Stefan A. Müller-Lissner

Symptoms in gastro-oesophageal reflux disease

Symptomatology was evaluated in 304 patients referred for 24 h oesophageal pH monitoring. Of several symptoms thought to be related to gastrooesophageal reflux disease (GORD), only heartburn (68% vs 48%) and acid regurgitation (60% vs 48%) occurred in more of the patients with GORD (as determined by pH monitoring) than of those with normal pH monitoring. When heartburn or acid regurgitation clearly dominated the patients complaints, they had very high specificity (89% and 95%, respectively) but low sensitivity (38% and 6%) for GORD. A third of the patients reported such inconclusive symptomatology at history-taking that no preliminary diagnosis about the presence or absence of GORD could be made. In the remaining 200 patients, a clinical diagnosis by history had a sensitivity of 78% and specificity of 60%. A discriminant analysis of symptoms was inferior to a history taken by an experienced gastroenterologist.

What is behind dyspepsia

The first aim of the present study was to determine the cause of dyspepsia after negative conventional diagnostic work-up. In such patients, an extended diagnostic work-up was performed including esophageal pH monitoring and manometry, gastric and hepatobiliary scintigraphy, and lactose tolerance test. In 88 of 220 dyspeptic patients (mean age 49 years, range 17–87; 114 women) presenting to our gastroenterological outpatient department, a cause for dyspepsia was found by conventional work-up. Thirty-one of the remaining patients did not enter extended work-up, because of minor symptoms. In 47 of 101 patients entering extended work-up, a diagnosis was established (21 endoscopynegative gastroesophageal reflux disease, 11 gastric stasis, 6 biliary dyskinesia, and 5 lactase deficiency among them). A second aim of the study was to determine whether clusters of symptoms such as “gastroesophageal reflux-like”, “dysmotility-like”, and “dyspepsia of unknown origin” reliably predict the groups of diseases suggested by these terms. This was not the case. In conclusion, in 40% of dyspeptic patients, a conventional diagnostic work-up led to a diagnosis that explained a patients symptoms. After a negative conventional diagnostic work-up, an extended diagnostic work-up with functional tests yielded a possible explanation for their symptoms in 47% of patients. In such patients symptomatology was of little help for predicting the diagnosis.

Behavioral modification of colonic function

We challenged the two hypotheses: first, that defecation can be suppressed for an extended time, and second, if so, that this has an effect on upper colonic motility. Thus we studied 12 male volunteers with conditions of identical nutrition and patterns of physical activity over a two-week period, where one week with normal defecation and one week with voluntary prolonged suppression of defecation followed each other in randomized order. Frequencies of defecation, stool weights, total and segmentai colonic transit times (using radiopaque markers) were compared. Frequency of defecations and stool weights were lower during suppressed defecation [8.9±0.66 vs 3.7±0.41 (mean±SE) bowel movements per week, P=0.003, and 1.30±0.09 vs 0.98±0.13 kg/week, P=0.01]. Total transit times were increased from 28.8±4.4 to 53.1±4.3 hr, P=0.004. Segmental transit times were increased in the rectosigmoid (from 8.83±3.6 to 32.1±5.6 hr, P=0.04) and right hemicolon (from 14.5±0.9 hr to 19.7±1.5 hr, P=0.02) by suppression of defecation. We conclude that defecation habits may induce changes in colonic function such as those seen in constipation and that functional anorectal outlet obstruction may, probably by reflex mediation, affect the right colon.

Role of Alimentation in Irritable Bowel Syndrome

Background: Different food items are made responsible for irritable bowel syndrome (IBS) symptoms, but the physiopathology of IBS remains unclear. Aims: During a meeting in Nice, France, experts of the European Working Team of the IBiS Club discussed selected data regarding the relationships between alimentation, food items (including fibers) and IBS symptoms. Methods/Results: Food allergy remains a difficult diagnosis, but medical and general history, presence of general symptoms such as skin rash, and hypersensitivity tests may help in achieving a positive diagnosis. On the other hand, food intolerance is more confusing because of the subjectivity of the relationship between ingestion of certain foods and the appearance of clinical symptoms. Different food items which are commonly implicated in adverse reactions mimicking IBS were found to be stimulants for the gut, suggesting that patients with predominant diarrhea IBS have to be carefully questioned about consumption of different kinds of food (i.e., coffee, alcohol, chewing gum, soft drinks) and not only on lactose ingestion. Gas production is discussed on the basis of retention of intestinal gas as well as on malabsorption of fermentable substrates. The role of a large amount of this kind of substrate reaching the colon is suggested as a potential mechanism of IBS-type symptoms in overeating patients. Regarding the role of fiber in IBS, the expert group concluded that fibers are not inert substances and that they could trigger pain or bloating in some IBS patients. Conclusion: Despite numerous reviews on this subject, it is very difficult to give general dietary advice to IBS patients, but dieteticians may have a positive role in managing such patients.

Levels of satisfaction with current chronic constipation treatment options in Europe – an internet survey

Data on treatment satisfaction in European men and women with chronic constipation are limited.

