Balloon against Jackhammer Disorder

We describe a patient with dysphagia. The results of endoscopy, CT scan and echoendoscopy were normal. High-resolution manometry (HRM) showed esogastric junction dysfunction and hypercontractile peristaltic disorder. These HRM abnormalities completely disappeared after pneumatic esophageal dilatation. We discuss the treatment options and recovery of peristalsis after balloon dilatation.

Prognostic yield of esophageal manometry in chronic intestinal pseudo-obstruction: a retrospective cohort of 116 adult patients

BACKGROUND

Chronic intestinal pseudo-obstruction (CIPO) refers to a wide and heterogeneous group of neuromuscular disorders, which classically involve the small intestine. However, further investigation is required to determine if motility disturbances involve all parts of the gastrointestinal (GI) tract.

METHODS

Medical records and follow-up examinations of 116 adult CIPO patients [70F, median age 28 (0-79) years] were reviewed and performed at our institution since 1980. Manometry (esophageal, small bowel and anorectal) and gastric emptying scintigraphy reports were retrieved and analyzed. Survival, home parenteral nutrition requirement, and the inability to maintain sufficient oral feeding was analyzed using univariate and multivariate analysis.

KEY RESULTS

The median follow-up time was 6 (0.1-30) years. In all, 90% of patients who underwent at least one motility test, with the exception of small bowel manometry, exhibited at least one abnormal pattern. Esophageal manometry was abnormal in 73% of the cases, including 51% with severe ineffective esophageal motility. Anorectal manometry was abnormal in 59% of the cases, including only 17% with severe abnormalities. Gastric emptying was abnormal in 61% of the cases. Only esophageal motor disorders had significant predicting values for survival, home parenteral nutrition requirement, and an inability to maintain sufficient oral feeding.

CONCLUSIONS & INFERENCES

Our study showed that CIPO was associated with a diffuse involvement of all parts of the GI tract and was not restricted to the small intestine in 90% of the cases studied. Esophageal manometry had a significant prognostic yield and should be systematically performed in CIPO patients.

[Haemorrhoidal disease in pregnancy]

External hemorrhoids thrombosis affects 8% of women during last trimester pregnancy and 20% of women immediately after delivery. Their treatment is medical with local treatment (with corticoid and anesthetic), defecation regulation and paracetamol. NSAID can be used after delivery in absence of breath-feeding. Local excision is not possible in most of the cases because of inflammation. Surgery has to be an exception because medical treatment is sufficient in almost all cases. Anal fissure is the most frequent differential diagnosis, encountered in 15% after all deliveries. Symptoms associate anal pain during and after defecation with blood on toilet paper. The only identified risk factor for hemorrhoids thrombosis (and anal fissure) is dyschesia. We have to think about it.

[Dysphagia with no apparent cause]

Dysphagia can be caused by a number of disorders, benign or malignant, that involve either the oropharynx or the esophagus. The cause of dysphagia can be determinated with an accuracy on the basis of a careful history alone in most cases. In patients without endoscopic abnormality, eosinophilic esophagitis must be suspected. Esophageal manometry is especially useful for the diagnosis of achalasia. There are no specific treatment for motility disorders other than achalasia and its variants.

Gastroesophageal reflux in patients with morbid obesity: a role of obstructive sleep apnea syndrome?

BACKGROUND

Obesity is a risk factor for gastroesophageal reflux disease (GERD) and for obstructive sleep apnea (OSA). Our aim was to evaluate in morbidly obese patients the prevalence of OSA and GERD and their possible relationship.

METHODS

Morbidly obese patients [body mass index (BMI) >40 or >35 kg/m(2) in association with comorbidities] selected for bariatric surgery were prospectively included. Every patient underwent a 24-h pH monitoring, esophageal manometry, and nocturnal polysomnographic recording.

