Han-Chung Lien

Can percutaneous endoscopic jejunostomy prevent gastroesophageal reflux in patients with preexisting esophagitis

OBJECTIVE:Percutaneous endoscopic jejunostomy has been used for preventing pulmonary aspiration arising from gastric contents by concomitant jejunal feeding and gastric decompression in susceptible patients. Our objective was to evaluate gastroesophageal reflux in patients with percutaneous endoscopic jejunostomy tube feeding.METHODS:Eight cerebrovascular accident patients with percutaneous endoscopic jejunostomy tube placement caused by reflux esophagitis with hematemesis, food regurgitation or vomiting, and/or recurrent aspiration pneumonia were tested for gastroesophageal reflux using 24-h esophageal pH monitoring during continuous jejunal liquid meal or saline infusion with concomitant gastric decompression. Twenty-four hour pH monitoring was also performed during intragastric feeding on a different day.RESULTS:During the liquid meal feeding period, percutaneous endoscopic jejunostomy feeding reduced esophageal acid exposure 46% [12.9% (4.9–28.2%) versus 24.0% (19.0–40.6%), p= 0.01], compared to intragastric feeding. However, in the period of the jejunal tube infusion, esophageal acid exposure was significantly lower during saline infusion than during meal infusion [3.2 (0.0%–10.8%) versus 12.9% (4.9–28.2%), p= 0.008].CONCLUSION:Percutaneous endoscopic jejunostomy feeding reduced but did not eliminate gastroesophageal reflux, compared to intragastric feeding in patients with severe gastroesophageal reflux. However, gastroesophageal reflux during percutaneous jejunal feeding was associated with meal infusion. This might, in part, explain the failure of percutaneous endoscopic jejunostomy tube placement to prevent pulmonary aspiration.

Long-term follow up of gastric low-grade mucosa-associated lymphoid tissue lymphoma by endosonography emphasizing the application of a miniature ultrasound probe.

Background and Aims:  Endoscopic ultrasonography (EUS) is a useful tool for the evaluation of gastric wall infiltration including gastric lymphoma. The aims of this study were to characterize gastric low‐grade mucosa‐associated lymphoid tissue (MALT) lymphoma according to EUS findings and to evaluate the role of a miniature ultrasound probe in the long‐term follow up.

Effect of Cisapride on Gastric Dysrhythmia and Emptying of Indigestible Solids in Type-II Diabetic Patients

BACKGROUND Abnormal gastric slow-wave frequencies have been observed in diabetic gastroparesis. To evaluate the effect of cisapride on gastric dysrhythmia and emptying of indigestible solids, 20 type-II diabetic patients with symptoms suggestive of gastroparesis were enrolled in this study. METHODS Cutaneous electrogastrography, gastric emptying of radiopaque markers, and evaluation of upper gastrointestinal symptoms were performed before and after administration of an 8-week course of cisapride. RESULTS The fasting-state percentages of dominant frequency in normal and tachygastric ranges improved significantly after an 8-week course of cisapride treatment (P < 0.01 and P < 0.05, respectively). The post-meal percentages of dominant frequency in the tachygastric range also improved significantly after cisapride treatment (P < 0.05). The upper gastrointestinal symptoms score decreased significantly, and gastric emptying of radiopaque markers also increased significantly after 8 weeks of cisapride treatment (P < 0.01). CONCLUSIONS In conclusion, this study showed that cisapride can improve gastric dysrhythmia during both fasting and post-meal phases in patients with diabetic gastroparesis. In addition, upper GI symptoms and gastric emptying of indigestible solids may also show significant improvement after 8 weeks of cisapride treatment.

