Gastrointestinal endoscopy (1)

How Effective Is Drinking Natural Mineral Water against Heartburn from Functional Dyspepsia, Gastroesophageal Reflux Disease, or Other Causes? A Systematic Review of Clinical Intervention Studies

BACKGROUND

For centuries, spring and other natural waters have been recommended as external or internal remedies for numerous diseases. For studies that examined the effects of drinking mineral waters against heartburn, gastroesophageal reflux disease (GERD), or functional dyspepsia, a systematic review is lacking.

OBJECTIVES

The main aim of this systematic review was to examine the effects of drinking natural mineral waters on heartburn from various causes by identifying all published intervention studies and critically appraising their methods as well as summarizing their results.

METHODS

We systematically searched the largest medical literature database MEDLINE, further relevant web sources, and gray literature for randomized and nonrandomized trials, with or without control groups, up to September 2021 and no language restrictions. Further inclusion criteria were adult patients with heartburn, drinking cure with natural mineral water as the intervention, compared to no or other interventions (care-as-usual, waiting list). We defined the reduction of heartburn symptoms and duration of disease episodes as primary and quality of life as secondary outcomes. Two reviewers independently carried out the study quality assessments (risk of bias) using the National Institutes of Health-Study Quality Assessment Tools.

RESULTS

Nine trials comprising 393 patients from Italy, Russia, Ukraine, and Germany fulfilled all inclusion criteria. We identified three randomized controlled trials (all with poor methodological quality), plus six before-after (pre/post) intervention studies without a control group. The intervention groups of the three comparative trials seemed to show a stronger reduction of self-reported heartburn symptoms, and duration of heartburn episodes than the respective control groups; however, they all had poor methodological quality.

CONCLUSION

Based on the best available evidence of clinical studies, we cannot recommend or advise against drinking natural mineral waters as a treatment for heartburn. The potential benefits of natural mineral waters that were reported in some studies with a lower evidence level (e.g., lacking a control group) should be verified by good quality randomized clinical trials with adequate comparison groups and longer follow-up periods.

Hintergrund

Seit Jahrhunderten werden Quell- und andere natürliche Wässer als äußerliche oder innerliche Heilmittel für zahlreiche Krankheiten empfohlen. Für Studien, die die Wirkung des Trinkens von Mineralwasser gegen Sodbrennen, gastroösophageale Refluxkrankheit (GERD) oder funktionelle Dyspepsie untersuchten, fehlt eine systematische Übersicht.

Zielsetzung

Das Hauptziel dieser systematischen Übersichtsarbeit war es, die Auswirkungen von Trinkkuren mit natürlichen Mineralwässern auf Sodbrennen verschiedener Ursachen zu untersuchen, indem alle veröffentlichten Interventionsstudien identifiziert und ihre Methoden kritisch bewertet sowie ihre Ergebnisse zusammengefasst wurden.

Methoden

Wir durchsuchten systematisch die größte medizinische Literaturdatenbank MEDLINE, weitere relevante Internetquellen und graue Literatur nach randomisierten und nicht-randomisierten Studien, mit oder ohne Kontrollgruppen, bis September 2021 und ohne sprachliche Einschränkungen. Weitere Einschlusskriterien waren erwachsene Patienten mit Sodbrennen, Trinkkur mit natürlichem Mineralwasser als Intervention, im Vergleich zu keiner oder anderen Interventionen (care-as-usual, Warteliste). Wir definierten die Abnahme der Symptome des Sodbrennens und die Dauer der Krankheitsepisoden als primäre und die Lebensqualität als sekundäre Endpunkte. Zwei Gutachter bewerteten unabhängig voneinander die Qualität der Studien (Verzerrungsrisiko) anhand der National Institutes of Health-Study Quality Assessment Tools.

