The effects of inhaled albuterol and oral theophylline on gastroesophageal reflux in patients with gastroesophageal reflux disease and obstructive lung disease.

Patients with gastroesophageal reflux disease may have pulmonary symptoms due to repeated aspiration of gastric contents or reflex bronchospasm during a reflux event. Oral bronchodilators are known to worsen gastroesophageal reflux and may lead to vicious cycle when gastroesophageal reflux causes bronchospasm. The effect of inhaled bronchodilators on gastroesophageal reflux is unknown. We compared the severity of gastroesophageal reflux in patients with documented gastroesophageal reflux disease and obstructive lung disease while they were taking inhaled albuterol or oral theophylline. Nine patients with gastroesophageal reflux disease had 24-hour esophageal pH studies on two separate days approximately 1 week apart. On one study day, the patients received 0.5 mg of albuterol in 2.5 mL of normal saline vias hand-held nebulizer, four times a day. On the other day, the patients received sustained-release theophylline, 200 mg twice a day, or in a dosage taken previously to achieve a serum theophylline level of 55 to 110 mumol/L. The patients had 40% reduction in the total time the pH was less than 4.0 with albuterol than with theophylline (9.7% vs 16.1%). Seven patients had less gastroesophageal reflux while taking albuterol, and two patients had essentially no change. Patients with gastroesophageal reflux disease, who require bronchodilator therapy for obstructive lung disease, have less reflux with inhaled albuterol.

The impact of practice guidelines in the management of Barrett esophagus: a national prospective cohort study of physicians.

BACKGROUND: Surveillance of patients with Barrett esophagus (BE) is recommended to detect dysplasia and early cancer. In 1998, practice guidelines for the surveillance of patients with BE were developed under the auspices of the American College of Gastroenterology (ACG). Our objective is to assess physicians' awareness of agreement with and adherence to these guidelines. METHODS: A national prospective cohort study of practicing gastroenterologists who completed a self-administered questionnaire containing case studies prior to the release of the guidelines and another survey 18 months later. Analysis of adherence to the guidelines was done using the McNemar chi(2) test. RESULTS: Of the 154 gastroenterologists (66%) who responded to the follow-up survey, more than half (55%) were aware of the guidelines, and members of the ACG were more likely to know of their existence than nonmembers (61% vs 38%; P =.01). Overall, about 27% of physicians reported practicing in accordance with the guidelines at baseline; adherence increased modestly to 38% in the 18-month follow-up (P =.04) and was inversely related to fee-for-service reimbursement. Awareness was not associated with an increased likelihood of adherence, but agreement with the guidelines was strongly correlated with adherence (P<.001). The most frequent reasons for disagreement were concerns about liability, cancer risk, and inadequate evidence. CONCLUSIONS: Awareness of the guidelines published by the ACG was low. Guideline awareness did not predict adherence. Improvement in guideline adherence will require steps beyond mere dissemination and promotion. Addressing disagreements about liability, disease risk, and scientific evidence as well as restructuring payment incentives may help achieve optimal practice.

Management of pancreatic pseudocysts.

BACKGROUND: Operative internal drainage has been standard treatment for chronic unresolved pancreatic pseudocysts (PPs). Recently, percutaneous external drainage (PED) has become the primary mode of treatment at many medical centers. STUDY DESIGN: A retrospective chart review was performed of 96 patients with PPs who were managed between 1987 and 1996. Longterm followup information was obtained by telephone and mail questionnaire. RESULTS: Twenty-seven patients underwent computed tomographic (CT)-guided PED. PP resolution occurred in 17 patients. Clinical deterioration or secondary infection mandated urgent pancreatic debridement in 7 (26%) patients and cystgastrostomy in 2 (7%) patients. There was one hospital death in this group. Thirty-two patients underwent cystgastrostomy or cystjejunostomy (n = 21), distal pancreatectomy (n = 8), pancreatic debridement and external drainage (n = 2), or cystectomy (n = 1). Two (6%) patients required postoperative pancreatic debridement for failure of resolution and peritonitis and two patients underwent PED of abscess. There was one hospital death in the expectantly managed group of 37 patients. Median followup of 3 years (range, 0.5-9.3 years) in 66 patients revealed that 6, 3, and 4 patients of PED, surgery, and expectantly managed groups, respectively, had radiologic evidence of recurrent PPs. CONCLUSIONS: Operative management for PPs appears to be superior to CT-guided PED. Although the later was often successful, it required major salvage procedures in one third of the patients. An expectant management protocol may be suitable for selected patients.

