Flavour exposures after conditioned aversion or preference trigger different brain processes in anaesthetised pigs.

We describe the behavioural consequences of conditioned flavour aversion and preference in pigs and have investigated the brain circuits involved in the representation of flavours with different hedonic values. The study was performed on eight 30-kg pigs. (i) Animals were negatively conditioned to an F- flavour added to a meal followed by LiCl intraduodenal (i.d.) injection, and positively conditioned to an F+ flavour added to a meal followed by NaCl i.d. injection. F+ and F- were thyme or cinnamon flavours. After each conditioning, the behavioural activities were recorded; (ii) One and 5 weeks later, animals were subjected to three two-choice food tests to investigate their preferences between F+, F- and a novel flavour (O); and (iii) Anaesthetised animals were subjected to three SPECT brain imaging sessions: control situation (no flavour) and exposure to F+ and to F-. The negative reinforcement induced a physical malaise and visceral illness. After a positive reinforcement, animals showed playing or feeding motivation and quietness. F+ was significantly preferred over O and F-, and O was significantly preferred over F-. Both F- and F+ induced some metabolic differences in neural circuits involved in sensory associative processes, learning and memory, emotions, reward and feeding motivation. Exposure to F+ induced a higher activity in corticolimbic and reward-related areas, while F- induced a deactivation of the basal nuclei and limbic thalamic nuclei. This study reveals the unconscious cognitive dimension evoked by food flavours according to the individual experience, and highlights the importance of the food sensory image on hedonism and anticipatory eating behaviour.

[Characteristics of duodenogastric reflux in duodenal ulcer patients and its dynamics after Helicobacter pylori eradication].

UNLABELLED: Studying role of duodenogastric reflux (DGR) in pathogenesis and sanogenesis of duodenal ulcer (DU). MATERIAL AND METHODS: 233 DU patients (92 patients with a mild, 45--with modern and 96--with the complicated current of disease) are surveyed. Control group were 100 healthy volunteers. Clinical research, endoscopy and 24-hours pH-metria was carried out. In a year after eradication Helicobacter pylori (Hp) 30 patients are repeatedly surveyed. RESULTS: at healthy acidity more low, and DGR above and more for a long time, than at DU patients. DU was especially supressed at complicated current DU. Eradication Hp was accompanied by acidity normalization only at mild DU, and at complicated DU--is not present. CONCLUSION: at healthy people DGR arises in reply to antrum's acidification and has compensative value, and at DU there is the considerable suppression leading to insufficiency of antrum's alkalization. After eradication Hp normalization DGR is marked only at mild current DU.

Relevance and characteristics of gastroesophageal reflux in adult patients with otitis media with effusion.

OBJECTIVE: To investigate relevance and characteristics of gastroesophageal reflux (GER) in adult patients with otitis media with effusion (OME) of unknown etiology who attended private clinics. MATERIALS AND METHODS: A total of 186 adults with OME of unknown etiology (OME group) and 156 adults without OME (control group) were asked to answer a questionnaire specific for the diagnosis of GER disease. Pepsinogen (PG) levels in the middle-ear effusions (MEEs) of the OME group were measured using a chemiluminescence enzyme immunoassay kit. Distributions of PG concentrations by age or body mass index (BMI) in the OME group were analyzed. Patients with high PG levels received proton pump inhibitors (PPIs) and their responses were evaluated. RESULTS: Symptoms of GER were reported by significantly more patients in the OME group than in the control group (43.0% vs. 12.8%). Patients with GER symptoms tended to have higher MEE PG concentrations than those without symptoms. PG levels did not show a significant difference by age. However, high PG levels were less found in patients over 60 years old with high BMI >25. This tendency was not observed in patients under 60 years old. PG levels decreased in seven out of ten patients with high PG concentrations after PPI therapy, corresponding with palliation of GER-related symptoms. Two patients had high MEE bilirubin concentration, and OME resolved in these patients after instruction about lifestyle factors related to GER, including sleeping position. CONCLUSIONS: GER symptoms were more prevalent than expected in patients with OME of unknown etiology. BMI might affect GER-related OME, especially in elderly patients. Instruction about lifestyle factors related to GER, especially in patients who do not respond to PPI therapy, may be effective for patients with intractable OME.