Ergebnisse

Neun Studien mit 393 Patienten aus Italien, Russland, der Ukraine und Deutschland erfüllten alle Einschlusskriterien. Wir identifizierten drei randomisierte kontrollierte Studien (alle mit schlechter methodischer Qualität) sowie sechs Vorher-Nachher-Studien (Prä-/Post-Studien) ohne Kontrollgruppe. Die Interventionsgruppen der drei randomisierten Vergleichsstudien schienen eine stärkere Verringerung der selbstberichteten Symptome und der Dauer der Episoden des Sodbrennens zu zeigen als die jeweiligen Kontrollgruppen, allerdings waren sie alle von schlechter methodischer Qualität.

Schlussfolgerung

Auf der Grundlage der besten verfügbaren Belege aus klinischen Studien können wir das Trinken natürlicher Mineralwässer zur Behandlung von Sodbrennen weder empfehlen noch davon abraten. Die potenziellen Vorteile natürlicher Mineralwässer, die in einigen Studien mit geringerer Evidenz (z. B. ohne Kontrollgruppe) berichtet wurden, sollten durch qualitativ hochwertige randomisierte klinische Studien mit angemessenen Vergleichsgruppen und längeren Nachbeobachtungszeiträumen überprüft werden.

Comparison Effects of Propofol-Dexmedetomidine versus Propofol-Remifentanil for Endoscopic Ultrasonography: A Prospective Randomized Comparative Trial

Objective. To compare the effects of propofol-dexmedetomidine versus propofol-remifentanil for endoscopic ultrasonography (EUS). Design, Setting, and Participants. A single-center, randomized trial from August 20, 2020 to August 20, 2021, in patients undergoing EUS. Interventions. Propofol-dexmedetomidine (PD) versus propofol-remifentanil (PR). Outcome Measures. The primary outcome was the endoscopist satisfaction level. The secondary outcomes included patient satisfaction, the incidence of adverse events, induction time, and time to achieve postanesthesia discharge score (PADS) ≥9. Methods. Total of 200 patients were enrolled and randomized into PD and PR groups. A bolus dose of 0.5 μg/kg dexmedetomidine was injected intravenously for 5 min. Subsequently, a continuous infusion of 0.5 μg/kg/h for the PD group. Remifentanil was continuously infused at 1.5 μg/kg/h for the PR group. A bolus dose of 1 mg/kg propofol was administered to both groups and then continuously infused. Results. The endoscopist satisfaction level was higher in the PR group than in the PD group ( $P=0.009$ ). Patient satisfaction was not significantly different between the groups ( $P=0.738$ ). No patients required mask ventilation or tracheal intubation in both groups. All patients were relatively hemodynamically stable. The incidence of body movements during the procedure in the PD group was higher than in the PR group ( $P=0.035$ ). The induction time and time taken to achieve PADS ≥9 in the PD group were longer than in the PR group ( $P<0.05$ ). Conclusions. PR sedation can increase the satisfaction level of the endoscopist by providing faster induction time and lower body movement and that of the patient by achieving faster PADS than PD sedation. Trial registration number: http://www.chictr.org.cn (ChiCTR2000034987).

Acupuncture to improve tolerance of diagnostic esophagogastroduodenoscopy in patients without systemic sedation: results of a single-center, double-blinded, randomized controlled trial (DRKS00000164)

Background

Sedation prior to esophagogastroduodenoscopy is widespread and increases patient comfort. However, it demands additional trained personnel, accounts for up to 40 % of total endoscopy costs and impedes rapid hospital discharge. Most patients lose at least one day of work. 98 % of all serious adverse events occurring during esophagogastroduodenoscopy are ascribed to sedation. Acupuncture is reported to be effective as a supportive intervention for gastrointestinal endoscopy, similar to conventional premedication. We investigated whether acupuncture during elective diagnostic esophagogastroduodenoscopy could increase the comfort of patients refusing systemic sedation.

