Motoyasu Kusano

Development and evaluation of FSSG: frequency scale for the symptoms of GERD.

BackgroundThe aim of this study was to produce a simplified questionnaire for evaluation of the symptoms of gastroesophageal reflux disease (GERD).MethodsA total of 124 patients with an endoscopic diagnosis of GERD completed a 50-part questionnaire, requiring only “yes” or “no” answers, that covered various symptoms related to the upper gastrointestinal tract, as well as psychosomatic symptoms. The 12 questions to which patients most often answered “yes” were selected, and were assigned scores (never = 0; occasionally = 1; sometimes = 2; often = 3; and always = 4) to produce a frequency scale for symptoms of GERD (FSSG). Sensitivity, specificity, and accuracy of the FSSG questionnaire were evaluated in another group of patients with GERD and non-GERD. The usefulness of this questionnaire was evaluated in 26 other GERD patients who were treated with proton pump inhibitors for 8 weeks.ResultsWhen the cutoff score was set at 8 points, the FSSG showed a sensitivity of 62%, a specificity of 59%, and an accuracy of 60%, whereas a cutoff score of 10 points altered these values to 55%, 69%, and 63%. The score obtained using the questionnaire correlated well with the extent of endoscopic improvement in patients with mild or severe GERD.ConclusionsThis new questionnaire is useful for the objective evaluation of symptoms in GERD patients.

Guidelines for Diagnosis and Treatment of Carcinoma of the Esophagus April 2012 edited by the Japan Esophageal Society

Purpose These guidelines are intended for doctors who are engaged in the diagnosis and treatment of esophageal carcinoma, for the following purposes: (1) to present the standard practice for the diagnosis and treatment of esophageal carcinoma with a high regard for the principles of evidence-based medicine (EBM); (2) to improve the safety and results of treatment, thereby reducing the difference in treatment results among different institutions; (3) to reduce unnecessary costs and efforts; (4) help enable people to undergo treatment without anxiety. These guidelines provide only guidance on the indications for treatment and do not restrict or prohibit the use of any treatment deviating from those described herein.

Association between reflux oesophagitis and features of the metabolic syndrome in Japan

Background  There have been many reports about the relationship between reflux oesophagitis and obesity, but not the metabolic syndrome.

Helicobacter pylori infection correlates with severity of reflux esophagitis : with manometry findings

Abstract: The role of Helicobacter pylori infection in the development and exacerbation of reflux esophagitis was investigated. The prevalence of Helicobacter pylori infection, the severity of atrophic gastritis, and esophageal motility (determined by esophageal manometry by an infusion catheter method) were assessed in patients with mild (n = 46) and severe (n = 27) reflux esophagitis and subjects without reflux (n = 28). Compared with the prevalence of Helicobacter pylori infection in the non-reflux group, the prevalence in the mild and severe reflux groups (60.7%, 47.8%, and 14.8%, respectively) was significantly (P < 0.05) lower. Atrophic gastritis was milder in both reflux groups than in the non-reflux group. The degree of gastritis was also milder in the severe reflux group than in the mild reflux group. The esophageal sphincter pressure was significantly (P < 0.05) lower in the reflux groups than in the non-reflux group, and the amplitude of primary peristalsis was significantly (P < 0.05) lower in the severe reflux group than in the non-reflux group. There were no significant differences between reflux patients with and without Helicobacter pylori infection in the parameters of esophageal manometry. These data imply that a low prevalence of Helicobacter pylori infection may result in a milder grade of atrophic gastritis, and consequently, exacerbate reflux esophagitis.

Evidence-based clinical practice guidelines for functional dyspepsia

General interest in functional gastrointestinal disorders is increasing among Japanese doctors as well as patients. This increase can be attributed to a number of factors, including recent increased interest in quality of life and advances in our understanding of the pathophysiology of gastrointestinal disease. Japan recently became the world’s first country to list “functional dyspepsia” as a disease name for national insurance billing purposes. However, recognition and understanding of functional dyspepsia (FD) remain poor, and no standard treatment strategy has yet been established. Accordingly, the Japanese Society of Gastroenterology (JSGE) developed an evidence-based clinical practice guideline for FD, consisting of five sections: concept, definition, and epidemiology; pathophysiology; diagnosis; treatment; and prognosis and complications. This article summarizes the Japanese guideline, with particular focus on the treatment section. Once a patient is diagnosed with FD, the doctor should carefully explain the pathophysiology and benign nature of this condition, establish a good doctor–patient relationship, and then provide advice for daily living (diet and lifestyle modifications, explanations, and reassurance). The proposed pharmacological treatment is divided into two steps: initial treatment including an acid inhibitory drug (H2RA or PPI) or prokinetics, (strong recommendation); second-line treatment including anxiolytics, antidepressants, and Japanese traditional medicine (weak recommendation). H. pylori eradication, strongly recommended with a high evidence level, is positioned separately from other treatment flows. Conditions that do not respond to these treatment regimens are regarded as refractory FD. Patients will be further examined for other organic disorders or will be referred to specialists using other approaches such as psychosomatic treatment.