Abnormal acid reflux in asthmatic patients in a region with low GERD prevalence

BackgroundA high prevalence of gastroesophageal reflux disease (GERD) in asthmatic patients has been reported from North America and Europe. However, only a few data from Asia are available. This study evaluated the incidence of abnormal gastroesophageal reflux (GER) in asthmatic patients in Taiwan.MethodsFifty-six consecutive ambulatory patients with clinically stable asthma (41 men and 15 women; age, 57.7 ± 12.4 years; range, 24 to 74 years) were evaluated prospectively. All patients underwent esophagogastroduodenoscopy, esophageal manometry, and 24-h esophageal pH monitoring.ResultsTwenty-nine patients (51.8%) had abnormal GER, as defined by 24-h esophageal pH monitoring. There were 42 patients without endoscopic evidence of esophagitis, 10 patients with Los Angeles (LA) grade A esophagitis, and 4 patients with LA grade B esophagitis. The esophageal motility function studies revealed 21 patients with normal esophageal motility, 23 patients with ineffective esophageal motility (IEM), and 12 patients with nonspecific esophageal motility disorders other than IEM. Although the lower esophageal sphincter (LES) basal pressure was higher in the patients without GER, the difference was not statistically significant.ConclusionsAbnormal GER seems to be a clinically significant problem in asthmatic patients in Taiwan. The most common esophageal motility dysfunction is IEM. However, the status of Helicobacter pylori infection plays no role in abnormal GER.

Impact of body mass index and gender on quality of life in patients with gastroesophageal reflux disease

AIM To investigate the symptom presentation and quality of life in obese Chinese patients with gastroesophageal reflux disease (GERD). METHODS Data from patients diagnosed with GERD according to the Montreal definition, were collected between January 2009 to March 2010. The enrolled patients were assigned to the normal [body mass index (BMI) < 25 kg/m(2)], overweight (25-30 kg/m(2)), and obese (BMI > 30 kg/m(2)) groups. General demographic data, endoscopic findings, and quality of life of the three groups of patients were analyzed and compared. RESULTS Among the 173 enrolled patients, 102, 56 and 15 patients were classified in the normal, overweight, and obese, respectively. There was significantly more erosive esophagitis (73.3% vs 64.3% vs 39.2%, P = 0.002), hiatal hernia (60% vs 33.9% vs 16.7%, P = 0.001), and males (73.3% vs 73.2% vs 32.4%, P = 0.001) in the obese cases. The severity and frequency of heartburn, not acid regurgitation, was positively correlated with BMI, with a significant association in men, but not in women. Obese patients were prone to have low quality of life scores, with obese women having the lowest scores for mental health. CONCLUSION In patients with GERD, obese men had the most severe endoscopic and clinical presentation. Obese women had the poorest mental health.

