Prevalence and clinical spectrum of gastroesophageal reflux: a population-based study in Olmsted County, Minnesota

BACKGROUND & AIMS

Gastroesophageal reflux is considered a common condition, but detailed population-based data on reflux in the United States are lacking. The aim of this study was to determine the prevalence and clinical spectrum of gastroesophageal reflux in Olmsted County, Minnesota.

METHODS

A reliable and valid self-report questionnaire was mailed to an age- and sex-stratified random sample of 2200 Olmsted County residents aged 25-74 years.

RESULTS

The prevalence per 100 of heartburn and/or acid regurgitation experienced at least weekly was 19.8 (95% confidence interval [95% CI], 17.7-21.9). Heartburn and acid regurgitation were associated with noncardiac chest pain (odds ratio [OR], 4.2; 95% CI, 2.9-6.0), dysphagia (OR, 4.7; 95% CI, 2.9-7.4), dyspepsia (OR, 3.1; 95% CI, 1.9-5.0), and globus sensation (OR, 1.9; 95% CI, 1.0-3.6) but not with asthma, hoarseness, bronchitis, or a history of pneumonia. Among subjects with reflux symptoms, 1.0% reported an episode of hematemesis and 1.3% had a past esophageal dilatation.

CONCLUSIONS

Symptoms of reflux are common among white men and women who are 25-74 years of age. Heartburn and acid regurgitation are significantly associated with chest pain, dysphagia, dyspepsia, and globus sensation. The percentage of patients reporting complications is low, but the absolute number is probably considerable given the high prevalence of the condition in the community.

Haematemesis and melaena, with special reference to factors influencing the outcome

In a study of 2,149 emergency admissions because of haematemesis or melaena during a 15-year period, the sex ratio, age distribution, and main diagnostic groups showed no major change. Various factors affected the prognosis, such as the age of the patient, the underlying diagnosis, a low blood pressure on arrival at hospital, gross anaemia on arrival there, and the pattern of bleeding after admission. The fatality rate remained virtually constant throughout the period studied in spite of changes in diagnostic methods and management. There was a changing pattern in the type of operation performed in the treatment of bleeding peptic ulcer. Vagotomy combined with a drainage procedure and with a direct surgical attack on the bleeding point became more widely used at the expense of Polya or Billroth I partial gastrectomy and gave the best results. It is at first paradoxical that improved surgical results should not be reflected in a general improvement in the fatality rate, but this finding can be explained by the smaller proportion of patients treated by emergency surgery in the later years of the period studied. It is concluded that emergency surgery should be performed more frequently and that vagotomy plus drainage is the operation of choice in the peptic ulcer group.

Acute esophageal necrosis: a rare syndrome

BACKGROUND

Acute esophageal necrosis, which presents as a black esophagus on endoscopy, is a rare disorder that is poorly described in the medical literature. In this study, we analyze all cases reported to date to define risk factors, clinical presentation, endoscopic features, histologic appearance, treatment, complications, outcome and etiopathogenesis of the disease and to describe a distinct medical syndrome and propose a staging system.

METHODS

We searched Medline and PubMed from January 1965 to February 2006 for English-language articles using the key words "acute esophageal necrosis," "necrotizing esophagitis," and "black esophagus."

RESULTS

A total of 88 patients were reported in the literature during the 40 years, 70 men and 16 women with an average age of 67 years. Patients were generally admitted for gastrointestinal bleeding and cardiovascular event/shock. Patients presented with hematemesis and melena in more than 70% of the cases. Upper endoscopy showed black, diffusely necrotic esophageal mucosa predominantly affecting the distal third of the organ. Necrosis was confirmed histologically in most cases. Complications included strictures or stenoses, mediastinitis/abscesses, and perforations. Overall mortality was 31.8%.

CONCLUSIONS

This study provides a structured approach to identifying risk factors, diagnosis, and pathogenesis of the acute esophageal necrosis. Risk factors include age, male sex, cardiovascular disease, hemodynamic compromise, gastric outlet obstruction, alcohol ingestion, malnutrition, diabetes, renal insufficiency, hypoxemia, hypercoagulable state, and trauma. Mechanism of damage is usually multifactorial secondary to ischemic compromise, acute gastric outlet obstruction, and malnutrition. Overall, acute esophageal necrosis should be viewed as a poor prognostic factor, associated with high mortality from the underlying clinical disease.

