Michael E. Glick

Colonic Dysfunction in Multiple Sclerosis

Multiple sclerosis is a central nervous system disease frequently accompanied by urinary symptoms and severe constipation. In order to investigate the pathophysiology of these symptoms, we studied colonic motor and myoelectrical activity, as well as colonic volume-pressure relationships (colonometrograms) and have correlated these data with cystometry and electrophysiologic studies of the central and peripheral somatosensory nervous system. The study group consisted of 7 patients with advanced multiple sclerosis marked by symptoms and signs of somatic and visceral nervous system dysfunction including severe constipation. Ten normal volunteers served as control subjects. The multiple sclerosis group demonstrated electrophysiologic evidence of lesions in the somatosensory neuroaxis central to the lumbosacral spinal cord. Abnormal cystometrograms suggested visceral central nervous system dysfunction. Colonometrograms in the multiple sclerosis group demonstrated a more rapid pressure rise than in the control group (p less than 0.01). The multiple sclerosis group failed to demonstrate the postprandial increase in colonic motor and myoelectrical activity observed in the control group (p less than 0.01). Abnormal colonometrograms and absent postprandial colonic motor and myoelectric responses may be features of visceral neuropathy in patients with advanced multiple sclerosis and severe constipation.

HLA-B51 may serve as an immunogenetic marker for a subgroup of patients with Behcet's syndrome

Epidemiologic data, family history, clinical data, HLA typing, neutrophilic chemotaxis, and immunofluorescence of clinically normal non-sun-exposed skin were studied in 46 Israeli non-Ashkenazi Jewish and Arab patients with Behçets syndrome. HLA-B51 was present in 71 percent of the patient group as compared with 13 percent of the control group (relative risk = 17.1). In four of 30 families in the B51-positive group, there was a close relative of the proband with Behçets syndrome who was carrying the HLA-B51 antigen. Neutrophilic chemotaxis in this group was enhanced in 80 percent of the patients, and in most patients no deposition of immunoglobulin in the dermo-epidermal junction was observed, whereas C3 was present in papillary vessels. In the B51-negative group, the family history was negative for Behçets syndrome, neutrophilic chemotaxis was enhanced in only two of eight patients, and in four of six patients, IgM deposition was detected in the dermo-epidermal junction. It is concluded that in Israeli non-Ashkenazi Jews and Arabs, there is a significant association between HLA-B51 and the risk of developing Behçets syndrome. The B51-positive patient group has a family history of the disease, enhanced neutrophilic chemotaxis, and a lack of immunoglobulin deposition in the dermo-epidermal junction.

Clinical course of esophageal stricture managed by bougienage

To define the clinical course of patients with benign esophageal stricture treated with bougienage, we reviewed the records of 76 patients undergoing dilatation. Patients with the diagnosis of scleroderma and those with previous hiatal hernia repair or gastric surgery were excluded. Initial evaluation included contrast study, esophagoscopy, and biopsy. Patients underwent a series of dilatations until a 44-Fr or larger bougie was passed. Patients were then instructed to return for recurrence of dysphagia. In this group, mean duration of follow-up from the first dilatation was 21.1 months. A total of 569 dilatations were performed with one major complication and no mortality. Benign esophageal stricture recurred in 65% of patients. After two or more recurrences, the likelihood of requiring an additional dilatation was 86–94% after each recurrence. The interval between required dilatations was variable; however, after 8 dilatations, it approximated once monthly. The shorter mean follow-up time of patients requiring a single dilatation (9.7 months) compared to those requiring multiple dilatations (28.8 months) suggests that the recurrence rates noted in this study are underestimations. In spite of high recurrence rates and short recurrence intervals, the low morbidity and absent mortality over long-term follow-up suggests that repeated bougienage is, an effective modality for the management of benign esophageal stricture.

Hiccupping and regurgitation via the drain tube of the ProSeal laryngeal mask.

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Objective assessment of gastroesophageal reflux after short esophagomyotomy for achalasia with the use of manometry and pH monitoring

The role of an antireflux procedure as an adjunct to esophagomyotomy for achalasia remains a subject of controversy. Little objective documentation exists of this operations effect on sphincteric competence and the degree of postoperative gastroesophageal reflux. This report of esophageal manometry and 24-hour pH monitoring on 14 patients with esophageal achalasia whom we had previously treated by a short esophagomyotomy without an antireflux procedure provides such documentation. Esophagomyotomy reduced lower esophageal sphincter pressure by 12% to 71% (mean 41%) from a preoperative mean of 26.7 mm Hg to a postoperative mean of 14.6 mm Hg. The number of postoperative episodes of acid reflux per patient in 24 hours was fewer than 29 (normal < 49) in 13 patients, with a median of 12 episodes for the entire group. Esophageal acid exposure, measured as percentage of total time with pH less than 4.0 (normal < 4.5%), was below 4.5% in 10 patients, six of whom had values less than 1%. Among the four patients with values greater than 4.5%, only one had a temporal correlation of symptoms with an episode of acid reflux. Multivariate analysis showed that esophageal acid exposure time correlated only with the level of residual lower esophageal sphincter pressure during the relaxation phase of deglutition. A pressure less than 8 mm Hg was predictive of normal acid contact time (p < 0.001). Mean lower esophageal sphincter pressure, percent reduction in lower esophageal sphincter amplitude, postoperative vector volume, and length of the lower esophageal sphincter did not significantly correlate with amount of esophageal acid exposure. We conclude that a short esophagomyotomy without an antireflux procedure results in a competent lower esophageal sphincter in most patients. Increased esophageal acid exposure, when it occurs, is due to slow clearance of esophageal acid from relatively few reflux episodes and is more likely to occur when there is a high residual pressure during deglutition after myotomy. These findings suggest that the addition of an antireflux procedure to a short esophagomyotomy would not be expected to improve clinical results.

