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Vakil N. Developments in Gastroesophageal Reflux Disease over the Last 40 Years. Dig Dis 2023; 42:127-136. [PMID: 37778332 DOI: 10.1159/000533901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 08/28/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND The last 40 years have seen a remarkable change in our understanding of reflux disease. SUMMARY These changes encompass disease definition and impact, pathophysiology, diagnostic testing, regulatory oversight of clinical trials, pharmacotherapy, endoscopic, and surgical treatment. We have also seen a number of promising therapies fail. KEY MESSAGES The future holds the promise of further advances. Adaptive artificial intelligence will take over diagnostics in manometry and pH impedance testing and patient-driven outcomes may be changed by interactions with artificial intelligence rather than humans. Changes in chip technology will allow higher resolution chips to be carried on smaller devices making extra-esophageal areas where reflux may play a role more accessible to prolonged observation and testing.
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Affiliation(s)
- Nimish Vakil
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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2
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Lange UG, Moulla Y, Mehdorn M, Tuennemann J, Zabel-Langhennig A, Ouaid A, Dietrich A. Laparoscopic conversion of omega loop gastric bypass to Roux-en-Y gastric bypass for Barrett's esophagus: case report. BMC Surg 2022; 22:273. [PMID: 35836240 PMCID: PMC9284751 DOI: 10.1186/s12893-022-01695-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 06/21/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The number of mini gastric bypass / one anastomosis bypass (MGB-OAGB) procedures in bariatric patients that have been performed world-wide has drastically increased during the past decade. Nevertheless, due to the risk of subsequent biliary reflux and development of ulcer and neoplastic (pre)lesions caused by long-time bile exposure, the procedure is still controversially discussed. In here presented case report, we could endoscopically demonstrate a transformation from reflux oesophagitis to Barrett's metaplasia most likely caused by bile reflux after mini-gastric bypass. To our knowledge, this is a first case study that shows development of Barrett's metaplasia after MGB-OAGB. CASE PRESENTATION We present the case of a 50-year-old female which received a mini-gastric bypass due to morbid obesity (body mass index (BMI) 42.4 kg/m2). Because of history gastroesophageal reflux disease (GERD), a fundoplication had been performed earlier. Preoperative gastroscopy showed reflux esophagitis (Los Angeles classification grade B) with no signs of Barrett's metaplasia. Three months post mini-gastric bypass, the patient complained about severe bile reflux under 40 mg pantoprazole daily. Six months postoperative, Endoscopically Barrett's epithelium was detected and histopathologically confirmed (C1M0 after Prague classification). A conversion into Roux-en-Y gastric bypass was performed. The postoperative course was without complications. In a follow up after 6 months the patient denied reflux and showed no signs of malnutrition. CONCLUSIONS The rapid progress from inflammatory changes of the distal esophagus towards Barrett's metaplasia under bile reflux in our case is most likely a result of previous reflux disease. Nevertheless, bile reflux appears to be a potential decisive factor. Study results regarding presence of bile reflux or development of endoscopically de-novo findings after MGB-OAGB are widely non-conclusive. Long-term prospective studies with regular endoscopic surveillance independent of clinical symptoms are needed.
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Affiliation(s)
- U G Lange
- Clinic for Visceral, Transplant and Thoracic and Vascular Surgery, University Hospital Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany.
| | - Y Moulla
- Clinic for Visceral, Transplant and Thoracic and Vascular Surgery, University Hospital Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - M Mehdorn
- Clinic for Visceral, Transplant and Thoracic and Vascular Surgery, University Hospital Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - J Tuennemann
- Division of Gastroenterology, Department of Internal Medicine, Neurology and Dermatology, University Hospital of Leipzig, Leipzig, Germany
| | - A Zabel-Langhennig
- Division of Gastroenterology, Department of Internal Medicine II, St. Elisabeth Hospital, Leipzig, Germany
| | - A Ouaid
- Division of Gastroenterology, Department of Internal Medicine II, St. Elisabeth Hospital, Leipzig, Germany
| | - A Dietrich
- Clinic for Visceral, Transplant and Thoracic and Vascular Surgery, University Hospital Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
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Fuchs KH, Lee AM, Breithaupt W, Varga G, Babic B, Horgan S. Pathophysiology of gastroesophageal reflux disease-which factors are important? Transl Gastroenterol Hepatol 2021; 6:53. [PMID: 34805575 DOI: 10.21037/tgh.2020.02.12] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 02/10/2020] [Indexed: 12/16/2022] Open
Abstract
Background Pathophysiology of gastroesophageal reflux disease (GERD) shows a multifactorial background. Different anatomical and functional alterations can be determined such as weakness of the lower esophageal sphincter (LES), changes in anatomy by a hiatal hernia (HH), an impaired esophageal motility (IEM), and/or an associated gastric motility problem with either duodeno-gastro-esophageal reflux (DGER) or delayed gastric emptying (DGE). The purpose of this study is to assess a large GERD-patient population to quantitatively determine different pathophysiologic factors contributing to the disease. Methods For this analysis only patients with documented GERD (pathologic esophageal acid exposure) were selected from a prospectively maintained databank. Investigations: history and physical, body mass index, endoscopy, esophageal manometry, 24 h-pH-monitoring, 24 h-bilirbine-monitoring, radiographic-gastric-emptying or scintigraphy, gastrointestinal quality of life index (GIQLI). Results In total, 728 patients (420 males; 308 females) were selected for this analysis. Mean age: 49.9 years; mean BMI: 27.2 kg/m2 (range, 20-45 kg/m2); mean GIQLI of 91 (range: 43-138; normal level: 121); no esophagitis: 30.6%; minor esophagitis (Savary-Miller type 1 or Los Angeles Grade A): 22.4%; esophagitis [2-4]/B-D: 36.2%; Barrett's esophagus 10%. Presence of pathophysiologic factors: HH 95.4%; LES-incompetence 88%, DGER 55%, obesity 25.6%, IEM 8.8%, DGE 6.8%. Conclusions In our evaluation of GERD patients, the most important pathophysiologic components are anatomical alterations (HH), LES-incompetence and DGER.