Effect of domperidone therapy on nocturnal dyspeptic symptoms of functional dyspepsia patients.

AIM: To investigate the incidence of nocturnal dyspeptic symptoms in patients with functional dyspepsia (FD) and whether prokinetic drugs can alleviate them. METHODS: Eighty-five consecutive Chinese patients with FD were included in this study. One week after single-blinded placebo run-in treatment, baseline nocturnal intragastric pH, bile reflux and nocturnal dyspeptic symptoms of eligible patients, including epigastric pain or discomfort, abdominal distention and belching, were investigated with questionnaires. Patients exhibiting nocturnal dyspeptic symptoms were randomly and double-blindly assigned to domperidone group or placebo group. Nocturnal intragastric pH and percentage of duodenogastric bile reflux time were determined after treatment. RESULTS: Of the 85 FD patients, 2 females without nocturnal symptoms, who responded to placebo run-in treatment, were excluded from the study, 30 (36.1%) exhibited nocturnal dyspeptic symptoms with increased duodenogastric bile reflux time (intragastric bilirubin absorbance > 0.14) and mean gastric pH (confirming the existence of bile reflux) (P = 0.021, 0.023) at night were included in the study. Of these 30 patients, 21 (70%) had overt nocturnal duodenogastric bile reflux, which was significantly higher than that of those without nocturnal symptoms (P = 0.026). The 30 patients were allocated to domperidone group or placebo group (n = 15). The nocturnal duodenogastric bile reflux and gastric pH were significantly decreased after domperidone treatment (P = 0.015, 0.021). The severity score of nocturnal dyspeptic symptoms was also significantly decreased after domperidone treatment (P = 0.010, 0.015, 0.026), which was positively correlated with the reduced nocturnal bile reflux or gastric pH (r = 0.736, 0.784, 0.753 or r = 0.679, 0.715, 0.697, P = 0.039, 0.036, 0.037 or P = 0.043, 0.039, 0.040). CONCLUSION: A subgroup of Chinese FD patients show overt nocturnal dyspeptic symptoms, which may be correlated with the excessive nocturnal duodenogastric bile reflux. Domperidone therapy can alleviate these symptoms.

Comparison of the degree of duodenogastroesophageal reflux and acid reflux between patients who failed to respond and those who were successfully treated with a proton pump inhibitor once daily.

OBJECTIVES: The objective of this study was to compare the degree of esophageal acid exposure and duodenogastroesophageal reflux (DGER) during treatment between gastroesophageal reflux disease (GERD) patients who responded fully to proton pump inhibitor (PPI) once a day and those who failed to respond. METHODS: Gastroesophageal reflux disease patients who continued to report symptoms 3 times a week for 3 months while on PPI once a day were assigned to the PPI failure group. GERD patients who were asymptomatic on PPI once a day for 3 months were assigned to the PPI success group. All patients underwent upper endoscopy to assess esophageal mucosal injury. Subsequently, all patients underwent simultaneous 24-h esophageal Bilitec 2000 and pH testing while on treatment. Patients recorded GERD-related symptoms during the test. RESULTS: Twenty-four patients were enrolled in the PPI failure group and 23 patients were enrolled in the PPI success group. Endoscopy was normal in 63% of PPI failure patients and 76% of PPI success patients. Abnormal DGER was documented in 82% of PPI success patients vs. 67% of PPI failure patients (P=NS). All pH testing and Bilitec parameters in the PPI failure group were similar to those in the PPI success group (P=NS). Of the 34 GERD symptoms recorded by the PPI failure group, 64% were associated with acid reflux and 41% were associated with DGER (P<0.05). CONCLUSIONS: There is no difference in the degree of DGER and acid exposure during treatment between patients who failed to respond and those who achieved complete symptom resolution on PPI once daily. GERD symptoms in the PPI failure group are more commonly associated with acid reflux than with DGER.

Impact of pantoprazole on duodeno-gastro-esophageal reflux (DGER).

