Jürgen Barnert

Diagnosis and management of lower gastrointestinal bleeding

Lower gastrointestinal bleeding (LGIB) can present as an acute and life-threatening event or as chronic bleeding, which might manifest as iron-deficiency anemia, fecal occult blood or intermittent scant hematochezia. Bleeding from the small bowel has been shown to be a distinct entity, and LGIB is defined as bleeding from a colonic source. Acute bleeding from the colon is usually less dramatic than upper gastrointestinal hemorrhage and is self-limiting in most cases. Several factors might contribute to increased mortality, a severe course of bleeding and recurrent bleeding, including advanced age, comorbidity, intestinal ischemia, bleeding as a result of a separate process, and hemodynamic instability. Diverticula, angiodysplasias, neoplasms, colitis, ischemia, anorectal disorders and postpolypectomy bleeding are the most common causes of LGIB. Volume resuscitation should take place concurrently upon initial patient assessment. Colonoscopy is the diagnostic and therapeutic procedure of choice, for acute and chronic bleeding. Angiography is used if colonoscopy fails or cannot be performed. The use of radioisotope scans is reserved for cases of unexplained intermittent bleeding, when other methods have failed to detect the source. Embolization or modern endoscopy techniques, such as injection therapy, thermocoagulation and mechanical devices, effectively promote hemostasis. Surgery is the final approach for severe bleeding.

Antral emptying of semisolid meal measured by real-time ultrasonography in chronic renal failure.

The etiology of upper digestive complaints in uremic patients, which frequently cause morbidity, is unclear. By means of ultrasonography we studied the emptying of the gastric antrum in 15 patients suffering from end-stage renal disease and in 15 controls. In addition, we tested for autonomic neuropathy in the chronic renal failure (CRF) patients using cardiovascular tests. The antral filling and emptying of a semisolid standardized test meal was assessed by measuring cross-sectional areas of the antrum along the plane of the mesenteric vein at regular intervals after a semisolid test meal. Postprandial antral cross-sectional areas were similar in controls and in the total of the renal failure patients. CRF patients without autonomic neuropathy (4/15) showed hastened antral emptying as evidenced by significantly diminished postcibal antral expansion. Only the CRF subgroup with symptoms of both parasympathetic plus sympathetic autonomic neuropathy (6/15) had delayed antral emptying compared to controls as assessed by planimetry of the area under the curve in postprandial antral cross-sectional areas. The CRF subgroup with exclusively parasympathetic neuropathy (5/15) had antral emptying similar to the controls. The symptom score as assessed by a standardized questionnaire of the CRF group with autonomic neuropathy (11/15) correlated significantly both with the fasting antral cross-sectional area and inversely with antral expansion immediately after finishing the test meal. Antral emptying showed a trend towards an inverse relationship to the symptom score, which reached statistical significance only in the CRF subgroup with sympathetic plus parasympathetic autonomic damage. We conclude that antral filling and emptying is disturbed in patients with CRF and that these disturbances may explain dyspeptic symptoms in the patients. The information provided by ultrasonography surpasses that of scintigraphic techniques.

Autonomic dysfunction and the gastrointestinal tract.

Autonomic neuropathy of the gastrointestinal tract may represent a primary disorder, but much more often it is secondary due to systemic disorders like diabetes mellitus. This review gives an overview about the common clinical manifestations and the principles and limitations in diagnostic work-up of autonomic dysfunction of the gastrointestinal tract. Diagnostic evaluation usually includes a combination of screening tests for autonomic neuropathy and specialized diagnostic procedures for the detection of sequela of autonomic neuropathy in gastrointestinal motility.

Gastric emptying in liver cirrhosis. The effect of the type of meal

Objective: Contradictory reports have been published on gastric emptying in patients with liver cirrhosis. The differences have been attributed to differences in the innervation of the stomach or in the behaviour of the gastric wall. The type of test meal used may, however, have its importance. We looked for the role of the test meal in the assessment of gastric emptying in cirrhosis. Design: In a prospective study, we included 15 patients with liver cirrhosis who had no symptoms of autonomic neuropathy, portal hypertensive gastropathy or antral vascular ectasia and 15 controls. In these subjects we estimated the gastric emptying and varied the type of test meals. Methods: An ultrasonographic method was used for the estimation of gastric emptying. Antral area was monitored in the aorto‐mesenteric plane in the fasting condition and at 0, 15, 30, 45, 60min after a test meal. Each patient was tested twice on 2 consecutive days in randomized order with a liquid meal (220kJ) and a semisolid meal (1472 kJ). Results: Fasting antral areas (mean±SD) had similar size in both groups with both meals. Gastric emptying (expressed by the area under the curve and half‐time (T1/2)) of the semisolid meal was not different in cirrhosis (2347 ±1648) compared to controls (2840±1983). Postprandial antral distension was also similar in both groups (312.2 ± 133.6% in cirrhosis vs. 397.9±155.6% in controls). But emptying of the liquid meal was accelerated in the cirrhotic patients with respect to the area under the curve (AUC: 882 ±548) and half‐time (12 ±2 min) vs. controls (AUC: 1863 ±1088, P<0.01; T1/2: 18±7 min, P<0.05). Postprandial antral distension with the liquid meal was decreased (299.4±76.5% vs. 431.5±154.0%, P<0.01, in controls). Conclusion: These data suggest that in patients with liver cirrhosis free of autonomic neuropathy and without portal hypertensive gastropathy or vascular antral ectasia, gastric emptying of liquid low calorie meals is accelerated. The gastric emptying of a semisolid meal richer in calories is normal. Thus, the physical and chemical properties of a meal are major determinants of gastric emptying and may account for the large divergence of results hitherto published on this topic.

