Evaluation and Management of Noncardiac Chest Pain / 胃肠病学

Noncardiac chest pain (NCCP) is defined as a recurrent, angina⁃like chest pain after cardiac causes are excluded. It is a common and challenging problem in clinical practice that requires appropriate assessment to identify the underlying origin of the symptom. Gastroesophageal reflux disease (GERD), esophageal dysmotility and functional chest pain are the three main causes of NCCP. GERD is the most common cause of NCCP and should be evaluated first. Proton pump inhibitor (PPI) test, upper gastrointestinal endoscopy, 24 ⁃ hour esophageal pH ⁃ impedance monitoring are used to identify GERD⁃induced NCCP. High⁃resolution esophageal manometry is the main tool to identify esophageal dysmotility in non⁃GERD⁃related NCCP. Diagnosis of functional chest pain requires a negative cardiac workup, no response to PPI test, as well as no obvious abnormalities in upper gastrointestinal endoscopy with mucosal biopsy, esophageal pH ⁃ impedance monitoring and esophageal manometry. Treatment of NCCP is tailored according to the underlying mechanism that is responsible for the chest pain. PPI for GERD ⁃ related NCCP and smooth muscle relaxants for esophageal dysmotility are very commonly prescribed. Endoscopic and surgical interventions can also be considered in GERD and esophageal dysmotility related NCCP. For patients with functional chest pain, neuromodulators, mainly the antidepressants are the cornerstone of therapy.

The development of colonic manometry and its clinical application in children with colonic dysmotility / 中华实用儿科临床杂志

Colonic dysmotility is a common gastrointestinal motility disease in children, with the main manifestations of abdominal distension and constipation.Colonic manometry is currently considered as a standard diagnostic method for assessing colonic motility, which real-time measures intracolonic pressure and the shape and coordination of colonic muscle pressure waves at rest and stimulating states and thus qualitatively and quantitatively assess the colonic movement.Recently, high-resolution colonic manometry has been rapidly developed into a major technique for obtaining more effective information involved in the physiology and/or pathophysiology of colonic contractile activity in colonic dysmotility patients.This review focuses on the development of colonic manometry and its clinical application in children with colonic dysmotility.

Diagnóstico y tratamiento actual de la gastroparesia: una revisión sistemática de la literatura / Current diagnosis and treatment of gastroparesis: A systematic literature review

Resumen El vaciamiento gástrico normal refleja un esfuerzo coordinado entre diferentes regiones del estómago y el duodeno, y también una modulación extrínseca por parte del sistema nervioso central y factores del intestino distal. Los principales eventos relacionados con el vaciamiento gástrico normal incluyen el fondo de relajación para acomodar la comida, contracciones antrales para triturar partículas grandes de comida, contracción pilórica para permitir la liberación de comida del estómago y coordinación antropiloroduodenal de los fenómenos motores de relajación. La dismotilidad gástrica incluye el vaciamiento tardío del estómago (gastroparesia), vaciamiento gástrico acelerado (síndrome de dumping) y otras disfunciones motoras, como el deterioro del fondo de distensión, que se encuentra con mayor frecuencia en la dispepsia funcional. Los síntomas de la gastroparesia son inespecíficos y pueden simular otros trastornos estructurales.

Abstract Normal gastric emptying reflects a coordinated effort between different regions of the stomach and the duodenum, and also an extrinsic modulation by the central nervous system and distal bowel factors. The main events related to normal gastric emptying include relaxation of the fundus to accommodate food, antral contractions to triturate large food particles, the opening of the pyloric sphincter to allow the release of food from the stomach, and anthropyloroduodenal coordination for motor relaxation. Gastric dysmotility includes delayed emptying of the stomach (gastroparesis), accelerated gastric emptying (dumping syndrome), and other motor dysfunctions, e.g., deterioration of the distending fundus, most often found in functional dyspepsia. The symptoms of gastroparesis are nonspecific and may mimic other structural disorders.