Asthma and gastroesophageal reflux: fundoplication decreases need for systemic corticosteroids.

An association between gastroesophageal reflux (GER) and asthma has been suggested for many decades. Although antireflux therapy (medical and surgical) has been shown to be beneficial in patients with asthma, response to therapy has not been well quantified. The aim of this study was to evaluate long-term outcome in patients with asthma and associated GER undergoing fundoplication. From a database of more than 600 patients with GER treated surgically between 1991 and 1996, 39 patients with asthma as their primary indication for surgery were identified. Asthma symptom scores were determined using the National Asthma Education Program classification, and medication frequency scores were determined preoperatively and at latest follow-up (median follow-up 2.7 years). Comparisons were made using the Wilcoxon rank-sum test. Asthma symptom scores decreased significantly after antireflux surgery. More important, the medication scores for use of systemic corticosteroids decreased significantly postoperatively (2.2 preoperatively vs. 0.7 postoperatively; P = 0.0001). Of the nine patients who required daily oral corticosteroids, seven have discontinued treatment entirely (78%). In patients with asthma associated with GER, symptoms of asthma are improved following fundoplication. Especially important has been the ability to wean patients from systemic corticosteroids postoperatively. Fundoplication should be offered to those patients with GER-associated asthma, especially those who are steroid dependent.

Intermediate follow-up of laparoscopic antireflux surgery.

BACKGROUND: Open antireflux surgery is an established long-term treatment for chronic gastroesophageal reflux disease. Short-term results of laparoscopic antireflux surgery are excellent, but long-term follow-up is not yet available. METHODS: Twenty-four-hour ambulatory esophageal pH monitoring and symptom scores were collected prior to laparoscopic antireflux surgery and 6 weeks postoperatively. These studies were repeated in an unselected cohort of patients 1 to 3 years after operation. RESULTS: One hundred patients who were > 1 year from surgery at the time of the present study volunteered for intermediate follow-up symptom assessment, and 35 also completed repeat 24-hour monitoring. The median interval after surgery among these volunteers was 17 months. Thirty-three (94%) had a normal pH study, which correlated with improvements in symptom scores. One patient had an abnormal pH study but no reflux symptoms, and 1 patient with an abnormal study developed recurrent symptoms of reflux after an episode of vomiting 11 months postoperatively. CONCLUSIONS: The intermediate-term results of laparoscopic fundoplication suggest that long-term efficacy of this operation will be equivalent to open fundoplication.

Medical therapy of gastroesophageal reflux and management of esophageal strictures.

The goals of modern medical therapy for gastroesophageal reflux disease are threefold: first, eliminate symptoms; second, heal injured esophageal mucosa; third, manage and/or prevent complications. Selection of a particular medical regimen depends on the severity of the disease, effectiveness of the therapy, cost, and convenience of the medical regimen. An accurate diagnosis needs to be made in patients suspected with esophageal strictures. If there is a treatable underlying disease, specific therapy is essential. The goal of dilation therapy should be established and set about to accomplish in a timely, but unhurried fashion. Fluoroscopy and wire-guided dilators should be used liberally, especially for difficult strictures.

Mucosal bridge formation in the esophagus caused by injury from a nasoenteric feeding tube.

We report the first case of an esophageal mucosal bridge that was caused by a nasoenteric feeding tube or its placement. The mucosal bridge was diagnosed by esophagoscopy and was nearly resolved 3 weeks later after removal of the feeding tube and treatment with histamine antagonists. Although uncommon, esophageal injury may occur in relation to the use of small-bore nasoenteric feeding tubes and great care should be taken during tube placement and use.

Outcomes of laparoscopic fundoplication for gastroesophageal reflux disease and paraesophageal hernia.

