Gastric pacing is a new surgical treatment for gastroparesis

BACKGROUND

Gastroparesis is a chronic gastric motility disorder affecting mostly young and middle-aged women who present with nausea, abdominal pain, early satiety, vomiting, fullness, and bloating.

METHODS

From April 1998 to September 2000, 25 patients underwent gastric pacemaker placement. All had documented delayed gastric emptying by a radionucleotide study. Nineteen patients had diabetic gastroparesis, 3 had developed postsurgical gastroparesis, and 3 had idiopathic gastroparesis. Baseline and postoperative follow-ups were done by a self-administered questionnaire on which the patients rated the severity and frequency of nausea and vomiting. Gastric emptying times were also followed up using a radionucleotide technique.

RESULTS

Both the severity and frequency of nausea and vomiting improved significantly at 3 months and was sustained for 12 months. Gastric emptying time was also numerically faster over the 12-month period. Three of the devices have been removed. One patient died of causes unrelated to the pacemaker 10 months postoperatively.

CONCLUSIONS

After placement of the gastric pacemaker, patients rated significantly fewer symptoms and had a modest acceleration of gastric emptying.

Direct observation of counseling on colorectal cancer in rural primary care practices

To better understand colorectal cancer (CRC) screening practices in primary care, medical students directly observed physician-patient encounters in 38 physician offices. CRC was discussed with 14% of patients >or=50 years of age; 87% of discussions were initiated by the physician. The rate of discussions varied among the practices from 0% to 41% of office visits. Discussions were more common for new patient visits, with younger patients, and in the 24% of offices that utilized flow sheets. The frequency of CRC discussions in physician offices varies widely. More widespread implementation of simple office systems, such as flow sheets, is needed to improve CRC screening rates.

Bile acid malabsorption in persistent diarrhoea

We have investigated bile acid malabsorption (BAM), and its response to treatment, in patients seen in this district general hospital with chronic continuous or recurrent diarrhoea.

METHODS

Seven-day retention of 75-SeHCAT was measured (normal: > 10%).

TREATMENT

Patients were initially given conventional therapy (prednisolone +/- ASA drugs in Crohn's disease, and antidiarrhoeals in the others). If this therapy failed, bile acid sequestrants (BAS) were prescribed. The definition of successful response was based on the patient's perception of sustained improvement.

PATIENTS

The 304 patients were categorised as follows: Group 1: Crohn's disease patients with ileal resection, in clinical remission (n = 37). Group 2: Crohn's disease, unoperated and in clinical remission (n = 44). Group 3: vagotomy and pyloroplasty, with/without cholecystectomy (n = 26). Group 4: diarrhoea predominant 'irritable bowel syndrome' (IBS) (n = 197).

RESULTS

BAM was found in 97% (36/37), 54% (24/44) and 58% (15/26) of patients in groups 1, 2 and 3 respectively. One third (65/197) of patients with IBS had BAM. The outcome of treatment was available in 96 patients with BAM: of the patients with ileal resection 32% responded to antidiarrhoeals, 60% to BAS. Of the unoperated Crohn's patients 55% responded to disease-specific therapy, 40% to BAS. Of the gastric surgery patients 18% responded to conventional treatment, 64% to BAS. Of the IBS patients 15% of responded to conventional therapy, 70% to BAS.

CONCLUSIONS

This observational study indicates that BAM is common in patients with chronic diarrhoea, and is frequently found in IBS. The results of open treatment suggest that, where antidiarrhoeal drugs fail in such patients, BAS are often effective.

Giant gastric ulcer: its natural history and outcome in the H2RA era

OBJECTIVE

The aim of this paper is to study the natural history and outcome of medical treatment of giant gastric ulcer in the histamine H2-receptor antagonist era.

METHODS

All patients with gastric ulcer were prospectively followed. We assessed the special features (in particular, demography and treatment outcome) in patients with giant gastric ulcer, defined as ulcers large enough to occupy at least one wall.

RESULTS

Between 1976 and 1991, 537 patients with gastric ulcer were seen, of whom 129 (24%) had giant gastric ulcer. Giant gastric ulcer patients were significantly older (p < 0.05) than patients with smaller ulcers and had more aggressive disease, reflected by a higher incidence of bleeding, anorexia, weight loss, and emergency admission. More giant gastric ulcers were located in the body of the stomach and a higher proportion looked malignant. Four of 129 patients died immediately (bleed n = 3, unrelated cause n = 1), 15 had urgent surgery (bleed n = 11, perforation n = 2, suspected cancer n = 2) and 110 were treated medically, mainly with cimetidine 1 g daily. Healing occurred in 97 of 110 (88%), including 14 of 15 with refractory disease, i.e., healing took >3 months and/or needed cimetidine 2-3 g daily. Of the remaining 13 patients, six died (from unrelated causes), three had surgery for failed medical treatment, two defaulted, and two were still on treatment (one with refractory ulcer). Refractoriness was more common in patients with associated major medical illness (42% vs 12%, p < 0.01) or with giant gastric ulcers that looked malignant although they were benign (53% vs 21%, p < 0.01). Relapse off treatment was higher (13 of 26) than on maintenance treatment with cimetidine 0.4-2 g daily (14 of 70). Complications occurred in six patients: four off treatment and two on maintenance treatment. Only two giant gastric ulcers finally proved to be malignant. Of the 129 patients, 47 (36%) died, 14 within 3 months (two from bleeding, three postoperatively, nine from unrelated causes) and 33 later (two with gastric cancer and 31 from unrelated causes).