Dysphagia and Advancing Age: Are Manometric Abnormalities More Common in Older Patients?

The universal process of aging may result in physiologic deterioration. Dysphagia may be more common in older patients. The effect of aging on esophageal manometry is not well established. The aim of this study was to determine if esophageal motility studies and associated symptoms in older patients with dysphagia differ significantly from younger patients. Patients who were 65 years of age or older (N = 53) were compared with patients who were 18–45 years of age (N = 53). Presenting symptoms, manometric findings, and diagnoses were compared between the two groups. In the older group, there were 29 women (55%), in the younger group there were 35 women (66%). The mean age of the older group was 75 ± 7 years, the mean age in the younger group was 34 ± 7 years. All patients reported dysphagia to solids. No significant differences were found in the reporting of associated symptoms. There were no significant differences in average lower esophageal sphincter (LES) resting pressure, residual LES pressure, LES relaxation, or peristalsis between groups. Older patients were as likely to have a normal study as younger patients (18% vs 23%, P = NS) and were also as likely to have the diagnosis of achalasia (32% vs 34%, P = NS). In conclusion, older and younger patients referred for manometric study of dysphagia have similar manometric findings. Esophageal manometry can be helpful in determining abnormalities in motility in both older and younger patients.

Why have controlled trials failed to demonstrate a benefit of esophagogastroduodenoscopy in acute upper gastrointestinal bleeding? A probability model analysis.

Numerous prospective randomized trials have failed to demonstrate a benefit attributable to early diagnostic esophagogastroduodenoscopy (EGD) in acute upper gastrointestinal bleeding (UGIB). The clinical implications of these studies have received extensive editorial comment and analysis. We have employed a probability model to further analyze the reasons why these studies have failed to demonstrate an impact of EGD on UGIB. The clinical course of each bleeding lesion can be predicted from the literature. For each lesion, the mortality associated with early specific intervention afforded by an early specific diagnosis can be compared with the mortality of intervention delayed by applying EGD only to those patients who have a complicated course marked by continued bleeding or rebleeding. Using optimistic assumptions that would tend to overstate the impact of EGD, this analysis estimates the maximum decrease in overall mortality in any of these trials afforded by early diagnostic EGD to be 1.2% which would require randomization of over 5000 patients to demonstrate this benefit in a prospective trial.

Efficacy of sucralfate and cimetidine in protection of the human gastric mucosa against alcohol injury

In order to study whether sucralfate or cimetidine may protect human gastric mucosa against alcohol injury, 28 healthy volunteers were pretreated with either: (1) placebo 1 g; (2) cimetidine (Tagamet) 300 mg; or (3) sucralfate (Carafate) 1 g. One hour later, 100 ml of 40 percent ethanol was sprayed directly on the gastric mucosa of the greater curvature during an endoscopic examination. Gastric mucosal changes were assessed by endoscopic appearance (according to grading scale) and by histology. In placebo-pretreated subjects, alcohol produced prominent mucosal damage (endoscopic score, 3.9 +/- 0.3, histologic score, 4.0 +/- 1.1 at 30 minutes). Cimetidine alkalinized gastric pH but did not prevent alcohol-induced damage (endoscopic score, 4.0 +/- 0.6; histologic score, 3.8 +/- 1.1, at 30 minutes). Sucralfate reduced endoscopic and histologic features of alcohol injury (endoscopic score, 1.8 +/- 0.6; histologic score, 1.8 +/- 1.1, at 30 minutes) without affecting gastric luminal pH. Reduction of alcohol-induced injury of the human gastric mucosa by sucralfate but not cimetidine demonstrates that effective protection of the gastric mucosa can be achieved without neutralization or inhibition of gastric acid secretion and points out another clinical application for sucralfate.

Dysphagia and advancing age: are manometric abnormalities more common in older patients?

The universal process of aging may result in physiologic deterioration. Dysphagia may be more common in older patients. The effect of aging on esophageal manometry is not well established. The aim of this study was to determine if esophageal motility studies and associated symptoms in older patients with dysphagia differ significantly from younger patients. Patients who were 65 years of age or older (N = 53) were compared with patients who were 18–45 years of age (N = 53). Presenting symptoms, manometric findings, and diagnoses were compared between the two groups. In the older group, there were 29 women (55%), in the younger group there were 35 women (66%). The mean age of the older group was 75 ± 7 years, the mean age in the younger group was 34 ± 7 years. All patients reported dysphagia to solids. No significant differences were found in the reporting of associated symptoms. There were no significant differences in average lower esophageal sphincter (LES) resting pressure, residual LES pressure, LES relaxation, or peristalsis between groups. Older patients were as likely to have a normal study as younger patients (18% vs 23%, P = NS) and were also as likely to have the diagnosis of achalasia (32% vs 34%, P = NS). In conclusion, older and younger patients referred for manometric study of dysphagia have similar manometric findings. Esophageal manometry can be helpful in determining abnormalities in motility in both older and younger patients.