Systemic sclerosis and gastrointestinal involvement / Esclerosis sistémica y participación gastrointestinal

ABSTRACT Systemic sclerosis (SSc) is a systemic autoimmune disease in which gastrointestinal manifestations are a frequent complication. Gastrointestinal involvement is present in up to 90 % of patients. The most affected areas are the esophagus and the anorectal tract. Reflux, heartburn and dysmotility are the leading causes of gastrointestinal discomfort. Disordered anorectal function can occur early in the course of SSc and is an important factor in the development of fecal incontinence. Current recommendations to treat gastrointestinal disorders in SSc include the use of proton pump inhibitors, prokinetics and rotating antibiotics. This review discusses the proposed pathophysiological mechanisms, the clinical presentation, the different diagnostic techniques and the current management of the involvement of each section of the gastrointestinal tract in SSc.

RESUMEN La esclerosis sistémica (ES) es una enfermedad autoinmune sistémica en la que las manifestaciones gastrointestinales son una complicación frecuente. El compromiso gastrointestinal está presente hasta en 90% de los pacientes. Las áreas más afectadas son el esófago y el tracto anorrectal. El reflujo, la pirosis y la dismotilidad son las principales causas de malestar gastrointestinal. La función anorrectal alterada puede presentarse temprano en el curso de la ES y es un factor importante en el desarrollo de incontinencia fecal. Las recomendaciones actuales para tratar los trastornos gastrointestinales en la ES incluyen el uso de inhibidores de la bomba de protones, procinéticos y de antibióticos en forma rotativa. Esta revisión discute los mecanismos fisiopatológicos propuestos, la presentación clínica, las diferentes técnicas de diagnóstico y el manejo actual del compromiso de cada sección del tracto gastrointestinal en la ES.

Does the Oral-Anal Transit Test Correlate with Colonic Manometry Findings in Children with Refractory Constipation? / 대한소아소화기영양학회지

PURPOSE: The Oral-anal Transit Test (OTT) is a simple method of obtaining information about colonic transit. We aim to assess the correlation of OTT with the neuromuscular integrity of the colon determined by colonic manometry (CM).METHODS: All patients who had OTT followed by CM were evaluated. Less than 6 of 24 markers remaining on OTT was considered normal. CM was performed per previously published guidelines. A normal CM was defined as at least one High Amplitude Propagating Contraction progressing from the most proximal sensor through the sigmoid colon.RESULTS: A total of 34 patients underwent both OTT and CM (44% male, age 4–18 years, mean 11.5 years, 97% functional constipation +/− soiling, Hirschsprung's Disease). Of normal and abnormal OTT patients, 85.7% (6/7) and 18.5% (5/27) respectively had normal CM. When all markers progressed to at least the sigmoid colon, this was 100% predictive against colonic inertia. Greater than 50% of patients with manometric isolated sigmoid dysfunction had markers proximal to the recto-sigmoid.CONCLUSION: OTT and CM are both valuable studies that assess different aspects of colonic function. OTT can be used as a screening test to rule out colonic inertia. However, the most proximal extent of remaining markers does not predict the anatomical extent of the manometric abnormality, particularly in isolated sigmoid dysfunction.

Does the nissen fundoplication procedure improve esophageal dysmotility in patients with barrett's esophagus? / A fundoplicatura a nissen melhora a dismotilidade esofágica em pacientes com esôfago de barrett?

