Esophageal Acidification During Nocturnal Acid-breakthrough with Ilaprazole Versus Omeprazole in Gastroesophageal Reflux Disease

BACKGROUND/AIMS: Though nocturnal acid-breakthrough (NAB) is common in gastroesophageal reflux disease (GERD) patients, its clinical importance results from esophageal acidification, which has been shown to be uncommon. Ilaprazole, a long-acting proton pump inhibitor, may cause NAB infrequently. Accordingly, we studied prospectively, (1) frequency and degree of esophageal acidification during NAB, and (2) frequency and severity of NAB while on ilaprazole versus omeprazole. METHODS: Fifty-eight consecutive patients with GERD on once daily ilaprazole, 10 mg (n = 28) or omeprazole, 20 mg (n = 30) for > one month underwent 24-hour impedance-pH monitoring prospectively. NAB was defined as intra-gastric pH one hour during night, and esophageal acidification as pH < 4 for any duration. Nocturnal symptoms (heartburn, regurgitation, and chest pain) were also recorded. RESULTS: Of the 58 patients (age 35.5 [inter-quartile range 26.5–46.0] years, 38 [65.5%], 42 (72.4%) had NAB. Though patients with NAB had lower nocturnal intra-gastric pH than without (2.8 [1.9–4.1] vs 5.7 [4.6–6.8], P < 0.001), frequency and duration of nocturnal esophageal acidification (17/42 vs 4/16, P = 0.360 and 0.0 [0.0–1.0] vs 0.0 [0.0–0.3] minutes, P = 0.260, respectively) and symptoms were comparable (13/42 vs 6/16, P = 0.750). Though ilaprazole was associated with less NABs (1 [range 1–2, n = 19] vs 1 [range 1–3, n = 23], P = 0.010) than omeprazole, the frequency, duration, and mean intra-gastric pH during NAB were comparable (19/28 vs 23/30, P = 0.560; 117 [0–315] vs 159 [69–287] minutes, P = 0.500; 1.02 [0.7–1.4] vs 1.04 [0.44–1.3], P = 0.620, respectively). CONCLUSIONS: Though NAB was common while patients were on a proton pump inhibitor, esophageal acidification was uncommon. Frequency and severity of NAB were comparable among patients on ilaprazole and omeprazole, except for the lesser number of NABs with ilaprazole.

Achalasia Is Associated With eNOS4a4a, iNOS22GA, and nNOS29TT Genotypes: A Case-control Study

BACKGROUND/AIMS: Achalasia is known to result from degeneration of inhibitory neurons, which are mostly nitrinergic. Characteristic features of achalasia include incomplete lower esophageal sphincter (LES) relaxation and esophageal aperistalsis. Nitric oxide (NO), produced by NO synthase (NOS), plays an important role in peristalsis and LES relaxation. Therefore, we evaluated genetic polymorphisms of NOS gene isoforms (endothelial NOS [eNOS], inducible NOS [iNOS], and neuronal NOS [nNOS]) in patients with achalasia and healthy subjects (HS). METHODS: Consecutive patients with achalasia (diagnosed using esophageal manometry) and HS were genotyped for 27-base pair (bp) eNOS variable number of tandem repeats (VNTR), iNOS22G/A (rs1060826), nNOS C/T (rs2682826) polymorphisms by polymerase chain reaction (PCR) and PCR-restriction fragment length polymorphism (RFLP), respectively. RESULTS: Among 183 patients (118 [64.5%] male, age 39.5 +/- 13.0 years) with achalasia and 366 HS (254 [69.4%] male, age 40.8 +/- 11.0 years), eNOS4a4a genotype of 27-bp VNTR was more common among achalasia than HS (20 [10.9%] vs 13 [3.6%]; P < 0.001; OR, 3.72; 95% CI, 1.8-7.7). Patients with achalasia had iNOS22GA genotypes more often than HS (95 [51.9%] vs 93 [25.4%]; P < 0.001; OR, 3.0; 95% CI, 2.1-4.4). Frequency of genotypes GA + AA was higher in patients than HS (97 [53%] vs 107 [29.2%]; P < 0.001; OR, 2.7; 95% CI, 1.8-3.9). Also, nNOS29TT variant genotype in rs2682826 was more common among patients compared to HS (14 [7.7%] vs 6 [1.6%]; P < 0.001; OR, 5.91; 95% CI, 2.2-15.8). CONCLUSIONS: Achalasia is associated with eNOS4a4a, iNOS22GA, and nNOS29TT genotypes. This may suggest that polymorphisms of eNOS, iNOS, and nNOS genes are risk factors for achalasia.

