Miguel A. Valdovinos

ACG practice guidelines: Esophageal reflux testing

Investigations and technical advances have enhanced our understanding and management of gastroesophageal reflux disease. The recognition of the prevalence and importance of patients with endoscopy-negative reflux disease as well as those refractory to proton pump inhibitor therapy have led to an increasing need for objective tests of esophageal reflux. Guidelines for esophageal reflux testing are developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee and approved by the Board of Trustees. Issues regarding the utilization of conventional, catheter-based pH monitoring are discussed. Improvements in the interpretation of esophageal pH recordings through the use of symptom-reflux association analyses as well as limitations gleaned from recent studies are reviewed. The clinical utility of pH recordings in the proximal esophagus and stomach is examined. Newly introduced techniques of duodenogastroesophageal reflux, wireless pH capsule monitoring and esophageal impedance testing are assessed and put into the context of traditional methodology. Finally, recommendations on the clinical applications of esophageal reflux testing are presented.

Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis

Prevention and Management of Gastroesophageal Varices and Variceal Hemorrhage in Cirrhosis Guadalupe Garcia-Tsao, M.D.,1 Arun J. Sanyal, M.D.,2 Norman D. Grace, M.D., FACG,3 William D. Carey, M.D., MACG,4 the Practice Guidelines Committee of the American Association for the Study of Liver Diseases and the Practice Parameters Committee of the American College of Gastroenterology 1Section of Digestive Diseases, Yale University School of Medicine and VA-CT Healthcare System, New Haven, Connecticut; 2Division of Gastroenterology, Virginia Commonwealth University Medical Center, Richmond, Virginia; 3Division of Gastroenterology, Brigham and Women’s Hospital, Boston, Massachusetts; 4The Cleveland Clinic, Cleveland, Ohio

Hydrogen and Methane-Based Breath Testing in Gastrointestinal Disorders: The North American Consensus

Objectives:Breath tests (BTs) are important for the diagnosis of carbohydrate maldigestion syndromes and small intestinal bacterial overgrowth (SIBO). However, standardization is lacking regarding indications for testing, test methodology and interpretation of results. A consensus meeting of experts was convened to develop guidelines for clinicians and research.Methods:Pre-meeting survey questions encompassing five domains; indications, preparation, performance, interpretation of results, and knowledge gaps, were sent to 17 clinician-scientists, and 10 attended a live meeting. Using an evidence-based approach, 28 statements were finalized and voted on anonymously by a working group of specialists.Results:Consensus was reached on 26 statements encompassing all five domains. Consensus doses for lactulose, glucose, fructose and lactose BT were 10, 75, 25 and 25 g, respectively. Glucose and lactulose BTs remain the least invasive alternatives to diagnose SIBO. BT is useful in the diagnosis of carbohydrate maldigestion, methane-associated constipation, and evaluation of bloating/gas but not in the assessment of oro-cecal transit. A rise in hydrogen of ≥20 p.p.m. by 90 min during glucose or lactulose BT for SIBO was considered positive. Methane levels ≥10 p.p.m. was considered methane-positive. SIBO should be excluded prior to BT for carbohydrate malabsorption to avoid false positives. A rise in hydrogen of ≥20 p.p.m. from baseline during BT was considered positive for maldigestion.Conclusions:BT is a useful, inexpensive, simple and safe diagnostic test in the evaluation of common gastroenterology problems. These consensus statements should help to standardize the indications, preparation, performance and interpretation of BT in clinical practice and research.

Performance, Tolerability, and Symptoms Related to Prolonged pH Monitoring Using the Bravo System in Mexico