BACKGROUND: Duodeno-gastro-esophageal reflux (DGER) is considered as an independent risk factor for complicated reflux disease (GERD). Patients with Barrett's esophagus have significantly higher levels of DGER than patients with uncomplicated GERD. However, the clinical response to conventional high-dose PPI therapy in patients with uncomplicated GERD and DGER is largely unknown. METHODS: 30 patients with uncomplicated GERD and combined pathological reflux (acid and bile) were enrolled in the study. Clinical work-up included evaluation of clinical symptoms, esophageal manometry and upper endoscopy. After 6 - 8 weeks of treatment with Pantoprazole 80 mg/d pH measurement and Bilitec 2000 were repeated, and the pattern of symptoms was re-evaluated. RESULTS: Under treatment with Pantoprazole 80 mg/d acid reflux was normalised in 28 patients (93 %). Similarly the mean percentage of DGER (time with an absorption greater than 0.14) was significantly reduced from 19.6 % (+/- 13.7) to 5.7 % (+/- 7.7, p < 0.05). In 15 patients (50 %) an elevated DGER persisted under treatment with Pantoprazole (DGER-NR group) whereas in 15 cases (50 %) a normalisation could be achieved (DGER-R group). The DGER-NR group had significantly higher levels of bile reflux before (and under) treatment compared to the DGER-R group: 22.9 % (9.98 %) vs. 15.6 % (0.72 %), respectively. Overall, the median quality of life index (QLI) improved from 4.78 (+/- 0.86) before to 8.04 +/- 1.84) under therapy. The clinical response under treatment was marikedly reduced in the DGER-NR group compared to the DGER-R group: QLI 7.3 vs. 8.9. Particularly heartburn and nocturnal coughing persisted. CONCLUSIONS: Our data confirm that high-dose pantoprazole therapy effectively exerts acid suppression in GERD patients with combined pathological reflux. However, DGER could only normalised in 50 % of patients. High levels of DGER at diagnosis enhance the risk of persistent DGER under PPI therapy and are associated with a reduced clinical outcome.

Proton pump inhibitors: an update of their clinical use and pharmacokinetics.

BACKGROUND: Proton pump inhibitors (PPIs) represent drugs of first choice for treating peptic ulcer, Helicobacter pylori infection, gastrooesophageal reflux disease, nonsteroidal anti-inflammatory drug (NSAID)-induced gastrointestinal lesions (complications), and Zollinger-Ellison syndrome. RESULTS: The available agents (omeprazole/esomeprazole, lansoprazole, pantoprazole, and rabeprazole) differ somewhat in their pharmacokinetic properties (e.g., time-/dose-dependent bioavailability, metabolic pattern, interaction potential, genetic variability). For all PPIs, there is a clear relationship between drug exposure (area under the plasma concentration/time curve) and the pharmacodynamic response (inhibition of acid secretion). Furthermore, clinical outcome (e.g., healing and eradication rates) depends on maintaining intragastric pH values above certain threshold levels. Thus, any changes in drug disposition will subsequently be translated directly into clinical efficiency so that extensive metabolizers of CYP2C19 will demonstrate a higher rate of therapeutic nonresponse. CONCLUSIONS: This update of pharmacokinetic, pharmacodynamic, and clinical data will provide the necessary guide by which to select between the various PPIs that differ-based on pharmacodynamic assessments-in their relative potencies (e.g., higher doses are needed for pantoprazole and lansoprazole compared with rabeprazole). Despite their well-documented clinical efficacy and safety, there is still a certain number of patients who are refractory to treatment with PPIs (nonresponder), which will leave sufficient space for future drug development and clinical research.

Duodenogastroesophageal reflux: results of medical treatment and antireflux surgery.

