[Short practice guideline for the management of gastroesophageal reflux disease]

Simultaneous non-invasive measurement of liquid gastric emptying and small bowel transit by combined 13C-acetate and H2-lactulose breath test

The 13C-acetate breath test (13C-ABT) allows noninasive measurement of liquid gastric emptying time (LGET), the H2-lactulose breath (H2-LBT) measures orocecal transit time (OCTT). Because of different test principles, both tests can generally be combined. This would not only spare time and resources but may also deliver additional information on the integrated regulation of gastrointestinal motor functions. Our aim was to define an adequate test protocol and to generate normal values for the combined 13C-ABT/H2-LBT. Twenty two healthy volunteers participated (HV, 12 females, age: 26.5  ±  4.7 years, BMI: 22  ±  2.1 kgm(-2). Fasting subjects received 200 ml of an aequous solution containing 150 mg 13C-acetate and 10 g lactulose. Breath samples for H2 measurements were collected before ingestion of the test solution and afterwards at 5 min intervals for 180 min, for 13C measurements sampling intervals were prolonged to 15 min after the first hour. LGET was defined as time of maximal 13C-exhalation, OCTT as increase in H2 of ⩾ 20 ppm above basal. Small bowel transit time (SBTT) was calculated as the difference between OCTT and LGET. Mean [95% CI] values for LGET, OCTT and SBTT were 26 [23-30] min, 85 [68-102] min and 60 [44-76] min, respectively. Normal values for LGET and OCTT corresponded with published data. SBTT was not correlated with LGET (R2 = 0.019; p = 0.546). By contrast, there was a very tight and highly significant correlation between SBTT and OCTT (R2 = 0.933; p < 0.001). Multivariate linear regression analyses confirmed that age, sex and BMI had no significant effects on OCTT or SBTT while LGET was weakly correlated with BMI (R2 = 0.240; p = 0.021). In conclusion, the combined 13C-ABT/H2-LBT allows simultaneous measurement of LGET and OCTT as well as calculation of SBTT.

Barrett's adenocarcinoma of the esophagus: better outcomes through new methods of diagnosis and treatment

BACKGROUND

Esophageal adenocarcinoma has attracted more attention among gastroenterologists recently because of its rapidly rising incidence in Western countries. Many new epidemiological findings have been published, and there have been numerous technical advances in diagnostic procedures and in multimodal treatment based on the staging of the disease.

METHODS

In this paper, we selectively review the literature on esophageal adenocarcinoma, also considering the evidence-based recommendations contained in the guidelines of the German Society for Digestive and Metabolic Diseases (Deutsche Gesellschaft für Verdauungs- und Stoffwechselkrankheiten, DGVS) as well as the latest data from our own research team.

RESULTS AND CONCLUSION

here have been major recent advances in the diagnosis and treatment of esophageal adenocarcinoma. New refinements in endoscopic techniques now make endoscopic treatment possible for early esophageal carcinoma. New surgical techniques and new strategies of neoadjuvant chemotherapy have lowered the morbidity and improved the outcome of patients with locally advanced disease. Molecular therapies, too, have shown promising initial results.

Follow-up endoscopy in gastroenterology: when is it helpful?

BACKGROUND

The indications for follow-up endoscopy have not been established in all diseases that can be diagnosed by endoscopy.

METHODS

Selective review of the literature and a survey of national guidelines.

RESULTS

In confirmed erosive or non-erosive reflux disease, follow-up endoscopy is indicated only in the presence of complications or Barrett's esophagus. In the case of gastric ulcer or complicated duodenal ulcer, monitoring by endoscopy is mandatory. There is no consensus regarding the indication for follow-up biopsy in confirmed endemic sprue. In an acute episode of confirmed ulcerative colitis, endoscopy is indicated only if the treatment depends on the findings. In confirmed Crohn's disease, this procedure is indicated only in the presence of complications, if the findings are unclear, and before elective intestinal surgery. Those at risk of hereditary colorectal carcinoma without polyposis should undergo colonoscopy annually, starting 5 years before the youngest age of occurrence in their family or at the age of 25 years, whichever comes first.

CONCLUSIONS

With particular reference to further gastrointestinal diseases discussed in the main text, this review unfortunately shows that many of the indications for follow-up endoscopy remain to be ascertained. Controlled studies are needed to establish with sufficient certainty what really helps our patients.

Rule-based standardised switching of drugs at the interface between primary and tertiary care

INTRODUCTION

Changes in drug treatment are frequently mandatory with hospital admission and discharge because hospital drug formularies are generally restricted to about 3000 drugs as compared to the many times this number - 62,000 in Germany - that are commercially available. Without computerised support, the process involved with switching drugs to a corresponding generic or a therapeutic equivalent is time-consuming and error-prone.

METHODS

We have developed and tested a standardised interchange algorithm for subsequent implementation into a computerised decision support system that switches drugs to the corresponding generic or a therapeutic equivalent if they are not listed on the hospital drug formulary.

RESULTS

The algorithm was retrospectively applied to the medication regimens of 120 patients (774 prescribed drugs containing 886 active ingredients) at their time of admission to surgical wards. Of the prescribed drugs, 52.8% (409/774) were part of the hospital drug formulary, thereby rendering a switch unnecessary. The 365 drugs not listed consisted of 392 active ingredients that were successfully switched to a corresponding generic (84.7%) or a therapeutic equivalent (10.2%). No specific switching procedures were defined for only 2.3% (20/886) of the active ingredients. In these cases, the drugs were either discontinued (4/20) or special drug classes, current diseases or co-medication required manual switching (8/20), or the drugs were continued unchanged and ordered from a wholesaler (8/20).

CONCLUSION

Using a standardised interchange algorithm, pre-admission drug regimens can successfully be switched to drugs on a hospital drug formulary. These findings suggest that a computerised decision support system will likely be useful to support this important practice.