The Effect of Jejunal Meal Feeding on Gastroesophageal Reflux

BACKGROUND Postprandial gastric distention is frequently associated with transient lower esophageal sphincter relaxation and gastroesophageal reflux (GER). Since the role of nutrient perfusion into the jejunum in inducing GER is not well understood, we studied the effect of jejunal feeding on GER through a percutaneous gastrojejunal tube in patients with and without reflux esophagitis. METHODS Nine stroke patients with reflux esophagitis were fed through a percutaneous gastrojejunal tube with either a liquid meal (2 kcal/2 ml/min) or saline for 2 h randomly on 2 separate days. An esophageal pH probe was placed 5 cm above the gastroesophageal junction to detect acid reflux. Six stroke patients without esophagitis were enrolled as controls. RESULTS In both the patients with esophagitis and the controls, esophageal acid exposure (15.3% (4.9%-28.2%) versus 2.7% (0.0%-10.8%), P=0.003; 5.9% (0.5%-6.7%) versus 0.0% (0.0%-1.5%), P = 0.01) and events of acid reflux (5 (1-16) versus 2 (0-8), P = 0.02; 12 (3-17) versus 1 (0-4), P = 0.02) were significantly greater during jejunal meal feeding than during saline infusion. Furthermore, in the reflux patients, but not in the controls, acid clearance time was also greater during jejunal meal feeding than during saline infusion (2.9 min (0.5-9.6 min) versus 0.7 min (0.0-4.3 min), P = 0.04). CONCLUSIONS We therefore conclude that jejunal nutrient infusion without gastric distention can induce GER in both patients with reflux esophagitis and controls. This implies that GER induced by jejununal nutrients may in part explain the incapability of jejunal tube feeding to prevent gastropulmonary aspiration in patients at risk.Background: Postprandial gastric distention is frequently associated with transient lower esophageal sphincter relaxation and gastroesophageal reflux (GER). Since the role of nutrient perfusion into the jejunum in inducing GER is not well understood, we studied the effect of jejunal feeding on GER through a percutaneous gastrojejunal tube in patients with and without reflux esophagitis. Methods: Nine stroke patients with reflux esophagitis were fed through a percutaneous gastrojejunal tube with either a liquid meal (2 kcal/2 ml/min) or saline for 2 h randomly on 2 separate days. An esophageal pH probe was placed 5 cm above the gastroesophageal junction to detect acid reflux. Six stroke patients without esophagitis were enrolled as controls. Results: In both the patients with esophagitis and the controls, esophageal acid exposure (15.3% (4.9%-28.2%) versus 2.7% (0.0%-10.8%), P = 0.003; 5.9% (0.5%-6.7%) versus 0.0% (0.0%-1.5%), P = 0.01) and events of acid reflux (5 (1-16) versus 2 (0-8), P = 0.02; 12 (3-17) versus 1 (0-4), P = 0.02) were significantly greater during jejunal meal feeding than during saline infusion. Furthermore, in the reflux patients, but not in the controls, acid clearance time was also greater during jejunal meal feeding than during saline infusion (2.9 min (0.5-9.6 min) versus 0.7 min (0.0-4.3 min), P = 0.04). Conclusions: We therefore conclude that jejunal nutrient infusion without gastric distention can induce GER in both patients with reflux esophagitis and controls. This implies that GER induced by jejununal nutrients may in part explain the incapability of jejunal tube feeding to prevent gastropulmonary aspiration in patients at risk.

Heartburn and regurgitation have different impacts on life quality of patients with gastroesophageal reflux disease.

AIM To investigate the impact of heartburn and regurgitation on the quality of life among patients with gastroesophageal reflux disease (GERD). METHODS Data from patients with GERD, who were diagnosed according to the Montreal definition, were collected between January 2009 and July 2010. The enrolled patients were assigned to a heartburn or a regurgitation group, and further assigned to an erosive esophagitis (EE) or a non-erosive reflux disease (NERD) subgroup, depending on the predominant symptoms and endoscopic findings, respectively. The general demographic data, the scores of the modified Chinese version of the GERDQ and the Short-form 36 (SF-36) questionnaire scores of these groups of patients were compared. RESULTS About 108 patients were classified in the heartburn group and 124 in the regurgitation group. The basic characteristics of the two groups were similar, except for male predominance in the regurgitation group. Patients in the heartburn group had more sleep interruptions (22.3% daily vs 4.8% daily, P = 0.021), more eating or drinking problems (27.8% daily vs 9.7% daily, P = 0.008), more work interferences (11.2% daily vs none, P = 0.011), and lower SF-36 scores (57.68 vs 64.69, P = 0.042), than patients in the regurgitation group did. Individuals with NERD in the regurgitation group had more impaired daily activities than those with EE did. CONCLUSION GERD patients with heartburn or regurgitation predominant had similar demographics, but those with heartburn predominant had more severely impaired daily activities and lower general health scores. The NERD cases had more severely impaired daily activity and lower scores than the EE ones did.