BACKGROUND/AIMS: Recent studies have shown that reflux of the duodenal content to the esophagus plays an important role in esophageal mucosal damage. The aim of the study is to compare the duodenogastroesophageal (DGER) reflux with the severity of reflux esophagitis and evaluate its response to either medical and/or antireflux surgery. METHODOLOGY: Ninety-six patients with DGER were subjected to thorough history, upper GI endoscopy, barium study, esophageal manometry and 24-hr esophageal pH metry combined with Bilitec 2000. Medical treatment was given for all, while Nissen fundoplication was done for 28 patients. All patients were evaluated after Nissen fundoplication and treatment. RESULTS: The age of studied patients was 36.26+/-12.7 years with male to female ratio 2:1. The chief symptom was heartburn in 73 (76%) patients. Upper GI endoscopy revealed, 30 (31.2%) patients had grade I reflux, 30 (31.2%) patients had grade II reflux, 7 patients had grade III reflux, 5 patients had grade VI reflux, Barrett's esophagus in 14 patients (14.5%), hiatus hernia (HH) in 26 (27%) patients. Barium study revealed that, 40 (41.6%) patients had evidence of reflux, while 34 (35.4%) patients had reflux with HH. Esophageal motility revealed the mean LESP (12.7+/-7.6), 68 patients (70.8%) had normotensive body while ineffective esophageal body motility was encountered in 28 (29.1%) patients. Esophageal 24-hr pH study and Bilitec 2000 revealed that 54 (56.2%) patients had bile reflux with pathological acid reflux, while 42 (43.7%) patients had bile reflux in alkaline pH. Medical treatment gave excellent to good response in 68 (70.8%) patients, while Nissen fundoplication was done for 28 (29.2%) patients. Endoscopic examination 6 months after Nissen fundoplication showed marked improvement in endoscopic injury. Barium study after Nissen fundoplication revealed repair of HH and control of GERD in all patients except one. Esophageal motility, 24 hr pH study and Bilitec 2000, after 6 months of Nissen shows high significant increase in LESP, decrease in acid and bile reflux. No significant difference between open or laparoscopic fundoplication in LESP, acid and bile reflux. CONCLUSIONS: DGER in acid medium is more injurious to the esophagus than DGER in alkaline pH. The severity of esophageal injury does not correlate with the severity of acid or bile reflux but has a direct correlation with impaired distal esophageal motility. Medical treatment gives satisfactory control of symptoms and healing of esophageal lesion in 70% of DGER. The response to medical treatment does not depend on the severity of esophageal injury but depends on the severity of bile and acid reflux. Nissen fundoplication in refractory patients, either open or laparoscopic, was effective in control of heartburn in 95% of patients contrary to 50% in mixed symptoms.

Bile acids and Barrett's oesophagus: a sine qua non or coincidence?

BACKGROUND: Barrett's oesophagus (BO), a premalignant condition associated with the development of oesophageal adenocarcinoma (OAC), is thought to be a consequence of chronic duodeno-gastro-oesophageal reflux. Of the refluxates, bile acids, either alone or in combination with acid, are probably the most important. METHODS: Analysis of the literature on the role played by bile acids in inducing BO and/or progression to OAC. RESULTS: Combined pH and Bilitec 2000 (as a measure of bile reflux) monitoring and oesophageal aspiration studies in humans suggest a combined role for bile acids, particularly taurine conjugated bile acids, in causing oesophageal mucosal injury. Evidence from animal models has demonstrated that duodenal juice alone is also able to induce BO and/or OAC. Likewise, ex vivo studies with biopsies from BO patients show that increased proliferation and cyclo-oxygenase-2 expression are present after a pulsed exposure to acid or conjugated bile acids, but not if acid and bile acids are combined. Proton-pump inhibitors (PPIs) have been shown to decrease the biliary component of the refluxate. There is some evidence that PPIs are able to reduce neoplastic progression in BO. On the other hand, chronic PPIs can also stimulate bacterial overgrowth, which can result in increased production of secondary bile acids, particularly deoxycholic acid, in the stomach. Deoxycholic acid has been demonstrated to have a tumour-promoting capacity. CONCLUSIONS: It is unknown what factors of the refluxate (acid and/or bile) induce BO and/or promote carcinogenesis, but there is evidence that secondary bile acids play a role. A better understanding of the molecular steps involved in the induction of BO, and the role of bile acids herein, may identify targets at which preventive therapies can be directed.

Treatment of uncomplicated reflux disease.

