal junction is much less certain. Different definitions are in use and the increasing number of studies dealing with these mucosal changes therefore may create confusion. In this article, the current knowledge concerning epidemiology, pathophysiology, clinical associations, diagnostic possibilities including endoscopy, pathology, measurement of differences in electrical potential, and treatment of columnar-lined oesophagus of any length and of intestinal metaplasia at the gastro-oesophageal junction is reviewed. Furthermore, the need for a consistent definition is emphasized.

[Acute tumor lysis syndrome due to mono-therapy with a corticosteroid in a patient with non-Hodgkin lymphoma]. / Acuut tumorlysissyndroom door monotherapie met een corticosteroïd bij een patiënt met non-Hodgkin-lymfoom.

A 20-year-old man was hospitalised because he nearly suffocated when lying on his back. After bronchoscopy which revealed severe external compression of the airways, suddenly respiratory insufficiency developed. Because a malignant lymphoma was suspected chemotherapy was started, using monotherapy with prednisolone as the risk of acute tumour lysis syndrome (ATLS) is high with polychemotherapy of bulky tumours. Nevertheless ATLS developed, for which haemodialysis had to be applied. The tumour, a T-cell lymphoblastic non-Hodgkin lymphoma with high grade malignancy, was treated successfully with cyclophosphamide, doxorubicin, vincristine en prednisone. ATLS is characterized by hyperkalaemia, hyperuricaemia, hyperphosphataemia, hypocalcaemia, lactate acidosis and acute renal failure. It can occur in the course of aggressive cytoreductive therapy in rapidly growing lymphoproliferative malignancies with large tumour size, due to massive tumour cel lysis. Corticosteroid monotherapy is a very rare cause of ATLS.

The roles of excessive gastro-oesophageal reflux, disordered oesophageal motility and decreased mucosal sensitivity in the pathogenesis of Barrett's oesophagus.

Barrett's oesophagus is often considered an end stage of gastro-oesophageal reflux disease. In its pathogenesis increased oesophageal acid exposure, disturbed oesophageal motility and decreased oesophageal mucosal sensitivity are thought to be of importance. In this review the role of each of these factors will be discussed and an update of the recent literature will be given.

Prevalence of esophageal disorders in patients with chest pain newly referred to the cardiologist.

STUDY OBJECTIVE: The prevalence of esophageal disorders (dysmotility and/or gastroesophageal reflux) in patients with chest pain newly referred to a cardiologic clinic is unknown. The aims of our study were to investigate the prevalence of esophageal abnormalities in these patients and to assess the value of medical history in predicting the origin of the patient's chest pain. DESIGN: We evaluated 28 consecutive patients who were newly referred to the cardiologist because of angina-like chest pain. Patients with evidence of severe myocardial ischemia were excluded. Cardiologic evaluation included medical history, physical examination, ECG, and exercise testing; further cardiologic workup was carried out only when considered necessary. Gastroenterologic evaluation consisted of medical history, esophageal manometry, endoscopy, and 24-h ambulatory monitoring of esophageal pH and pressure. MEASUREMENTS AND RESULTS: In five patients a diagnosis of ischemic coronary artery disease was made. In only two of these five patients, the cardiologic history strongly suggested a cardiac origin of the pain. Twelve patients had a pathologic 24-h pH profile, four of whom also had reflux esophagitis. Ten patients had symptomatic reflux. In only three of these ten patients, the history was judged to be indicative of an esophageal origin of the chest pain. No motility disorders were found. CONCLUSIONS: Thirty-six percent of the patients with chest pain newly referred to a cardiologic out-patient clinic have symptomatic gastroesophageal reflux. Neither cardiologic nor gastroenterologic history data have a high predictive value with respect to the origin of the chest pain.

Low-amplitude distal esophageal spasm as a cause of severe dysphagia for solid food.

This case report presents a patient with progressive dysphagia, accompanied by weight loss, in the absence of organic disease. Esophageal motility studies initially failed to reveal a diagnosis. At simultaneous manometry and fluoroscopy, with bread/barium boluses, the diagnosis of esophageal spasm in a relatively weak esophagus was made. All conservative treatment modalities failed. Thoracoscopic myotomy resulted in partial field of symptoms. Finally, an esophagectomy was performed because of sever dysphagia accompanied by persisting weight loss.

Effects of Nissen fundoplication on gastro-oesophageal reflux and oesophageal motor function.

