Review article: diagnosis and management of night-time reflux

Symptoms of gastro-oesophageal reflux disease (GERD) range from mild to severe and, when they occur during night-time hours, can interfere with sleep patterns and reduce overall quality of life. The clinical presentation of GERD is characterized by oesophageal as well as supra-oesophageal symptoms, including otolaryngologic and pulmonary complications. However, GERD may be overlooked as the cause of a patient's supra-oesophageal symptoms because these complaints can occur in the absence of oesophageal symptoms or endoscopic changes. The role of available tools used for GERD diagnosis, including endoscopy, oesophageal pH monitoring and an empirical course of proton pump inhibitor therapy, is discussed. Interventions available to achieve the therapeutic goals of symptom relief and prevention include specific lifestyle modifications and over-the-counter as well as prescription pharmacological agents. Patient-initiated, as-needed treatment may not be the best choice for managing persistent night-time reflux because it requires patient arousal from sleep. Proton pump inhibitor therapy remains the treatment of choice for patients with more severe symptoms and those with erosive oesophagitis. Few studies have specifically evaluated the role of pharmacological agents in the management of night-time reflux and comparisons are difficult due to the variability in study design and endpoints assessed.

Low- versus high-dose azithromycin triple therapy for Helicobacter pylori infection

BACKGROUND

We report a clinical trial which evaluated the effectiveness of triple therapy containing low- and high-dose azithromycin to treat Helicobacter pylori infection.

METHODS

From March 1997 to March 1998, patients infected with H. pylori were assigned to receive either: Treatment 1: ranitidine bismuth citrate (RBC) (400 mg b.d.) and amoxycillin (1 g b.d.) for 10 days with azithromycin 500 mg o.m. for 3 days: or Treatment 2: RBC and amoxycillin for 10 days with azithromycin 1 g o.m. for 3 days. H. pylori eradication was established by a urea breath test at least 4 weeks after therapy. Side-effects and compliance were assessed using a diary.

RESULTS

Sixty-eight patients were enrolled. Fifty-seven per cent of patients were treated for active peptic ulcer disease or a history of peptic ulcer disease. Treatment 1 cured H. pylori in 44% and 44% by per protocol and intention-to-treat analysis, respectively. The corresponding eradication rates for Treatment 2 were 79% and 75%. Two patients taking Treatment 2 dropped out of the study because of side-effects.

CONCLUSIONS

With RBC and amoxycillin for 10 days, azithromycin at a dose of 1 g/day for 3 days was significantly better at curing H. pylori infection than azithromycin 500 mg/day for 3 days.

Bismuth subsalicylate instead of metronidazole with lansoprazole and clarithromycin for Helicobacter pylori infection: a randomized trial

OBJECTIVE

We evaluated the efficacy of lansoprazole, clarithromycin, and metronidazole (LCM) administered twice daily for 7 days. Because there is growing concern about the development of metronidazole-resistant H. pylori (HP) strains, we also tested a novel regimen consisting of lansoprazole, clarithromycin, and bismuth subsalicylate (LCB).

METHODS

Patients with active HP infection and peptic ulcer, a history of peptic ulcer, or nonulcer dyspepsia were randomized to either lansoprazole 30 mg b.i.d., clarithromycin 500 mg b.i.d., and metronidazole 500 mg b.i.d. or lansoprazole 30 mg b.i.d., clarithromycin 500 mg b.i.d., and bismuth subsalicylate 524 mg b.i.d. (LCB) for 7 days. Compliance and side effects were recorded by using a diary.

RESULTS

"Per protocol" eradication with LCM was achieved in 41 of 47 (87%). By using "intention to treat" analysis, LCM eradicated HP infection in 43 of 53 patients (81%). By using "per protocol" analysis, LCB eradicated HP infection in 40 of 47 patients (85%). On an "intention to treat" basis, LCB led to HP eradication in 42 of 52 (81%). The most common significant side effects observed with LCM were altered taste (39%) and abdominal pain (19%). With LCB, the most common significant side effects were altered taste (23%) and dark stools (23%).

CONCLUSIONS

LCB for 7 days was as effective in eradicating HP infection as a 7-day course of LCM. Further studies evaluating the role of bismuth compounds in proton-pump inhibitor based triple therapy are warranted. Such therapy may have particular importance in areas where high metronidazole resistance is a concern.

