Solomon Tefera

Intragastric maldistribution of a liquid meal in patients with reflux oesophagitis assessed by three dimensional ultrasonography

Background and aims: Our aim was to study intragastric volume and distribution of a liquid meal in patients with reflux oesophagitis using three dimensional ultrasonography. Methods: Twenty patients and 20 healthy controls underwent ultrasonographic measurements of the stomach using a position sensor based on magnetic scanhead tracking for acquisition of three dimensional images. In vivo accuracy of the method was evaluated by scanning a soup filled barostat bag positioned in the proximal stomach of six healthy subjects. Results: In the volume range 100–700 ml, our three dimensional system showed excellent correlation (r=0.99) between estimated and true volumes (limits of agreement −3.4 to 11.0 ml) and a low interobserver variation (limits of agreement −10.9 to 6.7 ml). After ingestion of a 500 ml meat soup meal, patients with reflux oesophagitis revealed a larger volume of the total and proximal stomach at two and 10 minutes (p=0.05; p=0.01, respectively), and an increased proximal/distal intragastric volume ratio at 10 minutes (p=0.04). Patients also experienced more epigastric fullness than controls (p=0.0006). Conclusions: The present three dimensional ultrasound system showed excellent agreement with true volumes and low interobserver variation. Soon after a liquid meal, patients with reflux oesophagitis have abnormal pooling of the ingested liquid in the proximal stomach.

Rapid initial gastric emptying and hypersensitivity to gastric filling in functional dyspepsia: effects of duodenal lipids.

Objective. Impaired distension-induced gastric accommodation and hypersensitivity to distension have been demonstrated by gastric barostat in patients with functional dyspepsia (FD). In this study we investigated distension-induced responses to gastric filling with water in healthy volunteers and FD patients, using non-invasive ultrasonography. Material and methods. Eighteen healthy volunteers and 18 FD patients were given infusions of 10 ml saline or lipid (3 kcal/ml) through a nasoduodenal tube. After tube retraction, the stomach was filled with 1000 ml water during 10 min. Intragastric volume was monitored by 3D ultrasonography, and fullness, pain and nausea were assessed. Results. Compared with healthy volunteers, patients with FD had faster gastric emptying at 5 min (p=0.0008) and reported more fullness (p=0.006) during gastric filling with water. Prior duodenal lipid exposure reduced initial gastric emptying rate in FD patients to the level seen in healthy volunteers. However, despite similar gastric volumes, the patients still reported greater fullness (p=0.002) and nausea (p=0.01). Conclusions. Patients with FD had abnormally rapid initial gastric emptying of water and hypersensitivity to gastric filling. Though normalizing gastric emptying rate and volumes, duodenal lipid exposure did not improve hypersensitivity. Rapid initial gastric emptying of water might be a sign of impaired distension-induced gastric accommodation.

Gastric accommodation studied by ultrasonography in patients with reflux esophagitis.

The aim of this study was to investigate gastric accommodation to a meal in patients with reflux esophagitis using ultrasonography. Twenty consecutive patients with reflux esophagitis of grade I (14) or II (6) and 20 healthy subjects underwent ultrasonographic measurements of the stomach before and after ingestion of a 500 ml soup meal. Reflux esophagitis patients revealed a significantly larger sagittal area of the proximal stomach at 5 min (P = 0.002) and 15 min (P = 0.007) postprandially and experienced more epigastric fullness after the meal (P = 0.0006). Postprandial fullness and sagittal area of the proximal stomach correlated significantly (r = 0.69; P = 0.0007). We conclude that patients with mild or moderate reflux esophagitis have a larger sagittal area of the proximal stomach and more postprandial fullness in response to a soup meal than healthy subjects. Postprandial distension of the proximal stomach may be a pathogenetic factor in reflux esophagitis.

