C. Pera

Predictive factors of the long term outcome in gastro-oesophageal reflux disease: six year follow up of 107 patients.

There is little information concerning the long term outcome of patients with gastro-oesophageal reflux disease (GORD). Thus 109 patients with reflux symptoms (33 with erosive oesophagitis) with a diagnosis of GORD after clinical evaluation and oesophageal testing were studied. All patients were treated with a stepwise approach: (a) lifestyle changes were suggested aimed at reducing reflux and antacids and the prokinetic agent domperidone were prescribed; (b) H2 blockers were added after two months when symptoms persisted; (c) anti-reflux surgery was indicated when there was no response to (b). Treatment was adjusted to maintain clinical remission during follow up. Long term treatment need was defined as minor when conservative measures sufficed for proper control, and as major if daily H2 blockers or surgery were required. The results showed that one third of the patients each had initial therapeutic need (a), (b), and (c). Of 103 patients available for follow up at three years and 89 at six years, respective therapeutic needs were minor in 52% and 55% and major in 48% and 45%. Eighty per cent of patients in (a), 67% in (b), and 17% in (c) required only conservative measures at six years. A decreasing lower oesophageal sphincter pressure (p < 0.001), radiological reflux (p = 0.028), and erosive oesophagitis (p = 0.031), but not initial clinical scores, were independent predictors of major therapeutic need as shown by multivariate analysis. The long term outcome of GORD is better than previously perceived.

Deterioration of esophageal motility with age : A manometric study of 79 healthy subjects

OBJECTIVES:Data are limited on the effect of age on esophageal function. We evaluated whether aging influences the motor activity of the esophagus.METHODS:Standard esophageal manometry was performed in 79 healthy, nonpaid volunteers of both sexes, 18–73 yr of age. Lower (LES) and upper esophageal sphincter (UES) characteristics and the properties of esophageal peristaltic waves were assessed by age groups: ≤25 yr, 26–35 yr, 36–45 yr, 46–55 yr, 56–65 yr, and >65 yr.RESULTS:Age correlated inversely with LES pressure and length, UES pressure and length, and peristaltic wave amplitude and velocity, and correlated directly with the proportion of simultaneous contractions. Age was inversely correlated with the upper limits of normality (95th percentiles) of LES pressure (r =−0.943, p= 0.005), UES pressure (r =−0.943, p= 0.005), middle and lower peristaltic wave amplitude (r =−0.947, p= 0.004, and r =−0.844, p= 0.035, respectively), upper/middle peristaltic progression speed (r =−0.943, p= 0.005), and the proportion of simultaneous contractions (r = 0.926, p= 0.008), but not with the lower normal limits (5th percentiles) of these variables. Gender did not affect esophageal motility variables. The 95th percentiles of LES pressure differed by 20 mm Hg, those of lower peristaltic amplitude by 82 mm Hg, and those of percent simultaneous contractions by a factor of 2, between the younger and the older age groups.CONCLUSIONS:The results suggest that normal esophageal motility deteriorates with advancing age. Thus, age-related normality limits of esophageal pressures should be considered before establishing the manometric diagnosis of hypercontractile esophageal motility disorders.

Randomized trial of portacaval shunt, stapling transection and endoscopic sclerotherapy in uncontrolled variceal bleeding

Seventy consecutive cirrhotic patients with persistent or recurrent variceal bleeding were included in a clinical trial to compare the efficacy and safety of portacaval shunt (PCS) and stapler transection (ST) in patients with low surgical risk, and of stapler transection and endoscopic sclerotherapy (ES) in patients with high surgical risk. To classify the patients into low- and high-risk groups a new scoring system was used, based on an analysis of factors influencing operative mortality in an earlier series of emergency portacaval shunt. Thirty-eight low-risk patients were randomly allocated for treatment with portacaval shunt (19 patients) or stapler transection (19 patients), and 32 high-risk patients for stapler transection (17 patients) or ES (15 patients). The operative mortality of patients treated by PCS was close to that expected according to retrospective data, this indicating that the proposed scoring system is highly discriminant. In low-risk patients, portacaval shunt evidenced greater haemostatic efficacy and fewer complications than stapler transection. However, hepatic encephalopathy during follow-up was more frequent in the portacaval shunt group and there were no significant differences in operative mortality and long-term survival between the two groups. In high-risk patients, stapler transection and sclerotherapy had a similar haemostatic efficacy, operative mortality and long-term survival. However, sclerotherapy occasioned fewer complications than stapler transection. Our results motivate us to recommend stapler transection for low-risk patients and to consider sclerotherapy as an alternative for high-risk patients in the emergency treatment of uncontrolled variceal bleeding.