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Affiliation(s)
- Karl-Hermann Fuchs
- Department of Surgery, Center for the Future of Surgery, University of California San Diego, La Jolla, CA, USA
| | - Arielle M Lee
- Department of Surgery, Center for the Future of Surgery, University of California San Diego, La Jolla, CA, USA
| | - Wolfram Breithaupt
- AGAPLESION Markus Krankenhaus, Klinik für Allgemeine und Viszeralchirurgie, Frankfurt am Main, Germany
| | - Gabor Varga
- AGAPLESION Markus Krankenhaus, Klinik für Allgemeine und Viszeralchirurgie, Frankfurt am Main, Germany
| | - Benjamin Babic
- Klinik und Poliklinik für Allgemeine-, Viszeral- und Tumorchirurgie, Universitätskliniken Köln, Cologne, Germany
| | - Santiago Horgan
- Department of Surgery, Center for the Future of Surgery, University of California San Diego, La Jolla, CA, USA
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Fuchs KH, DeMeester TR, Otte F, Broderick RC, Breithaupt W, Varga G, Musial F. Severity of GERD and disease progression. Dis Esophagus 2021; 34:6133416. [PMID: 33575739 DOI: 10.1093/dote/doab006] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 12/01/2020] [Accepted: 01/12/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Many factors may play a role in the severity and progression of gastroesophageal reflux disease (GERD) since pathophysiology is multifactorial. Data regarding the progression of GERD are controversial: some reports of increased esophageal acid exposure (EAE) and mucosal damage were considered as evidence for a stable disease course, while others interprete these findings as disease progression. The aim of this study is to analyze a large patient-population with persisting symptoms indicative of GERD under protonpumpinhibitor-therapy and identify components characterizing disease severity and progression. METHODS Patients with symptoms indicative of GERD were included in the study in a tertiary referral center (Frankfurt, Germany). All selected patients were under long-term protonpumpinhibitor-therapy with persistant symptoms. All patients underwent investigations to collect data on their physical status, EAE, severity of esophagitis, anatomical changes, and esophageal functional defects as well as their relation to the duration of the disease. Incidence over time was plotted as survival curves and tested with Log-rank tests for the four main disease markers. Multivariate modeling with COX-regression model was used to estimate the general impact of the four main disease markers on the time course of the disease. In order to elucidate possible causal relationships over time, a path analysis (structural equation model) was calculated. RESULTS From the database with 1480 data sets, 972 patients were evaluated (542 males, 430 females). The mean age was 50.5 years (range18-89). The mean body mass index was 27.2(19-48). The mean time between the onset of symptoms and the diagnostic investigations was 8.2 years (1-50). A longer disease history for GERD was significantly associated with a higher risk for LES-incompetence. The mean duration from symptom onset to the time of clinical investigation was 9 years for patients with LES-incompetence (n = 563), compared to a mean of 6 years for those with mechanically intact LES (n = 95). A longer period from symptom onset to diagnostics was significantly associated with higher acid exposure. The pathway analysis was significant for the following model: 'history' (P < 0.001➔LES-incompetence & Hiatal Hernia➔(p < 0,001)➔pH-score (P < 0.001).Conclusion: LES-incompetence, the functional deterioration of the LES, and the anatomical alteration at the esophagogastric junction (Hiatal Hernia) as well as an increased EAE were associated with a long history of suffering from GERD. Path modeling suggests a causal sequence overtime of the main disease-parameters, tentatively allowing for a prediction of the course of the disease.
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Affiliation(s)
- K H Fuchs
- University of California San Diego, Department of Surgery, Center for the Future of Surgery, La Jolla, CA, USA
| | - T R DeMeester
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - F Otte
- University of Cologne, Department of General-, Visceral- and Cancer Surgery Cologne, Germany
| | - R C Broderick
- University of California San Diego, Department of Surgery, Center for the Future of Surgery, La Jolla, CA, USA
| | - W Breithaupt
- St. Elisabethen Krankenhaus, Department of General and Visceral Surgery, Frankfurt am Main, Germany
| | - G Varga
- AGAPLESION Markus Krankenhaus, Department of General and Visceral Surgery, Frankfurt am Main, Germany
| | - F Musial
- The National Research Center in Complementary and Alternative Medicine NAFKAM, Department of Community Medicine, UiT, The Artic University of Noeway, Tromsø, Norway
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5
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Braghetto I, Gonzalez P, Lovera C, Figueroa-Giralt M, Piñeres A. Duodenogastric biliary reflux assessed by scintigraphic scan in patients with reflux symptoms after sleeve gastrectomy: preliminary results. Surg Obes Relat Dis 2019; 15:822-826. [PMID: 31182413 DOI: 10.1016/j.soard.2019.03.034] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Accepted: 02/20/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Bile reflux is a factor in the appearance of severe esophagitis and Barrett's esophagus, which have been reported after sleeve gastrectomy (SG). Incompetent lower esophageal sphincter and increased gastroesophageal acid reflux have been demonstrated after this operation. Some reports have shown bile content in the antrum during endoscopic control, but no investigations objectively confirm the presence of duodenogastric bile reflux in these patients. OBJECTIVES To evaluate the presence of duodenogastric bile reflux (DGR) after SG in patients presenting reflux symptoms. SETTING University hospital. METHODS Prospective study of 22 patients presenting reflux symptoms who underwent SG for morbid obesity and who received endoscopic evaluation and scintigraphic study to confirm esophagitis and duodenogastric bile reflux. RESULTS Erosive esophagitis was observed in 11 patients and Barrett's esophagus in 2 patients. Seven patients (31.8%) presented positive DGR. Among them, 3 had type B and C esophagitis. The other 4 patients did not present esophagitis in spite of reflux symptoms. CONCLUSION DGR may be present in patients with gastroesophageal reflux after SG. This line of investigation requires further studies to confirm this hypothesis.
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Affiliation(s)
- Italo Braghetto
- Department of Surgery, Faculty of Medicine, Hospital "José J. Aguirre", University of Chile, Santiago, Chile.
| | - Patricio Gonzalez
- Department of Medicine, Nuclear Medicine Section, Faculty of Medicine, Hospital "José J. Aguirre", University of Chile, Santiago, Chile
| | - Cesar Lovera
- Nuclear Medicine Unit, Avansalud Clinic, Santiago, Chile
| | - Manuel Figueroa-Giralt
- Department of Surgery, Faculty of Medicine, Hospital "José J. Aguirre", University of Chile, Santiago, Chile
| | - Amy Piñeres
- Department of Surgery, Faculty of Medicine, Hospital "José J. Aguirre", University of Chile, Santiago, Chile
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Tomkova M, Tomek J, Kriaucionis S, Schuster-Böckler B. Mutational signature distribution varies with DNA replication timing and strand asymmetry. Genome Biol 2018; 19:129. [PMID: 30201020 PMCID: PMC6130095 DOI: 10.1186/s13059-018-1509-y] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 08/16/2018] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND DNA replication plays an important role in mutagenesis, yet little is known about how it interacts with other mutagenic processes. Here, we use somatic mutation signatures-each representing a mutagenic process-derived from 3056 patients spanning 19 cancer types to quantify the strand asymmetry of mutational signatures around replication origins and between early and late replicating regions. RESULTS We observe that most of the detected mutational signatures are significantly correlated with the timing or direction of DNA replication. The properties of these associations are distinct for different signatures and shed new light on several mutagenic processes. For example, our results suggest that oxidative damage to the nucleotide pool substantially contributes to the mutational landscape of esophageal adenocarcinoma. CONCLUSIONS Together, our results indicate an interaction between DNA replication, the associated damage repair, and most mutagenic processes.