Methods

We performed a single-center, double-blinded, placebo-controlled superiority trial to compare the success rates of elective diagnostic esophagogastroduodenoscopies using real and placebo acupuncture. All patients aged 18 years or older scheduled for elective, diagnostic esophagogastroduodenoscopy who refused systemic sedation were eligible; 354 patients were randomized. The primary endpoint measure was the rate of successful esophagogastroduodenoscopies. The intervention was real or placebo acupuncture before and during esophagogastroduodenoscopy. Successful esophagogastroduodenoscopy was based on a composite score of patient satisfaction with the procedure on a Likert scale as well as quality of examination, as assessed by the examiner.

Results

From February 2010 to July 2012, 678 patients were screened; 354 were included in the study. Baseline characteristics of the two groups showed a similar distribution in all but one parameter: more current smokers were allocated to the placebo group. The intention-to-treat analysis included 177 randomized patients in each group. Endoscopy could successfully be performed in 130 patients (73.5 %) in the real acupuncture group and 129 patients (72.9 %) in the placebo group. Willingness to repeat the procedure under the same conditions was 86.9 % in the real acupuncture group and 87.6 % in the placebo acupuncture group.

Conclusions

Esophagogastroduodenoscopy without sedation is safe and can successfully be performed in two-thirds of patients. Patients planned for elective esophagogastroduodenoscopy without sedation do not benefit from acupuncture of the Sinarteria respondens (Rs) 24 Chengjiang middle line, Pericard (Pc) 6 Neiguan bilateral, or Dickdarm (IC) 4 Hegu bilateral, according to traditional Chinese medicine meridian theory.

Trial registration

DRKS00000164. Registered on 10 December 2009.

Double-blinded, randomized controlled trial comparing real versus placebo acupuncture to improve tolerance of diagnostic esophagogastroduodenoscopy without sedation: a study protocol

Background

Sedation prior to performance of diagnostic esophagogastroduodenoscopy (EGDE) is widespread and increases patient comfort. But 98% of all serious adverse events during EGDEs are ascribed to sedation. The S3 guideline for sedation procedures in gastrointestinal endoscopy published in 2008 in Germany increases patient safety by standardization. These new regulations increase costs because of the need for more personnel and a prolonged discharge procedure after examinations with sedation. Many patients have difficulties to meet the discharge criteria regulated by the S3 guideline, e.g. the call for a second person to escort them home, to resign from driving and working for the rest of the day, resulting in a refusal of sedation. Therefore, we would like to examine if an acupuncture during elective, diagnostic EGDEs could increase the comfort of patients refusing systemic sedation.

Methods/Design

A single-center, double blinded, placebo controlled superiority trial to compare the success rates of elective, diagnostic EGDEs with real and placebo acupuncture. All patients aged 18 years or older scheduled for elective, diagnostic EGDE who refuse a systemic sedation are eligible. 354 patients will be randomized. The primary endpoint is the rate of successful EGDEs with the randomized technique. Intervention: Real or placebo acupuncture before and during EGDE. Duration of study: Approximately 24 months.

Discussion

Organisation/Responsibility The ACUPEND - Trial will be conducted in accordance with the protocol and in compliance with the moral, ethical, and scientific principles governing clinical research as set out in the Declaration of Helsinki (1989) and Good Clinical Practice (GCP). The Interdisciplinary Endoscopy Center (IEZ) of the University Hospital Heidelberg is responsible for design and conduct of the trial, including randomization and documentation of patients' data. Data management and statistical analysis will be performed by the independent Institute for Medical Biometry and Informatics (IMBI) and the Center of Clinical Trials (KSC) at the Department of General, Visceral and Transplantation Surgery, University of Heidelberg.

Trial registration

The trial is registered at Germanctr.de (DRKS00000164) on December 10^th 2009. The first patient was randomized on February 2^nd 2010.