The effect of cisapride on dysmotility-like functional dyspepsia: reduction of the fasting and postprandial area, but not of the postprandial antral expansion.

Objective To test the effect of cisapride on symptom score and on fasting and postprandial antral area in patients with dysmotility-like functional dyspepsia compared with controls. Methods Nineteen consecutive patients with dysmotility-like functional dyspepsia (13 females, six males, aged 18–79 y) and 12 control subjects (six females, six males, aged 19–68 y) were investigated. A symptom score including six upper digestive symptoms rated from 0 to 3 was applied. The patients received in a randomized order cisapride 10 mg t.i.d. (n = 10), or placebo (n = 9) for 3 days. The controls also received cisapride (n = 6) or placebo (n = 6) in the same way. The antral area in fasting condition and immediately after a semiliquid test meal (250 ml, 342 kcal) was assessed by real-time ultrasonography in front of the aorta and mesenteric vein. The measurements were carried out before starting and after finishing the trials with cisapride and placebo. Results The symptom score (mean ± SD) was 7.1 ± 2.4 in dysmotility-like functional dyspepsia vs 0.5 ± 0.2 in controls (P < 0.0001). The fasting antral area was 4.5 ± 0.9 cm2 in dysmotility-like functional dyspepsia vs 2.2 ± 0.2 cm2 in controls (P < 0.0001). Postprandial antral area was also larger in dysmotility-like dyspepsia than in controls (6.2 ± 1.0 vs 3.0 ± 0.3 cm2, P = 0.0001). Symptom score correlated with fasting antral area in dysmotility-like functional dyspepsia (r = 0.38, P = 0.05). Cisapride decreased the symptom score to 4.5 ± 2.5 (P= 0.0009) and placebo to 5.3 ± 2.4 (P=0.02). Cisapride significantly reduced the fasting antral area and the postprandial antral area in the dyspeptic group, but not in the control group. Postprandial antral expansion was not influenced by cisapride. Placebo did not change the sonographic parameters in both groups. Conclusions In dysmotility-like functional dyspepsia, fasting and postprandial antral areas are wider than in controls. Despite a good placebo response, cisapride is effective in improving the symptoms in dysmotility-like functional dyspepsia, associated with the reduction of fasting and postprandial antral areas.

Postprandial gastric relaxation in achalasia

Background In achalasia the incidence of autonomie neuropathy is increased, indicating that achalasia is not a disease of the oesophagus only. Little information is available concerning the function of the stomach in achalasia. We compared the postprandial gastric fundus relaxation in patients with achalasia to that of healthy controls. Methods In six patients with achalasia and six healthy controls postprandial fundus relaxation after a liquid test meal (500 ml, 500 kcal) was studied using an intragastric bag connected to an electronic barostat. The postprandia gastric relaxation was measured as an increase of intragastric bag volume; bag pressure was set at a constant level of 1 mmHg above the intra-abdominal pressure. All data are given as means ± SEM, and the Mann-Whitney test was used for statistical analysis. Results The intragastric volume before ingestion of the test meal was not different between groups. The maximum relaxation in patients with achalasia was significantly lower than in controls (132 ± 46 ml vs 238 ± 70 ml, P < 0.02). Postprandial relaxation was diminished and shortened in patients with achalasia as compared with controls. Similarly, the area under the volume curve was significantly smaller in patients with achalasia than in controls (29.8 ± 28.9 ml/h vs 102.9 ± 58.4 ml/h, P < 0.03) consistent with a diminished postprandial relaxation. Conclusion Patients with achalasia show a decreased postprandial gastric relaxation compared with healthy controls. We hypothesize that the neural damage in achalasia is not restricted to the oesophagus, but also involves the proximal stomach.