Controversies in dyspepsia

Even in the absence of visible lesions like an ulcer, cancer or oesophagitis, patients with functional dyspepsia may complain of severe dyspeptic symptoms and have a poor quality of life. Characteristically, these patients also often have a low estimate of their own health and have complaints from several organ systems. The cause of the disease is not known. Both central nervous system and gastric disturbances appear to be involved, and their relative importance is controversial. There is no clear beneficial effect of acid suppression or H. pylori eradication although effects of such therapy may be seen in minor subgroups. New findings emphasise the importance of distinguishing between functional dyspepsia and gastro-oesophageal reflux disease, which exhibit completely different gastric accommodation patterns to a meal and have very different therapeutic potential. The effect of drugs like glyceryl trinitrate, glucagon, sumatriptan and buspirone which all concomitantly improve symptoms and gastric accommodation support the important role of abnormal gastric accommodation to meals in patients with functional dyspepsia. A hypothetical model for the pathogenesis of functional dyspepsia is presented. It incorporates four established abnormalities: various psychological abnormalities, low vagal tone, impaired gastric relaxation, and visceral hypersensitivity, in a logical interplay along the brain-gut axis.

Eradication of Helicobacter pylori does not increase acid reflux in patients with mild to moderate reflux oesophagitis

Background : A substantial minority of patients with gastro-oesophageal reflux disease (GERD) are infected with Helicobacter pylori , but there is controversy as to whether these patients should be treated for their infection. We hypothesized that H. pylori eradication increases gastro-oesophageal acid reflux in such patients with time. Methods : Thirty-five consecutive H. pylori -infected patients (16 M and 19 F) with mild or moderate reflux oesophagitis were enrolled. Twenty-four-hour intra-oesophageal ( n = 35) and intragastric ( n = 12) pH-metry was recorded before and 15 months after H. pylori eradication. Gastric biopsy specimens from the antrum and corpus were obtained from 10 consecutive patients before and 15 months after H. pylori eradication. Results : Fifteen months after eradication of H. pylori there was a significant decrease in percentage time oesophageal pH <4 in the recumbent position only ( P = 0.04). Despite a marked reduction in the severity of gastritis, there was no significant change in gastric acidity, total intra-oesophageal acid exposure or symptom score. Heartburn improved in 12, worsened in 7, and remained unchanged in 16 patients ( P = 0.36) without any significant relationship to individual changes in acid exposure ( P = 0.60). Conclusions : H. pylori eradication does not increase gastric acidity or gastrooesophageal acid reflux in patients with mild to moderate reflux oesophagitis over the first 15 months.

Pressure-induced gastric accommodation studied with a new distension paradigm. Abnormally low accommodation rate in patients with functional dyspepsia.

Objective. A new distension paradigm, by which the gastric volume response to ramp-tonic distension can be analysed in detail, has been developed. The aim of this study was to investigate the applicability of this new paradigm in man, and to compare pressure-induced gastric accommodation in healthy volunteers (HV) and patients with functional dyspepsia (FD). Material and methods. Ten HV, and 11 FD patients were examined twice; once in the fasting state and once postprandially. Intragastric bag pressure was raised from 1 to 12 mmHg in 4 min (ramp phase) and then kept constant for 5 min (tonic phase). Results. Compared to HV, fasting FD patients had lower gastric accommodation rates (0.9±0.2 versus 2.5±0.4 ml/s, p=0.002), lower maximum volume (239±39 versus 428±64 ml, p=0.01) and a longer accommodation time (157±26 versus 92±15 s, p=0.03). A test meal prior to distension tended to normalize the response in FD patients. Conclusions. This new barostat paradigm allowed detailed analysis of short-term pressure-induced accommodation in man. Impaired gastric distension-induced accommodation is a novel abnormality in FD.

