Bani Chander

24 Versus 48-hour bravo pH monitoring.

Background: Historical ambulatory pH monitoring systems for the evaluation of gastroesophageal reflux disease have been catheter based and uncomfortable for patients, commonly limiting both their diet and activities. Catheter-based studies have also been reported to underestimate the amount of reflux a patient may have in a normal, routine day. Compared with conventional catheter-based pH monitoring systems, wireless (Bravo) pH monitoring is better tolerated by patients and allows for an increased duration of pH recording. Currently, there is lack of data regarding the optimal duration of wireless studies and concern that day 1 results are not typical of a patient’s routine lifestyle, given the effects of sedation. Few studies have evaluated the merits of 24 versus 48-hour wireless pH monitoring. Aims: The aims of this study were (1) to identify differences in reflux parameters between 24 versus 48-hour testing as measured by wireless pH monitoring and (2) to assess the effect of 48-hour studies on the number of reflux episodes and symptom correlation as compared with 24-hour studies. Methods: A retrospective chart review of 124 consecutive patients who underwent 48-hour wireless esophageal pH monitoring studies was prepared. All patients underwent esophagogastroduodenoscopy using intravenous conscious sedation before wireless capsule placement. Acid reflux variables (including total reflux time, number of reflux episodes, and total percent time of pH<4) and symptom-association probability (SAP) scores were compared for day 1 versus day 2 versus total. Results: Forty-eight-hour SAP scores were significantly higher when compared with the first 24 hours for all reported primary symptoms. SAP scores were calculated at 24 and 48 hours, respectively for heartburn (56 vs. 65, P<0.0001), regurgitation (65 vs. 80, P<0.0001), chest pain (59 vs. 78, P=0.0009), and cough (55 vs. 64, P=0.0027). In addition, the percentage of SAP scores >95 was significantly higher for both heartburn and regurgitation (34% vs. 48%, P=0.003 and 38% vs. 62%, P=0.005). As expected, 48-hour testing also captured a significantly higher number of reflux episodes as compared with day 1 results alone (97 vs. 47, P<0.0001). There were no statistical differences noted between the 2 days for total percent time of pH <4. Conclusions: Forty-eight-hour wireless (Bravo) pH monitoring strengthens symptom correlation as compared with 24-hour results alone and yields a greater percentage of SAP scores >95 for typical symptoms of gastroesophageal reflux disease. Prolonged recording of patient symptoms and/or sedation effects may account for the better symptom correlation. Although there were no statistical differences seen in this study between 24 and 48-hour studies for total percent time pH <4, 48-hour studies captured significantly more reflux episodes as compared with 24 hours of monitoring alone. These results suggest that patients undergoing wireless pH monitoring should have 48-hour studies performed as a standard of practice.

Eosinophilic Myenteric Ganglionitis: A Case of Intestinal Pseudo-obstruction in a 93-Year-old Female

Eosinophilic myenteric ganglionitis is a disorder characterized by infiltration of the Auerbach plexus by eosinophils. It can be associated with a bowel dysmotility and a few cases of intestinal pseudo-obstructive syndrome have been described in children. In this case report, we present an elderly 93-year-old woman who presented with episodes of functional bowel obstruction of unknown etiology. After several admissions for recurrent obstipation requiring fecal disimpaction, she had a Hartmann procedure performed with a resection of the sigmoid colon. The sigmoid colon was markedly dilated and the only significant finding on histology was infiltration of the Auerbach plexus by eosinophils. The mucosa and the muscular layers appeared unremarkable. Her symptoms resolved after the resection and the patient is currently well after 5 months. Recurrent gastrointestinal pseudo-obstruction can arise secondary to eosinophilic myenteric ganglionitis even in adults. Clinical improvement is likely if this disease entity is promptly recognized and treated.