BACKGROUND: Nissen fundoplication reduces gastro-oesophageal reflux effectively, but the mechanisms through which this effect is brought about have remained rather obscure. METHODS: In this study the effect of fundoplication on oesophageal acid exposure, oesophageal body motility, and lower oesophageal sphincter pressure (LOSP) was assessed prospectively. Eleven patients were studied before and 3 months after a floppy Nissen fundoplication. A Dent sleeve was used to measure LOSP, and ambulatory pH and pressure monitoring were used to evaluate oesophageal motor function. RESULTS: Gastro-oesophageal reflux was significantly decreased after fundoplication without an increase in LOSP. The motor function of the oesophageal body was not affected by the antireflux procedure. CONCLUSIONS: Nissen fundoplication is an effective antireflux operation, even though the procedure does not increase LOSP, and the motility pattern of the oesophageal body is not affected by the construction of a floppy fundic wrap.

Oesophageal motility and gastro-oesophageal reflux before and after healing of reflux oesophagitis. A study using 24 hour ambulatory pH and pressure monitoring.

In this study 24 hour oesophageal pH and pressure monitoring was used to assess oesophageal motility and acid clearance in 27 patients with reflux oesophagitis (Savary-Miller grades I-IV), before and after healing of oesophagitis. After the first 24 hour study patients were treated with omeprazole 40 mg for 8-24 weeks. After endoscopically verified healing and withdrawing omeprazole for four days 24 hour monitoring was repeated. A total of 106,630 pressure events was analysed. No significant differences were found for any of the motility variables, especially the number and the type of contractions, the peristaltic amplitude, duration, and propagation velocity did not show any changes. Separate analysis of motility variables before and after healing in the low and high grade oesophagitis groups yielded similar results. Oesophageal motor response to reflux was investigated by analysis of all contractions occurring in the two minute period after the onset of each reflux episode. Both motor response and oesophageal acid exposure (% time pH < 4, number of reflux episodes) did not change after healing of oesophagitis, thus implying that acid clearance remained unchanged. These results indicate that impaired motility in reflux oesophagitis is either an irreversible consequence of oesophageal inflammation, or a (pre-existent) factor in its pathogenesis.

Ambulatory esophageal pressure and pH monitoring in patients with high-grade reflux esophagitis.

Using conventional manometry and 24-hr ambulatory pressure and pH monitoring, we investigated esophageal motility and the esophageal motor response to reflux in 11 patients with reflux esophagitis Savary-Miller grade III and IV, and an age- and sex-matched group of 11 healthy controls. The patients had a significantly increased esophageal acid exposure. Conventional manometry showed a significantly decreased LES pressure and distal peristaltic amplitude in patients. The 24-hr monitoring yielded a significant decrease in peristaltic contraction duration and peristaltic propagation velocity in the patient group. Distal peristaltic amplitude was not decreased. Analysis of the contractions occurring in the 2-min period after each reflux episode showed a reduced number of contractions during the upright period, caused by a significantly decreased number of peristaltic contractions. During the supine period, there was a trend towards an increased number of contractions. It is concluded that esophageal motor activity and the response to reflux are impaired in patients with high-grade reflux esophagitis. However, the abnormalities found are only minor and are unlikely to play an important role in the pathogenesis of reflux esophagitis.

Temporal relationships between episodes of non-cardiac chest pain and abnormal oesophageal function.

Analysis of the association between symptoms and abnormal oesophageal function is a central part of 24 hour oesophageal pressure and pH recording in patients with non-cardiac chest pain. Such studies have used different time windows including a period after the onset of pain. Since stress and pain can induce oesophageal motor abnormalities and transient lower oesophageal sphincter relaxations, a proportion of the motor abnormalities and the reflux episodes observed after the onset of pain may be a consequence rather than the cause of that pain. This study aimed to assess this possibility in patients with chest pain that was presumed to be of oesophageal origin by comparing the results of analysis using time windows before and after the onset of pain. Forty eight patients experienced a total of 166 spontaneous chest pain episodes during 24 hour ambulatory monitoring. A time window beginning two minutes before and ending at the onset of pain (-2/0) was compared with a window beginning at the onset of pain and ending two minutes afterwards (0/+2). The percentage of episodes related to reflux, abnormal oesophageal motility, or neither were 22.9%, 24.7%, and 52.4% in the -2/0 time window and 9.0%, 22.3%, and 68.7% in the 0/+2 time window, respectively. However, 11 of the 37 episodes associated with abnormal motility in the 0/+2 time window were preceded by a reflux episode, and 19 of these 37 episodes had abnormal motility in the -2/0 time window. Consequently, in only seven of the 166 chest pain episodes (4.2%) in two patients were the findings consistent with secondary oesophageal motor disorders provoked by pain. Likewise, only six of the 166 chest pain episodes (3.6%) were consistent with reflux provoked by pain. These findings indicate that in patients with non-cardiac chest pain, gastro-oesophageal reflux and oesophageal motor abnormalities are rarely a consequence of the pain.