BACKGROUND: Laparoscopic fundoplication has become the standard for operative treatment of gastroesophageal reflux disease (GERD). METHODS: We reviewed our experience with 1,000 consecutive patients receiving laparoscopic fundoplication for GERD (n = 882) or paraesophageal hernia (n = 118) between October 1991 and July 1999. Patients with achalasia and failed fundoplication were excluded from analysis. All the patients were evaluated preoperatively by upper endoscopy, esophageal manometry, and barium swallow. After 1994, 24-h pH monitoring was performed selectively in patients with extraesophageal symptoms and/or those without erosive esophagitis. There were 490 men 510 women in this review. Their mean age was 49 years. Procedures performed were 360 degrees floppy fundoplication (n = 879), 360 degrees fundoplication without fundus mobilization (Rossetti) (n = 22), 270 degrees posterior fundoplication (n = 96), and anterior fundoplication (n = 2). Esophageal lengthening procedure (Collis gastroplasty) was performed in combination with fundoplication in 15 patients. In seven patients the treatment was converted to open fundoplication. OUTCOMES: The average length of hospitalization was 2.2 days, and 136 patients stayed longer than 2 days. Major complications occurred in 21 patients: esophageal perforation (n= 10), acute paraesophageal herniation (n = 4), splenic bleeding (n = 2), cardiac arrest (n = 1), pneumonia (n = 3), and testicular abscess (n = 1). Additional operations were required to manage the complications in 14 patients (70%): Four of these procedures were performed emergently, and 10 patients underwent reoperation between 6 h and 10 days. There were three deaths, all of which involved elderly patients with paraesophageal hernia. There were 35 late failures requiring reoperation for recurrence of GERD or development of new symptoms: The treatment of 32 patients was revised laparoscopically, and 4 patients required laparotomy. Beyond 1 year (median follow-up period, 27 months), 94% of the reviewed patients were satisfied with their surgical outcome.

Nissen fundoplication improves gastric motility in patients with delayed gastric emptying.

BACKGROUND: Fundoplication hastens gastric emptying in pediatric patients with gastroesophageal reflux disease (GERD). However, among adult GERD patients with impaired gastric emptying, the degree of improvement offered by fundoplication and the value of pyloroplasty are less well defined. Therefore, we compared outcomes in GERD patients with delayed gastric emptying after fundoplication alone or fundoplication with pyloroplasty. METHODS: Of 616 consecutive GERD patients who submitted to primary fundoplication (601 laparoscopic) between October 1991 and October 1997, 82 underwent preoperative solid-phase nuclear gastric emptying analysis. Of these, 25 had delayed gastric emptying (half-time >100 min). Of 12 patients with emptying half-times between 100 and 150 min, one underwent pyloroplasty at the time of Nissen fundoplication. Of 13 patients with emptying half-times >150 min, 11 had pyloroplasty at the time of Nissen fundoplication. Patients were asked to use a 0 ("none") to 4 ("incapacitating") scale to describe the severity of their symptoms of heartburn, regurgitation, dysphagia, bloating and diarrhea preoperatively and at 6 weeks and 1 year postoperatively. Eight patients consented to a postoperative analysis of gastric emptying. RESULTS: One year after fundoplication, patients with delayed gastric emptying and controls reported a similar improvement in heartburn, regurgitation, and dysphagia, with no increase in undesirable side effects such as bloating and diarrhea. Among the patients with delayed gastric emptying who consented to undergo a repeat gastric emptying study after their operation, fundoplication alone provided a 38% improvement (p < 0.05) in gastric emptying, whereas fundoplication with pyloroplasty resulted in a 70% improvement in gastric emptying (p < 0.05). CONCLUSION: Fundoplication improves gastric emptying. The addition of pyloroplasty results in even greater improvement and may have particular value for patients with severe gastric hypomotility.

Gastroesophageal reflux and sclerotherapy strictures.

The development of esophageal stricture is common following endoscopic variceal sclerotherapy (EVS). Gastroesophageal reflux may be at least partly responsible. Twelve randomly selected male patients underwent chronic EVS for the management of bleeding esophageal varices. Six patients developed strictures during or after EVS, six did not. There were no significant differences between stricture and nonstricture patients during 24 hour esophageal pH monitoring. Three of the six stricture patients and four of the six nonstricture patients had an abnormal amount of reflux. Gastroesophageal reflux occurs frequently in patients undergoing EVS, and it is not likely to play a major role in EVS stricture formation.

Management of postfundoplication complications.

The role of surgical therapy in the management of gastroesophageal reflux disease (GERD) continues to evolve in the laparoscopic era. As the number of surgical procedures increases, so does the number of patients with postfundoplication complications. The most effective strategy is to prevent the complication in the first place. Patients who are most likely to have trouble after surgery are those with refractory, atypical, or complicated disease. Gastroenterologists should take care to make an accurate diagnosis, heal the esophagitis, and dilate any strictures before sending a patient to surgery. The surgeon should be a skilled laparoscopist. In patients with complicated GERD, the surgeon must be able to recognize severe disease and perform advanced procedures. Postoperatively, symptoms are usually the same (suggesting a failure of the operation or incorrect original diagnosis) or different (suggesting a complication) than before surgery. Most patients should have a barium swallow and an endoscopy to evaluate the integrity of the wrap. If intact, postoperative heartburn and dysphagia will usually resolve with conservative therapy. If the fundoplication is poorly oriented, too long, too tight, twisted, or herniated above the diaphragm, surgical revision is often necessary.