BACKGROUND:The traditional system for esophageal 24-h pH monitoring requires transnasal introduction of the catheter with pH sensors; this technique produces discomfort, inconvenience, and interference with daily activity. Recently, a catheter-free pH monitoring system (Bravo) has been proposed as an alternative and promising method for 24-h pH.AIM:To evaluate performance, tolerability, and symptoms related to this new technology in our population.METHODS:Consecutive patients with gastroesophageal reflux disease (GERD) with indication for 24-h pH were included. pH Bravo capsule was placed 6 cm above the squamocolumnar junction using endoscopic measurement. Symptoms associated were evaluated daily in a personal diary until 7 days after the capsule attachment. Severity of symptoms was assessed by a 5-point Likert scale. Capsule detachment was assessed by chest X-ray.RESULTS:Eighty-four patients were included. Forty-nine were female (mean age 44 ± 12 yr). Indications for pH monitoring were: nonresponse to proton pump inhibitor therapy in 38 (45%), preoperative evaluation for anti-reflux surgery in 36 (43%), previous failed transnasal 24-h pH monitoring in 6 (7%), and extra-esophageal manifestations of GERD in 4 (5%). The capsule was successfully attached in 95% of patients. At day 7, capsule detachment occurred spontaneously in all cases. Symptoms related to capsule attachment were: chest pain in 26 (33%), foreign body sensation in 11 (14%), nausea in 5 (6%), and 9 (11%) patients had more than one symptom. Severities of those symptoms were mild, and no patient required removal of the capsule. Women and younger patients had more symptoms related to the procedure (p < 0.05).CONCLUSIONS:Esophageal pH monitoring with Bravo capsule is a safe, reliable, and tolerable method in patients with GERD.

A rare case of multiple lymphomatous polyposis with widespread involvement of the gastrointestinal tract.

Multiple lymphomatous polyposis (MLP) is an uncommon type of primary non-Hodgkin gastrointestinal (GI) B-cell lymphoma characterized by the presence of multiple polyps along the GI tract. Malignant cells of MLP have mantle cell characteristics and thus are considered to be the counterpart of the mantle cell lymphoma (MCL) in the GI tract. Since 1961, no more than 70 well-documented cases have been published. We report the case of 53-year-old man diagnosed as having MLP. The patient presented with diffuse abdominal pain, chronic lower GI bleeding, peripheral lymphadenopathy, and weight loss. The lymphomatous polyps extended from the esophagus to the rectum, with bone marrow infiltration. Immunohistologic findings were characteristic of MCL. The patient was treated with a combined cyclophosphamide, vincristine, and prednisone chemotherapy regimen, resulting in a partial response.

Chili pepper and rectal hyperalgesia in irritable bowel syndrome

H. pylori seroprevalence in controls were significantly higher (2.7 95% CI 1.48–4.89, p 0.001), as compared with IBD patients. Body mass index, sex, history of chronic disorders, and place of origin were not related to H. pylori infection. Concerning positivity for H. pylori infection, no significant differences between patients with ulcerative colitis, Crohn’s disease, and indeterminate colitis were noticed (33.1% vs 28.6%, respectively). Disease activity, duration of disease, and treatment with 5-aminosalicylic acid, azathioprine, and corticosteroids were not related to H. pylori positivity. On the contrary, treatment with antibiotics was significantly negatively related to H. pylori positivity (20.5% vs 55.0%, p 0.0001). Logistic regression analysis confirmed that treatment with antibiotics, as well as age and educational level were independent factors related to H. pylori seropositivity (Table 1). It is of interest that the percentage of patients positive for H. pylori who did not report antibiotics use in the past was similar to that of normal controls (55.0% vs 55.1%, respectively). Although there is a large geographic variation in the prevalence of both IBD and H. pylori infection, it is worth clarifying why patients with IBD exhibit universally and steadily low prevalence of H. pylori infection. The results of the present study confirm the low prevalence of H. pylori seropositivity in patients with IBD and that among the various therapeutic modalities applied to patients with IBD, only use of antibiotics was related to low incidence of H. pylori infection. It is worth noticing that the number of studies that have examined the significance of antibiotic treatment on the low incidence of H. pylori infection in IBD is extremely small, and most of them are retrospective. Sousa et al. described that the low prevalence of H. pylori infection in Crohn’s disease patients was associated with current or previous metronidazole therapy (5). Recently, Matsumura et al. (6) described results similar to ours. They found that the prevalence of H. pylori infection in Crohn’s disease patients was significantly lower in those who received antibiotics for at least 2 wk. Our findings are indicative that the low prevalence of H. pylori infection found in patients with IBD could be attributed to previous antibiotic treatment. However, further longitudinal studies must verify this assumption.