What is the optimal time window in symptom analysis of 24-hour esophageal pressure and pH data?

Since noncardiac chest pain is the only well-established indication for 24-hr esophageal pH and pressure recording, the analysis of the association between chest pain episodes and esophageal motility abnormalities or reflux is the most important part of data analysis in 24-hr monitoring. Until now, different time windows have arbitrarily been used by various research groups. The aim of this study was to determine the optimal time window for symptom analysis in 24-hr esophageal pH and pressure monitoring. For this purpose repetitive symptom association analysis was carried out, using time windows of various onsets and durations. For each time window, the symptom indices for reflux and dysmotility were calculated. The symptom index for both reflux and dysmotility showed a gradual increase for windows with increasingly early onset, following a pattern that would be predicted on the basis of Poisson's theory. However, both indices had a relatively sharp cutoff point at 2 min before the onset of pain. Both indices only showed a predictable gradual increase when the time window starting at -2 min was extended beyond the moment of pain onset. It is concluded that the optimal time window for symptom analysis in 24-hr esophageal pH and pressure recording begins at 2 min before the onset of pain and ends at the onset of pain.

Esophageal motility in low-grade reflux esophagitis, evaluated by stationary and 24-hour ambulatory manometry.

Whereas previous studies have unequivocally shown that esophageal motility is abnormal in patients with severe reflux esophagitis, the results of motility testing in patients with low-grade esophagitis are inconsistent. We studied 27 patients with Savary grade I and II esophagitis and 24 healthy controls matched for age and sex. Both underwent conventional manometry and 24-h ambulatory pH and pressure monitoring. Esophageal acid exposure was greater in patients than controls. The mean lower esophageal sphincter pressure was significantly lower in esophagitis patients [1.46 +/- 0.09 vs. 1.79 +/- 0.11 kPa (10.98 +/- 0.68 vs. 13.46 +/- 0.83 mm Hg)]. The total number of contractions recorded in the 24-h period was not different in the patient group (2168 +/- 108.4 vs. 2033 +/- 130.5), but esophagitis patients had an increased number of nontransmitted contractions (968 +/- 39.4 vs. 773 +/- 50.2, p < 0.01). A tendency toward a decreased prevalence of peristaltic contractions just failed to reach statistical significance (p = 0.07). Both conventional manometry and 24-h monitoring showed no significant difference in peristaltic amplitude between the two groups. Differences in contraction duration (2.02 +/- 0.08 vs. 2.39 +/- 0.12 s, p < 0.01) and velocity of the peristaltic wave (3.65 +/- 0.10 vs. 4.63 +/- 0.13 cm/s, p < 0.01) were only detected by 24-h monitoring. The findings made in this study do not support the concept that impaired esophageal peristalsis is a major factor in the pathogenesis of low-grade esophagitis.

Oesophageal motor response to reflux is not impaired in reflux oesophagitis.

Whether the oesophageal motor response to reflux, as recorded over 24 hours, is impaired in patients with reflux oesophagitis was investigated. Twenty three patients with oesophagitis (Savary-Miller grades I-IV) and 23 control subjects matched for age and sex underwent 24 hour ambulatory pH and pressure monitoring. All contractions occurring in the 2 minute period after the onset of each reflux episode were analysed automatically using dedicated computer algorithms. A total of 2085 reflux episodes occurred--1513 in patients and 572 in controls. Oesophageal acid exposure was greater (p < 0.01) in patients than in controls (mean (SEM) % time pH < 4 13.3 (1.7) and 5.3 (0.9)%, respectively). The mean duration of the supine reflux episodes was longer (p < 0.01) in patients (11.2 (2.8) minutes) than in controls (5.1 (1.8) minutes). In the upright period, no significant differences in the motor response to reflux were found. In the supine period, the patients showed a higher number of reflux induced contractions (4.40 (0.61) v 1.62 (0.31), p < 0.01), a higher contraction amplitude (4.55 (0.42) v 2.99 (0.71) kPa, p < 0.02) and longer contractions (1.86 (0.19) v 1.32 (0.29) seconds, p < 0.05). The percentages of peristaltic and simultaneous contractions that occurred in response to supine reflux did not differ between the two groups. In patients with reflux oesophagitis the motor response of the oesophagus to reflux is not impaired. During the supine period the response is even stronger than in healthy controls.