ABSTRACT Objective: to evaluate esophageal dysmotility (ED) and the extent of Barrett's esophagus (BE) before and after laparoscopic Nissen fundoplication (LNF) in patients previously diagnosed with BE and ED. Methods: twenty-two patients with BE diagnosed by upper gastrointestinal (GI) endoscopy with biopsies and ED diagnosed by conventional esophageal manometry (CEM) were submitted to a LNF, and followed up with clinical evaluations, upper GI endoscopy with biopsies and CEM, for a minimum of 12 months after the surgical procedure. Results : sixteen patients were male (72.7%) and six were females (27.3%). The mean age was 55.14 (± 15.52) years old. and the mean postoperative follow-up was 26.2 months. The upper GI endoscopy showed that the mean length of BE was 4.09 cm preoperatively and 3.91cm postoperatively (p=0.042). The evaluation of esophageal dysmotility through conventional manometry showed that: the preoperative median of the lower esophageal sphincter resting pressure (LESRP) was 9.15 mmHg and 13.2 mmHg postoperatively (p=0.006). The preoperative median of the esophageal contraction amplitude was 47.85 mmHg, and 57.50 mmHg postoperatively (p=0.408). Preoperative evaluation of esophageal peristalsis showed that 13.6% of the sample presented diffuse esophageal spasm and 9.1% ineffective esophageal motility. In the postoperative, 4.5% of patients had diffuse esophageal spasm, 13.6% of aperistalsis and 22.7% of ineffective motor activity (p=0.133). Conclusion: LNF decreased the BE extension, increased the LES resting pressure, and increased the amplitude of the distal esophageal contraction; however, it was unable to improve ED.

RESUMO Objetivo: avaliar a dismotilidade esofágica (DE) e a extensão do esôfago de Barrett (EB) antes e depois da fundoplicatura laparoscópica a Nissen (FLN) em pacientes previamente diagnosticados com EB e DE. Método: vinte e dois pacientes com EB diagnosticada por endoscopia digestiva alta (EDA) com biópsias e DE diagnosticada por manometria esofágica convencional (MEC) foram submetidos a FLN, e acompanhados por avaliações clínicas, endoscopia digestiva alta com biópsias e MEC, por no mínimo 12 meses após o procedimento cirúrgico. Resultados: dezesseis pacientes eram do sexo masculino (72,7%) e seis do feminino (27,3%). A média de idade foi de 55,14 (± 15,52) anos e o seguimento pós-operatório médio foi de 26,2 meses. A endoscopia digestiva alta mostrou que o comprimento médio do EB foi de 4,09 cm no pré-operatório e 3,91 cm no pós-operatório (p = 0,042). A avaliação da dismotilidade esofágica por meio da manometria convencional mostrou que a mediana pré-operatória da pressão de repouso do esfíncter esofágico inferior (PREEI) foi de 9,15 mmHg, e de 13,2 mmHg no pós-operatório (p = 0,006). A mediana pré-operatória da amplitude de contração esofágica foi de 47,85 mmHg, e de 57,50 mmHg no pós-operatório (p = 0,408). A avaliação pré-operatória do peristaltismo esofágico mostrou que 13,6% da amostra apresentava espasmo esofágico difuso e 9,1%, motilidade esofágica ineficaz. No pós-operatório, 4,5% dos pacientes apresentaram espasmo esofágico difuso, 13,6% de aperistalse e 22,7% de atividade motora ineficaz (p = 0,133). Conclusões: a FLN diminuiu a extensão do EB, aumentou a pressão de repouso do EEI e aumentou a amplitude da contração esofágica distal; no entanto, não foi capaz de melhorar a DE.

Ameliorating Effects of Electroacupuncture on Dysmotility, Inflammation, and Pain Mediated via the Autonomic Mechanism in a Rat Model of Postoperative Ileus

BACKGROUND/AIMS: Postoperative ileus increases healthcare costs and reduces the postoperative quality of life (QOL). The aim of this study is to investigate effects and mechanisms of electroacupuncture (EA) at ST36 and PC6 on gastrointestinal motility in rat model of postoperative ileus. METHODS: Laparotomy was performed in 24 rats (control [n = 8], sham-EA [n = 8], and EA [n = 8]) for the implantation of electrodes in the stomach and mid-jejunum for recording of gastric and small intestinal slow waves. Electrodes were placed in the chest skin for electrocardiogram (ECG). Intestinal manipulation (IM) was performed in Sham-EA and EA rats after surgical procedures. Small intestinal transit (SIT), gastric emptying (GE), postoperative pain, and plasma TNF-α were evaluated in all rats. RESULTS: (1) Compared with sham-EA, EA accelerated both SIT (P < 0.05) and GE (P < 0.05) and improved regularity of small intestinal slow waves. (2) Compared with the control rats (no IM), IM suppressed vagal activity and increased sympathovagal ratio assessed by the spectral analysis of heart rate variability from ECG, which were significantly prevented by EA. (3) EA significantly reduced pain score at 120 minutes (P < 0.05, vs 15 minutes) after the surgery, which was not seen with sham-EA. (4) Plasma TNF-α was increased by IM (P = 0.02) but suppressed by EA (P = 0.04) but not sham-EA. CONCLUSION: The postoperative ileus induced by IM, EA at ST36 and PC6 exerts a prokinetic effect on SIT and GE, a regulatory effect on small intestinal slow waves and an analgesic effect on postoperative pain possibly mediated via the autonomic-cytokine mechanisms.