Gastroenterologists utilize the referral for EGD to enhance colon cancer screening more effectively than primary care physicians

BACKGROUND

Colorectal cancer screening rates among patients with upper gastrointestinal symptoms undergoing oesophagogastroduodenoscopy have not been previously established. We hypothesize that gastroenterologists seize this opportunity more frequently than primary care providers.

AIMS

To assess colorectal cancer screening rates at the time of direct access oesophagogastroduodenoscopy and gastrointestinal clinic evaluation for upper gastrointestinal symptoms. To compare rates in the 6 months following the oesophagogastroduodenoscopy in both cohorts of patients.

METHODS

Retrospective review. primary care physician group: direct access oesophagogastroduodenoscopy (n = 247) vs. gastrointestinal group (n = 278). Multivariable regression analysis utilized to assess predictors of screening outcome.

RESULTS

Colorectal cancer screening at the time of referral was 54%. Among the 243 unscreened patients, an additional 29% in the primary care physician group vs. 59% in the gastrointestinal group completed colorectal cancer screening in 6 months of follow-up. Nearly 60% patients evaluated in gastrointestinal clinic for upper symptoms had documented discussion, and 99% of those patients underwent colonoscopy (P < 0.001). Gastrointestinal consultation increased the probability of colorectal cancer screening completion eightfold (95% CI 3.69-18.96).

CONCLUSIONS

At the time of evaluation for upper symptoms, half of patients were not current with colorectal cancer screening recommendations. Referrals for the direct access oesophagogastroduodenoscopy and, more importantly, the gastroenterology consult represent key opportunities for colorectal cancer screening education and improved compliance.

Assessing clinical generalizability in sedation studies of upper GI endoscopy

BACKGROUND

Prior endoscopic studies evaluating conscious sedation have recruited only a small proportion of the patients actually approached. The generalizability of such results to an unselected adult ambulatory care population is thus questionable. The objectives of this study were to determine the characteristics of patients who refused inclusion in a randomized controlled trial of sedation and to compare these characteristics to those of patients who agreed to participate.

METHODS

Patients who refused participation in a randomized controlled trial of sedation completed standardized questionnaires addressing demographic data and possible confounding variables, and they also completed a validated anxiety questionnaire. Characteristics associated with refusal to participate in the randomized controlled trial were assessed by using uni- and multivariate analysis. Exploratory comparisons of outcomes between both groups included self-reported satisfaction with level of comfort and technical adequacy.

RESULTS

Of 302 patients screened, 203 refused to participate in the randomized controlled trial. The most common reason for refusal was the request for no sedation (135/203). A total of 163 were enrolled in this synchronous study. Patients who refused to participate exhibited 3 distinguishing characteristics: prior treatment for an anxiety disorder (risk difference 9.4%: 95% CI[3%, 17%]), use of analgesic medication (risk difference 10.4%: 95% CI[2%, 19%]), and prior experience with EGD (risk difference 17.9: 95% CI[5%, 30%]). Only upper endoscopy experience was predictive of refusal to participate in the randomized controlled trial. No differences in outcomes existed between patients randomized to sedation and those refusing the randomized controlled trial who chose to receive sedative medication. Patients who refused participation in the randomized controlled trial and who underwent upper endoscopy without sedation were more satisfied than patients randomized to placebo (1.33 vs. 2.58; risk difference -1.25: 95% CI[-0.38, -2.1]). Moreover, the procedure in these patients was more adequate technically (4.86 vs. 4.18; risk difference 0.68: 95% CI[0.21, 1.13]).

CONCLUSIONS

Characteristics of patients accepting and refusing randomization were highly similar, differing only with regard to upper endoscopy experience. An exploratory analysis of outcomes suggests that randomized controlled trial results may be biased in a direction that may underestimate the benefits of not administering sedative medication in a real-life setting.