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Affiliation(s)
- Marketa Tomkova
- Ludwig Cancer Research Oxford, University of Oxford, Old Road Campus Research Building, Oxford, OX3 7DQ, UK
| | - Jakub Tomek
- Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, OX1 3PT, UK
| | - Skirmantas Kriaucionis
- Ludwig Cancer Research Oxford, University of Oxford, Old Road Campus Research Building, Oxford, OX3 7DQ, UK
| | - Benjamin Schuster-Böckler
- Ludwig Cancer Research Oxford, University of Oxford, Old Road Campus Research Building, Oxford, OX3 7DQ, UK.
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Soricelli E, Casella G, Baglio G, Maselli R, Ernesti I, Genco A. Lack of correlation between gastroesophageal reflux disease symptoms and esophageal lesions after sleeve gastrectomy. Surg Obes Relat Dis 2018; 14:751-756. [PMID: 29571635 DOI: 10.1016/j.soard.2018.02.008] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 01/12/2018] [Accepted: 02/04/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND The postoperative development or worsening of gastroesophageal reflux disease (GERD) represents the major drawback of laparoscopic sleeve gastrectomy (SG). A GERD diagnosis is often based only on symptoms and proton pump inhibitors (PPI) intake, while objective tests like esophagogastroduodenoscopy and pH measurements are performed less frequently. OBJECTIVES To evaluate the association between reflux symptoms and GERD-related esophageal lesions. SETTINGS University hospital, Rome, Italy. METHODS A comprehensive clinical control entailing GERD symptoms, PPI intake, and esophagogastroduodenoscopy was proposed to all patients who underwent SG between June 2007 and February 2011, irrespective of the presence of GERD symptoms. One hundred forty-four of 219 patients agreed to take part in the study (follow-up rate: 65.8%). RESULTS After a mean follow-up of 66 months, GERD symptoms and PPI intake were recorded in 70.2% and 63.9% of patients, respectively. Mean visual analogue scale score was 2.9 ± 3.3. The overall frequency of erosive esophagitis was 59.8%, while nondysplastic Barrett's esophagus was detected in 13.1%. The frequency of esophageal biliary reflux was 68%. GERD symptoms and visual analogue scale score were not significantly associated with the development of erosive esophagitis and Barrett's esophagus and the severity of the esophageal lesions. Moreover, the frequency of erosive esophagitis and Barrett's esophagus in patients consuming PPI were similar to that of patients without PPI. CONCLUSION Symptoms investigation alone is not a reliable tool to diagnose GERD after SG. The use of objective diagnostic tests, such as esophagogastroduodenoscopy, should be carefully considered in the postoperative follow-up schedule of SG patients.
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Affiliation(s)
- Emanuele Soricelli
- Department of Surgical Sciences, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy.
| | - Giovanni Casella
- Department of Surgical Sciences, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | | | - Roberta Maselli
- Endoscopic unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Ilaria Ernesti
- Department of Experimental Medicine-Medical Physiopathology, Food Science and Endocrinology Section, Sapienza University of Rome, Rome, Italy
| | - Alfredo Genco
- Department of Surgical Sciences, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
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Gronnier C, Bruyère E, Lahdaoui F, Jonckheere N, Perrais M, Leteurtre E, Piessen G, Mariette C, Van Seuningen I. The MUC1 mucin regulates the tumorigenic properties of human esophageal adenocarcinomatous cells. BIOCHIMICA ET BIOPHYSICA ACTA-MOLECULAR CELL RESEARCH 2014; 1843:2432-7. [PMID: 25003315 DOI: 10.1016/j.bbamcr.2014.06.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 06/19/2014] [Accepted: 06/27/2014] [Indexed: 02/07/2023]
Abstract
MUC1 is a membrane-bound mucin known to participate in tumor proliferation. It has been shown that MUC1 pattern of expression is modified during esophageal carcinogenesis, with a progressive increase from metaplasia to adenocarcinoma. The principal cause of development of esophageal adenocarcinoma is gastro-esophageal reflux and MUC1 was previously shown to be up-regulated by several bile acids present in reflux. In this report, our aim was thus to determine whether MUC1 plays a role in biological properties of human esophageal cancer cells. For that, a stable MUC1-deficient esophageal cancer cell line was established using a shRNA approach. In vitro (proliferation, migration and invasion) and in vivo (tumor growth following subcutaneous xenografts in SCID mice) biological properties of MUC1-deficient cells were analyzed. Our results show that esophageal cancer cells lacking MUC1 were less proliferative and had decreased migration and invasion properties. These alterations were accompanied by a decreased activity of NFKB p65, Akt and MAPK (p44/42, JNK and p38) pathways. MCM6 and TSG101 tumor-associated markers were also decreased. Subcutaneous xenografts showed a significant decrease in tumor size when cells did not express MUC1. Altogether, the data indicate that MUC1 plays a key role in proliferative, migrating and invasive properties of esophageal cancer cells as well as in tumor growth promotion. MUC1 mucin appears thus as a good therapeutic target to slow down esophageal tumor progression.