Fecal Evacuation Disorder Among Patients With Solitary Rectal Ulcer Syndrome: A Case-control Study

BACKGROUND/AIMS: Data on frequency of fecal evacuation disorder (FED) among patients with solitary rectal ulcer syndrome (SRUS), hitherto an enigmatic condition, are scanty. Moreover, most such studies had limitations due to small sample size and lack of inclusion of healthy controls (HC). METHODS: Forty patients with SRUS underwent symptom assessments, sigmoidoscopy, anorectal manometry, defecography, balloon expulsion test (BET); endoscopic ultrasound (EUS) of anal sphincter complex was performed in a subgroup. Physiological tests (anorectal manometry and BET) were also performed in 19 HC. RESULTS: Patients with SRUS (26/40 male, age 37 [18-80] years) more often had FED than HC (10/19 male, age 43 [25-72] years) as shown by weight needed to expel the balloon (300 [0-700] g vs. 100 [0-400] g; P = 0.006), a trend towards abnormal BET (need of > 200 g weight for expulsion) (21/40 [53%] vs. 5/19 [26%], P = 0.058) and impaired anal relaxation (14/40 [35%] vs 2/19 [10.5%]; P = 0.048). Using Rome III criteria, most patients with SRUS reported having chronic constipation (36/40 [90%]) in spite of having normal (Bristol stool type IV, 21/40 [53%]) and diarrheal (types V, VI, VII, 6/40 [20%]) stool forms (Asian classification). SRUS patients more often (17/40 [43%]) had functional defecation disorder (Rome III criteria). Patients with SRUS with abnormal BET had thicker internal anal sphincter than those without (3.9 [3.4-7.0] mm vs 2.8 [2.0-4.0] mm; P = 0.01). CONCLUSIONS: FED was commoner among patients with SRUS as evidenced by abnormal BET and sphincter relaxation. Those with abnormal BET had thicker internal sphincter on EUS than those without.

Physiological and Functional Evaluation of the Transposed Human Pylorus as a Distal Sphincter

BACKGROUND/AIMS: Studies evaluating the human pylorus as a sphincter are scanty and contradictory. Recently, we have shown technical feasibility of transposing the human pylorus for end-stage fecal incontinence. This unique cohort of patients provided us an opportunity to study the sphincter properties of the pylorus in its ectopic position. METHODS: Antro-pylorus transposition on end sigmoid colostomies (n = 3) and in the perineum (n = 15) was performed for various indications. Antro-pylorus was assessed functionally (digital examination, high resolution spatiotemporal manometry, barium retention studies and colonoscopy) and by imaging (doppler ultrasound, MRI and CT angiography) in its ectopic position. RESULTS: The median resting pressure of pylorus on colostomy was 30 mmHg (range 28-38). In benign group, median resting pressure in perineum was 12.5 mmHg (range 6-44) that increased to 21.5 mmHg (range 12-29) (P = 0.481) and 31 mmHg (range 16-77) (P = 0.034) on first and second follow-up, respectively. In malignant group, median post-operative pressures were 20 mmHg (range 14-36) and 21 mmHg (range 18-44) on first and second follow-up, respectively. A definite tone and gripping sensation were felt in all the patients on digital examination. On distal loopogram, performed through the diverting colostomies, barium was retained proximal to the neo-pyloric valve. Both perineal ultrasound and MRI showed viable transposed graft. CT angiography and color doppler studies confirmed vascular flow in the transposed position. CONCLUSIONS: The human pyloric valve can function as a tonic sphincter when removed from the gastroduodenal continuity.

Slow Transit Constipation Associated With Excess Methane Production and Its Improvement Following Rifaximin Therapy: A Case Report

Constipation, a common problem in gastroenterology practice, may result from slow colonic transit. Therapeutic options for slow transit constipations are limited. Excessive methane production by the methanogenic gut flora, which is more often found in patients with constipation, slows colonic transit. Thus, reduction in methane production with antibiotic treatment directed against methanogenic flora of the gut may accelerate colonic transit resulting in improvement in constipation. However, there is not much data to prove this hypothesis. We, therefore, report a patient with slow transit constipation associated with high methane production both in fasting state and after ingestion of glucose, whose constipation improved after treatment with non-absorbable antibiotic, rifaximin, which reduced breath methane values.