Influence of smoking and esophageal intubation on esophageal pH-metry

The effect of cigarette smoking on gastroesophageal reflux and the effect of the pH electrode on salivary secretion and swallowing frequency were studied in 30 healthy volunteers (15 habitual smokers, 15 non-smokers) and in 10 smoking patients with proven gastroesophageal reflux disease. Twenty-four-hour pH profiles were measured while the subjects were ambulatory using a combined glass electrode connected to a portable recorder. In 8 of the smoking volunteers, swallowing frequency and salivary secretion were measured, both when smoking and when not. Smokers had more reflux episodes than nonsmokers [median per hour 2.8 (range 0.4-7.1) for the upright body position and 0.5 (range 0.0-1.7) for the supine body position vs. 1.4 (range 0.0-2.1) upright and 0.0 (range 0.0-0.7) supine, p less than 0.01], but the total time of exposure of the esophageal mucosa to acid was affected neither by the status of being a smoker nor by actual smoking. Nasopharyngeal intubation with the pH electrode did not affect the swallowing frequency, but it increased salivary secretion two-to threefold for a period of 4 h. Six hours after introduction of the pH electrode and later, salivary flow was similar to baseline. It is concluded that smoking and nasopharyngeal intubation does not adversely affect the results of 24-h pH-metry.

Cisapride offsets dopamine-induced slowing of fasting gastric emptying

The effect of cisapride, a new gastrokinetic drug, on gastroduodenal motility was tested in six healthy volunteers. In order to obtain a model for slowed gastric emptying, dopamine was infused at a rate of 8 μg/kg/min. Dopamine significantly slowed the fractional emptying rate of fasting gastric contents from 5.14±0.37 to 1.45±0.67%/min. Injection of either 10 mg of cisapride or 10 mg of metoclopramide restored emptying rate to normal (5.87±0.56 and 5.62±0.61%/min, respectively). When cisapride was given without dopamine background, emptying was only moderately enhanced. Reflux of bile salts was not significantly affected by either cisapride or dopamine alone. When given on a dopamine background, however, both metoclopramide and cisapride decreased bile salt reflux below control values without any active treatment. It is concluded that emptying of fasting gastric contents can be speeded by cisapride, particularly when emptying is slowed by dopamine. A clear effect on bile salt reflux cannot be demonstrated.

Quality of life and illness costs in irritable bowel syndrome

Quality of life is reduced in patients with irritable bowel syndrome, and the costs for this disease are substantial to society. During a meeting in London, UK, the IBiS club reviewed the literature on these subjects. Drawbacks and advantages with existing instruments to assess quality of life and costs were discussed and the clinical and scientific relevance of the current knowledge was assessed. A summary from the meeting is presented in this paper.

Bile Salt Reflux after Cholecystectomy

Gastric bile salt concentrations, the rates of bile salt reflux, gastric emptying, and gastric volume secretion were measured in 9 women with previous cholecystectomy and 13 unoperated female controls. The subjects were studied using a marker technique with gastric intubation both fasting and after gastric instillation of a mixed liquid meal. Cholecystectomy was without effect on gastric emptying and gastric volume secretion. Cholecystectomized patients had increased bile salt reflux rates (1.4 +/- 0.4 versus 0.6 +/- 0.2 mumol/min) and gastric bile concentrations (1753 +/- 266) versus 441 +/- 114 mumol/l) in the fasting state, but lower rates (0.3 +/- 0.3 versus 3.4 +/- 0.9 mumol/min) and concentrations (131 +/- 46 versus 496 +/- 123 mumol/l) after feeding. These findings can be explained by the changes of bile flow into the duodenum induced by cholecystectomy.

Effect of the probiotic strain Bifidobacterium animalis subsp. lactis , BB-12 ® , on defecation frequency in healthy subjects with low defecation frequency and abdominal discomfort: a randomised, double-blind, placebo-controlled, parallel-group trial

The aim of the present study was to investigate the effect of Bifidobacterium animalis subsp. lactis, BB-12®, on two primary end points – defecation frequency and gastrointestinal (GI) well-being – in healthy adults with low defecation frequency and abdominal discomfort. A total of 1248 subjects were included in a randomised, double-blind, placebo-controlled trial. After a 2-week run-in period, subjects were randomised to 1 or 10 billion colony-forming units/d of the probiotic strain BB-12® or a matching placebo capsule once daily for 4 weeks. Subjects completed a diary on bowel habits, relief of abdominal discomfort and symptoms. GI well-being, defined as global relief of abdominal discomfort, did not show significant differences. The OR for having a defecation frequency above baseline for ≥50 % of the time was 1·31 (95 % CI 0·98, 1·75), P=0·071, for probiotic treatment overall. Tightening the criteria for being a responder to an increase of ≥1 d/week for ≥50 % of the time resulted in an OR of 1·55 (95 % CI 1·22, 1·96), P=0·0003, for treatment overall. A treatment effect on average defecation frequency was found (P=0·0065), with the frequency being significantly higher compared with placebo at all weeks for probiotic treatment overall (all P<0·05). Effects on defecation frequency were similar for the two doses tested, suggesting that a ceiling effect was reached with the one billion dose. Overall, 4 weeks’ supplementation with the probiotic strain BB-12® resulted in a clinically relevant benefit on defecation frequency. The results suggest that consumption of BB-12® improves the GI health of individuals whose symptoms are not sufficiently severe to consult a doctor (ISRCTN18128385).