Need of combining proton pump inhibitors with prokinetics : A prospective observation study conducted in India

@#Gastro esophageal reflux disease (GERD), a highly prevalent disorder has adverse impact on quality of life. An estimated 40% of GERD patients have incomplete response to therapy by standard proton pump inhibitors (PPI). For these PPI refractory patients, doubling the PPI dose or switching to another PPI are usually pursued by the treating physicians, even though that might not be optimal. Therefore, an appropriate second line treatment should focus on addition of gastro-prokinetic drugs that stimulates gastric motility. This prospective observational study was conducted in 118 patients suffering from symptoms suggestive of GERD. The study was carried out at four centers in Indian National Capital region. The major objectives were to assess the overlap between GERD and delayed gastric emptying and to predict the need for combination therapy of PPI with pro-kinetic drug using Frequency Scale for the Symptoms of GERD (FSSG) score. The mean total FSSG score was 16.37 ± 7.50. From 118 patients, 98 (83.05%) met the criteria for GERD with FSSG total score more than eight. The mean reflux score was 7.43 ± 4.08, while the mean dysmotility score was 8.94 ± 4.83. GERD patients in this study had high mean FSSG score, whereas dysmotility symptoms proved to be more dominant than acid reflux. Based on the findings of this study, combination therapy of PPI with prokinetics is recommended in subsets of patients with high FSSG score.

Radionuclide Esophageal Transit Scintigraphy in Primary Hypothyroidism

BACKGROUND/AIMS: Esophageal dysmotility is associated with gastrointestinal dysmotility in various systemic and neuroregulatory disorders. Hypothyroidism has been reported to be associated with impaired motor function in esophagus due to accumulation of glycosaminoglycan hyaluronic acid in its soft tissues, leading to changes in various contraction and relaxation parameters of esophagus, particularly in the lower esophageal sphincter. In this study we evaluated esophageal transit times in patients of primary hypothyroidism using the technique of radionuclide esophageal transit scintigraphy. METHODS: Thirty-one patients of primary hypothyroidism and 15 euthyroid healthy controls were evaluated for esophageal transit time using 15–20 MBq of Technetium-99m sulfur colloid diluted in 10–15 mL of drinking water. Time activity curve was generated for each study and esophageal transit time was calculated as time taken for clearance of 90% radioactive bolus from the region of interest encompassing the esophagus. Esophageal transit time of more than 10 seconds was considered as prolonged. RESULTS: Patients of primary hypothyroidism had a significantly increased mean esophageal transit time of 19.35 ± 20.02 seconds in comparison to the mean time of 8.25 ± 1.71 seconds in healthy controls (P < 0.05). Esophageal transit time improved and in some patients even normalized after treatment with thyroxine. A positive correlation (r = 0.39, P < 0.05) albeit weak existed between the serum thyroid stimulating hormone and the observed esophageal transit time. CONCLUSIONS: A significant number of patients with primary hypothyroidism may have subclinical esophageal dysmotility with prolonged esophageal transit time which can be reversible by thyroxine treatment. Prolonged esophageal transit time in primary hypothyroidism may correlate with serum thyroid stimulating hormone levels.