Treatment of Wilson's disease with zinc: X. Intestinal metallothionein induction

Oral zinc therapy is effective in controlling copper balance in patients with Wilson's disease and blocks the intestinal absorption of copper, as demonstrated by uptake of copper 64 and copper balance measurements. In this study, 64Cu uptake measurements were concomitantly carried out with intestinal biopsies to investigate the relationship of reduced copper absorption to the levels of intestinal metallothionein in patients with Wilson's disease at different stages of zinc therapy. A pronounced increase in intestinal metallothionein levels and a sharp drop in 64Cu absorption were found 4 to 5 days after the initiation of zinc treatment. Conversely, metallothionein levels decreased and 64Cu uptake increased on the discontinuation of zinc therapy. The data indicate that 64Cu absorption varies as a function of intestinal metallothionein level. Intestinal metallothionein levels were found to correlate linearly with urinary zinc levels, which reflect body zinc status. These findings support our hypothesis that intestinal metallothionein induction mediates decreased copper absorption observed during zinc therapy. The suppressive effect of zinc on copper absorption appears to have a half-life of about 11 days.

Common bile duct obstruction in cystic fibrosis: utility of hepatobiliary scintigraphy

Abdominal pain occurs commonly in patients with cystic fibrosis, and is the result of a variety of causes, including hepatobiliary disorders. With the increasing duration of survival in these patients, diagnostic investigations for abdominal pain, including hepatobiliary scanning, may be utilized more frequently than in the past. Difficulties in the interpretation of scintigraphic studies may arise because of associated gallbladder anomalies that occur in more than 50% of patients with cystic fibrosis. Hypoplasia of the gallbladder (microgallbladder) occurs commonly. A case is presented in which Tc-99m disofenin hepatobiliary scanning proved diagnostic in a patient with cystic fibrosis and cholelithiasis leading to common bile duct obstruction. The hepatobiliary abnormalities and causes of common bile duct obstruction encountered in cystic fibrosis are reviewed.

Chronic gastric ischemia. A cause of abdominal pain or bleeding identified from the presence of gastric mucosal acidosis

Acidosis in gastric mucosa (pHi less than 7.32) was evaluated as a diagnostic test for gastric ischemia, using 80 asymptomatic subjects as controls. Mucosal acidosis was found in 6 patients with abdominal pain and 1 with gastrointestinal bleeding. Three had occlusive disease of 2 or more visceral arteries, 3 had occlusive disease of the celiac axis alone, and 1 had an occluded portal vein. One patient had infarcted gut. The abnormal pHi (7.10 +/- 0.11, mean +/- SD) in those with pain was returned to normal levels (7.43 +/- 0.08, p = 0.0003) and the symptoms relieved by revascularization. The abnormal pHi (6.84 +/- .04) in the patient who bled was restored to normal levels (7.48 +/- .03, t = 9.69, p less than .0001) and the bleeding stopped by a central splenorenal shunt. Measurements of pHi in gastrointestinal mucosa may be used as an objective test for evaluating patients suspected of having chronic gastrointestinal ischemia.

Colonic xanthomatosis. Relationship to disordered motility and review of the literature

We report two additional cases of colonic xanthomatosis associated with persistent rectal symptoms. Disordered colonic motility in the areas of lipid infiltration was documented in one patient. We conclude these lesions may have a pathophysiologic role in the alteration of intestinal motility which appears to be the cause of our patients' symptoms.