Erythromycin intravenous bolus infusion in acute upper gastrointestinal bleeding: a randomized, controlled, double-blind trial

BACKGROUND & AIMS

Emergency endoscopy may be difficult in upper gastrointestinal bleeding when blood obscures the visibility. Erythromycin, a motilin agonist, induces gastric emptying. We investigated whether an intravenous bolus infusion of erythromycin would improve the yield of endoscopy in these patients.

METHODS

Patients admitted within 12 hours after hematemesis were randomly assigned to erythromycin (250 mg) or placebo, 20 minutes before endoscopy. The primary end point was endoscopic yield, as assessed by objective and subjective scoring systems and endoscopic duration. Secondary end points were the need for a second look, endoscopy-related complications, blood units transfused, and length of hospital stay.

RESULTS

Fifty-one patients received erythromycin and 54 received placebo. A clear stomach was found more often in the erythromycin group (82% vs. 33%; P < 0.001). This difference remained significant in patients with cirrhosis. Erythromycin shortened the endoscopic duration (13.7 vs. 16.4 minutes in the placebo group; P = 0.036) and reduced the need for second-look endoscopy (6 vs. 17 cases; P = 0.018). Length of hospital stay and blood units transfused did not significantly differ between the 2 groups. No complications were noted.

CONCLUSIONS

Erythromycin infusion before endoscopy in patients with recent hematemesis makes endoscopy shorter and easier, thereby reducing the need for a repeat procedure.

Patterns of endoscopy use in the United States

BACKGROUND & AIMS

The aim of this study was to use a large national endoscopic database to determine why routine endoscopy is performed in diverse practice settings.

METHODS

A computerized endoscopic report generator was developed and disseminated to gastrointestinal (GI) specialists in diverse practice settings. After reports were generated, a data file was transmitted electronically to a central databank, where data were merged from multiple sites for analysis.

RESULTS

From April 1, 1997, to October 28, 1998, 276 physicians in 31 practice sites in 21 states provided 18,444 esophagogastroduodenoscopy (EGD) reports, 20,748 colonoscopy reports, and 9767 flexible sigmoidoscopy reports to the central databank. EGD was most commonly performed to evaluate dyspepsia and/or abdominal pain (23.7%), dysphagia (20%), symptoms of gastroesophageal reflux without dysphagia (17%), and suspected upper GI bleeding (16.3%). Colonoscopy was most often performed for surveillance of prior neoplasia (24%) and evaluation of hematochezia (19%) or positive fecal occult blood test (15%). Flexible sigmoidoscopy was most commonly performed for routine screening (40%) and evaluation of hematochezia (22%). There were significant differences between academic and nonacademic sites.

CONCLUSIONS

The endoscopic database can be an important resource for future research in endoscopy by documenting current practice patterns and changes in practice over time.

Office procedures. Esophagogastroduodenoscopy

This article describes diagnostic esophagogastroduodenoscopy and its use by primary care physicians. Included in the discussion are reviews of indications and contraindications, patient preparation (including sedation and monitoring), equipment and supplies needed, pertinent normal anatomy, techniques, and applicable common pathologic findings.

Gallery of medical devices

This article provides an overview of the multitude of medical devices used in patients from head to toe. Simple line drawings show a wide assortment of medical devices. These drawings and the accompanying short descriptions are to be used for quick reference to identify some of the more common medical devices that are certain to appear on everyday radiographs. There is an extensive bibliography for the reader to obtain more detailed information about a particular device or medical apparatus. Knowing the specific name of a device is nearly impossible and is really not necessary, in particular, the eponyms attached to all manner of orthopedic apparatus. Many device names have evolved from their original meaning. What is important is the device's function and the recognition of its presence, as well as an understanding of its use and potential complications.

Endoscopic ethanol injection for treatment of bleeding peptic ulcer

We treated three children aged 10, 11 and 13 years with actively bleeding ulcers using local endoscopic injection of pure ethanol. Ethanol was injected into several sites around a visible vessel with or without bleeding. Haemostasis following ethanol injection therapy was confirmed by endoscopy performed the day after treatment. No rebleeding was observed. There were no complications related to the procedure. Injection therapy is technically simple and inexpensive. Conclusion Our results suggest that endoscopic ethanol injection is safe and may be the treatment of choice for control of bleeding from peptic ulcers in children.