Esophageal Body Motility for Clinical Assessment in Patients with Refractory Gastroesophageal Reflux Symptoms

BACKGROUND/AIMS: Little data exists about esophageal body dysmotility and reflux patterns in refractory gastroesophageal reflux disease (RGERD) patients off therapy. We aimed to evaluate effects of esophageal body dysmotility on reflux parameters in RGERD patients by combining impedance-pH monitoring and high-resolution manometry (HRM). METHODS: We retrospectively reviewed the impedance-pH data and HRM metrics in patients with refractory gastroesophageal reflux symptoms. Impedance-pH monitoring and manometric data were compared between 2 groups: ineffective esophageal motility (IEM) and normal motility. RESULTS: Forty-eight patients (30 males, mean age 54.5 years) were included (16 erosive esophagitis, 24 non-erosive reflux disease, and 8 functional heartburn), amongst which 24 subjects showed IEM, and others had normal motility. Number of patients who had a large break in the IEM group was significantly higher than that of normal motility patients. IEM group had more patients with weakly acid reflux and long term acid reflux than the normal group (P = 0.008, P = 0.004, respectively). There was no statistical difference in baseine impedance levels from z4 to z6 between the 2 groups (2911 ± 1160 Ω vs 3604 ± 1232 Ω, 2766 ± 1254 Ω vs 3752 ± 1439 Ω, 2349 ± 1131 Ω vs 3038 ± 1254 Ω, all P > 0.05). Acid exposure time, numbers of long term acid reflux and weakly acid reflux showed strong negative correlation with esophageal body motility and/or lower esophageal sphincter function. CONCLUSIONS: IEM was associated more with acid exposure, abnormal weakly acid reflux, and long term acid reflux in RGERD patients. These data suggested the role of esophageal body dysmotility in the pathophysiological mechanisms of RGERD patients.

Targeting Ion Channels: An Important Therapeutic Implication in Gastrointestinal Dysmotility in Patients With Spinal Cord Injury

Gastrointestinal (GI) dysmotility is a severe, and common complication in patients with spinal cord injury (SCI). Current therapeutic methods using acetylcholine analogs or laxative agents have unwanted side effects, besides often fail to have desired effect. Various ion channels such as ATP-sensitive potassium (KATP) channel, calcium ions (Ca2+)-activated potassium ions (K+) channels, voltage-sensitive Ca2+ channels and chloride ion (Cl-) channels are abundantly expressed in GI tissues, and play an important role in regulating GI motility. The release of neurotransmitters from the enteric nerve terminal, innervating GI interstitial cells of Cajal (ICC), and smooth muscle cells (SMC), causes inactivation of K+ and Cl- channels, increasing Ca2+ influx into cytoplasm, resulting in membrane depolarization and smooth muscle contraction. Thus, agents directly regulating ion channels activity either in ICC or in SMC may affect GI peristalsis and would be potential therapeutic target for the treatment of GI dysmotility with SCI.

Visceral Hypersensitivity and Altered Colonic Motility in Type 2 Diabetic Rat

BACKGROUND/AIMS: Abnormal visceral sensitivity and disordered motility are common in patients with diabetes mellitus. The purpose of the present study was to investigate whether visceral sensation and bowel motility were altered in a rat model of type 2 diabetes mellitus accompanied by weight loss. METHODS: A type 2 diabetic rat model in adulthood was developed by administrating streptozotocin (STZ; 90 mg/kg, i.p.) to neonatal rats. Eight weeks after STZ administration, rats with blood glucose level of 200 mg/dL or higher were selected and used as diabetic group (n = 35) in this study. Abdominal withdrawal reflex and arterial pulse rate were measured to examine visceral nociception induced by colorectal distension (0.1-1.0 mL). The amplitude, frequency, and area under the curve (AUC) of spontaneous phasic contractions of colonic circular muscles were recorded in vitro to examine colonic motility. RESULTS: STZ-treated diabetic rats gained significantly less weight for 8 weeks than control (P < 0.01). Forty-eight percent of the diabetic rats showed enhanced visceral nociceptive response to colorectal distension. Diabetic rats did not differ from control rats in colorectal compliance. However, the frequency and AUC, not the amplitude, of colonic spontaneous contraction in vitro was significantly decreased in diabetic rats compared to control rats (P < 0.01 in frequency and P < 0.05 in AUC). CONCLUSIONS: These results demonstrate visceral hypersensitivity and colonic dysmotility in a rat model of type 2 diabetes mellitus accompanied by weight loss.