Interobserver and intraobserver variation in endoscopic assessment of GERD using the “Los Angeles” classification

BACKGROUND A new endoscopic classification of gastroesophageal reflux disease (GERD) has been proposed, and the term mucosal break has been introduced to describe mucosal damage. This new classification was evaluated by endoscopists with different levels of experience. METHODS Fifty endoscopic photographs for each of 20 randomly selected patients with GERD were assessed retrospectively by three groups of seven endoscopists classified by experience: group 1 (100 to 500 procedures), group 2 (500 to 3000), and group 3 (more than 3000). The new classification was modified by adding grade 0 to describe healed mucosal breaks, so that there were five grades. All photographs were assessed twice at an interval of more than 1 week, and kappa statistics were used to determine observer variation. RESULTS Interobserver variation within group 3 (kappa = 0.39, n = 21) and between groups 3 and 2 (kappa = 0.36, n = 49) was significantly different (p < 0.01) from that between groups 3 and 1 (kappa = 0.26, n = 49). Intraobserver variation in group 1 (kappa = 0.39, n = 7) was significantly different (p < 0.01) from that in group 2 (kappa = 0.51, n = 7) and group 3 (kappa = 0.54, n = 7). CONCLUSIONS Observer variation depends on level of endoscopic experience. Only experienced endoscopists should use the new classification for grading of GERD.

Comparison of endoscopic findings with symptom assessment systems (FSSG and QUEST) for gastroesophageal reflux disease in Japanese centres

Background and Aim:  We compared endoscopic findings of the frequency scale for the symptoms of gastroesophageal reflux disease (FSSG), a written questionnaire developed in Japan, to that for the questionnaire for the diagnosis of reflux esophagitis (QUEST) for the diagnosis of reflux esophagitis.

Inhibition of resting lower esophageal sphincter pressure by pharyngeal water stimulation in humans

BACKGROUND/AIMS Normal inhibition of lower esophageal sphincter (LES) tone occurs during swallowing and belching. However, it is known that it may occur independently of these functions. The aim of this study was to characterize the effect of pharyngeal water stimulation on resting LES pressure. METHODS The effect of rapid-pulse and slow continuous intrapharyngeal injection of minute increments of water on the resting tone of the upper and LES of 14 healthy young volunteers was evaluated by concurrent manometry, submental electromyography, and respirography. RESULTS At a threshold volume, pharyngeal water injection induced an isolated LES relaxation in all volunteers. The threshold volume inducing LES relaxation by rapid-pulse injection, 0.16 +/- 0.01 mL, was significantly lower than that with slow continuous injection (0.5 +/- 0.05 mL) (P < 0.05). The duration and magnitude of LES relaxation were not volume dependent. The duration of LES relaxation induced by rapid-pulse injection was significantly longer than that of swallows. CONCLUSIONS Minute amounts of liquid injected into the pharynx induce LES relaxation different from that of the normal swallow. Neither the duration nor the magnitude of this relaxation is volume dependent. Whereas the contribution of this finding to the mechanism of transient LES relaxation remains to be ascertained, it may partially explain the variability of the basal LES pressure.

Monosodium l-glutamate added to a high-energy, high-protein liquid diet promotes gastric emptying

BACKGROUND Free glutamate activates taste receptors on nerves in the oral cavity to elicit a unique taste known as umami. Recently, umami taste receptors were also found in the gastric mucosa. Although reports suggest that mucosal receptors may respond to free glutamate to modulate gastric function, no evidence of any effect on gastric emptying has been documented. OBJECTIVE We hypothesized that glutamate may act as a modulator of gastric function. We studied the effects of L-glutamate enrichment of a protein-rich liquid meal, and similar enrichment of an equicaloric carbohydrate meal or noncaloric water, on gastric emptying. DESIGN Ten healthy men were enrolled. Nine of the 10 subjects included in the study ingested all test meals with and without monosodium L-glutamate (MSG), and the remaining subject ingested only the protein-rich meals with and without MSG. All experimental and control liquid meals included [1-(13)C]sodium acetate as a tracer. After a test meal or water was ingested, (13)C breath tests were performed to estimate gastric emptying. RESULTS MSG enrichment not only resulted in a significant decrease in the mathematically simulated half-excretion (emptying) time of a protein-rich meal, but also increased the area under the curve (%dose/h) significantly. In contrast, MSG had no significant effect on the gastric emptying of a carbohydrate meal or a noncaloric water meal. CONCLUSIONS Enrichment with MSG facilitated gastric emptying of a protein-rich meal exclusively, which suggests that free glutamate is important for protein digestion and may be helpful in the management of delayed gastric emptying.

A Prospective Randomized Controlled Study of Long-Term Combination Therapy Using Ursodeoxycholic Acid and Bezafibrate in Patients With Primary Biliary Cirrhosis and Dyslipidemia

OBJECTIVES:The aim of this study was to assess the long-term prognosis, efficacy, and safety of combination therapy using ursodeoxycholic acid (UDCA) and bezafibrate (BF) for primary biliary cirrhosis (PBC) patients exhibiting dyslipidemia.METHODS:We performed a prospective, randomized, controlled, multicenter study to compare the long-term clinical results between combination therapy and UDCA monotherapy for patients refractory to UDCA monotherapy. Twenty-seven consecutive PBC patients were enrolled.RESULTS:The median treatment period in the UDCA and UDCA+BF groups was 107 and 110 months, respectively. The serum alkaline phosphatase (ALP) levels and the Mayo risk score in the combination therapy group (mean 290 IU/l and 0.91, respectively) were significantly lower than those in the UDCA monotherapy group (mean 461 IU/l and 1.42, respectively) at 8 years after the beginning of the study (P<0.05). The serum creatinine levels in the combination therapy group (mean 0.94 mg/dl) were significantly higher than those in the UDCA monotherapy group (mean 0.56 mg/dl) at 8 years after the beginning of the study (P<0.05). However, the survival rate was not significantly different between the groups. We observed dose reduction or discontinuation of the administration of BF, but not UDCA, due to renal dysfunction or muscle pain.CONCLUSIONS:Long-term combination therapy significantly improved the serum ALP levels and the Mayo risk score. However, the survival rate was not significantly different between the groups. In addition, long-term combination therapy significantly increased the serum creatinine levels. We should pay close attention to adverse events during this long-term combination therapy.