Auke Bogte

Intrahepatic cholestasis of pregnancy: maternal and fetal outcomes associated with elevated bile acid levels

OBJECTIVE The primary aim of this study was to investigate the correlation between pregnancy outcome and bile acid (BA) levels in pregnancies that were affected by intrahepatic cholestasis of pregnancy (ICP). In addition, correlations between maternal and fetal BA levels were explored. STUDY DESIGN We conducted a retrospective study that included women with pruritus and BA levels ≥10 μmol/L between January 2005 and August 2012 in 3 large hospitals in the Netherlands. The study group was divided in mild (10-39 μmol/L), moderate (40-99 μmol/L), and severe (≥100 μmol/L) ICP. Main outcome measures were spontaneous preterm birth, meconium-stained amniotic fluid, asphyxia, and perinatal death. Univariate and multivariate logistic regression analysis was used to study associations between BA levels and adverse outcome. RESULTS A total of 215 women were included. Gestational age at diagnosis and gestational age at delivery were significantly lower in the severe, as compared with the mild, ICP group (P < .001). Spontaneous preterm birth (19.0%), meconium-stained fluid (47.6%), and perinatal death (9.5%) occurred significantly more often in cases with severe ICP. Higher BA levels were associated significantly with spontaneous preterm birth (adjusted odds ratio [aOR], 1.15; 95% confidence interval [CI], 1.03-1.28), meconium-stained amniotic fluid (aOR, 1.15; 95% CI, 1.06-1.25), and perinatal death (aOR, 1.26; 95% CI, 1.01-1.57). Maternal BA levels at diagnosis and at delivery were correlated positively with umbilical cord blood BA levels (P = .006 and .012, respectively). CONCLUSION Severe ICP is associated with adverse pregnancy outcome. Levels of BA correlate between mother and fetus.

Normal values for esophageal high-resolution manometry

Esophageal high‐resolution manometry (HRM) is a novel method to assess esophageal motility. Several software and hardware systems are currently available. A set of normal values for HRM parameters was established in the US, using proprietary tactile‐sensing catheter technology (Given Imaging). We wished to determine normal values for HRM performed with another type of catheter (Unisensor).

Relationship between esophageal contraction patterns and clearance of swallowed liquid and solid boluses in healthy controls and patients with dysphagia

Background  Non‐obstructive dysphagia patients prove to be a difficult category for clinical management. Esophageal high‐resolution manometry (HRM) is a novel method, used to analyze dysphagia. However, it is not yet clear how findings on HRM relate to bolus transport through the esophagus.

Reproducibility of esophageal high‐resolution manometry

Background  Esophageal high‐resolution manometry (HRM) is a novel method for esophageal function testing that has prompted the development of new parameters for quantitative analysis of esophageal function. Until now, the reproducibility of these parameters has not been investigated.

Electrical stimulation therapy of the lower oesophageal sphincter for refractory gastro-oesophageal reflux disease - interim results of an international multicentre trial.

A previous single‐centre study showed that lower oesophageal sphincter electrical stimulation therapy (LES‐EST) in gastro‐oesophageal reflux disease (GERD) patients improves reflux symptoms and decreases oesophageal acid exposure.

Sensation of stasis is poorly correlated with impaired esophageal bolus transport.

It is common belief that symptoms of patients with non‐obstructive dysphagia are the result of impaired bolus clearance in the esophagus, usually caused by esophageal motility disorders. We therefore investigated the relationship between transit of swallowed boluses and the symptom dysphagia.

Esophageal motility and impedance characteristics in patients with Barrett's esophagus before and after radiofrequency ablation