Irritable Bowel Syndrome in Mexico

The current review includes all the available original data on irritable bowel syndrome in Mexico. Data were organized in items of interest such as prevalence and gender distribution, health care utilization, psychosocial factors, diagnostic criteria, bowel habit predominance, physiological studies, clinical trials and quality of life assessment. After a systematic review, a total of 18 papers were included, the majority published between 1996 and 2000. We can conclude that irritable bowel syndrome in Mexico is similar to that reported in the international literature with regard to the areas analyzed, and therefore it is suitable to run clinical trials with similar outcomes as has been done in other populations.

Gastroesophageal reflux in healthy subjects induced by two different species of chilli (Capsicum annum).

Background: Although the ingestion of chilli has been associated with gastroesophageal reflux (GER) symptoms, there are no studies that have explored the effect of a chronic ingestion of different kinds of chilli with a variable content of capsaicin as a cause of GER. Methods: The effect of chilli on esophageal 24-hour pH monitoring was studied in 12 healthy subjects without GER symptoms before and after of ingestion one of two kinds of chilli. Patients were randomized to ingest 3 g daily of cascabel chilli (Capsicum annum coraciforme containing 880 ppmof capsaicin) or ancho chilli (Capsicum annum grossum containing 488 ppm of capsaicin). Results: After chilli ingestion, the Johnson De Meester Index (JDI) increased significantly [basal: 7 (1–14), after chilli: 13 (2–69), p = 0.0047]. When considering both kinds of chilli separately, the JDI varied, although nonsignificantly, with the ancho chilli [basal: 3 (1–8), after chilli: 10 (2–69), p = 0.11], and significantly with the cascabel chilli [basal: 10 (5–14), after chilli: 18 (2–44), p = 0.028]. Conclusion: Our results suggest that the chronic ingestion of chilli induces GER, and that the magnitude of the induced reflux seems to be related to the kind of chilli.

Current and future treatment of chest pain of presumed esophageal origin

Patients with chest pain of presumed esophageal origin should be reassured and should undergo an esophageal manometry study. In patients with spastic esophageal disorders, a trial with calcium channel blockers or low-dose antidepressants used as visceral analgesics is the best approach. Inpatients with non GERD-related, nonspastic esophageal motility disorder, low-dose antidepressants seem reasonable. Anxiolytics are useful in patients with panic disorders, and psychological interventions (eg, cognitive-behavioral therapy) are also valuable, mainly in patients in whom reassurance is not sufficient to avoid the misinterpretation of their symptoms. In the future, visceral sensitivity modifying agents such as serotoninergic agonists or antagonists may become the cornerstone of therapy in patients with chest pain of presumed esophageal origin. Combinations of different approaches, such as proton pump inhibitors and psychotropic or antinociceptive agents, should also be evaluated in clinical trials.

Endoscopic balloon catheter dilation for treatment of primary cricopharyngeal dysfunction.

Primary cricopharyngeal dysfunction (PCD) is a disorder of unknown etiology that is an increasingly recognized and potentially reversible cause of oropharyngeal dysphagia (1). It is characterized by failed or partial sphincter relaxation, lack of pharyngoesophageal coordination, or a reduction in the muscular compliance of the upper esophageal sphincter (UES) (2, 3). It has a low prevalence and affects mainly elderly people. The most frequent symptoms are dysphagia, choking during meals, aspiration, and immediate expectoration of an offending bolus. Diagnosis can be made by videofluoroscopy or by contrast radiographic studies; these may show a typical cricopharyngeal bar that is a prominent posterior indentation at the level of the UES (4). Manometric studies may not show uniform characteristics and these can include normal or increased resting UES pressure with incomplete relaxation and loss of pharyngoesophageal coordination (5). Treatment is started after secondary causes of oropharyngeal dysphagia are excluded and symptoms can be relieved by cricopharyngeal myotomy in most patients (6). Recently, the use of botulinum toxin injection and endoscopic balloon catheter dilation has been reported to be safe and effective for the treatment of cricopharyngeal dysphagia (7–10). Here we describe the results of treatment with balloon dilation and follow-up in a patient with PCD.