Uncomplicated reflux disease comprises the non-erosive reflux disease (NERD) and erosive reflux disease (ERD). The objectives of treatment are the adequate control of symptoms with restoration of quality of life, healing of lesions and prevention of relapse. Treatment of NERD consists in the administration of proton pump inhibitors (PPI) for 2-4 wk, although patients with NERD show an overall poorer response to PPI treatment than patients with ERD owing to the fact that patients with NERD do not form a pathophysiologically homogenous group. For long-term management on-demand treatment with a PPI is probably the best option. In patients with ERD, therapy with a standard dose PPI for 4-8 wk is always recommended. Long-term treatment of ERD is applied either intermittently or as continuous maintenance treatment with an attempt to reduce the daily dosage of the PPI (step-down principle). In selected patients requiring long-term PPI treatment, antireflux surgery is an alternative option. In patients with troublesome reflux symptoms and without alarming features empirical PPI therapy is another option for initial management. Therapy should be withdrawn after initial success. In the case of relapse, the long-term care depends on a careful risk assessment and the response to PPI therapy.

[The influence of Helicobacter pylori eradication on oesophageal pH-metry and bilimetry results in patients with nonulcer dyspepsia]. / Wplyw eradykacji Helicobacter pylori na wyniki pH-metrii i bilimetrii przelyku u osób z czynnosciowa dyspepsja wrzodopodobna.

Substernal, fasting and night pains with no endoscopic findings in the upper gastrointestinal tract are the leading symptoms of nonulcer dyspepsia (NUD). Our study aimed at determining whether there is duodenogastroesophageal reflux in patients with NUD and to evaluate what role Helicobacter pylori plays in NUD pathophysiology. The study comprised 40 patients, in whom endoscopy, breath test (UBT-13C), 24-hour pH-metry (Digitrapper III) and bilimetry (Bilitec 2000) of the esophagus were performed before and after 7-day antibacterial treatment (pantoprazole 2 x 40 mg, amoxicillin 2 x 1000 mg, clarithromycin 2 x 500 mg). Eradication was achieved in 29 patients, in whom total index of acid reflux (t% pH < 4.0) decreased from 23.1+/-10.4% to 13.1+/-6.2% (p<0.05) and alkaline reflux index (t% abs > 0.14) from 12.9+/-6.3 to 8.1+/-5.7% (p>0.05). Positive correlations between urea breath test results and the indexes of acid (r=0.692) and alkaline refluxes (r=0.246) were observed. In patients with nonulcer dyspepsia infected with Helicobacter pylori complex functional disorders are present. They are expressed as duodenogastroesophageal reflux. The refluxes intensity depends on the extent of Helicobacter pylori infection, which should be remembered when planning antibacterial treatment.

Gastroesophageal reflux disease poorly responsive to single-dose proton pump inhibitors in patients without Barrett's esophagus: acid reflux, bile reflux, or both?

OBJECTIVES: Studies using ambulatory pH and esophageal bile reflux monitoring (Bilitec) have shown that both acid reflux and duodeno-gastro-esophageal reflux (DGER) frequently occur in patients with gastroesophageal reflux disease (GERD). A subset of patients with GERD has persistent reflux symptoms in spite of standard doses of proton pump inhibitors (PPIs). The aim of the present study was to investigate the role of acid and DGER in patients with reflux disease poorly responsive to PPIs. METHODS: Sixty-five patients (32 men, 44 +/- 2 yr) without Barrett's esophagus and with persistent heartburn or regurgitation during standard PPI doses were studied. They underwent upper gastrointestinal endoscopy and simultaneous 24-h ambulatory pH and Bilitec monitoring while PPIs were continued. RESULTS: Thirty-three patients (51%) had persistent esophagitis. Seven patients (11%) had only pathological acid exposure, 25 (38%) had only pathological DGER exposure, and 17 (26%) had pathological exposure to both acid and DGER. Acid exposure under PPI was positive in only 37%, but adding Bilitec increased the diagnoses of persistent reflux to 75%. Patients with persistent esophagitis had similar acid exposure, but significantly higher DGER exposure than those without esophagitis. The highest prevalence of esophagitis was found in patients with pathological exposure to both acid and DGER; symptoms did not differ according to the type of reflux. CONCLUSIONS: Combined pH and Bilitec monitoring is superior to pH monitoring alone in demonstrating ongoing pathological reflux in patients with medically poorly responsive reflux disease.

"Refractory GERD": acid, nonacid, or not GERD?