Radiofrequency Catheter Ablation for Atrial Fibrillation Elicited "Jackhammer Esophagus": A New Complication Due to Vagal Nerve Stimulation?

Radiofrequency catheter ablation (RFCA) is a potentially curative method for treatment of highly symptomatic and drug-refractory atrial fibrillation (AF). However, this technique can provoke esophageal and nerve lesion, due to thermal injury. To our knowledge, there have been no reported cases of a newly described motor disorder, the Jackhammer esophagus (JE) after RFCA, independently of GERD. We report a case of JE diagnosed by high-resolution manometry (HRM), in whom esophageal symptoms developed 2 weeks after RFCA, in absence of objective evidence of GERD. A 65-year-old male with highly symptomatic, drug-refractory paroxysmal AF was candidate to complete electrical pulmonary vein isolation with RFCA. Prior the procedure, the patient underwent HRM and impedance-pH to rule out GERD or hiatal hernia presence. All HRM parameters, according to Chicago classification, were within normal limits. No significant gastroesophageal reflux was documented at impedance pH monitoring. Patient underwent RFCA with electrical disconnection of pulmonary vein. After two weeks, patient started to complain of dysphagia for solids, with acute chest-pain. The patient repeated HRM and impedance-pH monitoring 8 weeks after RFCA. HRM showed in all liquid swallows the typical spastic hypercontractile contractions consistent with the diagnosis of JE, whereas impedance-pH monitoring resulted again negative for GERD. Esophageal dysmotility can represent a possible complication of RFCA for AF, probably due to a vagal nerve injury, and dysphagia appearance after this procedure must be timely investigated by HRM.

Changes of vasocative intestinal peptide neurons in the myenteric plexus of gastric antrum in rats with se-vere acute pancreatitis / 医学研究生学报

Objective Patients with severe acute pancreatitis ( SAP) always suffer decrease in gastrointestinal motility , even gastrointestinal failure.The article aimed to investigate the changes of vasoactive intestinal peptide (VIP) in the myenteric plexus of the gastric antrum in rats with severe acute pancreatitis ( SAP) complicated by gastrointestinal dysmotility . Methods Twenty Sprague Dawley rats were randomly allocated into two groups:control group and SAP group .Acute pancreatitis was induced by intraductal infu-sion of 5%sodium taurodeoxycholate .24 h after operation , records were made on pathological evaluation of pancreatic lesion , amylase, C-reactive protein ( CRP) , gastric emptying rate and the percentage of VIP neurons in the total neurons . Results Compared with the control group, the gastric emptying rate in the SAP group was significantly lower ([31.49 ±3.96]% vs [70.99 ±1.82]%).The score of pancreatic lesion, amylase, CRP and the percentage of VIP neurons was significantly higher ([14.63 ±1.06]score vs [1.60 ± 0.52]score, [2061.25 ±434.86]U/L vs [360.20 ±30.29]U/L, [140.10 ±17.07]μg/mL vs [35.71 ±6.43]μg/mL, [22.45 ± 4.10]%vs [10.72 ±1.92]%)(P<0.05). Conclusion Plas-ticity took place in VIP neurons in the myenteric plexus of gastric an-trum in rats with SAP complicated by gastrointestinal dysmotility , which was connected with neural mechanism underlying SAP compli-cated by gastrointestinal dysmotility .