Postfundoplication complications. Prevention and management.

Management of post-fundoplication problems begins by preventing complications from occurring. The prevention of complications after antireflux surgery can be divided into three important areas: (1) patient selection, (2) selection of the surgery, and (3) selection of the surgeon. After addressing prevention techniques, the author discusses the management of new postoperative symptoms such as Dysphagia, gas-bloat syndrome, and nausea and vomiting.

Nonerosive reflux disease.

Until recently, the finding of erosive esophagitis in patients with chronic heartburn was thought to indicate more severe gastroesophageal reflux disease. However, recent data suggests that this is not necessarily true. Seventy-five percent of patient's chronic heartburn have moderate to severe symptoms, regardless of the presence or absence of esophagitis. Nonerosive reflux disease (NERD) is characterized by heartburn symptoms for at least 3 months with no evidence of esophagitis. Patients with NERD are similar to patients with esophagitis in symptom severity, quality of life scores, and response to anti-reflux therapy. There are probably 3 distinct groups of NERD patients, those with pathologic reflux, those with a heightened sensitivity to physiologic reflux and those with other medical problems mistaken for reflux. This article discusses the 3 clinical scenarios.

Food impaction and strictures after sclerotherapy of esophageal varices.

Esophageal stricture is a common complication of endoscopic variceal sclerotherapy (EVS). The belief was that it could be managed safely and easily by esophageal dilation. Of 103 patients treated at our institution with EVS, 31 developed strictures, and of these, five have presented with food impaction (16.1%), a previously unreported complication. Three of the five had undergone prior esophageal dilation. Our patients received an average of 89 ml of 1.5% sodium tetradecyl in 7.6 sessions, compared with 51 ml in three sessions in an earlier group of EVS-induced strictures without food impaction. Esophageal manometric abnormalities were seen in three of four patients studied, two with markedly impaired peristaltic activity. All patients had successful treatment of both esophageal stricture and bleeding varices. Further sclerotherapy continued in four of five patients without additional problems. Food impaction in EVS-induced esophageal stricture can occur, despite dilation therapy.

Cervical esophageal web caused by an inlet patch of gastric mucosa.

A 55-year-old woman had chronic, progressive dysphagia. An esophageal web in the cervical esophagus was identified by barium swallow and endoscopy. At endoscopy, an inlet patch of gastric mucosa was identified in proximity to the cervical web. It is believed that gastric acid production from the inlet patch led to development of the cervical esophageal web. We present our patient's case and review the literature relevant to this topic.

Endoscopic techniques and complications in variceal sclerotherapy.

Increasing interest in esophageal variceal sclerotherapy (EVS) for bleeding varices is attested to by hundreds of recent articles on the subject. Hardly a medical journal is published that does not contain a report or editorial opinion about the procedure. Indeed, enthusiastic battle lines have been drawn by those who employ the procedure and skeptics who are awaiting proof of its efficacy. On the sidelines is a fairly large group of medical "fence-sitters," whose agnostic critiques keep the entire question lively and worth dissecting. EVS is not without complications, but it is not very difficult to perform. It can control active variceal hemorrhage and prevent rebleeding in stabilized patients. Its effect on survival seems to be related to the underlying liver disease, the endoscopist's ability to obliterate the varices, and treatment-related morbidity and mortality. Prophylactic EVS may be helpful in carefully selected patients. We review current controversies about EVS and offer technical suggestions to improve efficacy and lower EVS-related morbidity and mortality.

Endoscopic injection therapy for nonvariceal bleeding lesions of the upper gastrointestinal tract.

A number of techniques have been developed to control active upper gastrointestinal tract bleeding. These include thermal devices such as the laser, heater probe, and bipolar circumactive probe (BICAP). Although these devices have proved effective, they vary in cost and at times are cumbersome to use. A simple, inexpensive, readily available means of treating active bleeding from the gastrointestinal tract is injection of the lesion with a sclerosing substance. This method has proved helpful in stopping variceal hemorrhage, and the simplicity of the equipment and procedure makes it an outstanding candidate therapy for treating other causes of hemorrhage. Although the method is not well known in the United States, it has been applied in Japan and Europe. Most studies so far have been uncontrolled, but in over 700 patients reported in the world literature, effective initial hemostasis has been achieved in about 90% of patients overall. Success rates have been somewhat dependent on the site and rate of bleeding. No deaths have been reported from the procedure. We review the current status, techniques, and types of sclerosing agents and provide a detailed analysis of results of injection sclerotherapy. We propose that although the technique is simple, the effectiveness and routine application to the patient with upper gastrointestinal hemorrhage await careful controlled studies and comparison with other available hemostatic methods.

