Reza A. Hejazi

Efficacy of tricyclic antidepressant therapy in adults with cyclic vomiting syndrome: a two-year follow-up study.

Aim To investigate the effects of prolonged tricyclic antidepressants (TCAs) therapy on the frequency and duration of episodes of cyclic vomiting syndrome (CVS) in adults, and the global assessment of clinical improvement and the number of emergency department (ED) visits and/or hospitalizations. Method An open labeled study was conducted in adult CVS patients treated with a TCA and followed for up to 2 years. Demographic data, TCA dosage, duration and frequency of CVS episodes, ED visits, and hospitalizations at baseline and during TCA therapy were recorded, and patients were monitored for any adverse events. Results Forty-six patients initially met the inclusion criteria and 41 patients (22 male) with mean age of 35 years (range: 18 to 63 y) on TCA were able to be followed for 1 year and 23 were evaluated for 2 years. Mean age of onset of CVS symptoms was 26 years (range: 10 to 52 y) and mean age for making the diagnosis of CVS was 32 years (range: 15 to 63 y). The frequency and duration of an episode and ED visits related to CVS were all significantly reduced after both the first and second year of TCA therapy (P<0.05). Eighty-eight percent reported an improved clinical status by subjective global assessment. Mild side effects were reported in 34% not necessitating stoppage of the TCA. Conclusions Long-term TCA therapy significantly reduces the frequency and duration of CVS episodes, ED visits, and hospitalizations (P<0.05), and improves overall clinical well-being providing evidence that they are effective therapy for adult CVS.

Spectrum of gastric emptying patterns in adult patients with cyclic vomiting syndrome.

Background  Cyclic vomiting syndrome (CVS) in adults is a disorder characterized by recurrent and stereotypic episodes of severe nausea, vomiting and abdominal pain separated by symptom‐free intervals. Both rapid and delayed gastric emptying (GE) have been observed but the reports involved small numbers of CVS patients.

Defining esophageal landmarks, gastroesophageal reflux disease, and Barrett's esophagus

The following paper on gastroesophageal reflux disease (GERD) and Barretts esophagus (BE) includes commentaries on defining esophageal landmarks; new techniques for evaluating upper esophageal sphincter (UES) tone; differential diagnosis of GERD, BE, and hiatal hernia (HH); the use of high‐resolution manometry for evaluation of reflux; the role of fundic relaxation in reflux; the use of 24‐h esophageal pH–impedance testing in differentiating acid from nonacid reflux and its potential inclusion in future Rome criteria; classification of endoscopic findings in GERD; the search for the cell origin that generates BE; and the relationship between BE, Barretts carcinoma, and obesity.

Association of Marijuana Use and Cyclic Vomiting Syndrome

Cannabis use has become one of the most commonly abused drugs in the world. It is estimated that each year 2.6 million individuals in the USA become new users and most are younger than 19 years of age. Reports describe marijuana use as high as 40–50% in male Cyclic Vomiting Syndrome patients. It is this interest in cannabis in the World, coupled with recognition of a cyclic vomiting illness associated with its chronic use that beckons a review of the most current articles, as well as a contribution from our own experiences in this area. The similarities we have demonstrated for both cannibinoid hyperemesis syndrome and cyclic vomiting make the case that cannibinoid hyperemesis syndrome is a subset of patients who have the diagnoses of cyclic vomiting syndrome and the role of marijuana should always be considered in the diagnosis of CVS, particularly in males.

Treatment of Acute Colonic Pseudo-Obstruction With Tegaserod

Acute colonic pseudo-obstruction is characterized by symptoms, signs and radiologic appearance of large bowel obstruction in the absence of a true mechanical obstruction. Several pharmacologic treatments have been proposed. We present a case of a patient with Guillain-Barré syndrome complicated by acute colonic pseudo-obstruction, who had a clinical response to tegaserod, a partial 5-hydroxytryptamine type-4 agonist. 5-Hydroxytryptamine type 4 agonists may be an option in the treatment of acute colonic pseudo-obstruction.