Gastroesophageal reflux disease (GERD) is a common condition with 44% of Americans surveyed reporting heartburn at least once a month and 20% once a week (1, 2). However, despite major advances in our understanding of this disease, management of GERD is still a challenge. Proton pump inhibitors (PPIs) are more effective than H2-receptor antagonists (H2RA) in the initial healing of erosive esophagitis, which provide symptom relief and maintenance (3). Due to its established efficacy and safety, PPI treatment is used as the initial "test" in diagnosing GERD in the absence of bleeding, anemia, weight loss, or dysphagia. A single dose of PPI provides adequate symptom relief in most patients; however, dose escalation to twice a day may be needed in some. Patients unresponsive to PPI therapy are often labeled as having "refractory GERD." However, this term is poorly defined and has a different meaning in different countries. More importantly, the cause of "refractory GERD" is poorly understood.

Lanzoprazole promotes gastric carcinogenesis in rats with duodenogastric reflux.

BACKGROUND: Duodenogastric reflux is known to cause an increased frequency of cancer in the glandular portion of the stomach in rats. Furthermore, it is debated whether inhibition of gastric acid secretion may promote gastric carcinogenesis. In the present study we examined the combined effect of gastroduodenal reflux and acid inhibition with respect to the development of gastric carcinoma in the rat. METHODS: Following the construction of a gastrojejunostomy in male Wistar rats, half of them were given the proton pump inhibitor lanzoprazole for 1 year. The rats were then killed and the pH in the stomach and gastrin in blood were measured. The stomach was examined macroscopically as well as histologically. RESULTS: Gastrin levels at autopsy were significantly increased in treated rats compared to the control group, confirming an effect of lanzoprazole on gastric acid secretion. Body weight was significantly reduced in the treated rats. Thirty of 79 rats developed gastric cancer, and they were all adenocarcinomas of the Lauren intestinal type. Gastric cancers occurred significantly more often in lanzoprazole-treated rats (50%) compared with controls (27%). CONCLUSION: Lanzoprazole given orally enhances the carcinogenic effect of duodenogastric reflux in rats.

[H2-blockers of histamine receptors in the therapy of early stages of gastroduodenal reflux disease]. / H2-blokatory gistaminovykh retseptorov v terapii gastroduodenal'noi refliuksnoi bolezni.

The efficacy of the administration of famotidine, 20 mg BID, at early stages of gastroduodenal reflux disease (GDRD) based on a clinical and endoscopy study and treatment of patients of 0 and 1 degrees on the modified Savary-Miller scale.

Effect of the GABA(B) agonist baclofen in patients with symptoms and duodeno-gastro-oesophageal reflux refractory to proton pump inhibitors.

BACKGROUND AND AIMS: A subset of patients with gastro-oesophageal reflux disease (GORD) with refractory symptoms during therapy with proton pump inhibitors (PPIs), have persistent non-acid duodeno-gastro-oesophageal reflux (duodenal reflux). The aim of the present study was to investigate the effect of the GABA(B) receptor agonist baclofen, which was shown to inhibit the occurrence of transient lower oesophageal sphincter relaxations (TLOSRs) in patients with persistent non-acid duodenal reflux during PPI therapy. METHODS: Patients were eligible for the study if they had persistent reflux symptoms, normal pH monitoring, and pathological Bilitec monitoring during PPI treatment. Upper gastrointestinal endoscopy and reflux symptom score were performed at the beginning of the study. Baclofen 5 mg three times daily was associated with treatment, and was increased by 5 mg every fourth day until a maintenance dose of 20 mg three times daily was reached. A reflux symptom questionnaire, ambulatory pH monitoring, and Bilitec monitoring were repeated four days later while PPI and baclofen were continued. All data are given as mean (SEM) or median (interquartile range) and were compared using the Student's t test or the Mann-Whitney U test. RESULTS: Sixteen patients (11 women, mean age 46 (3) years) with persistent heartburn or regurgitation for at least three months, in spite of PPI therapy, were included in the study. Erosive oesophagitis was present in seven patients (five with grade 1, two with grade 2). Under PPI therapy alone, all patients had normal acid exposure (0.3 (0.05; 2.2)% of the time) but pathological duodenal reflux exposure (13.8 (11.8; 15.5)% of the time). After addition of baclofen 20 mg three times daily, acid exposure was similar (0.4 (0.15; 2.3)% of the time; NS) but duodenal reflux had significantly decreased (6.1 (0.8; 10.3)% of the time; p<0.05). The number of duodenal reflux episodes and the number of longlasting duodenal reflux episodes (>5 minutes) was decreased, respectively, from 23 (14.5; 34) to 12 (5; 21) (p = 0.06) and from 5 (3; 8) to 2 (0.5;4.5) (p<0.05). The cumulative severity score for 14 reflux symptoms decreased from 10.3 (1.7) to 5.8 (1.3) (p<0.01). Four patients reported mild side effects of nausea or drowsiness. CONCLUSIONS: The GABA(B) receptor agonist baclofen improves duodenal reflux and associated reflux symptoms that persist during PPI therapy.