Candida hepatitis. Histopathologic diagnosis

Candida hepatitis, usually a manifestation of disseminated candidiasis in immunocompromised patients, is difficult to diagnose antemortem. We studied six patients with proven hepatic candidiasis to assess features helpful in deriving a correct diagnosis. Five patients were immunosuppressed as a result for treatment for leukemia; one was immunosuppressed due to renal transplantation. All had sustained fevers greater than 101 degrees F, elevated alkaline phosphatase levels, and multiple hepatic and splenic defects--presumably abscesses--on abdominal CT scan. Twelve liver biopsies (nine needle, three wedge) were examined. Biopsies from four patients contained identifiable Candida organisms within suppurative granulomas; a biopsy from a fifth patient grew Candida albicans in cultures. In the sixth patient, the first biopsy was culture positive for Candida albicans, and the second biopsy, a fine-needle aspirate, contained Candida organisms and purulent material. In all of the nondiagnostic biopsies, as well as in regions of the diagnostic biopsies around the suppurative granulomas, mass-associated obstructive changes were noted. These included pericentral sinusoidal dilatation and cholestatic inflammation characterized by periportal ductular proliferation with surrounding neutrophils and edema. We conclude that in the appropriate clinical setting, these mass-associated histologic findings are suggestive of adjacent Candida abscesses. Definite diagnosis requires either the identification of Candida organisms within inflammatory hepatic lesions or positive culture of Candida from the liver biopsy.

Endoscopic diagnosis of gastritis: causative factors in 100 patients

The frequency of gastritis in relation to its various predisposing conditions is unclear, as is the respective distribution of damage caused by its predisposing conditions. We studied 100 patients with the endoscopic diagnosis of gastritis. The incidence of gastritis in our university gastroenterology endoscopy service was 23%. A history of aspirin (ASA) or nonsteroidal anti-inflammatory drug (NSAID) use was present in 42%. No predisposing factors were found in 28% of cases. Stress gastritis was present in 10% of patients, all of whom were in the intensive care unit. Alcoholism, gastric resection, and portal hypertension were considered causative in 19%. Multiple predisposing factors were uncommon (3%). Coincident duodenal ulcer(s) and erosive duodenitis were common and were more frequent in the patients having idiopathic gastritis (46%) than in those who used ASA or NSAIDs (29%). The antrum was the portion of the stomach most frequently involved. This antral distribution of damage was predominant in both the ASA/NSAID-associated cases and in the idiopathic group. In contrast, patients with stress gastritis were more likely to have involvement of the gastric fundus and body.

Endoscopic retrograde computed tomography of the pancreas

Endoscopic retrograde cholangiopancreatography (ERCP) and computed tomography (CT) are well established diagnostic studies for pancreatic evaluation. We conducted a study to determine whether performing these examinations in tandem increased diagnostic accuracy. Patients undergoing ERCP with successful cannulation of the pancreatic duct and who could be placed in the gantry of our CT scanner within 30 min were included in the study. The combined examination, or endoscopic retrograde computed tomography of the pancreas (ERCTP), provided additional useful information in several types of patients including those who had intrapancreatic air without clinical abscess, those with apparent total obstruction of the pancreatic duct on ERCP, and those who were post partial pancreatectomy and were being considered for additional surgery. No additional useful information was provided in patients with a normal ERCP or in routine cases of pancreatitis.

Common bile duct strictures associated with chronic pancreatitis

Common bile duct (CBD) strictures associated with chronic pancreatitis may cause significant hepatobiliary disease. Nine patients with chronic alcohol-related pancreatitis and CBD obstruction requiring operative biliary or pancreatobiliary decompression are reported. Alkaline phosphatase was the most specific biochemical indicator of cholestasis. Abnormal CBD anatomy was delinated accurately in 89 per cent of cases with percutaneous transhepatic cholangiography (PTC) and endoscopic retrograde cholangiopancreatography (ERCP). All strictures were localized to the intrapancreatic portion of the distal CBD. Pancreatic pseudocysts (PPC) were identified in six (67%) cases. All nine patients underwent biliary decompression. Simultaneous PPC drainage or pancreatic duct decompression (Peustow procedure) was performed in eight cases (89%). No perioperative mortality occurred, and all patients reported subjective improvement in symptoms. Biliary tract strictures sufficient to cause clinical or biochemical cholestasis are a poorly recognized complication of chronic pancreatitis. Cholangiography (PTC or ERCP) should be obtained in order to delineate radiographic features, and extent and severity of the biliary stricture because there is no predictable correlation between levels of serum alkaline phosphatase and liver histopathology. A percutaneous biopsy is requisite to document changes in hepatic morphology. In order to prevent potential hepatobiliary complications such as cholangitis and secondary biliary cirrhosis, biliary strictures should be managed surgically even in anicteric and otherwise asymptomatic patients. Simultaneous treatment of associated pancreatic pathology can be performed if necessary with little added morbidity.