Frequency of Jackhammer Esophagus as the Extreme Phenotypes of Esophageal Hypercontractility Based on the New Chicago Classification.

Background: Jackhammer Esophagus is defined as intact esophageal peristaltic contractions with extremely elevated amplitudes. We conducted a retrospective study to identify the frequency of esophageal hypercontractility and the clinical characteristics of Jackhammer Esophagus. Methods: Charts for the patients referred for manometric study at a tertiary-care motility center were reviewed. Data were collected utilizing the new Chicago classification criteria for Jackhammer Esophagus. Concomitant clinical variables were also explored. Results: Eight patients were identified with Jackhammer Esophagus from a total of 205 (127 female/77 male) patients referred for high-resolution esophageal manometry. Jackhammer patients had an average distal contractile integral (DCI) of 9061 mmHg/ sec/ cm and median maximal DCI of 16,433 mmHg/ sec/ cm. The greatest DCI from 15 swallows was 28,875 mmHg/ sec/ cm. Hypercontractility was associated with multipeaked contractions in every Jackhammer patient. The mean lower esophageal sphincter (LES) pressure was 41 mm Hg with 4 patients having a hypertensive pressure of >40 mm Hg. Three of the 8 (37.5%) Jackhammer group had incomplete LES relaxation by integrated relaxation pressure criteria (>15 mm Hg residual pressure). Dysphagia (8/8) was the dominant indication for the manometric study, whereas the clinical background setting was gastroesophageal reflux disease (4/8) and hiatal hernia (1/8). Treatments included smooth muscle relaxation, antireflux regimens, and pneumatic dilation of the LES. Conclusions: Jackhammer Esophagus, an extreme manometric phenotype, was identified in 4.0% of patients referred to a University Motility Center. The patients with these esophageal hypercontractility states present mainly with dysphagia. A subgroup of Jackhammer did have accompanying incomplete LES relaxation and responded to targeted therapy with pneumatic dilatation.

Nonspecific motility disorders, irritable esophagus, and chest pain.

This paper presents commentaries on whether Starlings law applies to the esophagus; whether erythromycin affects esophageal motility; the relationship between hypertensive lower esophageal sphincter and vigorous achalasia; whether ethnic‐ and gender‐based norms affect diagnosis and treatment of esophageal motor disorders; health care and epidemiology of chest pain; whether normal pH excludes esophageal pain; the role of high‐resolution manometry in noncardiac chest pain; whether pH–impedance should be included in the evaluation of noncardiac chest pain; whether there are there alternative therapeutic options to PPI for treating noncardiac chest pain; and the usefulness of psychological treatment and alternative medicine in noncardiac chest pain.

Massive Upper Gastrointestinal Bleed From Epiphrenic Diverticulum

Epiphrenic diverticula are outpouchings of the esophagus that retain some or all layers of the esophageal wall. Symptoms such as intermittent dysphagia and vomiting may occur. The authors present a case of an elderly woman with a history of dysphagia who presented with a massive upper gastrointestinal bleed because of a bleeding epiphrenic diverticulum seen at endoscopy who responded to conservative management. Bleeding epiphrenic diverticula should be considered as a cause of upper gastrointestinal bleeding.

Barrett's esophagus: surgical treatments

The following on surgical treatments for Barretts esophagus includes commentaries on the indications for antireflux surgery after medical treatment; the effects of the various procedures on the lower esophageal sphincter; the role of impaired esophageal motility and delayed gastric emptying in the choice of the surgical procedure; indications for associated highly selective vagotomy, duodenal switch, and gastric electrical stimulation; therapeutic strategies for detection and treatment of shortened esophagus; the role of antireflux surgery on the regression of metaplastic mucosa and the risk of malignant progression; the detection of asymptomatic reflux brfore bariatric surgery; the role of non‐GERD symptoms on the results of surgery; and the indications of Collis gastroplasty and choice of the type of fundoplication.