[Syndrome of cholestasis: modern concepts]

Definition of cholestasis syndrome is proposed, anatomic and physiological aspects of bile production and excretion are discussed, modern data on etiology and pathogenesis of intra- and extrahepatic chollestasis are presented along with the working classification of its forms. Much attention is given to clinical manifestations of the disease, its laboratory, instrumental, and morphological diagnosis. Major disorders clinically resembling cholestasis syndrome are briefly reviewed. Special emphasis is laid on up-to-date means and methods for the management of the disease.

[Diarrheic syndrome: state of the problem]

Review of recent data on diarrheic syndrome, its etiology, pathogenetic mechanisms, classification, clinical features, methods of laboratory and instrumental diagnosis and their informative value. Certain poorly known rare and refractory forms of diarrhea are briefly described. Much attention is given to differential diagnosis of acute and chronic diarrhea of different etiology.

Herniography: analysis of its role and limitations

INTRODUCTION

Herniography is a radiographic procedure shown to be valuable in the examination of groin symptoms. It is useful in clinical situations, including the detection of occult hernia, the investigation of groin hernia when physical findings are equivocal, and the assessment of pain after inguinal hernia repair.

OBJECTIVE

To systematically review the current literature on the use of herniography and to evaluate its reliability, risk, and limitations.

METHOD

The Medline database was searched for publications on herniography.

RESULTS

Herniography has a low false-positive rate, ranging from 0 to 18.75%. The sensitivity rate ranges from 81 to 100%, and the specificity rate ranges from 92 to 98.4%.

CONCLUSION

Herniography is a safe and effective diagnostic procedure for assessing obscure groin symptoms. It has the potential of reducing the incidence of unnecessary operations. It should be considered in the evaluation of patients where the etiology of inguinal pain is unclear.

Abdominal tuberculosis in a Nigerian teaching hospital

Abdominal tuberculosis (TB) alone or with disseminated TB is known to mimic other conditions with non-specific investigation findings. This study aims to evaluate the clinical presentations and investigation findings of patients in our setting. The clinical records of 47 patients diagnosed as abdominal TB between January 1986 and December 2005 at the Wesley Guild Hospital Unit of the Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria, were reviewed. Fifty-five percent of the patients were women and mean age was 28 years. Common presenting symptoms and signs were abdominal pain 76.6%; ascites 59.6%; weight loss 53.2%; fever 29.8%. Average duration of symptoms before presentation was 3 months. Thirteen percent of patients had earlier been treated for pulmonary tuberculosis in the hospital. ESR was elevated in 89%, ultrasound scans of abdomen were abnormal in 68%, showing ascites, hepatomegaly and or enlarged nodes. Mantoux test was positive in 33% and ascitic fluid was diagnostic for TB in 29%. Chest X-ray showed abnormal findings in 25% of the patients and sputum was positive for AFB in 14.3%. Three patients were HIV positive. Forty patients (85.1%) recovered after receiving anti-TB drugs for a period of 9-12 months. Seven patients, including the three with HIV infection died. Death of 2 patients was due to unrelated causes. We conclude that abdominal TB should be suspected in patients with chronic abdominal condition and ascites as no laboratory or radiological finding is gold standard in its diagnosis. However the condition carries good prognosis if promptly diagnosed and treated.

[How to find the cause of a chronic adult diarrhea]

Chronic diarrhea can be defined as the passage of more than 3 loose stools per day during more than 4 weeks. Differential diagnosis include fecal incontinence (stool consistency is normal), rectal syndrome (passage of blood and mucus but no liquid or loose stools) and fecal impaction. The proposed guidelines are based upon a classification of chronic diarrhea that distinguishes colonic, small bowel, pancreatic, endocrine and miscellaneous causes of chronic diarrhea. It also takes into account the frequency of the many causes of chronic diarrhea. One of its main objectives is to ensure the proper diagnosis of severe causes of chronic diarrhea, notably colorectal neoplasia.

[Gastric erosions: pathogenesis, clinical features, diagnosis, and treatment]

Recent data on etiology, pathogenesis, diagnosis, and treatment of gastric erosion are reviewed. Classification of acute and chronic erosions is proposed. The authors point out to the lack of documented scientific information related to the role and significance of erosions in gastroduodenal pathology. Special emphasis is laid on risk factors, diagnosis, prevention, and treatment of gastropathies with reference to their clinical features and diagnostic criteria. The main provisions of the Maastricht Treaty 3 (2005) concerning NSAID gastropathies are outlined.

