Ngai Moh Law

The Utility of Narrow Band Imaging in Improving the Endoscopic Diagnosis of Gastroesophageal Reflux Disease

BACKGROUND & AIMSnNarrow band imaging (NBI) facilitates mucosal surface evaluation and may improve the endoscopic diagnosis of gastroesophageal reflux disease (GERD). We investigated the utility of NBI in improving the endoscopic diagnosis of GERD when compared with conventional endoscopy.nnnMETHODSnA total of 107 subjects (nonerosive reflux disease [NERD], 36; erosive reflux disease [ERD], 41; controls, 30) were recruited prospectively. The mucosal morphology at the squamocolumnar junction (SCJ) in GERD and controls was visualized using conventional endoscopy and NBI. The main outcome measurements were as follows: (1) The differences in mucosal morphology at the SCJ between conventional endoscopy and NBI; and (2) the differences in mucosal morphology at the SCJ between GERD and controls with NBI.nnnRESULTSnMicro-erosions, increased vascularity, and pit patterns at the SCJ not seen on conventional endoscopy were well seen with NBI. Compared with controls, ERD and NERD had a significantly higher prevalence of micro-erosions (ERD, 100%; NERD, 52.8%; controls, 23.3%), and increased vascularity (ERD, 95.1%; NERD, 91.7%; controls, 36.7%), but a lower prevalence of round pit pattern (ERD, 4.9%; NERD, 5.6%; controls, 70%). ERD and NERD were similar in terms of increased vascularity and pit patterns. Increased vascularity with absence of round pit pattern was useful to distinguish NERD from controls (sensitivity, 86.1%; specificity, 83.3%). Interobserver agreement was good for increased vascularity (kappa = 0.95) and micro-erosions (kappa = 0.89), but lower for pit pattern (kappa = 0.59).nnnCONCLUSIONSnNBI enhanced mucosal morphology at the SCJ and appeared useful for improving the endoscopic diagnosis of GERD.

Asia-Pacific consensus on the management of gastro-oesophageal reflux disease: an update focusing on refractory reflux disease and Barrett's oesophagus

Objective Since the publication of the Asia-Pacific consensus on gastro-oesophageal reflux disease in 2008, there has been further scientific advancement in this field. This updated consensus focuses on proton pump inhibitor-refractory reflux disease and Barretts oesophagus. Methods A steering committee identified three areas to address: (1) burden of disease and diagnosis of reflux disease; (2) proton pump inhibitor-refractory reflux disease; (3) Barretts oesophagus. Three working groups formulated draft statements with supporting evidence. Discussions were done via email before a final face-to-face discussion. We used a Delphi consensus process, with a 70% agreement threshold, using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria to categorise the quality of evidence and strength of recommendations. Results A total of 32 statements were proposed and 31 were accepted by consensus. A rise in the prevalence rates of gastro-oesophageal reflux disease in Asia was noted, with the majority being non-erosive reflux disease. Overweight and obesity contributed to the rise. Proton pump inhibitor-refractory reflux disease was recognised to be common. A distinction was made between refractory symptoms and refractory reflux disease, with clarification of the roles of endoscopy and functional testing summarised in two algorithms. The definition of Barretts oesophagus was revised such that a minimum length of 1u2005cm was required and the presence of intestinal metaplasia no longer necessary. We recommended the use of standardised endoscopic reporting and advocated endoscopic therapy for confirmed dysplasia and early cancer. Conclusions These guidelines standardise the management of patients with refractory gastro-oesophageal reflux disease and Barretts oesophagus in the Asia-Pacific region.

