Hack J. Kim

A randomized controlled trial of a probiotic combination VSL# 3 and placebo in irritable bowel syndrome with bloating.

Abstract  Aim:  To evaluate the effects of a combination probiotic on symptoms and colonic transit in patients with irritable bowel syndrome (IBS) and significant bloating.

An economic analysis of endoscopic ablative therapy for management of nondysplastic Barrett's esophagus.

BACKGROUND AND AIMS Advances have occurred in the development of safe and effective ablative therapies for Barretts esophagus. The aim of the current study was to perform an economic analysis evaluating the cost-effectiveness of endoscopic ablation of nondysplastic Barretts esophagus. METHODS A Markov model evaluated three competing strategies in a hypothetical 50-year-old cohort with nondysplastic Barretts esophagus from a societal perspective. Strategy I -- natural history of Barretts disease (without surveillance); Strategy II -- surveillance performed according to the American College of Gastroenterology practice guidelines; Strategy III -- endoscopic ablative therapy. The model was biased against ablative therapy with a conservative estimate of complete response and continued standard surveillance even after complete ablation. All potential complications were accounted for, and an incomplete histological response after ablation was presumed to have the same risk of progression as untreated Barretts. Transitional probabilities, discounted cost, and utility values to estimate quality-adjusted life-years (QALY) were obtained from published information. Direct costs were used in our analysis. RESULTS In baseline analysis, the ablative strategy yielded the highest QALY and was more cost-effective than endoscopic surveillance. In a Monte Carlo analysis, the relative risk of developing cancer in the strategy based on endoscopic ablation was decreased compared with the other strategies. In threshold analysis, the critical determinants of cost-effectiveness of the ablative strategy were rate of complete response to ablation, total cost of ablation, and risk of progression to dysplasia. CONCLUSIONS Within the limits of the model, ablation for nondysplastic Barretts esophagus is more cost-effective than endoscopic surveillance. Clinical trials of ablative therapy in nondysplastic Barretts esophagus are needed to establish its effectiveness in reducing cancer risk.

Obesity is associated with increased 48-h esophageal acid exposure in patients with symptomatic gastroesophageal reflux

OBJECTIVES:Obesity has been associated with gastroesophageal reflux disease (GERD) but the relationship between body mass index (BMI) and esophageal acid exposure remains poorly understood. We hypothesized that overweight (OW) and obese (OB) patients with GER symptoms would have a higher degree of esophageal acid exposure than with normal weight (NW) patients.METHODS:157 patients separated in groups according to BMI were studied for 48h while off antisecretory medications using ambulatory wireless capsule pH-metry. The pH capsule was appropriately positioned and esophageal pH data were collected. Appropriate univariate and multivariate statistical methods were used.RESULTS:Groups did not differ in age, but more women were in the NW group. OB patients had a fivefold increase in odds for abnormal total acid exposure compared with NW (OR=5.01; 95% CI 2.94, 12.95). Total acid exposure time (AET) was elevated in OB (8.7%±5.1%) compared with NW (5.3%±5.2%; P<0.05). AET was highest during awake, upright periods. The DeMeester score was higher in OB (31.7±19.2) and OW (26.0±16.8) groups compared with the NW (19.8±17.6) group (P<0.001). AET increased from day 1 to day 2 in the OB group only.CONCLUSIONS:This is the first study to report a positive relationship between BMI and esophageal acid exposure time using prolonged, continuous wireless esophageal pH-metry. Abnormal AET was more frequent in OB patients. Variability in AET increased from day 1 to day 2 in the OB group, supporting the use of more prolonged pH studies in subsets of patients.

An Unusual Case of Colon Perforation Complicating Acute Pancreatitis.

Colonic complications of severe acute pancreatitis occur rarely. Although there have been several theories on how pancreatic pseudocysts rupture into the colon, the exact pathogenesis remains unknown. We report an unusual case of pseudocysts complicating severe acute pancreatitis presenting with colonic perforation in a 71-year-old man with a history of chronic mesenteric ischemia. Pressure effects from a giant pseudocyst and intravascular volume depletion with acute insult on chronic mesenteric ischemia are highlighted as possible etiologic factors.

Comparison of the impact of wireless versus catheter-based pH-metry on daily activities and study-related symptoms

Aims To evaluate the variation in tolerance to wireless pH-metry compared with catheter-based pH-metry, and to determine clinical characteristics that might predict reduced tolerance to wireless pH-metry. Methods Consecutive outpatients (n=341) completing wireless (n=234) or catheter-based pH-metry (n=106) were evaluated. All patients completed the pH-Metry Impact Scale and the pH-Metry Symptoms Scale to assess the impact of the pH-metry on activities of daily living and pH-metry associated changes in study-related symptoms. All data are presented as mean (SD) or odds ratios (95% confidence interval). Results The impact of pH-metry on activities of daily living were modest, but wireless pH-metry had less impact than catheter-based pH-metry (P=0.01). A sense of foreign body in the chest, chest discomfort, and chest pain were reported more frequently during wireless pH-metry. Difficulty swallowing and painful swallowing were more common during catheter-based pH-metry. Noncardiac chest pain was associated with increased symptom severity. Patients with poor tolerance were twice as likely to have a diagnosis of noncardiac chest pain (odds ratio=2. 53; 95% confidence interval, 1.4-4.6). Conclusions Wireless pH-metry has less of an impact on activities of daily living but is not associated with fewer study-related symptoms compared with catheter-based pH-metry. The prevalence of specific study-related symptoms does differ between the 2 groups and noncardiac chest pain seems to be the primary risk factor for more severe study-related symptoms and reduced tolerance for wireless pH-metry. This information may be useful in helping to decide which patients should undergo the wireless pH-metry or receive additional counseling on procedural expectations.

Methods to Measure Small-Bowel and Colonic Transit

Radiopaque markers provide a robust, inexpensive, and practical measurement of colonic transit. Scintigraphy has been simplified and provides information about transit throughout the gut.

996 Achalasia Subtypes: an Assessment of Inter- And Intra-Rater Reproducibility

of the c-kit gene in a case control-study of achalasia. Method: Eighty eight achalasia patients diagnosed by esophageal manometry and 101 healthy controls were included in the study. Genomic DNA was isolated from the peripheral blood, amplified and the results were analyzed using melting curve analysis. Results: The T allele at the rs6554199 locus was significantly associated with achalasia (p=0.03 OR: 1.55; 95%CI, 1.03-2.34). In a T dominant model, TT+GT genotype was significantly more frequent in achalasia patients (80.7%) than controls (65.3%) (p=0.02; OR: 2.21; %95CI, 1.13-4.32). Within the achalasia group, the presence of the G allele (GG+GT) increases the occurrence of regurgitation (p=0.008; OR: 5.09; 95% CI 1.56-16.58). The polymorphism at rs2237025 was not associated with achalasia. Conclusion: The T allele at rs6554199 of the c-kit gene is significantly associated with achalasia in this population. The functional consequences of this variant in achalasia remain to be determined. The distribution of rs6554199 polymorphism