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.

Ambulatory esophageal monitoring in noncardiac chest pain.

The esophageal origin of angina-like noncardiac chest pain can be identified with certainty only when spontaneous chest pain episodes are associated with gastroesophageal reflux, abnormal esophageal motility, or both. Since noncardiac chest pain typically occurs infrequently, prolonged monitoring is required to establish such an association. Ambulatory esophageal monitoring offers the additional advantages of studying the patient in everyday life and avoiding hospital admission. Although the amplification and storage of 24-hour signals in a portable recorder no longer poses technical problems, the complexity of the analysis of the recorded signals should not be underestimated. For noncardiac chest pain, the most relevant part of the analysis is the association between chest pain episodes and the recorded esophageal signals. To determine whether contraction amplitude or duration during chest pain episodes is abnormal, their measurements are compared with baseline values from the same patient. Fully automated analysis by computer is feasible and, since it avoids observer bias, preferable. The yield of 24-hour monitoring in noncardiac chest pain reported by different groups of investigators varies considerably. Motor abnormalities have been identified as the cause of chest pain in 4.5-18% of patients studied, and reflux in 4.5-25%. In addition, some patients had both dysmotility- and reflux-related pain episodes. As expected, the yield of the technique is higher in patients with frequent pain episodes. In patients who do not experience pain during 24-hour monitoring, the technique cannot provide a firm diagnosis of pain of esophageal origin. Recently, a much higher yield of 24-hour monitoring was reported in patients with noncardiac chest pain admitted to a coronary-care unit. A total of 76% of these patients were found to have either reflux- or dysmotility-related chest pain. Despite its relatively low yield, the addition of esophageal pressure monitoring to ambulatory pH monitoring is worthwhile and probably also cost-effective in patients with frequent episodes of unexplained chest pain.

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.

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.

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.

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.

Effects of a new effervescent cimetidine formulation on gastric acidity in healthy subjects.

The effect of a new effervescent formulation of 800 mg cimetidine on intragastric acidity was studied in 10 fasting healthy male volunteers. Using a randomised, cross-over design, the effect of this new cimetidine formulation was compared with that of a standard dose of a liquid aluminium/magnesium hydroxide antacid (Maalox). Intragastric pH was continuously monitored with a combination glass electrode and a digital data recorder. After a baseline period of 1 h the effect of the drugs was studied for 5 h. Both drugs increased the intragastric pH instantaneously, but the effect of Maalox ceased after 45.3 +/- 31.0 min (mean +/- SD), whereas that of effervescent cimetidine persisted for the entire 5 hr study period. Time with pH greater than 3.5, time with pH greater than 2, greater than 3, greater than 4, greater than 5 and greater than 6, and areas under the pH-time curves were significantly (P less than 0.001) higher for effervescent cimetidine than for Maalox. It is concluded that the new cimetidine formulation studied effectively combines, at least in healthy male volunteers, the immediate effect of a pH buffer with the prolonged systemic effect of an H2 blocker.

[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 value of ambulatory 24-hour esophageal manometry in the diagnosis of retrosternal pain of non-cardiac origin]. / De waarde van ambulante 24-uursslokdarmmanometrie bij de diagnostiek van retrosternale pijn van niet-cardiale origine.

The clinical relevance of a system of ambulatory 24-hour oesophageal pressure and pH recording with automated data analysis was investigated in 33 unselected patients with non-cardiac chest pain. After conventional manometry with edrophonium (Tensilon) provocation, 24-hour oesophageal pH and pressure monitoring was performed. In 17 patients conventional manometry, edrophonium provocation and 24-hour pH recording revealed an oesophageal origin of the symptoms: 6 patients had oesophageal motility disorders, 3 were positive responders to edrophonium and 8 had chest pain associated with gastro-oesophageal reflux. In none of the patients who had a pain attack during prolonged oesophageal pressure recording, was a new motility disorder detected.

The value of 24-hour combined esophageal pressure and pH recording in the detection of esophageal function abnormalities.

Gastroesophageal reflux and esophageal motor abnormalities are suspected of being the source of chest pain when a cardiac origin of the pain has been excluded. Because of the usually intermittent character of the motility disturbances, short conventional manometry, with or without provocation tests, often fails to establish the diagnosis. Therefore, 24-h esophageal pressure and pH recording was developed and has been proposed as a diagnostic tool in the study of patients who suffer from intermittent substernal pain. In this paper the value of 24-h combined esophageal pressure and pH recording in detecting disordered esophageal function in noncardiac chest pain and other esophageal disorders is discussed.

Clinical application of 24-hour ambulatory esophageal pH and pressure monitoring.

Recently, 24-h recording of intraesophageal pH and pressure signals in ambulatory subjects has become possible. Several research applications of the technique have emerged, but until now only a few clinical applications have been established, the most important of which is noncardiac chest pain. In the computer analysis of the signals, the patient with noncardiac chest pain is used as his or her own control; motility and pH profiles during pain are compared with asymptomatic base-line values obtained from the same patient. Automated analysis by means of a computer avoids observer bias and saves time. By means of 24-h monitoring, motor abnormalities have been identified as the cause of the chest pain in 4.5% to 18% and reflux in 4.5% to 25% of the patients studied. In addition, patients were identified who have both dysmotility- and reflux-related pain episodes. The yield of 24-h monitoring is highest in patients who have frequent pain episodes. A high yield of 24-h monitoring was found in patients with noncardiac chest pain admitted to a coronary care unit. Seventy-six per cent of these patients were found to have either reflux- of dysmotility-related chest pain. Patients with proven coronary artery disease who do not respond well to adequate treatment frequently have gastroesophageal reflux (39%) or esophageal motor abnormalities (50%) as the cause of their ongoing pain attacks. In these patients, identification of the esophageal cause of the symptoms not only helps the physician to select the optimal treatment but also reduces the patient's need for medical care.

The symptom sensitivity index: a valuable additional parameter in 24-hour esophageal pH recording.

Twenty-four-hour esophageal pH monitoring is useful for the quantitative measurement of gastroesophageal reflux and for the demonstration of a temporal relationship between symptoms and reflux. The symptom index, a numerical score, was developed to quantify the association between symptoms and reflux. Because the symptom index primarily assesses the specificity of a patient's reflux symptoms, we propose to refer to this score as the symptom specificity index. Because of certain limitations of this score, we developed and evaluated a new score, the symptom sensitivity index, that quantifies the subject's sensitivity for reflux. Fifty-two consecutive patients, referred to our laboratory for ambulatory 24-h pH recording were studied. Beside the conventional reflux variables, both indexes were calculated. Although a statistically significant correlation between the indexes was found, discordance between the specificity and sensitivity indexes was seen in 17 patients (33%). Based on the findings in this study we advocate that the symptom sensitivity index should be used, in addition to the symptom specificity index, and incorporated in future pH studies to optimalize the interpretation of the results.

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 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.

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.

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.