Obstructing colorectal carcinomas: Prospective study

Intestinal obstruction owing to colonic carcinoma is a relatively frequent cause of acute abdominal pain. The aim of this prospective study is to evaluate the prognostic factors that may influence the final outcome of those patients operated upon for an intestinal obstruction (OG) as opposed to those electively operated upon (EG). From September 1984 to March 1988, a total of 188 patients with colorectal cancer have been included in the study. One hundred thirty-five were EG, while 53 (28.1 percent) were OG. The mean ages were similar in both groups. Sex, morbidity, and mortality rates were equally distributed. Curative resection rate was significantly higher in the EG group (P=0.029). Tumor staging tended to be significantly more advanced in OG patients (chi-square = 9.054;df=3;P=0.026). Multivariate analysis (proportional hazards model) showed that the only independent prognostic factor was tumor staging (P=0.0000). Obstruction itself disappears as a predictive variable when tumor staging is introduced in the model. We conclude that obstructing colon carcinomas tend to be more locally advanced, that probably being the only reason for a worse long-term prognosis.

Lack of effect of metoclopramide and domperidone on esophageal peristalsis and esophageal acid clearance in reflux esophagitis: A randomized, double-blind study

The acute effects of oral metoclopramide (40 mg/day) and domperidone (80 mg/day) on esophageal motor activity and acid reflux were assessed in a randomized, double-blind, placebo-controlled study in 20 patients with erosive reflux esophagitis. Esophageal motor function was assessed by standard manometry with wet swallows, and reflux events were evaluated by ambulatory 24-hr pH-monitoring. Both drugs caused a significant (P<0.05) increase in lower esophageal sphincter pressure lasting at least 120 min. However, neither esophageal body motility, duration of esophageal exposure to acid, nor esophageal clearance were effected by drug administration in comparison to placebo. Side effects were reported in two patients who received metoclopramide, while no adverse effects occurred after domperidone intake. In conclusion, the so-called motility agents metoclopramide and domperidone have few acute effects on esophageal motility in patients with erosive reflux esophagitis.

Sclerosing cholangitis after surgical treatment of hepatic echinococcal cysts: Report of three cases

Three patients with sclerosing cholangitis after surgical treatment of echinococcosis of the liver are described. Before surgery, they had clinical symptoms that suggested a communication between the cyst and the biliary tract and, in two of them, the communication was later demonstrated by cholangiography. In each case, the cyst was injected with formalin solution. Soon after operation chronic cholestasis developed, with operative, cholangiographic, and histologic data suggesting sclerosing cholangitis. The role of formalin in the pathogenesis of this condition is discussed herein.

DYSPHAGIA AND ESOPHAGEAL MOTOR DYSFUNCTION IN GASTROESOPHAGEAL REFLUX ARE CORRECTED BY FUNDOPLICATION

Abnormalities in esophageal peristaltic function and acid clearance appear to be responsible for prolonged esophageal acid exposure, a major determinant of the reflux esophagitis and esophageal stricture. We evaluated esophageal motility by manometry in 50 healthy controls and in 35 symptomatic reflux patients before, within 6 months, and 1 year after Nissen fundoplication. Preoperative motility was analyzed in relation to the presence or absence of both nonobstructive dysphagia and erosive esophagitis. We found that (a) preoperative dysphagia was related more to peristaltic dysfunction than to esophagitis; (b) peristaltic wave amplitude and duration were significantly lower than control values in patients with reflux, without correlation to degree of esophagitis or lower esophageal sphincter hypotension; (c) dysphagia ceased in most patients after antireflux surgery at the same time that normal motility was restored independently of lower esophageal sphincter pressure increments. These results suggest that motility disturbances are an important cause of dysphagia in reflux disease, and that reflux is the cause of, rather than the consequence of, peristaltic dysfunction.

High amplitude contractions in the middle third of the oesophagus: a manometric marker of chronic alcoholism?