Recurrent massive haematemesis from Dieulafoy vascular malformations--a review of 101 cases

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Early endoscopy of oesophagus, stomach, and duodenal bulb in patients with haematemesis and melaena

Oesophago-gastro-duodenoscopy was successfully performed in 196 of 208 patients admitted with haematemesis or melaena, or both. A precise visual diagnosis was made in 80% of all patients and in 96% of those where the final diagnosis lay within the oesophagus, stomach, and first two parts of the duodenum. Bleeding oesophagitis was more common and bleeding duodenal ulcer less common than in other series using mainly radiology. Altogether, 26% of all patients with endoscopically-proved duodenal ulcers were bleeding from another site, and 15.4% of all patients had more than one lesion. This fact, and inability to detect surface lesions limits the value of acute barium radiology, which was performed in only 81 patients. Accurate diagnosis should lead to better understanding of individual lesions and more rational management of individual patients. Where a good service is available oesophago-gastro-duodenoscopy should be performed on all bleeding patients within 24 hours of admission.

Transesophageal echocardiography-related gastrointestinal complications in cardiac surgical patients

OBJECTIVE

The aim of this audit was to determine the incidence of major gastrointestinal (GI) complications associated with intraoperative transesophageal echocardiography (TEE) in adult cardiac surgical patients in this institution.

DESIGN

Retrospective database audit.

SETTING

University-affiliated teaching hospital.

PARTICIPANTS

Eight hundred fifty-nine consecutive cardiac surgical patients.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The records of all patients who developed a major upper GI complication within 30 days of cardiac surgery between January 2001 and May 2003 were examined. The patients were identified by cross-referencing cardiac surgery and endoscopy databases. A major GI complication was defined as a perforation of the esophagus or stomach or upper GI bleeding requiring transfusion, endoscopic, or surgical intervention. Early presentation was defined as <24 hours; late presentation was defined as >24 hours. During the audit period, 859 patients underwent cardiac surgery. Five hundred sixteen patients had cardiac surgery with TEE (group 1), and 343 patients had cardiac surgery without TEE (group 2). Six patients were identified, 1.2% (95% confidence interval [CI], CI, 0.5%-2.5%) in group 1 who had a major upper GI complication consistent with TEE injury. Two patients, 0.38% (95% CI, 0.05%-1.40%), presented early, and 4 patients, 0.76% (95% CI, 0.21%-1.98%), presented late. One patient in group 2 developed a major upper GI complication, 0.29% (95% CI, 0.01%-1.6%).

CONCLUSION

The incidence of major GI complications attributed to TEE in this group of cardiac surgical patients was higher than previously reported. Late presentation was more common than early presentation. Previous studies that have not included late presentations may have underestimated the true incidence of major GI complications related to TEE.

Fulminant and fatal gas gangrene of the stomach in a healthy live liver donor

A 57-year-old male with a history of hypercholesterolemia and anxiety but otherwise in good health volunteered to donate the right lobe of his liver to his brother. The operation was performed uneventfully, without transfusion. Postoperatively he did well, until he developed tachycardia, profound hypotension, and coffee ground emesis on postoperative day 3. Despite resuscitative measures, he arrested and expired. Autopsy demonstrated gas gangrene of the stomach as the underlying cause of the hemorrhage and numerous colonies of Gram-positive bacilli were identified. Subsequent polymerase chain reaction (PCR) analysis identified these bacteria to be Clostridium perfringens (C. perfringens) type D. This patient's death was devastating, both to his family and his medical team. The impact of his death has transcended that of an individual occurrence. In conclusion, herein we present the facts and discuss this extraordinary example of florid clostridial infection and toxin-mediated shock. It was completely unexpected and probably unpreventable, and its cause was almost inconceivable.

Primary aortoduodenal fistula: a case report and review of the literature

Abdominal aortic aneurysms (AAAs) can cause aortoenteric fistulae (AEF). AEF can either be primary, arising from the aneurysm or other diseases, causing the aorta to erode into the bowel, or secondary, from previous aortic grafting. Primary aortoduodenal fistula (ADF) is a rare clinical entity that usually presents with gastrointestinal bleeding that can be occult, intermittent, or massive. We report a 71-year-old woman with acute onset of abdominal pain and massive hematemesis. Esophagogastroduodenal endoscopy (EGD) and arteriography were nondiagnostic. The patient's condition became unstable, and she was brought emergently to the operating room where the diagnosis of an ADF was made. The ADF and AAA were surgically repaired, and the patient recovered without complications. This case represents an example of a rare complication of AAA with the unusual presentation of multiple aortic aneurysms. We will address the pathophysiology, diagnostic evaluation, and management of AEF.

Mortality in patients with haematemesis and melaena: a prospective study

In a prospective study of death in 817 patients with haematemesis and melaena admitted on 894 occasions, the protocol included admission of all patients to a defined unit, early endoscopy and resuscitation, and planned management. Over the three consecutive two-year periods of the study mortality significantly decreased from 9% to 2.4%. Although the operative rate remained the same, the operative mortality fell from 16% to 1.6%. The fall in mortality was greatest in patients with bleeding gastric ulcers. These results suggest that prospective studies with a defined policy can influence the mortality in patients with upper gastrointestinal bleeding.