Gastric Dysrhythmia in Uremic Patients on Maintenance Hemodialysis

BACKGROUND Dyspeptic symptoms are common in uremic patients receiving hemodialysis. Investigators have placed emphasis on the changes in histopathology and physiology of the gastrointestinal tract. But not much data about the gastric myoelectric activity are available. The aim of this study was to assess gastric myoelectric activity in uremic patients undergoing hemodialysis. METHODS Fifty-eight subjects were enrolled. They were assigned to: group I, uremic patients undergoing hemodialysis with dyspeptic complaints (n = 20); group II, non-uremic patients with matched dyspeptic complaints (n = 20); and group III, healthy volunteers without dyspeptic complaints (n = 18). Gastric myoelectric activity was measured with abdominal surface electrodes in each person. Patients in group I were measured twice, before (group Ia) and after (group Ib) hemodialysis. The data were compared between the groups. RESULTS In the prehemodialysis period there was a significantly lower percentage of normal slow-wave frequency when compared with group III (fasting, 66.54%+/-5.39% versus 84.58%+/-3.63%; P < 0.005; fed, 72.25%+/-4.16% versus 89.06%+/-2.57%; P < 0.01). In the post-hemodialysis period the difference was even more profound (fasting, 46.52%+/-4.26% versus 84.58%+/-3.63%; P < 0.001; fed, 51.49%+/-6.89% versus 89.06%+/-2.57%; P < 0.005). Yet, when compared with group II, a significant difference existed only in the post-hemodialysis period (fasting, 46.52%+/-4.26% versus 67.30%+/-3.46%; P<0.001; fed, 51.49%+/-6.89% versus 70.41%+/-4.39%; P < 0.01). Another finding is that hemodialysis decreased the gastric myoelectric activity after hemodialysis (fasting, 66.54%+/-5.39% versus 46.52%+/-4.26%; P < 0.001; fed, 72.25%+/-4.16% versus 51.49%+/-6.89%; P < 0.005). CONCLUSIONS Uremic patients undergoing hemodialysis have impaired gastric myoelectric activity. Interestingly, hemodialysis seems to cause deterioration in gastric myoelectric activity.

TUBERCULOUS LIVER ABSCESS IN A CASE WITHOUT LUNG INVOLVEMENT

Hepatic tuberculosis is an uncommon form of extrapulmonary tuberculosis, particularly when it presents in the form of liver abscess. Here, we report a 64‐year‐old man who was admitted to our hospital having experienced intermittent chills for 3 months. Aspiration of the liver abscess revealed neither bacteria nor acid‐fast bacilli, but pus and granulation tissue were found. Antituberculous therapy was started empirically and cultures of the abscess confirmed the presence of Mycobacterium tuberculosis 3 weeks later. We suggest that tuberculous liver abscess should be considered in patients not showing typical features or who fail to respond to antibiotics.

Proton Pump Inhibitors Did Not Increase Risk of Pneumonia in Patients With Chronic Obstructive Pulmonary Disease

Background Chronic obstructive pulmonary disease (COPD) involves the airways and pneumonia is a major cause of mortality. Proton pump inhibitors (PPIs) were found to have a positive association with pneumonia. The aim of this study was to investigate the impact of PPIs on the risk of pneumonia in patients with COPD. Methods This was a nationwide, population-based, case-control study using data from the National Health Insurance Research Database in Taiwan. The enrolled cases were defined as patients with COPD and appearance of pneumonia between 2001 and 2005. The control group was age- and sex-matched 1:2 with the cases without pneumonia. Potential confounders such as coronary artery disease, hypertension, diabetes mellitus, heart failure, chronic kidney disease, and prescriptions of glucocorticoids over 2 weeks, were included in the analysis. Prescriptions for PPIs were identified and entered into the analysis. Results A total of 10,131 COPD patients, including 3,377 cases with pneumonia and 6,754 without, were identified. There were 213 (5.3%) and 436 (6.5%) cases with concurrent PPIs in the two groups, respectively, and the risk of pneumonia was similar (aOR = 0.96; 95% CI: 0.83 - 1.10). Further subgroup analysis found no differences for younger patients (younger than 70 years old; aOR = 1.04; 95% CI: 0.83 - 1.10), elderly patients (older than 70 years old; aOR = 0.96; 95% CI: 0.81 - 1.15), short-term use of PPIs (less than 30 days; aOR = 1.12; CI: 0.53 - 2.34), medium-term use of PPIs (30 - 90 days; aOR = 0.86; CI: 0.72 - 1.03), or long-term use of PPIs (longer than 90 days; aOR = 0.97; CI: 0.81 - 1.15). Conclusion PPIs did not contribute to a greater occurrence of pneumonia in COPD patients compared with non-users in this population-based case-control study. Further research is required.