Constipação intestinal / Constipation

A constipação intestinal acomete cerca de 20% da população mundial e constitui um dos sintomas mais frequentes de procura ao médico. É mais comum em mulheres e idosos e se encontra entre as doenças funcionais do intestino. Pode ser referida pelo paciente como fezes endurecidas, esforço excessivo no ato evacuatório, evacuações infrequentes ou sensação de evacuação incompleta. Subdivide-se em primária e secundária, tendo essa última causa bem definida, como doenças endócrinas e neurológicas ou uso inadvertido de substâncias obstipantes. É importante orientarmos nossos pacientes para a necessidade de uma dieta rica em fibras e de uma hidratação adequada. O manejo farmacológico pode incluir suplementação de fibras, laxativos osmóticos, emolientes e laxativos irritativos

Constipation occurs in about 20% of the world population and it is a common reason for seeking medical attention. It is more common in women and in the elderly and may be part of a generalized gastrointestinal dysmotility syndrome. Patients may define constipation as hard stools, excessive straining, infrequent stools, or a sense of incomplete evacuation. There are two main types of constipation - primary or secondary, the latter caused by systemic disorders such as endocrine disorders, neurologic dysfunction, or as a side effect of medications. Proper dietary fiber and fluid intake should be emphasized. Pharmacologic management of constipation may include fiber laxatives, osmotic laxatives, stool surfactants, or stimulant laxatives

Gallbladder disease in type-2 Diabetes mellitus patients.

Background: Diabetes mellitus is a modern epidemic which leads to various complications over a period of time. Autonomic neuropathy is one such complication which may lead on to gallbladder dysmotility and gallbladder stones. Objectives: To determine the incidence of gallbladder disorders in patients of type 2 diabetes mellitus and to find out the incidence of autonomic dysfunction in type 2 diabetes mellitus and correlate it with presence of gall bladder disorders. Material and Methods: The present study was conducted in 50 cases of type 2 diabetes mellitus and 25 healthy age and sex matched normal individuals were taken as controls. The cases as well as the controls underwent ultrasonographic examination for gall bladder volume, wall thickness, intraluminal mass and contraction in response to fatty meal. Data thus collected was compared and analysed statistically by using students ‘t’ test and chi- square test. Results: Mean postprandial gallbladder volume was 20.56±8.87 cm3 in diabetics with ANP with gallstones, 26.16±1.24 cm3 in diabetics with ANP with dysmotility 13.0±6.26 cm3 in diabetics with gallstones without ANP, 12.14±4.88 cm3 in normal diabetics and 13.60±5.95 cm3 in controls. The percentage contraction post fatty meal was calculated from these values and found to be 24.73±14.64% in diabetics with ANP with dysmotility, 26.38±17 .04% in diabetics with ANP with dysmotility, 43.48±8.45% in diabetics with gallstones without ANP, 56.84±9.02% in normal diabetics and 57 .64±9.92% in controls. Conclusion: Incidence of gallbladder disease is much higher in type 2 diabetics (40%) as compared to normal healthy adults (4%). It was concluded that diabetics with ANP had significantly impaired gallbladder emptying. Poor control of diabetes, hypercholesterolemia and diabetic autonomic neuropathy are important risk factors for the development of gallbladder disease.

Efficacy of erythromycin on the functional gastrointestinal dysmotility in neonates / 中国小儿急救医学