RESULTS

Sixty-eight patients [59 women and 9 men, age 39.1 +/- 11.1 years; BMI 46.5 +/- 6.4 kg/m(2) (mean +/- SD)] were included. Fifty-six percent of patients had an abnormal Demester score, 44% had abnormal time spent at pH <4, and 80.9% had OSA [apnea hypopnea index (AHI) >10] and 39.7% had both conditions. The lower esophageal sphincter (LES) pressure was lower in patients with GERD (11.6 +/- 3.4 vs 13.4 +/- 3.6 mm Hg, respectively; P = 0.039). There was a relationship between AHI and BMI (r = 0.337; P = 0.005). Patients with OSA were older (40.5 +/- 10.9 vs 33.5 +/- 10.4 years; P = 0.039). GERD tended to be more frequent in patients with OSA (49.1% vs 23.1%, respectively; P = 0.089). There was no significant relationship between pH-metric data and AHI in either the 24-h total recording time or the nocturnal recording time. In multivariate analysis, GERD was significantly associated with a low LES pressure (P = 0.031) and with OSA (P = 0.045) but not with gender, age, and BMI.

CONCLUSION

In this population of morbidly obese patients, OSA and GERD were frequent, associated in about 40% of patients. GERD was significantly associated with LES hypotonia and OSA independently of BMI.

Gastro-Esophageal Reflux and Esophageal Motility Disorders in Morbidly Obese Patients before and after Bariatric Surgery

BACKGROUND

Obesity is a predisposing factor to gastro-esophageal reflux disease (GERD), but esophageal function remains poorly studied in morbidly obese patients and could be modified by bariatric surgery.

METHODS

Every morbidly obese patient (BMI > or =40 kg/m2 or > or =35 in association with co-morbidity) was prospectively included with an evaluation of GERD symptoms, endoscopy, 24-hour pH monitoring and esophageal manometry before and after adjustable gastric banding (AGB) or Roux-en-Y gastric bypass (RYGBP).

RESULTS

Before surgery, 100 patients were included (84 F, age 38.4 +/- 10.9 years, BMI 45.1 +/- 6.02 kg/m2), of whom 73% reported GERD symptoms. Endoscopy evidenced hiatus hernia in 39.4% and esophagitis in 6.4%. The DeMeester score was pathological in 53.3%; 69% of patients had lower esophageal sphincter (LES) pressure <15 mmHg and 7 had esophageal dyskinesia. BMI was significantly related to the DeMeester score (P = 0.018) but not to LES tone or esophageal dyskinesia. Postoperative data were available in 27 patients (AGB n = 12/60, RYGBP n = 15/36). The DeMeester score (normal < 14.72) was significantly decreased after RYGBP (24.8 +/- 13.7 before vs. 5.8 +/- 4.9 after; P < 0.001) but tended to increase after AGB (11.5 +/- 5.1 before vs. 51.7 +/- 70.7 after; P = 0.09), with severe dyskinesia in 2 cases.

CONCLUSION

GERD and LES incompetence are highly prevalent in morbidly obese patients. Preliminary postoperative data show different effects of RYGBP and AGB on esophageal function, with worsening of pH-metric data with occasional severe dyskinesia after AGB.

Is Esophageal Dysmotility after Laparoscopic Adjustable Gastric Banding Reversible?

Laparoscopic adjustable gastric banding (LAGB) has become an increasingly popular option to treat morbid obesity. Esophageal dysmotility secondary to LAGB has been described, but is usually reversible after removal of the band. Long-term esophageal dysmotility persisting after removal of the band is an unusual and not yet described complication. We report the case of a 58-year-old obese patient who developed severe dysphagia and vomiting associated with atypical esophageal dysmotility 22 months after gastric band placement. Radiological exploration revealed no acute band slippage but only a pseudoachalasia. Device deflation and then band removal were required in an attempt to treat her symptoms. Esophageal dysmotility persisted for several months after band removal and was still present after a Roux-en-Y gastric bypass performed as revisional operation. Possible mechanisms generating this complication and clinical implications are discussed.

An open-label study of rabeprazole in patients with Zollinger-Ellison syndrome or idiopathic gastric acid hypersecretion

BACKGROUND

Omeprazole and lansoprazole are both of proven efficacy in the treatment of Zollinger-Ellison syndrome and idiopathic gastric acid hypersecretion. Rabeprazole, which has a similar mechanism of action, has not previously been studied in these diseases.