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Affiliation(s)
- Caroline Gronnier
- Inserm, UMR837, Jean-Pierre Aubert Research Center, Team 5 "Mucins, Epithelial Differentiation and Carcinogenesis", Lille, France; Université Lille-Nord de France, Lille, France; Department of Digestive and Oncological Surgery, University Hospital Claude Huriez, Lille, France
| | - Emilie Bruyère
- Inserm, UMR837, Jean-Pierre Aubert Research Center, Team 5 "Mucins, Epithelial Differentiation and Carcinogenesis", Lille, France; Université Lille-Nord de France, Lille, France; Department of Digestive and Oncological Surgery, University Hospital Claude Huriez, Lille, France
| | - Fatima Lahdaoui
- Inserm, UMR837, Jean-Pierre Aubert Research Center, Team 5 "Mucins, Epithelial Differentiation and Carcinogenesis", Lille, France; Université Lille-Nord de France, Lille, France; Department of Digestive and Oncological Surgery, University Hospital Claude Huriez, Lille, France
| | - Nicolas Jonckheere
- Inserm, UMR837, Jean-Pierre Aubert Research Center, Team 5 "Mucins, Epithelial Differentiation and Carcinogenesis", Lille, France; Université Lille-Nord de France, Lille, France
| | - Michaël Perrais
- Inserm, UMR837, Jean-Pierre Aubert Research Center, Team 5 "Mucins, Epithelial Differentiation and Carcinogenesis", Lille, France; Université Lille-Nord de France, Lille, France
| | - Emmanuelle Leteurtre
- Inserm, UMR837, Jean-Pierre Aubert Research Center, Team 5 "Mucins, Epithelial Differentiation and Carcinogenesis", Lille, France; Université Lille-Nord de France, Lille, France; Centre de Biologie-Pathologie, Department of Pathology, Centre Hospitalier Régional et Universitaire, Lille, France
| | - Guillaume Piessen
- Inserm, UMR837, Jean-Pierre Aubert Research Center, Team 5 "Mucins, Epithelial Differentiation and Carcinogenesis", Lille, France; Université Lille-Nord de France, Lille, France; Department of Digestive and Oncological Surgery, University Hospital Claude Huriez, Lille, France
| | - Christophe Mariette
- Inserm, UMR837, Jean-Pierre Aubert Research Center, Team 5 "Mucins, Epithelial Differentiation and Carcinogenesis", Lille, France; Université Lille-Nord de France, Lille, France; Department of Digestive and Oncological Surgery, University Hospital Claude Huriez, Lille, France
| | - Isabelle Van Seuningen
- Inserm, UMR837, Jean-Pierre Aubert Research Center, Team 5 "Mucins, Epithelial Differentiation and Carcinogenesis", Lille, France; Université Lille-Nord de France, Lille, France.
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Huang L, Xu AM, Li TJ, Han WX, Xu J. Should peri-gastrectomy gastric acidity be our focus among gastric cancer patients? World J Gastroenterol 2014; 20:6981-6988. [PMID: 24944492 PMCID: PMC4051941 DOI: 10.3748/wjg.v20.i22.6981] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Accepted: 03/19/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the necessity and correctness of acid suppression pre- and post-gastrectomy among gastric carcinoma (GC) patients.
METHODS: From June 2011 to April 2013, 99 patients who were diagnosed with GC or adenocarcinoma of the gastroesophageal junction (type II or III) and needed surgical management were enrolled. They all underwent gastrectomy by the same operators [35 undergoing total gastrectomy (TG) plus Roux-en-Y reconstruction, 34 distal gastrectomy (DG) plus Billroth I reconstruction, and 30 proximal gastrectomy (PG) plus gastroesophagostomy]. We collected and analyzed their gastrointestinal juice and tissues from the pre-operational day to the 5th day post-operation, and 6 mo post-surgery. Gastric pH was detected with a precise acidity meter. Gastric juice contents including potassium, sodium and bicarbonate ions, urea nitrogen, direct and indirect bilirubin, and bile acid were detected using Automatic Biochemical Analyzer. Data regarding tumor size, histological type, tumor penetration and tumor-node-metastasis (TNM) stage were obtained from the pathological records. Reflux symptoms pre- and 6 mo post-gastrectomy were evaluated by reflux disease questionnaire (RDQ) and gastroesophageal reflux disease questionnaire (GERD-Q). SPSS 16.0 was applied to analyze the data.
RESULTS: Before surgery, gastric pH was higher than the threshold of hypoacidity (4.25 ± 1.45 vs 3.5, P = 0.000), and significantly affected by age, tumor size and differentiation grade, and potassium and bicarbonate ions; advanced malignancies were accompanied with higher pH compared with early ones (4.49 ± 1.31 vs 3.66 ± 1.61, P = 0.008). After operation, gastric pH in all groups was of weak-acidity and significantly higher than that pre-gastrectomy; on days 3-5, comparisons of gastric pH were similar between the 3 groups. Six months later, gastric pH was comparable to that on days 3-5; older patients were accompanied with higher total bilirubin level, indicating more serious reflux (r = 0.238, P = 0.018); the TG and PG groups had higher RDQ (TG vs DG: 15.80 ± 5.06 vs 12.26 ± 2.14, P = 0.000; PG vs DG: 15.37 ± 3.49 vs 12.26 ± 2.14, P = 0.000) and GERD-Q scores (TG vs DG: 10.54 ± 3.16 vs 9.15 ± 2.27, P = 0.039; PG vs DG: 11.00 ± 2.07 vs 9.15 ± 2.27, P = 0.001) compared with the DG group; all gastric juice contents except potassium ion significantly rose; reflux symptom was significantly associated with patient’s body mass index, direct and indirect bilirubin, and total bile acid, while pH played no role.
CONCLUSION: Acidity is not an important factor causing unfitness among GC patients. There is no need to further alkalify gastrointestinal juice both pre- and post-gastrectomy.
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10
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EAES recommendations for the management of gastroesophageal reflux disease. Surg Endosc 2014; 28:1753-73. [PMID: 24789125 DOI: 10.1007/s00464-014-3431-z] [Citation(s) in RCA: 109] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 01/08/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) is one of the most frequent benign disorders of the upper gastrointestinal tract. Management of GERD has always been controversial since modern medical therapy is very effective, but laparoscopic fundoplication is one of the few procedures that were quickly adapted to the minimal access technique. The purpose of this project was to analyze the current knowledge on GERD in regard to its pathophysiology, diagnostic assessment, medical therapy, and surgical therapy, and special circumstances such as GERD in children, Barrett's esophagus, and enteroesophageal and duodenogastroesophageal reflux. METHODS The European Association of Endoscopic Surgery (EAES) has tasked a group of experts, based on their clinical and scientific expertise in the field of GERD, to establish current guidelines in a consensus development conference. The expert panel was constituted in May 2012 and met in September 2012 and January 2013, followed by a Delphi process. Critical appraisal of the literature was accomplished. All articles were reviewed and classified according to the hierarchy of level of evidence and summarized in statements and recommendations, which were presented to the scientific community during the EAES yearly conference in a plenary session in Vienna 2013. A second Delphi process followed discussion in the plenary session. RESULTS Recommendations for pathophysiologic and epidemiologic considerations, symptom evaluation, diagnostic workup, medical therapy, and surgical therapy are presented. Diagnostic evaluation and adequate selection of patients are the most important features for success of the current management of GERD. Laparoscopic fundoplication is the most important therapeutic technique for the success of surgical therapy of GERD. CONCLUSIONS Since the background of GERD is multifactorial, the management of this disease requires a complex approach in diagnostic workup as well as for medical and surgical treatment. Laparoscopic fundoplication in well-selected patients is a successful therapeutic option.