Introduction Radiofrequency ablation (RFA) is a valuable treatment option in Barrett’s esophagus resulting in eradication of dysplasia and conversion of all Barrett’s epithelium into normal squamous epithelium. In Barrett’s esophagus, esophageal impedance monitoring is hampered by low baseline impedance values. Whether these low baselines are caused by an intrinsically low impedance of cylindrical epithelium or by the excessive reflux itself is hitherto unknown. Data on esophageal motility after RFA are scarce. Our aim was to examine the effect of RFA on esophageal motility and esophageal baseline impedance in patients with Barrett’s esophagus. Methods In 10 patients, conventional esophageal manometry and 24-h pH-impedance measurements were performed before and after RFA. The number and type of reflux episodes were assessed and baseline impedance values were measured in all recording segments. In another five patients, high-resolution manometry was performed before and after RFA. Results Complete regression of all Barrett’s epithelium was achieved in all 15 patients after 3±1 RFA sessions. Overall, no significant motility changes were found after RFA. Patients had excessive acid exposure times before and after RFA [25 (17–42) and 16 (9–24)%, respectively]. Baseline esophageal impedance values were low, with the lowest values in the distal recording segments. RFA increased baseline impedance in all recording segments in the upright position; in the supine position, the effect just failed to reach statistically significant levels. Conclusion RFA did not alter esophageal motility significantly. Low esophageal baseline impedance levels in patients with Barrett’s esophagus reflect, at least in part, intrinsic impedance properties of cylindrical epithelium, as baselines increased after conversion into neosquamous epithelium.

Hydraulic dilation with a shape-measuring balloon in idiopathic achalasia : a feasibility study

BACKGROUND AND AIM Pneumatic dilation is a commonly used treatment in achalasia. Recent studies have shown that esophageal distensibility measurements can be used to assess the effect of dilation and possibly the risk of perforation. A new hydraulic dilation balloon allows visualization of the shape of the balloon in vivo and measurement of distensibility during dilation. We aimed to evaluate the technical feasibility of a 30-mm shape-measuring hydraulic dilation balloon for the treatment of achalasia. METHODS Consecutive patients with newly diagnosed achalasia were dilated using a 30-mm shape-measuring hydraulic dilation balloon. Patients were contacted 1 week, 1 month, and 3 months after dilation. Technical success, clinical success, and major complications were evaluated. RESULTS Technical success was achieved in all of the 10 patients included. Median esophagogastric junction distensibility (mm(2)/mmHg) increased from 1.1 (IQR 0.6 - 1.3) before dilation therapy to 7.0 (IQR 5.5 - 17.8) afterwards (P = 0.005). No major complications were seen. Three patients (30 %) reported recurrent dysphagia. CONCLUSION Hydraulic dilation with a shape-measuring balloon in achalasia patients is feasible. In vivo esophageal distensibility measurements may allow for an individualized, patient-specific dilation regimen.The Netherlands National Trial Register: NTR4371.

Assessment of bolus transit with intraluminal impedance measurement in patients with esophageal motility disorders

The clinical management of patients with non‐obstructive dysphagia is notoriously difficult. Esophageal impedance measurement can be used to measure esophageal bolus transit without the use of radiation exposure to patients. However, validation of measurement of bolus transit with impedance monitoring has only been performed in healthy subjects with normal motility and not in patients with dysphagia and esophageal motility disorders. The aim was, therefore, to investigate the relationship between transit of swallowed liquid boluses in healthy controls and in patients with dysphagia.

Challenges in oral drug delivery in patients with esophageal dysphagia

ABSTRACT Introduction: Esophageal dysphagia is a commonly reported symptom with various benign and malignant causes. Esophageal dysphagia can impede intake of oral medication, which often poses a major challenge for both patients and physicians. The best way to address this challenge depends of the cause of dysphagia. Areas covered: The pathophysiology of esophageal dysphagia is discussed, diagnostic tools to determine its cause are reviewed and recent developments in the treatment of esophageal dysphagia are discussed. Alternative options to administer medication in dysphagia are discussed and the appropriateness of them reviewed. Expert opinion: Two ways can be followed to allow medication intake in patients with esophageal dysphagia, i.e. altering medication or resolving dysphagia. The latter is generally preferred, since esophageal dysphagia rarely only impedes medication intake. Esophageal resection is possible in more advanced esophageal cancer stages due to advances in neo-adjuvant therapy. Due to recent improvements in intraluminal radiotherapy, it can be expected that this will be the primary treatment in a palliative setting. Temporary self-expandable metal stent placement is a promising new alternative for bougienage in difficult-to-treat benign strictures.