AIM

To determine the dose of rabeprazole that decreased basal acid output to safe levels in patients with Zollinger-Ellison syndrome or idiopathic gastric acid hypersecretion.

METHODS

Patients with Zollinger-Ellison syndrome or idiopathic gastric acid hypersecretion were given rabeprazole 60 mg once daily for uncomplicated disease or 40 mg twice daily for complicated disease. Doses were titrated according to response and continued for 2 years. Efficacy was assessed primarily by measuring basal acid output.

RESULTS

All patients had basal acid output before the next dose controlled to <10 mmol/h either at the starting dose or after minor dose titration. Control of acid output was maintained for 2 years. Consistent with this, most patients reported few gastrointestinal symptoms. Gastric biopsy showed no enterochromaffin-like cell dysplasia or neoplasia.

CONCLUSIONS

Rabeprazole was an effective and well-tolerated treatment for Zollinger-Ellison syndrome or idiopathic gastric acid hypersecretion, which reliably reduced gastric acid output to safe levels. Although a dose of 60 mg once daily was appropriate for most patients in this study, doses may need adjustment according to individual response.

Effect of psyllium on gastric emptying, hunger feeling and food intake in normal volunteers: a double blind study

OBJECTIVE

To assess whether psyllium, a soluble dietary fibre, could, at an acceptable dose (7.4 g), delay gastric emptying of a low-calorie meal, and reduce hunger feeling and energy intake, without requiring intimate mixing with the meal.

DESIGN

A double blind randomized cross over study with 14 normal volunteers, to evaluate the effect of this dose of psyllium on postprandial serum glucose, triglycerides and insulin levels, and on gastric fullness, hunger feeling and food intake.

METHODS

Gastric emptying was measured using a standard double-radiolabeled 450 kcal meal and feelings by visual analogic scales. The postprandial serum glucose, triglycerides and insulin levels were also determined.

RESULTS

No delay in the gastric emptying of the solid and liquid phases of the meal was observed with psyllium. After the meal, hunger feelings and energy intake were significantly lower during the psyllium session than during the placebo session (13% and 17% lower respectively; P < 0.05). Postprandial increase in serum glucose, triglycerides and insulin levels was less with psyllium than with placebo (P < 0.05).

CONCLUSIONS

Psyllium reduces hunger feelings and energy intake in normal volunteers at reasonable dose and without requiring mixing with the meal. It does not act by slowing down the gastric emptying of hydrosoluble nutrients, but by increase in the time allowed for intestinal absorption, as suggested by the flattening of the postprandial serum glucose, insulin and triglycerides curves.

Gastro-oesophageal reflux prevalence and relationship with bronchial reactivity in asthma

The relationship between asthma and gastro-oesophageal reflux (GER) is controversial. In an allergy department, GER prevalence was evaluated in asthmatics, with a view to judging the potential influence of GER on asthma. One hundred and five asthmatics were recruited and co-investigated for GER and lung function. Descriptive analysis was performed, patients with (GER+) and without (GER-) GER were then compared, and finally, stepwise regression analysis was used. GER prevalence was 32%. Lung parameters did not differ between GER+ and GER- patients. When restricting analysis to GER+ patients, bronchial reactivity was closely correlated to the number of reflux episodes (NRE) (r=0.983; p=0.001). When comparing patients with more than 15 reflux episodes x day(-1) (n=50), with those having less (n=43), no differences were found in lung function and GER parameters. However, there was a positive correlation between the provocative dose of methacholine causing forced expiration volume to fall 20% from the baseline and NRE in patients with NRE>15 (r=0.561; p=0.05). In conclusion, gastro-oesophageal reflux was observed in a third of the asthma patients studied. These data do not support a firm aetiological relationship between gastro-oesophageal reflux and asthma, but do suggest an association between the number of reflux episodes and bronchial hyperresponsiveness.