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11
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Chen C, Wang Y, Yu J, Zhou Z, Shen L, Chen YQ. Automatic motion analysis system for pyloric flow in ultrasonic videos. IEEE J Biomed Health Inform 2014; 18:130-8. [PMID: 24403410 DOI: 10.1109/jbhi.2013.2272090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Ultrasonography has been widely used to evaluate duodenogastric reflux (DGR). But to the best of our knowledge, no automatic analysis system was developed to realize the quantitative computer-aided analysis. In this paper, we propose a system to perform the automatic detection of DGR in the ultrasonic image sequences by applying the automatic motion analysis. The motion field is estimated based on image velocimetry. Then, an intelligent motion analysis is applied. For the DGR detection, the motion and structural information is combined to analyze the transploric motion of the fluid. In order to test the performance of the proposed system, we designed the experiment with the real and synthetic ultrasonic data. The proposed system achieved a good performance in the DGR detection. The automatic results were accordant with the gold standard in analyzing the fluid motion. The proposed system is supposed to be a promising tool for the study and evaluation of DGR.
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Wang HP, Wang XM, Wang YZ. Significance of ultrasonic measurement of pyloric canal diameter in diagnosis of duodenogastric reflux. Shijie Huaren Xiaohua Zazhi 2013; 21:4014-4018. [DOI: 10.11569/wcjd.v21.i35.4014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the significance of ultrasonic measurement of pyloric tube diameter in the diagnosis of duodenogastric reflux (DGR).
METHODS: Sixty-eight patients diagnosed with duodenogastric reflux by contrast-enhanced ultrasound at our hospital were selected and divided into a high reflux group and a low reflux group on the basis of reflux time and frequency. Thirty subjects without DGR were used controls. All patients were subjected to measurement of pyloric tube diameter to analyze the relationship between pyloric tube diameter and reflux time and frequency. The ROC curve analysis was also performed.
RESULTS: The pyloric tube diameter in both the high reflux and low reflux groups was significantly higher than that in the control group. The pyloric tube diameter was positively correlated with reflux time and frequency (r = 0.822, 0.718). ROC curve analysis revealed that the area under the curve (AUC) of duodenogastric reflux and high reflux was 0.920 and 0.789, respectively.
CONCLUSION: Ultrasonic measurement of pyloric canal diameter is useful for the clinical diagnosis of DGR.
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Chen C, Wang Y, Yu J, Zhou Z, Shen L, Chen Y. Weighted cross-correlation based variational optical flow for gastric flow analysis in ultrasonic videos. Med Phys 2013; 40:052901. [DOI: 10.1118/1.4798978] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Abstract
Barrett's esophagus is a pathologic change of the normal squamous epithelium of the esophagus to specialized columnar metaplasia. Barrett's esophagus is a result of prolonged exposure of the esophagus to gastroduodenal refluxate. Although Barrett's itself is not symptomatic, and, in fact, patients with Barrett's esophagus may be completely asymptomatic, it does identify patients at higher risk of developing esophageal adenocarcinoma. Traditionally, antireflux surgery was reserved for patients with symptoms, because it was believed that antireflux surgery did not eliminate Barrett's esophagus and reduce cancer risk. Rationale for the treatment of Barrett's esophagus beyond treating symptoms of gastroesophageal reflux disease stems from the hope to decrease, if not eliminate, the risk of adenocarcinoma. Treatment options ranged from medical acid suppression without surveillance to resection. Ablation, particularly endoscopic radio-frequency ablation, has become the standard of care for Barrett's esophagus with high-grade dysplasia. It role in nondysplastic or low-grade dysplastic Barrett's is less clear. Combined endoscopic mucosal resection with ablation is effective in nodular high-grade Barrett's esophagus. Resection should be reserved for patients with persistent high-grade dysplasia despite multiple attempts at endoscopic ablation or resection or for patients with evidence of carcinoma.
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Affiliation(s)
- Vic Velanovich
- Division of General Surgery, University of South Florida, Tampa, Florida
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Nasr AO, Dillon MF, Conlon S, Downey P, Chen G, Ireland A, Leen E, Bouchier-Hayes D, Walsh TN. Acid suppression increases rates of Barrett’s esophagus and esophageal injury in the presence of duodenal reflux. Surgery 2012; 151:382-90. [DOI: 10.1016/j.surg.2011.08.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2011] [Accepted: 08/18/2011] [Indexed: 12/14/2022]
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Chen C, Wang Y, Yu J, Zhou Z, Shen L, Chen Y. Tracking pylorus in ultrasonic image sequences with edge-based optical flow. IEEE TRANSACTIONS ON MEDICAL IMAGING 2012; 31:843-855. [PMID: 22262680 DOI: 10.1109/tmi.2012.2183884] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Tracking pylorus in ultrasonic image sequences is an important step in the analysis of duodenogastric reflux (DGR). We propose a joint prediction and segmentation method (JPS) which combines optical flow with active contour to track pylorus. The goal of the proposed method is to improve the pyloric tracking accuracy by taking account of not only the connection information among edge points but also the spatio-temporal information among consecutive frames. The proposed method is compared with other four tracking methods by using both synthetic and real ultrasonic image sequences. Several numerical indexes: Hausdorff distance (HD), average distance (AD), mean edge distance (MED), and edge curvature (EC) have been calculated to evaluate the performance of each method. JPS achieves the minimum distance metrics (HD, AD, and MED) and a smaller EC. The experimental results indicate that JPS gives a better tracking performance than others by the best agreement with the gold curves while keeping the smoothness of the result.