Duodenogastric reflux after biliary surgery: scintigraphic quantification and improvement with erythromycin.

BACKGROUND: Persistence of dyspeptic symptoms after cholecystectomy or choledochoduodenostomy is common. There is -evidence that at least some of these symptoms may be attributed to duodenogastric reflux (DGR). The aim of the study was to quantify DGR before and after cholecystectomy, with or without choledochoduodenostomy, and endoscopic sphincterotomy for common bile duct stones, and to assess the effect of erythromycin on the increased DGR. METHODS: Forty-seven patients before and after cholecystectomy, 26 after cholecystectomy and choledochoduodenostomy and nine after sphincterotomy had postprandial (300 mL of fresh milk, 4% fat) duodenogastric reflux measured by 99mTc-hepatic imino diacetic acid scintigraphy. Patients with a DGR index (DGRi) >20% were considered as having pathological DGR that justifies symptoms, and their DGRi was reassessed after administration of 200 mg of erythromycin intravenously. RESULTS: Twenty-seven patients before cholecystectomy (57%) showed a normal DGRi <7%. In five cases DGRi was greater than 20%. After cholecystectomy, duodenogastric refluxes increased, so that only 16 patients (32%) showed a normal DGRi, while a DGRi >20% was observed in 10 cases. Only eight patients after cholecystectomy and choledochoduodenostomy (23%) presented with a DGRi within the normal range. The remaining 18 had a DGRi >7%. Five of them exhibited a DGRi >20%. Of the nine patients with sphincterotomy, three showed a DGRi >20%. Erythromycin almost completely normalized DGRi in all 18 patients with pathological DGR (P < 0.0001). CONCLUSIONS: Duodenogastric reflux is common after biliary surgery, including endoscopic sphincterotomy. Erythromycin appears to decrease duodenogastric reflux to normal levels.

Does the addition of a prokinetic to proton pump inhibitor therapy help reduce duodenogastro-oesophageal reflux in patients with Barrett's oesophagus?

OBJECTIVE: The metaplastic change of Barrett's oesophagus is linked to both acid and duodenal reflux together with impaired motility. Proton pump inhibitors (PPI) reduce acid reflux, but no treatment is available that reduces duodenogastro-oesophageal reflux (DGOR). The aim of this study was to investigate whether adding a prokinetic to PPI treatment could improve oesophageal motility and subsequently reduce reflux. METHODS: Two groups of patients with Barrett's oesophagus on PPI therapy (prokinetic, n = 12; placebo, n = 11) were investigated. At visit 1, ambulatory oesophageal manometry was performed, and peristaltic and simultaneous wave percentage and characteristics were measured. DGOR and pH measurements were also performed. After treatment with either the prokinetic cisapride or placebo, all investigations were repeated (visit 2). Analysis of covariance and Spearman's correlation coefficients of changes from visit 1 to visit 2 were used to compare data. RESULTS: There was no significant difference between the two groups with respect to DGOR, DGOR characteristics, or the percentage of peristalsis and simultaneous waves and their characteristics. There was no correlation between DGOR and motility changes. Although no significant differences existed between acid reflux in the two groups, five patients with high supine acid reflux showed a significant reduction after treatment with cisapride. CONCLUSIONS: Addition of cisapride to PPI treatment does not appear to improve oesophageal motility or reduce DGOR in patients with Barrett's oesophagus.