Stability of gastric secretory inhibition during 6-month treatment with omeprazole in patients with gastroesophageal reflux disease

OBJECTIVE:A trend toward relapse of reflux symptoms and esophagitis during long-term treatment with proton pump inhibitors has been reported. The purpose of this study was to evaluate the existence of tachyphylaxia to the effect of proton pump inhibitors on gastric acidity and gastroesophageal reflux over time.METHODS:A total of 23 patients with reflux esophagitis underwent 24-h intragastric and intraesophageal pH-metry after 7, 90, and 180 days of continued dosing with 20 mg of omeprazole once daily before breakfast.RESULTS:The total median percentages of time gastric pH <4 (interquartile range) were 49% (35–70%), 60% (36–76%), and 42% (26–66%) after 7, 90, and 180 days (p = 0.14). Percentages of time gastric pH <3 were 41%, 54%, and 34%, respectively (p = 0.19). The median percentages of total time esophageal pH <4 were 1.1%, 2.5%, and 1.1%, respectively (p = 0.70). Healing of esophagitis was achieved in 84% of the patients after 6 months. Heartburn improved in six, worsened in three, and was unchanged in 10 patients (p = 0.16). There was no statistical significant relationship between change in esophageal acid exposure and change in severity of heartburn.CONCLUSIONS:A dose of 20 mg of omeprazole once daily consistently controlled patients’ symptoms and kept gastric acidity at a stable level over a period of 6 months. There is no evidence of diminution in the effects of 20 mg of omeprazole over time that could indicate the development of tolerance.

Intragastric Maldistribution of a Liquid Meal in Children with Recurrent Abdominal Pain Assessed by Three-Dimensional Ultrasonography

BACKGROUND Using two-dimensional (2D) ultrasonography, we previously found indications of impaired adaptive relaxation of the proximal stomach in children with recurrent abdominal pain (RAP). In the present study, we applied a new three-dimensional (3D) ultrasonographic method to investigate intragastric volumes and distribution of a liquid meal in another group of children with RAP. METHODS Twenty patients with RAP (age 10-15 years) and 20 healthy subjects (age 11-15 years) underwent ultrasonographic measurements of the stomach. A position sensor was used based on magnetic scanhead tracking for acquisition of 3D images after a liquid meal. The children scored abdominal symptoms before and after the meal. RESULTS Expressed as a fraction of ingested volume, the patients had a smaller volume of the proximal stomach and a larger antral volume at 2 min postprandially compared to healthy subjects (P = 0.03 and P = 0.001, respectively). The patients also showed a decreased proximal to distal gastric volume ratio at 2 min postprandially (P = 0.001). Patients experienced more pain in response to the meal than healthy subjects (P = 0.04), but there was no correlation between pain and proximal or distal gastric volumes. CONCLUSIONS RAP in children may be associated with an early intragastric maldistribution of a meal.Background: Using two-dimensional (2D) ultrasonography, we previously found indications of impaired adaptive relaxation of the proximal stomach in children with recurrent abdominal pain (RAP). In the present study, we applied a new three-dimensional (3D) ultrasonographic method to investigate intragastric volumes and distribution of a liquid meal in another group of children with RAP. Methods: Twenty patients with RAP (age 10-15 years) and 20 healthy subjects (age 11-15 years) underwent ultrasonographic measurements of the stomach. A position sensor was used based on magnetic scanhead tracking for acquisition of 3D images after a liquid meal. The children scored abdominal symptoms before and after the meal. Results: Expressed as a fraction of ingested volume, the patients had a smaller volume of the proximal stomach and a larger antral volume at 2 r min postprandially compared to healthy subjects ( P r = r 0.03 and P r = r 0.001, respectively). The patients also showed a decreased proximal to distal gastric volume ratio at 2 r min postprandially ( P r = r 0.001). Patients experienced more pain in response to the meal than healthy subjects ( P r = r 0.04), but there was no correlation between pain and proximal or distal gastric volumes. Conclusions: RAP in children may be associated with an early intragastric maldistribution of a meal.

Impaired gastric accommodation in children

used the barostat to demon-strate that, in children with unexplained dyspepticsymptoms and poor weight gain, 69% of cases hadimpaired gastric accommodation. The authors acknow-ledge that in adults non-invasive methods, such asultrasonography, are used to measure gastric volumesand evaluate accommodation. However, they ignorethat these methods also have been applied in apaediatric population stating that ‘application of thesemethods in young children has not been reported’.Olafsdottir et al.