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Affiliation(s)
- Chaojie Chen
- Department of Electronic Engineering, Fudan University, Shanghai 200433, China
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Takahashi Y, Amano Y, Yuki T, Mishima Y, Tamagawa Y, Uno G, Ishimura N, Sato S, Ishihara S, Kinoshita Y. Impact of the composition of gastric reflux bile acids on Barrett's oesophagus. Dig Liver Dis 2011; 43:692-7. [PMID: 21466977 DOI: 10.1016/j.dld.2011.02.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2010] [Revised: 01/28/2011] [Accepted: 02/23/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND The effect of the composition of reflux bile acids, especially the ratio of hydrophobic to hydrophilic ones, on the development of Barrett's oesophagus has not been fully investigated in human studies. AIMS To evaluate the influence of the bile acid composition of gastric juice on Barrett's oesophagus, a prospective study was designed. METHODS Fifty patients with and 100 patients without Barrett's oesophagus were enrolled. For all enrolled patients, gastric juice was collected by the endoscopic procedure for bile acid analysis. The ratio of hydrophobic to hydrophilic bile acids (bile hydrophobicity ratio, BHR) was calculated from 6 kinds of bile acids analysed in gastric juice. The relationship between the ratio and clinico-pathological factors of Barrett's oesophagus was investigated. RESULTS The mean of BHR of patients with Barrett's oesophagus was significantly higher than that of patients without Barrett's oesophagus (0.26 ± 0.05 vs. 0.08 ± 0.02, p<0.05). In multivariate analysis, a high BHR value was a predictor for the presence of Barrett's oesophagus (OR 5.74, p<0.001). In patients with Barrett's oesophagus, the BHR correlated with COX-2 protein expression and with accelerated cellular proliferation. CONCLUSIONS Patients with Barrett's oesophagus had a higher BHR in the gastric juice than those without.
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Affiliation(s)
- Yoshiko Takahashi
- Second Department of Internal Medicine, Shimane University, Faculty of Medicine, Izumo, Japan
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Bruyère E, Jonckheere N, Frénois F, Mariette C, Van Seuningen I. The MUC4 membrane-bound mucin regulates esophageal cancer cell proliferation and migration properties: Implication for S100A4 protein. Biochem Biophys Res Commun 2011; 413:325-9. [DOI: 10.1016/j.bbrc.2011.08.095] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2011] [Accepted: 08/19/2011] [Indexed: 12/24/2022]
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Nassr AO, Gilani SNS, Atie M, Abdelhafiz T, Connolly V, Hickey N, Walsh TN. Does impaired gallbladder function contribute to the development of Barrett's esophagus and esophageal adenocarcinoma? J Gastrointest Surg 2011; 15:908-14. [PMID: 21484485 DOI: 10.1007/s11605-011-1520-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2010] [Accepted: 03/24/2011] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Esophageal adenocarcinoma is aetiologically associated with gastro-esophageal reflux, but the mechanisms responsible for the metaplasia-dysplasia sequence are unknown. Bile components are implicated. Impaired gallbladder function may contribute to duodenogastric reflux (DGR) and harmful GERD. AIMS This study aims to compare gallbladder function in patients with Barrett's esophagus, adenocarcinoma, and controls. METHODS Three groups of patients, all free of gallstone disease, were studied. Group 1: (n = 15) were normal controls. Group 2: (n = 15) were patients with >3-cm-long segment of Barrett's esophagus. Group 3: (n = 15) were patients with esophageal adenocarcinoma. Using real-time ultrasonography unit, gallbladder volume was measured in subjects following a 10-h fast. Ejection fraction was calculated before and after standard liquid meal and compared between the groups. RESULTS The mean percentage reduction in gallbladder volume was 50% at 40 min in the adenocarcinoma group compared with 72.4% in the control group (p < 0.001). At 60 min, gallbladder filling had recommenced in the control group to 64.1% of fasting volume while continuing to empty with further reduction to 63% in the Barrett's group and to 50.6% (p = 0.008) in the adenocarcinoma group. The mean gallbladder ejection fraction decreased progressively from controls to Barrett's to adenocarcinoma and was significantly lower in Barrett's group (60.9%; p = 0.019) and adenocarcinoma group (47.9%; p < 0.001) compared with normal controls (70.9%). CONCLUSION Gallbladder function is progressively impaired in Barrett's esophagus and adenocarcinoma. Gallbladder malfunction increases duodenogastric reflux, exposing the lower esophagus to an altered chemical milieu which, in turn, may have a role in promoting metaplasia-dysplasia-neoplasia sequence in the lower esophageal mucosa.
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Affiliation(s)
- Ayman O Nassr
- Department of Surgery, Academic Centre, Connolly Hospital, Blanchardstown, Dublin 15, Ireland
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Seidl H, Gundling F, Schepp W, Schmidt T, Pehl C. Effect of low-proof alcoholic beverages on duodenogastro-esophageal reflux in health and GERD. Neurogastroenterol Motil 2011; 23:145-50, e29. [PMID: 20939854 DOI: 10.1111/j.1365-2982.2010.01614.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Alcoholic beverages are known to increase acidic gastro-esophageal reflux (GER) and the risk of esophagitis. Moreover, duodenogastro-esophageal reflux (DGER), containing bile acids, was shown to harmfully alter the esophageal mucosa, alone and synergistically with HCl and pepsin. However, studies directly addressing potential effects of different low proof alcoholic beverages on DGER in health and disease are missing. METHODS Bilitec readings for beer and white, rose, and red wine were obtained in vitro from pure and from mixtures with bile. One-hour DGER monitoring and pH-metry were performed in 12 healthy subjects and nine reflux patients with DGER after ingestion of a standardized liquid meal together with 300 mL of water, white wine, and in the volunteers, beer and rose wine. KEY RESULTS Bilitec measurement was found to be feasible in the presence of beer, white wine, and using a threshold of 0.25, rose wine. However, the presence of red wine resulted in extinction values above this threshold. The consumption of all investigated alcoholic beverages, especially of white wine, triggered increased acidic GER, both in healthy participants and patients with reflux disease. In contrast, no relevant DGER was found after intake of alcoholic beverages. CONCLUSIONS & INFERENCES Fiber-optic bilirubin monitoring can be used for DGER monitoring in combination with alcoholic beverages, except with red wine. Low-proof alcoholic beverages are a strong trigger of GER, but not of DGER, both in healthy subjects and patients with reflux disease.
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Affiliation(s)
- H Seidl
- Department of Gastroenterology, Hepatology and Gastroenterological Oncology, Bogenhausen Academic Teaching Hospital, Staedtisches Klinikum Muenchen GmbH, Munich, Germany.