Type 1 diabetes and gastroparesis: diagnosis and treatment

Patients with gastroparesis present with gastrointestinal symptoms and non-gastrointestinal manifestations in association with objective delays in gastric emptying. The condition complicates the course of many patients with type 1 diabetes mellitus, usually in those with longstanding poor glycemic control with other associated diabetic complications. The diagnosis is made by directed evaluation to exclude organic diseases that can mimic the clinical presentation of gastroparesis, coupled with verification of gastric retention. Current therapy relies on dietary modifications, medications to stimulate gastric evacuation, and agents to reduce vomiting. Endoscopic and surgical options are increasingly used in patients who are refractory to drug treatment.

Gastroparesis in type 2 diabetes mellitus: prevalence, etiology, diagnosis, and treatment

The worldwide epidemic of type 2 diabetes mellitus (T2DM) is a substantial economic and social burden. Although gastroparesis associated with type 1 diabetes mellitus (T1DM) has been recognized for years, only recently have studies shown that patients with T2DM also have high rates of gastroparesis. Individuals with T2DM constitute 90% to 95% of the diabetic population. Unique characteristics that distinguish this population are obesity, insulin resistance, and associated comorbidities. These features highlight the importance of investigating gastric emptying in individuals with T2DM and upper gastrointestinal symptoms. The purpose of this review is to examine the literature pertaining to diabetes and the effect of diabetes on gastric neuromuscular function, with a focus on T2DM. An understanding of gastric motility in T2DM is important to diagnose gastroparesis, to treat upper gastrointestinal symptoms, and to restore normal gastric motility, which may lead, in turn, to improved glucose control.

The use of transient elastometry for assessing liver fibrosis in patients with HIV and hepatitis C virus coinfection

BACKGROUND

Transient elastometry (TE) is accurate for detecting significant liver fibrosis and cirrhosis in hepatitis C virus (HCV)-monoinfected patients. However, this procedure has been insufficiently validated in patients with human immunodeficiency virus (HIV) and HCV coinfection. The purpose of this study was to validate reported cutoff values of TE that discriminate significant liver fibrosis and cirrhosis in HIV-HCV-coinfected subjects.

METHODS

Liver stiffness measurements were obtained for 169 HIV-HCV-coinfected adult patients who had undergone a liver biopsy or who had received a nonhistologic diagnosis of cirrhosis within 12 months before or after a liver stiffness measurement. Patients had received no prior therapy for HCV infection.

RESULTS

TE measurements ranged from 3.6 kPa to 75 kPa. The area under the receiver operating characteristic curve was 0.87 (95% confidence interval, 0.84-0.93) for significant liver fibrosis and 0.95 (95% confidence interval, 0.92-0.99) for cirrhosis. To diagnose significant liver fibrosis, a cutoff value of 7.2 kPa was associated with a positive predictive value of 88% and a negative predictive value of 75%. Thirty-four patients (20%) were misclassified when this cutoff value was used. Thirteen (24%) of 54 patients with liver stiffness values <7.2 kPa had significant liver fibrosis detected by liver biopsy. To diagnose cirrhosis, a cutoff value of 14.6 kPa was associated with a positive predictive value of 86% and a negative predictive value of 94%. Thus, 13 patients (10%) had disease that was misclassified using this cutoff value.

CONCLUSIONS

We found that the diagnostic accuracy of TE was high for detecting cirrhosis and good for diagnosis of significant liver fibrosis. However, the performance of TE was low for discriminating mild fibrosis from significant liver fibrosis, which might limit the applicability of this technique in clinical practice.

Constipation: evaluation and treatment of colonic and anorectal motility disorders

This article focuses on the colonic and anorectal motility disturbances that are associated with chronic constipation and their management. Functional chronic constipation consists of three overlapping subtypes: slow transit constipation, dyssynergic defecation, and irritable bowel syndrome with constipation. The Rome criteria may serve as a useful guide for making a clinical diagnosis of functional constipation. Today, an evidence-based approach can be used to treat patients with chronic constipation. The availability of specific drugs for the treatment of chronic constipation, such as tegaserod and lubiprostone, has enhanced the therapeutic armamentarium for managing these patients. Randomized controlled trials have also established the efficacy of biofeedback therapy in the treatment of dyssynergic defecation.

[Evaluation of diagnostic scales for appendicitis in patients with lower abdominal pain]

INTRODUCTION

Diagnosis of apendicitis is difficult; however several clinical scales have been developed that attempt to improve diagnostic accuracy.

OBJECTIVE

The operational characteristics of Alvarado and Fenyö scales were defined in patients with abdominal pain suggestive of appendicitis and were compare with clinical and pathological diagnoses.

MATERIAL AND METHODS

A prospective trial assessed the diagnostic tests. Sign, symptoms, and laboratory tests were included in scales selected. Surgeon decision was maintained independent from the results of the scales. Sensitivity, specificity, positive and negative predictive value and positive and negative likelihood ratio for each scale was compared with the surgeon evaluation.