Efficacy of small-volume simethicone given at least 30 min before gastroscopy

AIM To evaluate the efficacy of 5 mL simethicone solution in decreasing gastric foam if given at least 30 min before gastroscopy. METHODS This was a randomized, placebo controlled, endoscopist blinded study performed at Changi General Hospital. Patients were at least 21 years old, had no prior surgical resection of the upper gastrointestinal tract, and scheduled for elective diagnostic gastroscopies. The primary outcome was the total mucosal visibility score (TMVS) which was evaluated using McNally score. The sample size was calculated to be 24 per group (SD 2.4, 80% power, P < 0.05, 2-sample t test). RESULTS Fifty-four patients were randomised to receive either simethicone [1 mL liquid simethicone (100 mg) in 5 mL of water] or placebo (5 mL of water) at least 30 min before their gastroscopy. Six accredited consultants conducted the gastroscopy, and the interobserver agreement of scoring TMVS was good with a Kappa statistic of 0.73. The simethicone group had significantly better mean TMVS compared to placebo (5.78 ± SD 1.65 vs 8.89 ± SD 1.97, P < 0.001). The improvement was statistically significant for the duodenum and the gastric antrum, angularis, body, and fundus. Percent 51.9 of patients in the simethicone group had a TMVS of 4 (no bubbles at all) to 5 (only 1 area with minimal bubbles), while in the placebo group 3.7% of patients had TMVS of 4 or 5. The number needed to treat was 2.1 to avoid a TMVS of 6 and more. The simethicone group also had a significantly shorter procedure time with less volume of additional flushes required during gastroscopy to clear away obscuring gastric foam. CONCLUSION With a premedication time of at least 30 min, 5 mL simethicone can significantly decrease gastric foam, decrease the volume of additional flushes, and shorten gastroscopy time.

Wireless oesophageal pH monitoring: Establishing values in a multiracial cohort of asymptomatic Asian subjects

BACKGROUNDnWireless oesophageal (Bravo) readings in healthy European and American subjects show varied results. Values in Asians remain unstudied.nnnAIMSnWe performed Bravo studies in healthy Asians to determine if values differed from previously published and identified reflux parameters to differentiate healthy volunteers from patients.nnnMETHODSnFifty healthy volunteers were recruited between August 2009 and August 2011 to undergo 48 h wireless pH monitoring. Bravo capsule was introduced transorally and placed 6 cm above the squamocolumnar junction. Acid reflux parameters were compared against 41 patients previously evaluated for non-erosive reflux disease.nnnRESULTSnFive volunteers were excluded. Capsule dislodgement occurred in four and three volunteers on study days 1 and 2 respectively. Forty and 37 volunteers (73% male, mean age 33.0 ± 7.6 years) had interpretable readings at 24 and 48 h, respectively. Percentage of time oesophageal pH<4 in 37 volunteers who completed 48 h recordings was 1.6% (7.5%), 1.5% (6.3%) and 1.9% (5.8%) on days 1, 2 and overall study duration, respectively.nnnCONCLUSIONnBravo readings in Asians differed from previously published. Percentage of time oesophageal pH<4 on day 2 and DeMeester score on day 2 (95th percentile 22.9) best discriminated healthy volunteers from patients.

TC-325 versus the Combined Conventional Technique for Endoscopic Treatment of Peptic Ulcers with High-Risk Bleeding Stigmata: A Pilot Randomised Study.

Preliminary studies on a new topical hemostatic agent, TC‐325, have shown its safety and effectiveness in treating active upper gastrointestinal (GI) bleeding. However, to date there have been no randomized trials comparing TC‐325 with the conventional combined technique (CCT). Our pilot study aimed to compare the efficacy and safety of TC‐325 with those of CCT in treating peptic ulcers with active bleeding or high‐risk stigmata.

Current status of functional gastrointestinal evaluation in clinical practice

Neurogastroenterology and motility disorders of the gastrointestinal (GI) tract encompass a broad spectrum of diseases involving the GI tract and central nervous system. They have varied pathophysiology, clinical presentation and management, and make up a substantial proportion of outpatient clinic visits. Typically, patients experience persistent symptoms referable to the GI tract despite normal endoscopic and radiologic findings. An appropriate evaluation is thus important in the patients care. Advances in technology and understanding of the disease pathophysiology have provided better insight into the physiological basis of disease and a more rational approach to patient management. While technological advances serve to explain patients persistent symptoms, they should be balanced against the costs of diagnostic tests. This review highlights the GI investigative modalities employed to evaluate patients with persistent GI symptoms in the absence of a structural lesion, with particular emphasis on investigative modalities available locally and the clinical impact of such tools.