Diltiazem therapy for symptoms associated with nutcracker esophagus.

UNLABELLED: A randomized double-blind, cross-over prospective trial in 22 patients was designed to evaluate possible effect of an oral calcium channel blocker, diltiazem, on symptoms of chest pain and/or dysphagia in patients with nutcracker esophagus. We studied 22 consecutive patients referred to an esophageal diagnostic center for evaluation of noncardiac chest pain or dysphagia having high amplitude esophageal contractions, 14 of whom completed the study. Diltiazem (60-90 mg qid) was compared with placebo, each being administered for 8 wk. Patients were evaluated with esophageal motility pre- and posttreatment periods and with regular symptom assessment throughout each 8-wk treatment. Active diltiazem therapy resulted in significantly lower (p less than 0.05) mean distal esophageal peristaltic pressure (128 +/- 20 mm Hg; +/- SE) than placebo (158 +/- 16 mm Hg). Mean chest pains scores were significantly (p less than 0.05) lower with diltiazem therapy than with placebo. Only nine of the 14 patients fulfilled presently acceptable criteria for diagnosing nutcracker esophagus, and the diltiazem effect was similar, although not significant, because of the smaller sample. CONCLUSIONS: In this preliminary study involving 14 patients, the oral calcium channel blocker, diltiazem, appeared to improve noncardiac chest pain associated with strong esophageal contraction, the nutcracker esophagus. These improved symptoms were associated with significant decreases in contraction pressure.

A prospective study of the prevalence of colonic neoplasms in asymptomatic patients with an age-related risk.

This study was designed to determine the prevalence of colorectal neoplasia in healthy, asymptomatic adults with an age-related risk for colorectal neoplasia. Ninety patients were studied with air contrast barium enema and colonoscopy. The study population included 61 males and 21 females, with an age range of 51-82 yr (65 +/- 2 yr). Adenomatous polyps were found in 27% of males and 14% of females or 24% of patients overall. Sixty-six percent of these neoplasms were above the rectosigmoid junction and the mean size of the polyps was 6.5 +/- 1.2 mm. In two patients, carcinoma was discovered. A linear association between age and the prevalence of colonic neoplasia was not demonstrated. This study demonstrates a relatively high prevalence of colonic neoplasia in patients with an age-related risk.

A study of patient acceptance of double-contrast barium enema and colonoscopy. Which procedure is preferred by patients?

To our knowledge, no previous study has addressed the question of which method of evaluation of the lower gastrointestinal tract is preferred by patients, air-contrast barium enema or colonoscopy. Over a four-month period, we asked 189 consecutive patients who had undergone colonoscopy to express their preference for either air-contrast barium enema or colonoscopy. A clear preference for colonoscopy was expressed by our patients in terms of comfort and polyp detection despite higher cost. Time lost from work and post-procedure constipation were significantly less for colonoscopy than for barium enema. These factors should be considered in the evaluation of suspected lower gastrointestinal tract disease.

Metoclopramide response in patients with progressive systemic sclerosis. Effect on esophageal and gastric motility abnormalities.

Twelve patients with progressive systemic sclerosis (four with CREST [calcinosis, Raynaud's phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia] variant) underwent systematic evaluation to assess the esophagogastric effects of metoclopramide hydrochloride in this patient population. Esophageal manometry, esophageal radionuclide scintigraphy, solid-phase gastric emptying, and 24-hour esophageal pH monitoring were performed in all patients with and without metoclopramide. Metoclopramide improved lower esophageal sphincter pressure and reduced the gastric emptying delay and gastroesophageal reflux in most patients but had a less consistent effect improving esophageal transit or esophageal body pressures. Metoclopramide should be strongly considered in the pharmacologic approach to the gastroesophageal reflux-related complications of this disease.

Patient preference in upper gastrointestinal studies: roentgenography versus endoscopy.

We prospectively compared roentgenography and endoscopy of the upper gastrointestinal tract in terms of patient acceptance and tolerance. Endoscopy was significantly better tolerated and easier overall for patients. Patients found no difference between endoscopy and radiography with respect to pain or life-style interruption. Patients stated that they would prefer endoscopy to roentgenography if repeat evaluation were needed. We conclude that UGI endoscopy is better tolerated and more acceptable to patients than UGI roentgenography.

