Clinical impact of esophageal function tests and argon plasma coagulation in heterotopic gastric mucosa of the esophagus and extraesophageal reflux symptoms - a prospective study

BACKGROUND/AIMS

Globus, chronic cough, mucous obstruction and hoarseness are frequently interpreted and classified as manifestation of extraesophageal reflux (EER) or laryngopharyngeal reflux (LPR). Recent studies have indicated that ablation of heterotopic gastric mucosa of the proximal esophagus (HGMPE) by argon plasma coagulation (APC) significantly reduces EER/LPR symptoms.

METHODS

In a prospective study we evaluated 14 patients with HGMPE and EER/LPR symptoms by esophageal function testing (esophageal manometry, combined 24 h-pH-metry-impedance - oropharyngeal-pH measurement), standardized symptom questionnaire (visual analogue scales), and esophagealgastroduodenoscopy (EGD). The patients were stratified into 3 groups: GERD (n = 5), functional heartburn (n = 5) and non-GERD-non-functional heartburn (n = 4). Patients (n = 12) received endoscopic ablation of HGMPE by APC.

RESULTS

73 % of the patients responded to APC with a reduction of frequency and intensity of their EER/LPR symptoms. The response to APC varied between the quality of symptoms and was most frequently seen in globus, swallowing difficulty and mucous obstruction. The magnitude of symptom reduction was highest in heartburn, sore throat, and globus. The response to APC was comparable between the three groups of patients irrespective of GERD and the presence or absence of reflux symptoms. Although 50 % of the patients showed an increased Ryan Score as measured by acid reflux in the posterior oropharynx, comparison between responders and non-responders to APC showed no significant differences with regard to symptom quality, acid and non-acid reflux, LES resting pressure, esophageal motility and Ryan Score.

CONCLUSION

The study indicates that a large proportion of patients with HGMPE and EER/LPR symptoms responded to APC. However, we could not demonstrate a clinical or functional parameter that differentiated between responders and non-responders to APC or could predict the response to APC.

Prospective and randomized study to evaluate the clinical impact of cap assisted colonoscopy (CAC)

BACKGROUND

Although colonoscopy is the standard procedure in the diagnosis of colorectal neoplasia, a significant number of clinical relevant lesions may be missed even by experienced endoscopists using current technology. A transparent cap mounted at the tip of a colonoscope may be an easy way to extend the visual field during colonoscopy and may improve the detection rate of mucosal lesions.

MATERIAL AND METHODS

The significance of cap assisted (CAC) vs. conventional colonoscopy (CC) on polyp detection rate was evaluated in a prospective randomized controlled trial in 504 patients.

RESULTS

CC and CAC detected polyps in 39.3 % and 31.8, not significantly different. There was also no significant difference between CAC and CC according to age, sex, indication for colonoscopy, diverticulosis, sedation, bowel cleansing, withdrawal time, time/number of attempts to intubate the cecal walve, number, localization, size or histology of polyps,. However, the time to reach the cecal floor and the overall time of colonoscopy were significantly lower for CAC (1 minute).

CONCLUSION

CAC was without clinical impact on polyp detection rate or performance of colonoscopy.

[Diagnosis of oesophageal reflux by PH, impedance, and bilirubin measurement: recommendations of the German Society of Neurogastroenterology and of the working group for neurogastroenterology of the German Society for Digestive and Metabolic Diseases]

The current recommendations on indications, technical performance, and interpretation of diagnostic techniques for oesophageal reflux update the German recommandations about 24 hour pH measurement of 2003. The recommendations encompass conventional pH measurement, wireless pH measurement, pH and impedance measurements, and bilirubin measurement (duodenogastro-oesophageal reflux).

Fructose malabsorption: how much fructose can a healthy subject tolerate?

BACKGROUND/AIMS

In a prospective study, we evaluated fructose absorption capacity in 17 healthy female volunteers aged 16-27 years.

METHODS

All volunteers underwent analysis of their daily food intake diary and standardized breath tests. The volunteers were challenged consecutively with oral intake of 50, 25 and 15 g of fructose.