Objective To assess the efficacy of oral erythromycin on the functional gastrointestinal dysmotility in neonates.Methods In this double-blind,randomized,placebo controlled trial,90 neonates consecutively admitted to the neonatal intensive care unit of Shenzhen Children's Hospital from Jan 2009 to Dec 2011 were enrolled and randomly divided into low-dosage erythromycin group ( LE group,n =30 ),highdosage erythromycin group ( HE group,n =30 ) and control group ( n =30).Patients received either erythromycin ( 3 mg/kg or 10 mg/kg) or equivalent normal saline with oral or nasal feeding every 8 hours one time for 14 d.The time to achieve half,three-quarters,and full enteral nutrition,the time of parenteral nutrition,and hospital length of stay were compared among each group.Results The time to achieve half,three-quarters,and full enteral nutrition in HE group [ ( 3.0 ± 0.5 ) d,( 6.2 ± 0.7 ) d,( 8.2 ± 1.0 ) d ] and in LE group [(6.2±0.5) d,(8.3 ±0.6) d,(10.6 ±1.1) d] were shorter than that in control group [(8.1 ±0.4) d,( 13.5 ± 1.0) d,( 15.7 ± 1.2) d] ( P ＜ 0.05 ).The duration of parenteral nutrition [ ( 14.2 ± 1.4) d vs (9.3 ± 1.2) d vs (7.8 ± 1.1 ) d ] and hospital length of stay [ ( 13.0 ± 1.4 ) d vs ( 8.1 ± 0.8 ) d vs ( 6.8 ±0.7) d] were significantly prolonged in control group compared with LE and HE groups,and there were significant differences among the three groups ( P ＜ 0.05).The incidence of liver injury and septicemia during the treatment of erythromycin were similar between HE group and LE group,but it was significantly lower than control group.No serious adverse effect such as prolongation of QT intervals,dysrhythmia associated with erythromycin treatment was found.Conclusion Oral erythromycin can be considered as a treatment for neonates with functional gastrointestinal dysmotility who fail to establish adequate enteral nutrition,and highdosage oral erythromycin is more effective than low-dosage.

A Review of Factors Predicting Outcome of Pneumatic Dilation in Patients With Achalasia Cardia

Pneumatic dilation (PD) is an effective treatment for achalasia cardia. Outcome of PD, however, varies among different studies. Recently, some groups started considering laparoscopic myotomy to be competitive to PD in treatment of achalasia considering dreaded complication like perforation following the latter therapeutic approach. Therefore, there is need to predict outcome of PD for achalasia, so that appropriate therapy, both for treatment naive and for treatment failed patients can be chosen. Apart from age and gender, 2 investigations, namely post-PD manometry and timed barium esophagogram are most often used to predict outcome after PD. Even though there are studies available in the literature with regard to these modalities to predict outcome of PD, these are quite few in number, including small number of patients, primarily because of rarity of the disease. In this article, we review the literature predicting outcome of PD for achalasia.

Effects of tegaserod and erythromycin in upper gut dysmotility: a comparative study.

Objectives Tegaserod may enhance upper gut transit, but, its prokinetic effects on antral/small bowel motility and how this compares with erythromycin is unknown. We prospectively assessed and compared the effects of tegaserod and erythromycin on upper gut motility. Methods In an open label, non-crossover study, 22 patients (M/F=4/18; mean age=37 years) with symptoms of upper gut dysmotility underwent 24-hour ambulatory antroduodenojejunal manometry with a six-sensor solid state probe. The effects of 12 mg oral tegaserod were compared with 125 mg intravenous erythromycin by quantifying pressure wave activity and assessing motor patterns. Results Motor activity increased (p<0.05) in antrum, duodenum and jejunum with both drugs when compared to baseline period. The motor response with tegaserod was higher (p<0.05) in jejunum and occurred during the second or third hours, whereas with erythromycin, it was higher (p<0.05) in antrum and occurred within 30 minutes. After tegaserod, a ‘fed-response’ like pattern was seen whereas after erythromycin, large amplitude (>100 mmHg) antral contractions at 3 cycles per minute were seen. Following tegaserod and erythromycin, phase III MMCs occurred in 12 (55%) and 8 (36%) patients respectively (p>0.05). Conclusions Both drugs increase upper gut motility and induce MMC’s, but exert a differential response. Tegaserod produces a more sustained prokinetic effect in the duodenum/ jejunum, whereas erythromycin predominantly increases antral motor activity.

Postpyretic Gastroparesis

Gastroparesis is a clinical term for gastric dysmotility or paralysis that presents without mechanical obstruction, but with functional obstruction. Nausea, vomiting, abdominal discomfort and abdominal distension may result from the functional obstruction of gastroparesis. Gastroparesis is frequently associated with such systemic diseases as diabetic mellitus and scleroderma or with certain operations such as vagotomy. Yet gastroparesis is rarely described in older children after viral infection. The authors observed a case of gastroparesis after pyretic symptoms. We report here on this case and its clinical consequences.