Endoscopic examination of the operated stomach: a review and a systematic approach

The endoscopist examining a patient with a history of gastric surgery is expected to know details of the history, the present physical condition, and relevant laboratory results. Familiarity with the appropriateness or limitations of different types of fiberscopes in relation to the individual case, and knowledge of how to overcome common difficulties, is important. The preparation must address the particular characteristics of the case, and the endoscopist must be aware of contraindications, complications, and recommendations to be observed in special circumstances. Based on situations confronted in daily practice, the authors suggest a systematic approach to the examination of patients with a history of gastric surgery, and point to the importance of observing the following steps: measurement of the length of the greater curvature in the gastric stump, verification of artifacts and anatomic modifications and their repercussions, removal of symptomatic suture line or staples, dilatation of strictures, fragmentation of bezoars, exeresis of polypoid lesions, collection of tissue samples, and regular follow up of the patients.

Interpretation of large intestinal mucosal biopsy specimens

The development of flexible endoscopes has led to a great increase in the examination and mucosal biopsy evaluation of all portions of the large intestine and rectum. Examinations are now performed not only for the determination of diagnosis but also for the monitoring of the course of a wide variety of conditions and for the early detection of complications. This review concentrates on the uses and interpretations of such biopsies in a large number of inflammatory conditions, with special emphasis on the correlations with clinical and functional features. Illustrated are examples of infections, idiopathic inflammatory bowel disease (IBD), vascular disorders, motor and mechanical conditions, toxic and physical reactions, and other inflammatory conditions. Mucosal biopsy specimens also are obtained to identify dysplasia and to evaluate mass lesions, and these subjects are well covered in other articles within this symposium. In patients with chronic disorders multiple examinations are now expected to follow the course of the disease and to detect and correct any complications at an early stage. The exact reasons for the endoscopy and relevant clinical data are essential for the optimal analysis of these mucosal biopsy specimens.

The spread of upper gastrointestinal endoscopy in Japan and the United States. An international comparative analysis of technology diffusion

The use of upper gastrointestinal (GI) fiberoptic endoscopy has spread at different times and rates in Japan than in the United States. Factors that explain this disparity and its effects on patient outcomes are reported. This essay outlines Japanese data in gastroenterology, giving an account of the resources and time that were spent on the development of upper GI endoscopy in Japan. It also draws implications for the assessment of endoscopy for populations at high risk for gastric cancer.

Adaptation and renewal of the gastrointestinal surgeon to meet the continuous challenge of modern gastroenterology

The treatment of gastrointestinal diseases has entered into a period of rapid evolution. Gastroenterology has in the last 50 years evolved into a major specialty, covering not only complex clinical and diagnostic areas, but inclusive of sophisticated investigative work and major therapeutic endoscopic technology. Unfortunately, the evolution of gastrointestinal surgery has lagged behind. The scope of the gastrointestinal surgeon has become more limited, as potent pharmacotherapeutic probes, invasive radiological techniques and diagnostic and therapeutic endoscopic advances have been implemented. The development of minimally invasive surgical techniques has introduced a new era in surgical management. However, the establishment of new training programs and the acquisition of skills requiring the acquisition of costly equipment are major issues which surgical departments need to address. A novel training and programmatic configuration for the group of physicians involved in the management of gastrointestinal disease is required to meet this challenge. In particular, internists and surgeons must focus on the development of cost and time effective strategies for the management of clinical gastrointestinal disease. It seems likely, however, that adequate resources and management of these undertakings will only be forthcoming if corporate establishments, venture capital groups, medical health insurance institutions and national research agencies develop a consortium approach with medical schools to address these issues.