48 Hour BRAVO (Wireless) Esophageal pH Monitoring Improves Symptom Correlation as Compared to 24 Hour Studies Alone

Background: Historical ambulatory pH monitoring systems for the evaluation of GERD have been catheter-based and uncomfortable for patients, commonly limiting both their diet and activities. These studies may also underestimate the amount of reflux a patient has in a routine day. Compared to conventional catheter based pH monitoring systems, wireless (Bravo) pH monitoring is better tolerated by patients and allows for an increased duration of pH recording. Currently, there is lack of data regarding the optimal duration of wireless studies and concern that day 1 results are not typical of a patients routine lifestyle given the effects of sedation. Few studies have evaluated the merits of 24 versus 48 hour wireless pH monitoring. Aims: The aims of this study were: 1)To identify differences in reflux parameters between day 1 and day 2 as measured by wireless pH monitoring and 2)To assess the effect of 48 hour studies on the number of reflux episodes and symptom correlation as compared to 24 hour studies. Methods: A retrospective chart review of 124 consecutive patients who underwent 48 hour wireless esophageal pH monitoring studies. All patients underwent EGD using IV conscious sedation prior to wireless capsule placement. Acid reflux variables [including total reflux time, number of reflux episodes, and total percent time of pH 95 was significantly higher at 48 hrs vs 24 hrs for both heartburn and regurgitation (31% vs 22%, p=0.003 and 21% vs 13%, p= 0.005). As expected, 48 hour testing also captured a significantly higher number of reflux episodes as compared to 24 hour results alone (97 vs 47, p 95 for typical symptoms of GERD. Prolonged recording of patient symptoms and/or sedation effects may account for the better symptom correlation. Although there were no statistical differences seen in this study between 24 and 48 hour studies for total percent time pH <4, 48 hr studies captured significantly more reflux episodes as compared to 24 hr monitoring alone. These results suggest that patients undergoing wireless pH monitoring should have 48 hour studies performed as standard of practice.

Mosapride in the Treatment of Gastrointestinal Disorders

Prokinetic drugs are being used with increasing frequency in the treatment of functional gastrointestinal disorders including functional dyspepsia (FD) and constipation-predominant Irritable Bowel Syndrome (IBS-C). Mosapride is a gastro-prokinetic agent that acts as a selective 5-HT4 agonist thereby accelerating gastric emptying. It has been used for the treatment of irritable bowel syndrome (IBS), functional dyspepsia (FD), and gastroesophageal reflux (GERD). Mosapride shares physiologic effects with previous 5-HT4 agonists, cisapride and tegaserod, but with a safer cardiac profile.

Marked Ethnic Differences in the Frequency, Type, and Distribution of Gastrointestinal Lesions in Patients with Iron Deficiency Anemia

Marked Ethnic Differences in the Frequency, Type, and Distribution of Gastrointestinal Lesions in Patients with Iron Deficiency Anemia Bani Chander, Edmund J. Bini Background: There are marked ethnic differences in the prevalence of iron deficiency anemia (IDA) in the U.S., with the frequency being highest in blacks and Hispanics. To date, however, it is not known whether there are ethnic differences in the gastrointestinal (GI) causes of IDA. The aims of this study were to evaluate ethnic variations in the frequency, type, and distribution of GI lesions in a large cohort of patients with IDA. Methods: Consecutive patients who were referred for the evaluation of IDA were prospectively enrolled at a single medical center. Patients were interviewed by a research assistant who obtained detailed demographic and clinical data, and all subjects had same-day EGD and colonoscopy. Iron deficiency was defined as a transferrin saturation of !15% and a ferritin of !20 ug/L, whereas anemia was defined as a hemoglobin of !13 g/dL in men and !12 g/dL in women. Lesions were classified as clinically important according to standard predetermined criteria. Results: A total of 1,081 patients with IDA were enrolled (406 whites, 442 blacks, 168 Hispanics, and 65 from other ethnic groups). One or more clinically important lesions were identified in 53.9% of whites, 64.7% of blacks, 63.1% of Hispanics, and 69.2% of other ethnic groups (P Z 0.004). There were significant differences between whites, blacks, Hispanics, and other ethnic groups in the prevalence of clinically important lesions in the upper GI tract (32.9% vs. 32.0% vs. 43.1% vs. 53.8%, P Z 0.001), lower GI tract (31.8% vs. 47.5% vs. 42.9% vs. 41.5%, P ! 0.001), and in those with both upper and lower GI lesions (10.6% vs 14.6% vs. 22.8% vs. 26.2%, P ! 0.001). The frequency of clinically important colonic lesions identified proximal to the splenic flexure was significantly higher (P ! 0.001) in blacks (34.8%) and Hispanics (27.4%) than in whites (12.8%) or other ethnic groups (7.7%). In addition, there were significant differences in the prevalence of colonic adenomas R1 cm (17.5% vs. 27.1% vs. 28.6% vs. 32.3%, P Z 0.001) and colorectal cancer (7.4% vs. 14.5% vs. 7.1% vs. 6.2%, P Z 0.002) between whites, blacks, Hispanics, and other ethnic groups. Of those with colorectal cancer, advanced lesions (Dukes’ C & D) were significantly higher (P Z 0.02) in blacks (85.9%) and Hispanics (100%) than in whites (63.3%) and other ethnic groups (75.0%). Conclusions: Among patients with IDA, there are marked ethnic differences in the frequency, type, and distribution of clinically important GI lesions. These findings are important because of the high prevalence of IDA among blacks and Hispanics in the U.S., and may be helpful in guiding the appropriate GI evaluation of IDA.