William L. Berger

Terminal ileum resection is associated with higher plasma homocysteine levels in Crohn's disease.

Background Elevated plasma total homocysteine (tHcy) is associated with a higher risk of thrombosis. Crohns disease (CD) is associated with hypercoagulability of undefined etiology. We investigated tHcy in patients with CD and its relationship with vitamin status, disease activity, location, duration, and history of terminal ileum (TI) resection. Study We examined fasting plasma tHcy, folate, serum vitamin B 12 levels, and sedimentation rate in consecutive adult patients with CD. Harvey–Bradshaw index of CD activity and history of TI resection and thromboembolism were recorded. Results Median plasma tHcy was 10.2 &mgr;mol/L in 125 patients with CD. Men (n = 60) had higher plasma tHcy than women (n = 65) (11.2 vs. 9.1 &mgr;mol/L;p = 0.004). Patients with a history of TI resection showed lower serum B 12 levels (293 vs. 503 pg/mL;p < 0.001) and higher plasma tHcy levels (11.0 vs. 9.35 &mgr;mol/L;p = 0.027) than patients without such history. Multivariate analysis showed history of TI resection, serum B 12 , and creatinine levels to be significant predictors of elevated plasma tHcy. Fourteen patients with CD with a history of thrombosis had an elevated median plasma tHcy of 11.6 &mgr;mol/L. Conclusions Terminal ileum resection contributes to elevated plasma tHcy levels in CD cases. We recommend tHcy screening in patients with CD, especially in those with prior history of TI resection, and the initiation of vitamin supplementation when appropriate.

End-expiratory pressure best approximates intrinsic lower esophageal sphincter pressure

Lower esophageal sphincter (LES) pressure is routinely measured during esophageal manometry. However, the method of recording LES pressure, of actually taking the measurement, and its clinical usefulness remain areas of debate. Current esophageal manometric systems employ water-perfused catheters or intraluminal transducers, although a recently developed sleeve apparatus is used in a research setting for continuous sphincter pressure monitoring (1). The respiratory effect on intraluminal LES pressure is easily appreciated on manometric tracings obtained by station pull-through (SPT) (2). Because of the respiratory oscillation inherent in the SPT technique, LES pressure may be scored in several ways with reference to gastric baseline pressure: end-expiratory pressure, mid-respiratory pressure, and peak respiratory oscillation (3–5). There is no consensus as to which is preferable. A recent study in cats showed that respiratory-induced oscillations in LES pressure are primarily the result of active diaphragmatic contraction (6). An absence of oscillation in LES pressure was found during periods of central apnea induced by manual hyperventilation. LES pressure during apnea was equal to end-expiratory pressure during spontaneous respiration in the cats. It was concluded that intrinsic LES pressure is best approximated by end-expiratory pressure during spontaneous respiration. This finding is confirmed in a patient we report with Cheyne-Stokes breathing and achalasia who underwent esophageal manometry. LES pressure during periods of central apnea approximated end-expiratory pressure during periods of hyperpnea.

Chronic Belching and Chronic Hiccups

Belching and hiccups are normal phenomena. We all have them—occasionally. But when they become chronic and refractory, they can be psychologically exhausting and socially distressing. They can also be symptoms of more serious underlying disease. This chapter explores the causes and treatments for these unfortunate maladies.

Tube Feeding: Indications, Considerations, and Technique

Tube feeding, as an alternative to eating, conveys nutrition, fluid, and medications safely and reliably to the intestinal tract. This chapter reviews the many ways of establishing and maintaining tube feeding. For a satisfactory outcome, the requesting provider, patient, family, and consultant must understand the indication, purpose, and expectations of this approach. Because tube position determines function, proper selection and placement are discussed in detail. Special attention is given to surgical and percutaneous endoscopic and radiological approaches. Long-term complications are reviewed in detail and a comprehensive approach to management is outlined, with emphasis on the role of a multidisciplinary enteral nutrition team. Position papers and core references are provided.

3559 T-egd: a new technique for accurately detecting and grading esophageal varices in cirrhotic patients.

Background:Endoscopic screening of cirrhotic patients for large esophageal varices (EV) is advocated prior to initiation of prophylactic medical therapy for variceal bleeding. Conscious sedation for conventional endoscopy (CEGD), however, is problematic in cirrhotic patients due to the risk of prolonged encephalopathy. Previously, unsedated transnasal endoscopy (T-EGD) has been shown to be feasible for screening of cirrhotic patients for the presence of EV. Aims:Compare the diagnostic yield of T-EGD with C-EGD for detecting and grading of EV. Methods:Eleven cirrhotics (10 men, mean age 56)with no history of variceal bleeding, prior documentation of EV, severe thrombocytopenia or history of recurrent epistaxis were evaluated by T-EGD. Initially, unsedated T-EGD was done using a 5.3 mm endoscope. Immediately afterwards, a different endoscopist, blinded to the initial findings, performed sedated C-EGD. The presence and size of EV and gastric varices (GV) were recorded. Patient tolerance was evaluated based on a visual analogue scale. Results:Esophageal varices were detected by both modalities in six of eleven patients(table). No stigmata of variceal bleeding was noted by either modality. Average time for unsedated examination was 4.9 +/- 1.1 minutes. Patients found both procedures acceptable overall, with no significant difference in choking, discomfort, or sore throat. No untoward effects, including epistaxis, occurred. Conclusions:1) Esophageal varices are accurately detected and graded by T-EGD in cirrhotic patients. 2) T-EGD is a safe and less costly alternative for screening of cirrhotic patients for esophageal varices.