[Factors of gastroesophageal acid reflux in severe obesity]

OBJECTIVE

To study in morbid obesity the relationship between the degree of gastro-oesophageal reflux (GER) and the excess of body weight, or the related factors such as the energy intake or the fat distribution (waist-hip ratio).

METHODS

In 20 morbid obese subjects (body weight: 125 +/- 32 kg) consulting in a weight-loss programme, anthropometric measurements, 3-hr oesophageal pHmetry, double isotope labelled meal for studying gastric emptying, study of gastric acid and pepsin secretions using PEG 4,000 as marker, and upper endoscopy were performed.

RESULTS

Nine out of the 20 patients had more than 10 GER per 3-hr period. Seven patients had at least one GER symptom per day. In 6 patients, pH was under 4 for more than 10% of the time. The total number of GER and the number of GER of more than 5 min duration were correlated to the body mass index (P = 0.016 and P < 0.05 respectively). The number of GER was also correlated to the android type of overweight (P < 0.03). These relationships persisted when sex, age, smoking, and obesity complications (such as diabetes) were taken into account. There was a positive correlation between the number of GER and energy and lipid intake (energy intake: 3,119 +/- 1,082 kcal/day; P < 0.003 for both). The degree of GER was positively related to basal acid output (P = 0.049), and to sham feeding-stimulated acid output (P = 0.05); it was negatively related to gastric emptying half time, but was not correlated with basal or stimulated pepsin output. A relationship was found between body mass index (BMI) and gastric emptying half time for solid (P = 0.002) and liquid phases (P = 0.001).

CONCLUSION

GER seems to be common in long lasting morbid obesity. The number of refluxes increased with waist/hip ratio, BMI and energy or fat intake. GER was also increased by decreased gastric emptying rate, which was in part determined by BMI. The real prevalence of GER in morbid obeses must be determined by a large prospective study.

[Female dyschesia, functional associations and pelvic disorders]

OBJECTIVES

Although the usual methods of exploring anorectal disorders give information on specific aspects of defecation, they do not take into account the related effect of disorders involving the pelvic contents including the genital and urinary tract. We therefore used physical examination and global imaging to demonstrate the effect of urinary and genital anomalies in female patients with dyschesia.

METHODS

A prospective study was conducted in 50 consecutive female patients (age range 21-83) who consulted for dyschesia. The following protocol was used. History taking included a search for urinary and gynaecology surgery or medical treatment and the number of pregnancies and instrumental deliveries as well as a precise scoring of defecation disorders. The general physical examination included a search for signs of prolapsus or ulcerations. A rectocolpocystogram was performed in all patients.

RESULTS

There were 7 patients under 40 years of age, 25 from 41 to 61 years and 18 over 61. Urinary incontinence was the most frequent functional complaint (80%). In 92% of the patients, the rectocolpocystogram revealed associated anatomic anomalies. Dynamic stimulation was associated with cervicocystoptosis (72%), hysteroptosis (50%) and rectocele (66%).

CONCLUSION

Female dyschesia is a complex phenomena involving the anatomic status of the urinary, genital and anorectal tracts. Therapeutic management should be based on a complete examination including an evaluation of the pelvic contents and the perineum.

[Role of lower digestive tract endoscopy and biopsy in inflammatory bowel diseases in adults]

The term inflammatory bowel diseases applies to two intestinal diseases (ulcerative colitis and Crohn's disease) localized to the colon. Clinical, morphological and histological data often point to one or the other of these diseases, but they are not always distinguishable, and intermediate forms classified under one name or the other are numerous. Lower digestive tract endoscopy and biopsies are determinant (1) for the diagnosis, as they provide a precise description of the lesions for each segment and evaluate their severity; (2) to monitor the course of the disease under treatment and detect precancerous lesions.