RESULTS

The sample included 374 patients with approximately equal sexes. Of these 269 patients underwent surgery. Howeve, 16.9% of the male and 31.4% of female patients did not have appendicitis. For men, a diagnosis made by the surgeon had better sensitivity than scales (86.2% vs. 73% for Alvarado and 67.2% for Fenyö) without significant differences in specificity. For women, surgeon and Alvarado scale diagnoses were similar, and better than Fenyö scale (77.1% vs. 79.5% for Alvarado and 47% for Fenyö), but specificity was higher for Fenyö scale (92.9% vs. 71.4% for Alvarado and 75.9% for surgeon). Accuracy in diagnosis of appendicitis increases with a higher Alvarado score.

CONCLUSION

For men with abdominal pain on right lower quadrant, surgeon diagnosis is more accurate than scales. For women, Fenyö scale offers a better sensitivity. Alvarado score can facilitate decision-making in patients with these abdominal symptoms.

Normative values of the balloon expulsion test in healthy adults

BACKGROUND/AIMS

Constipation is the most frequent complaint of the digestive tract. It has been reported that approximately half of the patients with constipation have functional defecation disorders (dyssynergic defecation). An important diagnostic tool for the diagnosis of functional defecation disorders is the balloon expulsion test. Normative values have not been widely determined in different populations. We aimed to determine the data which could be indicative of normative values of the balloon expulsion test for healthy individuals in our society.

METHODS

A total of 116 healthy volunteers were evaluated in the study (55 men). Subjects were classified into three subgroups according to age (20-39 yrs, 40-59 yrs, > or = 60 yrs). Catheters with balloon and application room were standardized, and then a balloon expulsion test was performed in all groups. The results of the balloon expulsion test were statistically compared between groups.

RESULTS

The distribution of males/females according to age groups was: 20-39 yrs: 20/22, 40-59 yrs: 20/23, > or = 60 yrs: 15/16. The balloon expulsion time was determined as 44.1+/-19.0 seconds in male subjects and 56.4+/-21.4 seconds in females (p=0.001). An increase in the balloon expulsion time was observed to be related with age in males (p=0.00001); however, no statistically significant difference was shown by age in female subjects (p=0.80). If the entire study group was considered, there was a significant correlation between age and balloon expulsion time (p=0.0001).

CONCLUSIONS

The balloon expulsion test is a simple procedure to identify impaired evacuation in constipated patients. This study represents the first assessment of the balloon expulsion test in a healthy Turkish population. It has been demonstrated that expulsion should take less than 30 seconds for men younger than 40 years of age and less than 1 minute above 40 years. For women, expulsion should occur in 1 minute regardless of age. Our results could serve as a valuable resource of normative data.

Medex test, a novel modality for liver disease diagnosis: a pilot study

BACKGROUND AND AIMS

Liver diseases are associated with significant morbidity and health- related expenditure. Although cost-effective treatments are available, the disease is often asymptomatic until late in its course. "Medex Test," is the noninvasive detection of liver abnormalities by the measurement of changes in electrical impedance of dermal zones. This method is based on neuroreflexology, a branch of complementary medicine. This study addressed 2 questions: can Medex Test detect liver disease, and can it measure the severity of a known liver disease.

METHODS

This blinded case-control study included 2 parts. First, 113 patients with a known liver disease (hepatitis C, hepatitis B, and nonalcoholic fatty liver disease) and 85 controls with no known liver disease were evaluated by the Medex Test device. Second, necroinflammatory grading of biopsy results of 60 patients with chronic hepatitis C were compared with grade determined by Medex Test.

RESULTS

Medex Test detected with high sensitivity (85%) and specificity (94.1%) the presence of liver disorders. The high rates were similar for the different disorders and were independent of age and sex. Additionally, Medex Test matched the biopsy pathologic grading of necroinflammation in 78% of patients. Positive predictive value was not affected by age and sex and was better for higher degree of necroinflammation.

CONCLUSIONS

This pilot study demonstrated that Medex Test detects with high accuracy the presence of liver disorders and the necroinflammatory grade. This noninvasive, low cost test may in the future become an important tool in the diagnosis and management of liver disorders. We believe the further study of this novel method is warranted.