Varicella Zoster Cranial Polyneuropathy Presenting With Dysphagia, Esophagitis and Gastroparesis

No abstract available.

Frequency of Small Intestinal Bacterial Overgrowth in Patients with Irritable Bowel Syndrome and Chronic Non-Specific Diarrhea

INTRODUCTION: Small intestinal bacterial overgrowth (SIBO) occurs in varying frequency in irritable bowel syndrome (IBS). We studied the frequency of SIBO in IBS and chronic non-specific diarrhea (CNSD). METHODS: 129 patients with IBS (Manning's criteria), 73 with CNSD (> or = 4 weeks diarrhea with two of these tests normal [urine D-xylose, fecal fat and duodenal biopsy]) and 51 healthy controls (HC) were evaluated for SIBO using glucose hydrogen breath test (GHBT). Diarrhea-predominant IBS (D-IBS) was grouped into CNSD. Rise in breath hydrogen 12 ppm above basal following 100 g glucose was diagnostic of SIBO. RESULTS: Of 129 patients with IBS, 7 were constipation (C-IBS), and 122 were of indeterminate type (I-IBS). Patients with IBS were younger than HC and CNSD (IBS vs. HC: 36.6 yr +/- 11.4 vs. 44.1 yr +/- 13.6, p = 0.001; IBS vs. CNSD: 36.6 yr +/- 11.4 vs. 42 yr +/- 14.5, p = 0.003). Patients with CNSD were comparable to HC in age (42 yr +/- 14.5 vs. 44.1 yr +/- 13.6, p = ns). Patients with IBS were more often male than HC [108/129 (83.7%) vs. 34/51 (66.7%) p = 0.02]; gender of CNSD and HC was comparable [male 39/73 (53.4%) vs. 34/51 (66.7%) p = ns]. SIBO was commoner in CNSD than HC [16 (21.9%) vs. 1 (2%), p = 0.003], but was comparable in IBS and HC [11 (8.5%) vs. 1 (2%), p = 0.18]. Patients with CNSD more often had SIBO than IBS [16 (21.9%) vs. 11 (8.5%), p = 0.007]. CONCLUSIONS: SIBO was more common in CNSD including D-IBS than other types of IBS and HC.

Patients With Irritable Bowel Syndrome Exhale More Hydrogen Than Healthy Subjects in Fasting State

BACKGROUND/AIMS: Irritable bowel syndrome (IBS) is a common disorder with significant morbidity and impairment of quality of life. Most patients (26%-83%) with IBS from Asia reported bloating. Bloating may result from increased amount or distribution of gas in the gut or exaggerated perception of distension. To evaluate whether patients with IBS produce more hydrogen even in fasting state, we conducted a study with the following aims: (1) to estimate fasting breath hydrogen levels among patients with IBS as compared with healthy controls (HC) and (2) to study relationship between symptoms of IBS and stool frequency and fasting breath hydrogen levels. METHODS: Eighty-one patients with IBS (Rome III criteria) and 123 HC were included. Hydrogen breath test was performed using a gas analyzer after an overnight (12 hours) fast. Both patients with IBS and HC had similar preparation before breath hydrogen estimation. RESULTS: Of 93 patients with symptoms of functional gastrointestinal disorders, 81 (87.1%) met Rome III criteria and 12 (12.9%) were negative and hence, excluded from the study. Patients with IBS were comparable in age (35 +/- 11.8 years vs 37.5 +/- 13.1 years, p = NS) and gender (male 61/81 [75.3%] vs 77/123 [62.6%], p=0.67) with HC. Average fasting breath hydrogen was higher in patients with IBS as compared to HC (mean 10.1 +/- 6.5 ppm vs 5.5 +/- 6.2 ppm, p < 0.0001). Number of stools per week correlated with average fasting breath hydrogen excretion in patients with IBS (r = 0.26, p = 0.02). CONCLUSIONS: Inspite of similar preparation for the test, fasting breath hydrogen was higher in patients with IBS as compared to HC. Number of stools per week correlated with fasting breath hydrogen levels among patients with IBS.