[Tri-annual rhythm of basal acid secretion and secretion stimulated by pentagastrin in duodenal ulcer]

Duodenal ulcer is a recurrent disease with seasonal periodicity for pain and complications such as hemorrhage and perforation. Ulcer craters or symptoms seem to occur preferentially in early spring and autumn. Since acid secretion is one of the pathogenetic factors of the disease, we analyzed retrospectively basal and maximal (pentagastrin) acid secretion data obtained in 341 consecutive patients according to the month in which they were obtained. The patients were classified according to the activity of their ulcer (active, non active) and to the level of the peak acid secretion (hypersecretors, normosecretors). Basal acid concentration and output, and peak acid output were, both overall and month by month, higher in patients with active duodenal ulcer disease than in those who were non active, and in hypersecretors than in normosecretors. For all 341 patients as well as for normosecretors and non active ulcer patients, a triannual rhythm was detected for stimulated acid concentration and peak acid output. The highest values were noted in February, June, and October (period: 4 months). The amplitude of these rhythms was 3 to 4 percent, with differences between highest and lowest values of 30.4 mmol/l for concentration and 17.1 mmol/h for peak acid output. These rhythms for acid secretion during the year may contribute to the periodicity of duodenal ulcer events and should be analyzed in association with other factors which could be implied in ulcerogenesis. Moreover, this seasonal periodicity of acid secretion in duodenal ulcer should be taken into account in all therapeutic trials in which acid secretion is analyzed.

Delayed gastric emptying in anorexia nervosa is improved by completion of a renutrition program

The effects of renutrition on gastric emptying and upper gastrointestinal symptoms were evaluated in 14 anorexia nervosa patients before and after weight gain. A double-isotope technique was used to measure gastric emptying of both the solid and the liquid phases of the meal. Upper gastrointestinal symptoms were frequent before renutrition, occurring in 78% of the patients. Among these symptoms, nausea, vomiting and gastric fullness were correlated well with slowing in gastric emptying of both solid and liquid phases of the meal, which was demonstrated, respectively, in 10 (71%) and nine (64%) of the 14 patients. For the 11 patients who subsequently gained body weight, we observed, without any pharmacological treatment, an improvement of gastric emptying of both solid and liquid phases of the meal in eight (73%) and seven (64%) patients, respectively. Gastric emptying was unchanged in the three other patients who gained very little weight during the time of the study. As gastric emptying improved, so did nausea, vomiting, and gastric fullness. In three patients who had initially gained weight, nausea and gastric fullness recurred, associated again in all cases with a delay in gastric emptying. In conclusion, in anorexia nervosa, delayed gastric emptying, which is a frequent feature and which is well correlated with some of the upper digestive complaints, can return to normal without any pharmacological treatment. In this improvement, psychological assistance may play a role, together with the correction of the malnutrition.

[Consequences of antral and duodenal acidification on acid secretion, gastrin response and gastric emptying in duodenal ulcer patients and normal subjects]

The present study intended to investigate the effect of antroduodenal acidification on gastric acid secretion and emptying, gastrin and somatostatin release in response to food in healthy subjects as well as in duodenal ulcer patients. Ten duodenal ulcer patients and 9 normal controls were studied twice: the same 400 ml liquid protein meal (proteins: 10 g) was introduced into the stomach; then intragastric pH was either maintained at pH 4.5 or allowed to decrease in response to the meal. Acid secretion was calculated using the intragastric titration method (for which the intragastric pH is fixed at pH 4.5) and using the serial dilution indicator method (which allows antral acidification) respectively. Gastric emptying was estimated according to: a) iterative measurements of intragastric meal residual volume; b) volume passing through the pylorus. These two tests were performed in a random order and during each, plasma gastrin and somatostatin responses to the meal were determined. In healthy subjects, antral acidification following the meal was associated with a significantly lower acid secretion (17.3 +/- 0.9 mmol/h; m +/- SEM) than when the pH was maintained at pH 4.5 (20.2 +/- 1.3; p less than 0.05). Moreover, gastric emptying was slower when the pH was allowed to decrease (t 1/2: 26.2 +/- 1.4 min) than when the pH was constant (t 1/2: 20.5 +/- 2.2 min; p less than 0.05). By contrast, in the duodenal ulcer group, neither acid output nor gastric emptying were significantly different in the two situations.(ABSTRACT TRUNCATED AT 250 WORDS)