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.

Upper Gastrointestinal Bleeding: Etiologies and Management

Upper gastrointestinal bleeding is a medical condition routinely encountered in clinical practice. Overt upper gastrointestinal bleeding usually presents as melena or hematemesis but can also present as hematochezia in cases of brisk bleeding. The initial evaluation of a patient with suspected upper gastrointestinal bleeding begins with assessment of hemodynamic status, identification of potential risk factors, and appropriate triage of level of care. After resuscitation measures, endoscopic evaluation can be performed to diagnose and potentially treat the source of bleeding. Risk factors that increase the propensity for recurrent bleeding should be identified and addressed.

Value of a centralised approach in the management of haematemesis and melaena: experience in a district general hospital

All patients presenting with acute upper gastrointestinal bleeding between November 1986 and April 1988 were admitted to a centralised joint medical/surgical unit, with a policy of early clinical and endoscopic assessment and rapid surgical intervention in those at high risk. Of the 430 patients admitted 69.5% were over the age of 60 and 30% had significant additional medical conditions. 50.4% were bleeding from peptic ulcers and one third had been taking non-steroidal anti-inflammatory agents. Fifty five patients underwent surgery, which in two thirds was carried out within 24 hours of admission, usually for continued bleeding. In patients with peptic ulcer the operation rate was 21.6%. Overall mortality was 3.7%, and in those with bleeding gastric or duodenal ulcers 5.5%; surgical mortality in the later group was 15.2%. All patients who died had serious concomitant pathology and 87% were over 70 years of age. Adoption of a centralised approach to management of haematemasis and melaena is feasible in a District General Hospital and associated with an improved survival.

Aspirin, paracetamol, and haematemesis and melaena

Aspirin and paracetamol consumption have been compared in 346 matched pairs of patients with haematemesis and melaena, and control individuals in the general community. Both aspirin and paracetamol intake were more common in patients than in controls, but the association for aspirin was stronger and was apparent with both recent and habitual intake, whereas for paracetamol the association was not detectable for habitual intake. The results for paracetamol suggests that patients with bleeding take analgesic drugs in part because of symptoms associated with bleeding, and such intake is not necessarily causal of bleeding. Failure to control investigations to take account of this point has exaggerated the possible risks of aspirin consumption.

Infantile hypertrophic pyloric stenosis in Belfast, 1957-1969

Infants with hypertrophic pyloric stenosis born in Belfast during the 13 years 1957-1969 have been reviewed. Their distribution shows a bias towards higher social classes, breast feeding, and primogeniture. Obstetric factors and parental ages seem to be of no importance. More affected infants were born during winter months than would be expected. The overall incidence of infantile pyloric stenosis in this community has fallen during the period under review. Clinically, the patients started vomiting at a mean age of 22 days and it is recommended that the condition should not be called 'congenital'. The size of the tumour is mainly determined by the size of the patient, rather than by his age or duration of symptoms. Attention is drawn to the occurrence of haematemesis in 17-5% and melaena in 2-9% of infants. Jaundice occurred in 1-8% of patients in this series, and is attributed to the adverse effect of starvation on hepatic glucuronyl transferase activity. Other conditions noted in these patients included inguinal hernia, partial thoracic stomach, and phenylketonuria. Subsequent growth and development were in the anticipated range.

Anaemia and hiatus hernia: experience in 450 patients

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Aortoesophageal fistula-relief of massive hematemesis with an endovascular stent-graft

A 59-year-old man with an esophageal carcinoma developed massive hematemesis due to aortoesophageal fistula after irradiation therapy reached 58 Gy. Emergent treatment with an endovascular stent-graft was successfully performed and the patient followed an uneventful course until he died of pneumonia 4.5 months later, which was caused by a tracheoesophageal fistula. Stent-graft repair is a safe and effective method to treat aortoesophageal fistula and may be an alternative to surgical resection.

Enteritis necroticans (pigbel) in a diabetic child

BACKGROUND AND METHODS

Enteritis necroticans (pigbel), an often fatal illness characterized by hemorrhagic, inflammatory, or ischemic necrosis of the jejunum, occurs in developing countries but is rare in developed countries, where its occurrence is confined to adults with chronic illnesses. The causative organism of enteritis necroticans is Clostridium perfringens type C, an anaerobic gram-positive bacillus. In December 1998, enteritis necroticans developed in a 12-year-old boy with poorly controlled diabetes mellitus after he consumed pig intestines (chitterlings). He presented with hematemesis, abdominal distention, and severe diabetic ketoacidosis with hypotension. At laparotomy, extensive jejunal necrosis required bowel resection, jejunostomy, and ileostomy. Samples were obtained for histopathological examination. Polymerase-chain-reaction (PCR) assay was performed on paraffin-embedded bowel tissue with primers specific for the cpa and cpb genes, which code for the alpha and beta toxins produced by C. perfringens.