CONCLUSIONS

Giant gastric ulcer is uncommon. Patients are more seriously ill than those with smaller ulcers. Most giant gastric ulcers heal with histamine H2-receptor antagonist treatment. The condition is a marker of poor general health, reflected by the high long term mortality.

Pneumoperitoneum and ascites secondary to bacterial overgrowth

Abdominal bloating, weight loss, pneumoperitoneum, and ascites developed in a 73-year-old woman. She had scleroderma, megajejunum, small bowel dysmotility, and bacterial overgrowth. After treatment with a course of antibiotics, the pneumoperitoneum and ascites resolved, but her symptoms and the pneumoperitoneum recurred after the antibiotics were stopped. She was placed on cyclical antibiotics, and during a 2-year follow-up period she has remained well. The pneumoperitoneum and ascites may have been secondary to small bowel bacterial overgrowth. Ours is the first case that demonstrates this association.

Primary small intestinal adenocarcinoma

Seven patients with adeno-carcinoma of the small intestine were seen over a period of five years. Four were localized to the duodenum, the jejunum was involved in two and the ileum in one. Abdominal pain, weight loss, anemia and obstruction were the most common presenting complaints. Endoscopy was the primary diagnostic modality for the duodenal tumours. Diagnostic accuracy of barium contrast examination was 83%. Curative resections were performed in two patients and palliative surgery in the rest.

The management of refractory gastric ulcer using H2-receptor antagonists

BACKGROUND

There is little information on the natural history of refractory gastric ulcer, defined as non-healing on cimetidine > or = 1 g daily given for at least 3 months.

SETTING

A district general hospital serving an industrial population.

METHODS

Patients with refractory gastric ulcer had their treatment extended and/or the dose increased, and upon healing the majority were put on maintenance treatment with cimetidine 400 mg nightly or 1 g daily and their progress was followed.

RESULTS

Of 536 patients with gastric ulcer, 74 (14%) were refractory. Fifty of the 74 (68%) refractory gastric ulcer patients were refractory on their very first course of cimetidine. They had no distinguishing demographic features. Healing occurred in 62 patients (84%) after a mean treatment period of 11.1 months; 28 patients required cimetidine > or = 2 g daily. Eleven of 23 (48%) patients relapsed on maintenance with cimetidine 400 mg compared with seven of 24 (29%) on 1 g daily. A total of 22 out of 62 (35%) relapsed; nine had a second refractory recurrence but none thereafter. Eleven patients were operated upon, seven for failed medical treatment. Only two patients eventually proved to have malignant disease.

CONCLUSIONS

Refractory gastric ulcer is uncommon, transient and rarely malignant. Most patients can be satisfactorily managed medically.

Benign esophageal strictures in children and adolescents: etiology, clinical profile, and results of endoscopic dilation

BACKGROUND

The problem of dysphagia in children and adolescents differs from that in adults, and therefore requires special consideration.

METHODS

Forty-one consecutive children and adolescents 16 years of age or younger (mean, 7.2 years), with benign esophageal strictures were evaluated in a prospective manner over a 7-year period. The most frequent causes of esophageal strictures were caustic ingestion and complications of endoscopic sclerotherapy of esophageal varices. Dilation was done on a weekly basis using bougies and was considered adequate if the esophageal lumen could be dilated to 15 mm diameter (11 mm in children less than 5 years old) with complete relief of dysphagia.

RESULTS

Of the 30 patients who could be adequately followed after initial dilation, 16 had corrosive strictures and 14 had strictures due to other causes. Patients with corrosive strictures required a significantly higher number of sessions for adequate initial dilation (7.8 +/- 2.5 sessions vs 1.86 +/- 0.48 sessions; p < 0.01). Patients with corrosive strictures had a higher number of mean symptomatic recurrences per patient month as compared to the noncorrosive stricture group (0.15 +/- 0.01 vs 0.087 +/- 0.03, p < 0.01). Six esophageal perforations occurred during a total of 327 dilation sessions (1.8%); there was one fatality.

CONCLUSIONS

From our experience, we conclude that benign esophageal strictures in young patients can be treated effectively and with acceptable safety by means of endoscopic dilation.

Icterus due to tumor emboli--a rare presentation of hepatoma

Two cases of hepatocellular carcinoma presenting with features of obstructive jaundice are reported because of their unusual presentation. Both of them had obstruction of the common bile duct by tumor emboli and underwent palliation with surgical evacuation of the tumor thrombus.

Bile acid malabsorption associated with Graves' disease

A 40-year-old man developed dyspepsia, watery diarrhea, and weight loss. A clinical diagnosis of hyperthyroidism due to Graves' disease was confirmed [free thyroxine, 87 pmol/L (normal range, 8.6-27 pmol/L)]. Bile acid malabsorption was demonstrated by a low 23-selena-25-homocholyltauric acid retention of 7.1% (normal, > 15%). Antithyroid treatment (carbimazole and propranolol) was instituted, and his diarrhea subsided with the control of hyperthyroidism (free thyroxine, 15 pmol/L) along with an improvement of bile acid absorption (Se-HCAT retention, 14.7%). This case very strongly suggests the existence of bile acid malabsorption in hyperthyroidism. The temporal association suggests that the diarrhea may have been due at least in part to bile acid malabsorption, raising the possibility that the latter may be an etiological factor in thyrotoxic diarrhea. We believe this is the first such report.