Dual-channel ambulatory esophageal pH monitoring. A useful diagnostic tool?

Ambulatory pH monitoring of the distal esophagus is the most accurate diagnostic study for patients with suspected gastroesophageal reflux disease (GERD). The measurement of proximal esophageal acid exposure time may be useful in patients with atypical reflux symptoms. The aim of this study is to evaluate if proximal esophageal pH monitoring provides useful information beyond that learned with distal esophageal pH monitoring. We routinely performed dual-channel pH monitoring with pH electrodes positioned at 20 and 5 cm above the manometric lower esophageal sphincter from January 1992 to August 1995. All patients scored their esophageal symptoms from zero (none) to four (severe). We compared proximal esophageal reflux (PR) in patients with typical symptoms (i.e., heartburn, regurgitation) and in patients with atypical symptoms (i.e., chest pain, cough, hoarseness, and asthma). We compared symptom profiles between patients with and without PR. We reviewed our experience in patients with abnormal PR, but with a normal amount of distal esophageal reflux (DR). We studied 441 consecutive patients. There were no significant differences in PR between patients with typical and atypical symptoms. There were no differences in symptom profiles between patients with normal and abnormal PR. There were no differences of PR between the different atypical symptoms. PR did not correlate with the severity of the patient's symptoms. PR correlated well only with DR. Twenty-four patients had isolated abnormal PR, but only six patients improved with antireflux therapy. We conclude that routine ambulatory esophageal pH monitoring of the proximal esophagus appears to be of little value. The decision to offer patients an empiric trial of antireflux therapy for suspected GERD should not be based on the presence or absence of PR.

Laparoscopic antireflux surgery.

The availability of proton pump inhibitors and laparoscopic antireflux surgery has ushered in a new era in the management of chronic gastroesophageal reflux disease. Proton pump inhibitors allow physicians to treat nearly all patients with chronic gastroesophageal reflux with successful medical treatment. Laparoscopic antireflux surgery offers patients an opportunity to abandon their medications with an operation that is well tolerated. The major indication for antireflux surgery is failure of medical therapy. However, many patients with long-term medical therapy requirements are candidates, too. Several factors influence the decision to choose antireflux surgery, including patients' ages, costs of medications, types of symptoms the patients may have (for example, heartburn as opposed to chest pain or asthma), or complications such as Barrett's esophagus, metaplasia, or stricture formation. A through preoperative evaluation of patients being considered for antireflux surgery is essential. All patients should have an upper endoscopy and esophageal manometry. Selected patients, particularly those with nonerosive esophagitis, atypical reflux symptoms, or those in whom the diagnosis is in doubt, should have ambulatory esophageal pH monitoring. Barium swallow is helpful in evaluating patients with Barrett's esophagus, esophageal strictures, and in elderly patients who have a new onset of esophageal symptoms. Gastric testing infrequently identifies patients with significant abnormalities; however, in patients with symptoms of gastric disease it may change the type of surgery that is performed. The results of laparoscopic antireflux surgery are excellent in properly selected patients. Complications are rare and usually easily managed in the postoperative setting. The keys to successful antireflux surgery are a thorough evaluation of the patient, a thorough discussion of the advantages and disadvantages of antireflux surgery with the patient, and a skilled surgeon. Following these principles, antireflux surgery should be very successful in the great majority of patients for whom it is considered.

Improved patient care using the A/S/G/E guidelines on quality assurance: a prospective comparative study.

The American Society for Gastrointestinal Endoscopy has promulgated guidelines on quality assurance in gastrointestinal endoscopy. Thorough documentation of endoscopy reports and a peer review process were strongly recommended. We evaluated 1408 dictated endoscopy and colonoscopy reports for deficiency in reference to the guidelines during three periods: 6 months before (group 1), 6 months after the application of the guidelines (group 2), and 5 months of intensive peer review process (group 3). Deficiency was defined as lack of documentation of at least 1 of the 10 parameters that should be included in endoscopy reports according to the guidelines. There was a significant decrease in deficiency rates in groups 2 (91.6%) and 3 (32.7%) compared with group 1 (99.8%) (p less than 0.01). Peer review and direct confrontation of the endoscopists with their deficiencies significantly reduced the use of inappropriate indication for endoscopy (1.5%/group 3 vs. 5.2%/group 1, p less than 0.01). Adherence to the A/S/G/E guidelines on quality assurance improved documentation, decreased inappropriate use of endoscopy, and may thus improve quality of care.