BACKGROUND--Oesophageal motor abnormalities have been reported in alcoholism. AIM--To investigate the effects of chronic alcoholism and its withdrawal on oesophageal disease. PATIENTS--23 chronic alcoholic patients (20 men and three women; mean age 43, range 23 to 54). METHODS--Endoscopy, manometry, and 24 hour pH monitoring 7-10 days and six months after ethanol withdrawal. Tests for autonomic and peripheral neuropathy were also performed. Motility and pH tracings were compared with those of age and sex matched control groups: healthy volunteers, nutcracker oesophagus, and gastro-oesophageal reflux disease. RESULTS--14 (61%) alcoholic patients had reflux symptoms, and endoscopy with biopsy showed oesophageal inflammation in 10 patients. One patient had an asymptomatic squamous cell carcinoma. Oesophageal motility studies in the alcoholic patients showed that peristaltic amplitude in the middle third was > 150 mm Hg (95th percentile (P95) of healthy controls) in 13 (57%), the ratio lower/ middle amplitude was < 0.9 in 15 (65%) (> 0.9 in all control groups), and the lower oesophageal sphincter was hypertensive (> 23.4 mm Hg, P95 of healthy controls) in 13 (57%). All three abnormalities were present in five (22%). Abnormal reflux (per cent reflux time > 2.9, P95 of healthy controls) was shown in 12 (52%) alcoholic patients, and was unrelated to peristaltic dysfunction. Subclinical neuropathy in 10 patients did not effect oesophageal abnormalities. Oesophageal motility abnormalities persisted at six months in six patients with ongoing alcoholism, whereas they reverted towards normal in 13 who remained abstinent; reflux, however, was unaffected. CONCLUSIONS--Oesophageal peristaltic dysfunction and reflux are frequent in alcoholism. High amplitude contractions in the middle third of the oesophagus seem to be a marker of excessive alcohol consumption, and tend to improve with abstinence.

Utility of inpatient 24-hour intraesophageal pH monitoring in diagnosis of gastroesophageal reflux.

The aims of the present study were to evaluate the accuracy of 24-hr intraesophageal pH monitoring in the diagnosis of gastroesophageal reflux in the hospital setting and to establish whether there were any differences in terms of reflux events between patients with and without endoscopic esophagitis. Fifteen control subjects and 47 patients with proven gastroesophageal reflux disease were studied. A composite score of reflux events (number of reflux episodes; total, upright, and supine reflux time; number of refluxes lasting more than 5 min; and duration of the longest reflux) provided the best discrimination between controls and patients (94% sensitivity and 100% specificity). Patients with esophagitis showed concurrently a longer total reflux time and supine reflux time, and more prolonged reflux episodes than those without esophagitis. On the other hand the severity of esophagitis was directly related to the duration of both total and supine reflux. The results indicate that inpatient 24-hr pH-metry is very accurate in the diagnosis of gastroesophageal reflux. They also suggest that prolonged esophageal exposure to acid, particularly at night, and slow esophageal acid clearing are factors that determine the appearance and/or perpetuation of esophagitis in patients with reflux.

Effects of Red Wine on 24-Hour Esophageal pH and Pressures in Healthy Volunteers

The purpose of this study was to assess theeffects of red wine taken with meals on esophagealmotility, esophageal exposure to acid, and gastric pH.Following a randomized design, 14 healthy malevolunteers (mean age 25 years, range 18 -35 years weregiven 360 ml of red wine or tap water during lunch ordinner. All subjects underwent ambulatory 24-hresophageal motility and esophagogastric pH monitoringstudies. Three different periods were analyzed: duringmeals (30 min), postprandial (3 hr), and 8-hr supine.Two volunteers complained of heartburn after wineingestion. An increase in the number of high amplitude waves (>125 mm Hg, 95th percentile of ourmotility unit controls) was observed during mealsaccompanied by wine: water 1.2 (0-10.2), wine 1.6(0-32.6), P = 0.02 [median (range)]. No other esophagealmotility changes occurred. Percent reflux time increasedduring the postprandial period after wine ingestion incomparison with water: 1.7 (0-14.9) vs 0.1 (0- 0.8), P< 0.05. Gastric pH was unaffected by the type of drink. Ingestion of moderate amounts of redwine with meals increases postprandial esophagealexposure to gastric acid in healthy persons.