Eradication of Helicobacter pylori in peptic ulcer disease with amoxycillin, 2.0g, and omeprazole, 80 or 120mg: a prospective randomized trial

BACKGROUND The appropriate dose of proton pump inhibitors needed for eradicating Helicobacter pylori by dual therapy is still controversial. DESIGN The study was conducted as a single-blind, single-centre trial. METHODS Fifty-four patients with active duodenal ulcers were treated with amoxycillin tablets, 750 mg three times daily, and omeprazole, either 40 mg twice daily (group 1) or 40 mg three times daily (group 2), for 14 days in a prospective randomized trial. H. pylori eradication was assessed 10 weeks after starting treatment. Biopsies were taken for rapid urease tests and histological analysis and 13C-urea breath tests were ordered. RESULTS In both groups ulcer healing was complete in 96.3% of patients after 10 weeks. Ten weeks after starting treatment, Helicobacter pylori was eradicated in 76.9% of the patients in group 1 and 74.1% of those in group 2, as shown by rapid urease tests and histological analysis. In the subgroup of fully compliant patients (n = 49) the eradication rates were 80% and 79.2%, respectively. Hyperacidity significantly reduced the eradication rates. Patients showing successful H. pylori eradication were significantly older (59 +/- 14.0 years vs. 49 +/- 15.6 years; P = 0.025). Eradication rates were lower in smokers than in non-smokers (36.4% vs. 83.9%; P = 0.006). CONCLUSION It is concluded that higher omeprazole doses should be reserved for younger patients and smokers; in others they are not needed.

24-hour oesophageal motility in gastro-oesophageal reflux disease (GORD) : increased occurrence of simultaneous contractions

Impaired oesophageal peristalsis may play a major pathogenetic role in gastro-oesophageal reflux disease (GORD). Therefore 55 patients with suspected GORD were studied simultaneously by ambulatory 24-hour pH and pressure monitoring with three pressure transducers (3, 8 and 13 cm above the lower oesophageal sphincter) in order to to test for a relationship between oesophageal motility and GOR. Twenty-one patients (38%) had pathological reflux; these patients had significantly more simultaneous contractions than patients without pathological GOR (30.1 +/- 3.3% vs. 19.0 +/- 1.8%, P = 0.002, mean +/- SEM). Further analysis revealed a significant difference between groups in the occurrence of simultaneous contractions in the mid-oesophagus (33.7 +/- 3.8% vs. 23.9 +/- 1.8%, P = 0.012), but not in the distal oesophagus (34.4 +/- 2.7% vs. 33.9 +/- 3.1%, P = 0.90). In addition, a moderate but highly significant correlation between the rate of simultaneous contractions and reflux time was found (r = 0.463, P = 0.0005). Mean amplitude and mean duration of the contractions were no different between groups, neither in the proximal (43.4 +/- 3.3 mmHg vs. 44.9 +/- 1.9 mmHg, P = 0.68 and 2.4 +/- 0.2s vs. 2.5 +/- 0.1s, P = 0.50, respectively) nor in the distal oesophagus (48.8 +/- 4.6 mmHg vs. 54.2 +/- 3.4 mmHg, P = 0.34 and 3.0 +/- 0.2s vs. 2.9 +/- 0.2s, P = 0.71, respectively). It was concluded that pathological GOR is associated with an increased occurrence of simultaneous contractions in the mid, but not in the distal, oesophagus.

Dyspepsia in AIDS is correlated to ultrasonographic changes of antral distension

OBJECTIVES Patients with acquired immune deficiency syndrome (AIDS) frequently complain about dyspeptic symptoms. We set out to test whether changes in antral emptying or antral distension may account for these dyspeptic symptoms in AIDS. METHODS We studied antral emptying in ten patients with HIV infection (CDC 1993 classification stage C) by means of an established real-time ultrasonographic method. Organic abdominal lesions had been excluded. Six upper gastrointestinal symptoms were evaluated using a score ranging from 0 to 3. Fifteen subjects without any abdominal complaints and without any abdominal history served as controls. Antral cross sectional area was measured after an overnight fast and at 0, 15, 30, 45, 60, 90, 120 min after an semisolid test meal. Antral postprandial distension was expressed using an antral expansion ratio (postcibal antral area/fasting antral area). Gastric emptying of the test meal was derived from the measurement of the area under the postcibal antral distension curve (AUC). RESULTS Fasting antral cross sectional area and AUC (gastric emptying) were similar in both groups. Antral postprandial expansion tended to be lower in AIDS patients compared to controls (mean+/-S.D.): 288+/-84 versus 397+/-156%; P=0.08. In AIDS patients the symptom score of dyspepsia showed a positive correlation (r=0.55; P<0.05) with fasting antral area and a negative correlation (r=-0.62; P<0.05) with postprandial expansion. No signs of autonomic neuropathy were to be found in the AIDS patients tested in this study. CONCLUSION A wider fasting antral cross sectional area and an impaired antral postprandial expansion are related to dyspeptic symptoms in AIDS patients. This suggests the same relationship between dyspeptic symptoms and disturbed antral distension as seen in other patients with functional dyspepsia.

Der Einfluß des Alters auf die Analsphinkterfunktion bei der Frau

ZusammenfassungDie Analsphinkterfunktion der Frau nimmt mit zunehmendem Alter ab; sowohl der innere als auch der äußere Analsphinkter sind betroffen. Da die Ausgangsdruckwerte bei Frauen niedriger sind als bei Männern, Geburtsschäden am N. pudendus hinzukommen können und deren Folgen sich oft erst nach der Menopause manifestieren, betrifft die anale Inkontinenz besonders häufig alte Frauen. Als aussichtsreiche Therapie steht das Analbiofeedbacktraining zur Verfügung.