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21
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Sideri AI, Galatos AD, Kazakos GM, Gouletsou PG. Gastro-oesophageal reflux during anaesthesia in the kitten: comparison between use of a laryngeal mask airway or an endotracheal tube. Vet Anaesth Analg 2009; 36:547-54. [DOI: 10.1111/j.1467-2995.2009.00499.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Chen WS, Luo HY, Zhu YR, Zhong LY, Zhou HB, Zhang XJ. Pathological features of primary bile reflux gastritis in adolescents: an analysis of 40 cases. Shijie Huaren Xiaohua Zazhi 2009; 17:2417-2420. [DOI: 10.11569/wcjd.v17.i23.2417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To analyze the pathological features of primary bile reflux gastritis (BRG) in adolescents.
METHODS: Forty adolescents clinically diagnosed with primary BRG by endoscopy and 24-hour gastric pH and bile monitoring were included in the study. Thirty healthy adolescent volunteers were enrolled as controls. Gastric antrum and corpus mucosa biopsy specimens were taken and subjected to routine HE staining and modified Giemsa staining to conduct pathological examination.
RESULTS: Lymphocyte infiltration was mild in BRG adolescents, and grade 2 or less lymphocyte infiltration was noted in 87.5% of patients. Neutrophil infiltration was often concurrent with Helicobacter pylori (H. pylori) infection. Lengthening of gastric pits, trichangiectasia, interstitial edema, mucosal atrophy, intestinal metaplasia and H. pylori infection were observed in 22.5%, 40.0%, 40.0%, 12.5%, 20.0% and 22.5% of patients, respectively. Except intestinal metaplasia and H. pylori infection, the prevalences of other pathological alterations were significantly different between healthy adolescents and BRG adolescents (P < 0.05). Additionally, these pathological alterations were more severe in the antrum than in the corpus.
CONCLUSION: Primary BRG in adolescents shows some features of chemical gastritis and has a tendency to evolve towards mucosal atrophy and intestinal metaplasia.
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Endoscopic endoluminal radiofrequency ablation of Barrett’s esophagus: initial results and lessons learned. Surg Endosc 2009; 23:2175-80. [DOI: 10.1007/s00464-009-0364-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2008] [Revised: 11/24/2008] [Accepted: 01/12/2009] [Indexed: 02/07/2023]
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Prevalence of pathological duodenogastric reflux and the relationship between duodenogastric and duodenogastrooesophageal reflux in chronic gastrooesophageal reflux disease. Eur J Gastroenterol Hepatol 2008; 20:1136-43. [PMID: 18946360 DOI: 10.1097/meg.0b013e32830aba6d] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
UNLABELLED The role of duodenogastric reflux in gastrooesophageal reflux disease is still controversial. AIMS (i) To determine the prevalence of pathological duodenogastric reflux (DGR) in gastrooesophageal reflux disease patients and (ii) to define the relationship between DGR and duodenogastrooesophageal reflux. METHODS We evaluated 92 patients referred for investigation of recurrent reflux symptoms after proton pump inhibitors (PPI) therapy. All the patients filled out symptom questionnaires and underwent endoscopy, oesophageal manometry and combined oesophagogastric pH and bilirubin monitoring. RESULTS Endoscopy divided the 92 patients into four groups (group I: 25 nonoesophagitis patients, group II: 26 patients with grade A-B oesophagitis, group III: 21 patients with grade C-D oesophagitis and group IV: 20 patients with Barrett's oesophagus. Twenty-four of the 92 patients (26%) showed pathological DGR. Abnormal oesophageal bilirubin exposure was observed in 62 of the 92 patients (67.4%). Of the 62 patients with abnormal oesophageal bilimetry, 15 (24.2%) patients simultaneously showed pathological DGR. The gastric bilirubin exposure in patients with abnormal oesophageal, Bilitec tests did not differ from that in patients with normal oesophageal bilimetry (P>0.05). A weak correlation between oesophageal and gastric bilirubin exposure, both expressed as a percentage of time, was found (r=0.28; P<0.01). CONCLUSION Pathological DGR is present in a little more than a quarter of patients with recurrent reflux and dyspeptic symptoms after PPI therapy. Excessive DGR is not a prerequisite for pathological oesophageal exposure to duodenal contents. Gastric bilirubin monitoring may be useful to choose the best surgical treatment for patients with reflux and dyspeptic symptoms refractory to PPI.
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Chen WS, Luo HY, Zhu YR, Zhong LY, Zhou HB, Zhang XJ. Physiological duodenogastric reflux in young healthy adults. Shijie Huaren Xiaohua Zazhi 2008; 16:3451-3453. [DOI: 10.11569/wcjd.v16.i30.3451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the characteristics of physiological duodenogastric reflux (DGR) in young healthy adults, and to study the relationship between DGR and pathologically altered gastric mucosa.
METHODS: Twenty healthy young volunteers received the conventional endoscopy, 24 h dynamic stomach pH and bile reflux monitoring, HE staining routine pathological examination as well as improved chromatin Giemsa line inspection for H. pylori.
RESULTS: Of 20 cases, two subjects had bile reflux, 6 had H. pylori positive tests and the rest showed normal gastric mucosa or mild antral gastritis. No ulceration, erosions, atrophy or intestinal metaplasia were observed in all subjects (including 6 Helicobacter pylori infection) on endoscopic and histological findings. All subjects were found to have bile reflux at variable degrees (gastric bilirubin absorbance >0.14) and total period of bile reflux (abs>0.14) was 12.5% ± 8.8%. Of all bile reflux events, short reflux events (< 5 min) were 62.8 ± 36.0 times, long reflux events(> 5 min) were 5.9 ± 3.8 times, and the longest reflux duration was 53.5.0 ± 50.3 min, reflux time was significantly longer during upright phase than during supine phase (P = 0.017). But the percentages of pH > 4 times (13.91% ± 10.1%) in stomach were not related to the percentages of bile reflux time.
CONCLUSION: Physiological duodenogastric reflux occurs in young healthy adults. Degree or state of gastric bile reflux is individually different. However, the bile reflux doesn't induce gastric mucosal lesions nor affect gastric pH value.