RESULTS

Histologic examination of resected bowel tissue showed extensive mucosal necrosis, the formation of pseudomembrane, pneumatosis, and areas of epithelial regeneration that alternated with necrotic segments--findings consistent with a diagnosis of enteritis necroticans. Gram's staining showed large gram-positive bacilli whose features were consistent with those of clostridium species. Through PCR amplification, we detected products of the cpa and cpb genes, which indicated the presence of C. perfringens type C. Assay of ileal tissue obtained during surgery to restore the continuity of the patient's bowel was negative for C. perfringens.

CONCLUSIONS

The preparation or consumption of chitterlings by diabetic patients and other chronically ill persons can result in potentially life-threatening infectious complications.

Oesophageal tuberculosis: a review of eleven cases

Tuberculous infection of the oesophagus is rare. This is confirmed by our present review of cases managed in our teaching hospitals over a period of 18 years which uncovered only 11 patients. The main presentation is that of dysphagia whose algorithm of investigation should seek to differentiate tuberculosis from carcinoma, the more common cause of this symptom. Of the 11 patients, 9 presented with dysphagia while 2 had haemorrhage; 7 had an abnormal plain chest radiograph, of whom 4 had a mediastinal mass lesion (3 were lymphadenopathy and one an abscess). All but one had an abnormal radio-contrast oesophagogram, including a mediastinal sinus in two and a traction diverticulum in another two. The mainstay of investigation was oesophagoscopy through which diagnostic biopsy material was obtained in half of the patients. In the other half diagnosis was by either biopsy of associated mediastinal (3) or cervical (1) lymph node masses or by acid fast bacilli positive sputum (1). The diagnosis was established post-mortem in one patient. Treatment was primarily non-operative with standard anti-tuberculosis drug therapy. Two patients underwent a diagnostic thoracotomy and one a drainage of mediastinal abscess together with resection and repair of oesophago-mediastinal sinus during the early part of the series. Outcome of management was very rewarding in 9 patients and death occurred in 2 patients, one of whom had his anti-tuberculosis drug therapy interrupted by severe hepatitis B virus infection. The other death occurred in a patient whose haemorrhage from an aorta-oesophageal fistula was not established ante-mortem. It is recommended that when biopsy material of the oesophagus is unobtainable or non-diagnostic in patients with dysphagia, especially with an abnormal chest radiograph or human immunodeficiency virus infection, effort should be made to obtain biopsy material from associated lymph nodes, even by thoracotomy if necessary, or culture of biopsy from the radiologically abnormal part oesophagus and sputum for mycobacteria, in order to establish the diagnosis of this rare but eminently treatable cause of dysphagia. Clinicians should be aware of tuberculosis of the oesophagus as a possible cause of haematemesis in patients with otherwise unexplained upper gastrointestinal haemorrhage.

Operative management of symptomatic duodenal diverticula

BACKGROUND

Duodenal diverticula are common but rarely cause symptoms that require operative intervention.

METHODS

The charts of 34 patients who underwent a laparotomy at a single institution for complications of a duodenal diverticulum between the years of 1969 and 2001 were reviewed.

RESULTS

The indications for operation included perforation (n = 10), gastrointestinal bleeding (7), intractable pain (6), biliary or pancreatic obstruction (4), gastrointestinal obstruction (2), steatorrhea (2), questionable malignancy (2), and cholecystodiverticular fistula (1). The operation consisted of diverticulectomy in 27 patients, duodenal resection in 4, diverticular inversion in 2, and a controlled duodenal fistula in 1. An additional drainage procedure was performed in 7 patients. Perioperative mortality rate was 3%. Early (15%) and late (12%) morbidity rates were significant.

CONCLUSIONS

Operative treatment of duodenal diverticula is safe but should be reserved for those with emergent presentations or intractable symptoms.

Secondary aortoesophageal fistula after endoluminal exclusion because of thoracic aortic transection

Secondary aortoesophageal fistula (AEF) is a rare but catastrophic complication that occurs after thoracic aortic reconstruction. Recently endoluminal stent grafts have been used in selected patients with a thoracic aortic aneurysm, dissection, or traumatic aortic transection. A 24-year-old woman had massive upper gastrointestinal tract bleeding 15 months after endoluminal stent graft placement because of traumatic descending thoracic aortic transection. Evaluation demonstrated an AEF from the mid-esophagus to the endoluminal stent graft. The endoluminal graft was explanted, with primary repair of the thoracic aortic defect and simultaneous primary repair of the esophageal injury. The patient is well 15 months after open repair of the AEF.