Kathleen A. Maher

Day-to-day variability in acid reflux patterns using the BRAVO pH monitoring system.

Background & Goals: The wireless pH monitoring system such as the BRAVO pH system is a significant advancement in the evaluation of patients with gastroesophageal reflux because of its potentially better tolerability and the ability to record data over a 48-hour period. The aim of our study was to evaluate safety, performance, tolerability, and day-to-day variability in acid reflux patterns using the BRAVO pH system. Methods: A total of 90 consecutive patients (48 men and 42 women) with persistent reflux symptoms underwent BRAVO pH capsule placement from October 2002 to August 2003 at a tertiary care hospital. The BRAVO pH capsule was deployed 6 cm proximal to the squamocolumnar junction under endoscopic guidance. The pH recordings over 48 hours were obtained after uploading data to a computer from the pager-like device that recorded pH signals from the BRAVO pH capsule. Results: Successful pH data over 48 hours was obtained in 90% of patients. Nearly two thirds of patients experienced a variety of symptoms ranging from a foreign body sensation to chest discomfort or pain. Four patients had severe chest pain, 3 of whom required endoscopic removal of the BRAVO pH capsule. In 74.4% of patients, number of reflux events as well as time (%) pH < 4 correlated from the first 24-hour period to the second 24-hour period. However, in 28% of patients, no predictable pattern of (%) time pH < 4 in the supine position was reproduced from one 24-hour period to the next 24-hour period. Conclusions: The BRAVO pH system appears a safe and effective method of recording esophageal acid exposure. It is an acceptable alternative for patients who are unwilling or unable to tolerate nasopharyngeal catheter-based pH studies, and it has a potential advantage of the 2-day recording period.

The effect of the Garren-Edwards Gastric Bubble on solid and liquid gastric emptying

To determine the effect of the Garren-Edwards Gastric Bubble (GEGB) on gastric emptying, radionuclide solid and liquid gastric emptying in 12 obese patients prior to insertion of the GEGB was studied. Four were restudied at one and seven days and ten patients were restudied at twelve weeks with the GEGB in place. There were no significant differences in liquid gastric emptying at one and seven days nor in solid and liquid gastric emptying at twelve weeks. Solid gastric emptying was significantly decreased from a mean of 63% to 31% after one day (P < 0.05) and returned to preplacement baseline by seven days. These results indicate that gastric emptying is not significantly changed after twelve weeks with the GEGB in place. Therefore, the mechanism of action for weight reduction with the GEGB is not likely to be mediated by an effect on gastric emptying. However, the solid food-induced dyspeptic symptoms commonly noted 1-3 days after placement of the GEGB, which resolve within seven days, are probably explained by transiently delayed solid gastric emptying.

The role of endoscopic retrograde cholangiopancreatography injection training sessions for the gastroenterology nurse and associate.

Pancreatitis is a recognized serious complication of endoscopic retrograde cholangiopancreatography (ERCP). The pressure with which contrast media are injected may be a risk factor for developing pancreatitis. We, therefore, designed a study to determine if there were differences in pressures generated by experienced and inexperienced gastroenterology nurses and how much training would be required to instruct individuals to inject to a specific pressure. With the use of manometrically guided practice sessions, it was determined that inexperienced operators initially inject with significantly high pressure but can learn to inject accurately to a specific pressure as rapidly as experienced operators. Injection training sessions may be beneficial in minimizing the potential risk factor of hydrostatic pressure induced endoscopic retrograde cholangiopancreatography-associated pancreatitis.

Intraesophageal Balloon Distention in the Manometric Evaluation of Chest Pain

Drug provocation is routinely used during esophageal manometry in the evaluation of chest pain of presumed esophageal origin. As significant side effects have been associated with the use of drugs in provocation, and these provocative tests are inadequately sensitive to exclude esophageal etiology as the cause of chest pain, alternative provocative tests have been sought. Intraesophageal balloon distention (IEBD) has recently been reintroduced as a method of pain provocation in the manometric evaluation of chest pain. IEBD produces pain on distention which resolves immediately on deflation. To evaluate graded IEBD as an effective and safe method of pain provocation, 66 consecutive patients presenting with chest pain and 10 asymptomatic volunteers were studied. We conclude that balloon distention is an effective and safe method of pain provocation and can easily be performed in conjunction with standard esophageal manometry.

Kinevac (sincalide for injection)/Squibb Diagnostics.

Sincalide is a rapid-acting, synthetic analog of cholecystokinin for intravenous use in postevacuation cholecystography. Serious reactions to sincalide have not been reported. The intravenous administration of sincalide causes a prompt contraction of the gallbladder as compared to the stimulus of a fatty meal which causes progressive contraction that becomes maximal in about 40 minutes. The use of Kinevac to accelerate the transit time through the small bowel decreases the time and extent of radiation associated with fluoroscopy and length of the x-ray examination of the intestinal tract. Duodenal aspiration obtained after the administration of Kinevac provides a sample of concentrated bile for analysis of cholesterol, bile salts, phospholipids and crystals. When used in conjunction with secretin to stimulate pancreatic secretion, an aspirate is readily obtained for analysis of enzyme activity, composition and cytology. As the development of endoscopic manometry affords a modality to measure and record sphincter of Oddi pressures, the paradoxical responses noted to the intravenous administration of CCK during manometric evaluation supports the diagnostic value of Kinevac used as a provocative agent in the evaluation of biliary dyskinesia.

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