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van Roon AHC, Mayne GC, Wijnhoven BPL, Watson DI, Leong MP, Neijman GE, Michael MZ, McKay AR, Astill D, Hussey DJ. Impact of gastro-esophageal reflux on mucin mRNA expression in the esophageal mucosa. J Gastrointest Surg 2008; 12:1331-40. [PMID: 18452049 DOI: 10.1007/s11605-008-0522-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2008] [Accepted: 03/26/2008] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Changes in the expression of mucin genes in the esophageal mucosa associated with uncomplicated gastro-esophageal reflux disease have not been evaluated even though such changes could be associated with reflux-induced mucosal damage. We therefore sought to identify reflux-induced changes in mucin gene expression using a cell line and biopsies from the esophageal mucosa in patients with and without reflux. METHODS MUC-1, MUC-3, MUC-4, and MUC-5AC gene expressions were investigated in the HET-1A cell line following exposure to acid (pH 4) and/or bile (120 muM of a bile salt milieu), and in esophageal mucosal biopsies from controls, subjects with non-erosive gastro-esophageal reflux, and subjects with reflux associated with ulcerative esophagitis (erosive). The mucosal biopsies were also evaluated for IL-6 mRNA expression (inflammatory marker) and CK-14 mRNA expression (mucosal basal cell layer marker). Gene expression was determined using real-time reverse transcriptase-polymerase chain reaction analysis. RESULTS In the cell line studies, there were differences in mRNA levels for all of the evaluated mucins following treatment with either acid or the acid and bile combination. In the studies which evaluated tissue specimens, IL-6 and CK-14 mRNA levels increased according to degree of reflux pathology. The expression of MUC-1 and MUC-4 in mucosa from patients with erosive reflux was lower than in subjects without reflux and in patients with non-erosive reflux, whereas the expression of MUC-3 and MUC-5AC was increased (although these differences did not reach significance at p < 0.05). When mRNA expression data for tissue samples from all groups were combined, significant correlations were identified between IL-6 vs. CK-14 and IL-6 vs. MUC-3, MUC-3 vs. CK-14 and MUC-3 vs. MUC-5AC, and for MUC-1 vs. MUC-5AC. The correlation between IL-6 and CK-14 was also significant within the control and non-erosive reflux groups. The correlation between IL-6 and MUC-3 was significant within the control and erosive reflux groups, and the correlation between MUC-1 and MUC-5AC was significant within the erosive reflux group. CONCLUSIONS The results of this study suggest that the profile of mucin expression in the esophageal mucosa is influenced by the pH and composition of the gastro-esophageal reflux. Further work should explore the response of these genes to acid and bile reflux, and their role in the etiology of mucosal damage in gastro-esophageal reflux.
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Affiliation(s)
- Aafke H C van Roon
- Department of Surgery, Flinders Medical Centre, Flinders University, Room 3D211, Bedford Park, South Australia, 5042, Australia
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Fein M, Bueter M, Sailer M, Fuchs KH. Effect of cholecystectomy on gastric and esophageal bile reflux in patients with upper gastrointestinal symptoms. Dig Dis Sci 2008; 53:1186-91. [PMID: 17939040 DOI: 10.1007/s10620-007-9989-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2007] [Accepted: 08/15/2007] [Indexed: 12/20/2022]
Abstract
Epidemiologic data have shown that cholecystectomy is associated with a moderately increased risk of esophageal adenocarcinoma. The study objective was to evaluate the role of refluxed bile. A total of 696 patients with upper gastrointestinal symptoms were included in the study, of whom 55 had a history of cholecystectomy (CHE). Bilirubin exposure was measured in percent time above absorbance 0.25 in the stomach and above 0.14 in the esophagus. Total gastric and esophageal bilirubin exposure was similar in both groups. Supine gastric bile reflux was slightly increased after cholecystectomy (30.6 +/- 30.2 vs. CHE: 37.1 +/- 29.5, P < 0.05). In patients with erosive esophagitis or Barrett's esophagus, there were differences in total gastric exposure (24.3 +/- 22.6 vs. CHE: 36.7 +/- 26.8, P < 0.05) but not in esophageal exposure. Cholecystectomy slightly augments bile reflux into the stomach without detectable differences in the esophagus. Therefore, increased esophageal bile reflux following cholecystectomy as a potential cause for the associated cancer risk could not be substantiated.
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Affiliation(s)
- Martin Fein
- Department of Surgery, University of Wuerzburg, Wuerzburg, Germany.
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Burnat G, Rau T, Elshimi E, Hahn EG, Konturek PC. Bile acids induce overexpression of homeobox gene CDX-2 and vascular endothelial growth factor (VEGF) in human Barrett's esophageal mucosa and adenocarcinoma cell line. Scand J Gastroenterol 2007; 42:1460-5. [PMID: 17852856 DOI: 10.1080/00365520701452209] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Barrett's esophagus (BE) is an acquired precancerous condition that develops from mucosal injury incurred after chronic gastroesophageal acid and bile reflux. The mechanism of progression of carcinogenesis in BE is still not fully understood. Recently, the role of bile acids and the homeobox gene transcription factor CDX-2 has been suggested in the pathogenesis of BE. The aims of the present study were 1) to compare the mRNA and protein expression of CDX-2 in biopsies obtained from patients with BE and normal squamous epithelium and 2) to study the effect of two different bile salts, ursodeoxycholic acid (UDCA) and deoxycholic acid (DCA), on the mRNA expression of CDX-2 and vascular endothelial growth factor (VEGF) in Barrett's the adenocarcinoma cell line (OE-33). MATERIAL AND METHODS CDX-2 expression was measured in Barrett's mucosa and normal esophageal mucosa obtained from 15 patients with BE histologically diagnosed by immunohistochemistry, Western blot, and quantitative reverse transcriptase-polymerase chain reaction (RT-PCR). In in vitro experiments, OE-33 cells were incubated with DCA (100 microM) and UDCA (100 microM) in neutral and shortly acidified media (pulse acidification). The expression of CDX-2 and VEGF was assessed by quantitative RT-PCR. RESULTS Both mRNA and protein expression of CDX-2 were significantly up-regulated in Barrett's mucosa as compared to normal esophageal mucosa. In neutral medium, OE-33 cells showed an increase in CDX-2 expression after incubation with DCA or UDCA. After short acidification of the medium, expression of CDX-2 in OE-33 cells was significantly higher than that in cells incubated in neutral pH. The addition of DCA and UDCA did not cause any further alteration in CDX-2 expression. In neutral and acidified medium, VEGF mRNA expression was only significantly up-regulated by DCA, but not by UDCA. CONCLUSIONS Bile acids, especially in acidic medium, increase expression of CDX-2. DCA appears to be a stronger stimulant of the expression of VEGF than UDCA in the Barrett's carcinoma cell line, indicating a stronger carcinogenic potential of this bile salt.
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Affiliation(s)
- Grzegorz Burnat
- First Department of Medicine, University Erlangen-Nuremberg, Erlangen, Germany
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