RESULTS

The average daily ingestion of fructose (19.54 ± 14.95 g) was not different between volunteers with positive and negative breath tests. On day 1, 53% of subjects exhibited a significant (≥20 ppm) increase in breath hydrogen and gastrointestinal symptoms upon challenge with 50 g of fructose. Moreover, 37.5% of the volunteers with a negative breath test became positive upon a second challenge with 50 g of fructose but remained asymptomatic. On day 2, 1 of the 9 volunteers (12.5%) with a positive breath test on day 1 exhibited an asymptomatic positive breath test upon exposure to 25 and 15 g of fructose on day 3. The 8 volunteers with a negative test (25 g of fructose) remained negative after a second exposure to 25 g of fructose.

CONCLUSION

The results of this study indicate that hydrogen breath tests with fructose challenge of 50 g of fructose are inappropriate to characterize clinically significant fructose malabsorption.

Krefeld CONTRA study: conventional peroral Esophago-Gastro-Duodenoscopy (EGD) vs. transnasal EGD--a prospective and randomised study with independent evaluation of conscious sedation, endoscope diameter, and access path

BACKGROUND

The guidelines of the German Gastroenterology Society (Deutsche Gesellschaft für Verdauungs- und Stoffwechselkrankheiten, DGVS) demand the presence of an additional qualified person solely responsible for patient monitoring during sedated endoscopy. Transnasal esophagogastroduodenoscopy (EGD) allows easy access to the upper gastrointestinal tract and may avoid the complications induced by conscious sedation and reduce medical costs.

PATIENT AND METHOD

120 patients referred to diagnostic EGD were assigned to six groups: group 1, unsedated peroral EGD with normal-caliber endoscope; group 2, unsedated peroral EGD with small-caliber endoscope; group 3, sedated peroral EGD with normal-caliber endoscope; group 4, sedated peroral EGD with small-caliber endoscope; group 5, unsedated transnasal EGD with small-caliber endoscope; group 6, sedated transnasal EGD with small-caliber endoscope. Outcome parameters included objective (duration, oxygen saturation) and subjective measures (standardised visual analogue scales) of the endoscopy staff (handling, insertion, retroflexion, tolerability, overall assessment) and patients (pain, unpleasantness, sore throat, choking, gagging, meteorism, anxiety, acceptability).

RESULTS

The patients were comparable according to age, sex, anxiety, and respiratory function before EGD. Sedoanalgesia was without effect on EGD handling and duration, patient tolerability and overall assessment by endoscopists and assistants. Negative effects of sedoanalgesia (decreased oxygen saturation, patient acceptability) were much lower and without significance for transnasal compared to peroral EGD. Patient tolerability and acceptability of the endoscopic staff (handling, insertion, retroflexion) were significantly better for the small-caliber endoscope. Duration of unsedated transnasal EGD was slightly but significantly longer, pain, unpleasantness, and anxiety slightly but significantly higher compared to sedated peroral EGD. However, these differences could no loner be detected seven days after endoscopy. Cost analysis revealed major advantage for transnasal EGD.

CONCLUSION

Unsedated transnasal EGD may replace diagnostic peroral EGD, reduces costs with acceptable patient discomfort and has advantagous acceptability of the endoscopic staff.

Empfehlungen zur Anorektalen Manometrie im Erwachsenenalter

This document contains the guidelines of the German Societies of Neurogastroenterology and Motility, Gastroenterology (committee for proctology), Abdominal Surgery (coloproctology working group), and Coloproctology for anorectal manometry in adults. Recommendations are given about technical notes, study preparation (equipment; patient), technique for performing manometry and data analysis, reproducibility, and indications. Minimum standards for anorectal manometry are measurement of resting and squeeze pressure, testing of rectoanal inhibitory reflex, determination of rectal sensation (first perception and urge), and calculation of rectal compliance. Anorectal manometry is indicated in patients with fecal incontinence and constipation in the context of a structured programme.