Gastro-oesophageal reflux disease: oesophageal impedance versus pH monitoring

Gastro-oesophageal reflux occurs frequently during the first months of life. Infants receive frequent milk feeds, and because milk is a potent buffer of gastric acidity, oesophageal impedance should detect more reflux than pH recording. Indeed, impedance has the advantage over pH monitoring of being independent of pH, and as a consequence, of being better adapted to measure reflux during postprandial periods when reflux is buffered and to detect symptoms associated with non-acid or weakly acid reflux episodes. Numerous episodes are detected by one of these techniques (pH monitoring or impedance) in children. Most studies using the impedance technique consider very small numbers of patients, and there are few reports linking data from diagnostic impedance procedures to clinical outcome in symptomatic patients. Data suggesting that impedance does offer a clear-cut benefit in paediatric clinical practice are missing. The high cost of the material and the investment in time necessary for interpretation of the recording, remains a handicap. It is mandatory, despite ethical difficulties, to obtain normal ranges for intraluminal impedance monitoring.

CONCLUSION

As pH monitoring is part of impedance technology, it is likely that the latter will replace pH monitoring despite the current lack of scientific evidence demonstrating a relation between symptoms, oesophageal damage or response to reflux treatment and impedance-pH results.

[Bernstein test]

It is almost 50 years ago, when L.M. Bernstein and L.A. Baker wrote a paper on esophageal pain created by intra-luminal acid infusion. Their main purpose was to distinguish the chest pain due to esophagitis from cardiac pain. As former experiments had failed to show the direct roll of acid on chest pain, esophageal pain observed in esophagitis patients had been thought to be the result of esophageal wall extension. Bernstein showed that acid itself could cause chest pains in not only endoscopically positive esophagitis patients but also in pseudoesophagitis patients as Bernstein called. The simple and effective method he developed during his trial was called as Bernstein test with respect. Nowadays, more than half of the patients who suffer GERD symptoms are diagnosed as non-erosive reflux disease (NERD). Effective management of NERD is one of the most anticipated fields in the clinical upper GI treatment, and for that purpose, selecting the group of patients who are sensitive to acid is especially important. In this paper, I will describe about this Bernstein's "old but up-to-date" original paper in detail and consider its present-day interpretation. It has become obvious recently that acid is not the only cause of the esophageal pain of NERD patients. But, the importance of acid in NERD is still not small. Both as the theoretical basis of acid induced esophageal pain and as clinical method of measuring acid sensitivity in esophagus, Bernstein test should be recalled frequently and improved further.

Constipation in Long-Term Care

Constipation is more common in older adults and accounts for increased physician office visits and hospital admissions. There is lack of agreement on the definition of constipation regarding what patients perceive as constipation and what physicians traditionally see as constipation. Constipation is related to multiple factors, and when left untreated or not properly treated, results in complications, such as impaction, even perforation and death. Laxative use increases with age and at times multiple agents are used to relieve symptoms of constipation. Currently the most commonly used laxative is stool softener but it lacks efficacy. From the review of literature, osmotic laxatives are effective in older adults and well tolerated. Psyllium, a bulk laxative, is also effective in the treatment of constipation, while there is limited evidence for stimulants, dioctyl sulfosuccinate, and other bulk laxatives such as calcium polycarbophil and methylcellulose. A new drug, lubiprostone, is a type 2-chloride channel activator and is shown to be effective, safe, and well tolerated in older adults treated for chronic constipation in studies up to a year. It appears to be particularly useful in persons who have recurrent fecal impaction and in those with severe chronic constipation. There is a need for a large-scale trial examining an appropriate cost-effective approach to the management of constipation in the nursing home.

[Esophageal pH monitoring]

According to westernization of dairy life-style and aging, gastroesophageal reflux disease (GERD) with its physical symptoms such as heartburn is increasing in Japan. Although typical GERD has reflux esophagitis, GERD patients without abnormal endoscopic findings called non-erosive GERD (NERD) have been paid great attention. And more, the association between GERD and chronic respiratory diseases or laryngeal disease has been reported. To catch the more information about clinical questionnaire of GERD cases, esophageal pH monitoring is a useful method because of evaluating the direct condition of acid exposure of esophagus. Recently the new wireless pH monitoring system have been developed, this system is less stress than conventional method and has performance of pH recording for continuous 48 hours time. The widespread usage of pH monitoring system is expected to give us the new knowledge of GERD, NERD and GERD associated diseases.

Non-invasive measurement of liver fibrosis: application of the FibroScan in hepatology

The liver biopsy is still regarded as the gold standard for the assessment of liver disease. However, there is a growing demand for non-invasive assessment of liver fibrosis, which is the most important prognostic factor in chronic liver disease, in particular in viral hepatitis. Transient elastography is a novel, non-invasive and rapid bedside method for assessing liver fibrosis by measuring liver stiffness. Some recent extensive studies, mainly from France, have demonstrated that measurement with the FibroScan is a good alternative for the liver biopsy. The amount of fibrosis can be quantified very easily and reliably. In this review, we describe the technique and discuss the available studies in order to establish applicability and to provide points for discussion.