Esophageal acid sensitivity in Barrett's esophagus.

Esophageal acid sensitivity was evaluated in 15 patients with Barrett's esophagus and in 15 patients with reflux esophagitis uncomplicated by Barrett's. Patients with Barrett's esophagus had sensitivity to esophageal acid perfusion less frequently than those with uncomplicated reflux esophagitis (66 vs. 100%; p less than 0.05). Moreover, patients with Barrett's esophagus with acid sensitivity took longer to develop pain during acid perfusion (p less than 0.05), and overall, experienced less severe symptoms (p less than 0.01) than those with reflux esophagitis. Over a 2-week period, as judged by diary, the Barrett's group had less frequent (p less than 0.01) and less severe (p less than 0.01) heartburn symptoms than the other patients. These results indicate that patients with Barrett's esophagus have significantly reduced esophageal acid sensitivity and, as a consequence, have an impaired ability to recognize acid reflux.

Barrett's esophagus. A prevalent, occult complication of gastroesophageal reflux disease.

A prospective study of patients with symptoms of gastroesophageal reflux was undertaken to determine the prevalence of Barrett's esophagus and reevaluate the diagnostic approach necessary to detect this complication. Endoscopy with mucosal biopsy was performed in 97 subjects. Twelve (12.4%) were found to have Barrett's esophagus. The sensitivity and specificity of the endoscopic and radiologic examinations for Barrett's esophagus were prospectively evaluated. Endoscopy (92%) was significantly more sensitive than radiology (24%) in detecting Barrett's esophagus (p less than 0.001). The frequency and severity of reflux symptoms among patients determined to have Barrett's esophagus, reflux esophagitis, or normal esophageal biopsies were quantitatively similar in all three groups, except for significantly greater daytime heartburn in those with reflux esophagitis (p less than 0.01). These data indicate that Barrett's esophagus complicates gastroesophageal reflux more often than previously believed.

Pain of chronic pancreatitis: etiology, natural history, therapy.

The pain of chronic pancreatitis can be tremendously disabling. The pathogenesis of this pain is still poorly understood, but there is good evidence demonstrating an inverse relationship with the degree of pancreatic insufficiency. Pancreatic enzyme therapy of pain and celiac plexus blocks carry promise, but larger studies with these modalities are needed. Surgery for pain relief is the last resort and should be based on pancreatic duct anatomy.

Solid-phase gastric emptying in patients with Barrett's esophagus.

Delayed gastric emptying as a pathophysiologic factor in patients with gastroesophageal reflux (GER) is controversial. In order to further evaluate this question, we studied a population with severe reflux, specifically, patients with Barrett's esophagus. Solid-phase gastric emptying was measured in 17 patients and in 17 healthy volunteers using radionuclide imaging. Gastric emptying was variable among these patients with 70% normal, 18% rapid, and only 12% slow studies. From these observations, we conclude that delayed gastric emptying is unlikely to be a major factor in the pathogenesis of Barrett's esophagus.

Systematic esophageal evaluation of patients with noncardiac chest pain.

We prospectively studied 73 patients with angina-like chest pain severe enough to warrant admission to a coronary care unit over a five-month period. Thirty-four patients (47%) were found to have coronary artery disease as the cause of their symptoms, based on exercise testing, stress radionuclide imaging, or cardiac catheterization. The remaining 39 patients had normal cardiac findings and then underwent videoesophagography, radionuclide esophageal transit study, and esophageal manometry. Thirty-three of the 39 underwent acid perfusion testing (modified Bernstein's test). The findings at esophageal manometry were abnormal in 29 (74%) of 39. Manometric diagnoses were "nutcracker esophagus" in 17 (59%), nonspecific esophageal motility disorders in nine (31%), diffuse esophageal spasm in two (7%), and achalasia in one (3%). Bernstein's test reproduced symptoms in only 12%. The sensitivity of videoesophagography in detecting esophageal motility disorders was 66%, and that of radionuclide esophageal transit was 79%. The positive predictive values were 86% and 85%, respectively.