Normal values in ambulatory oesophageal pH monitoring at two levels in Spain.

AIM: Upper oesophageal pH monitoring may play a significant role in the study of extra-oesophageal GERD, but limited normal data are available to date. Our aim was to develop a large series of normal values of proximal oesophageal acidification. METHODS: 155 healthy volunteers (74 male) participated in a multi-centre national study including oesophageal manometry and 24 hours oesophageal pH monitoring using two electrodes individually located 5 cm above the LOS and 3 cm below the UOS. RESULTS: 130 participants with normal manometry completed all the study. Twelve of them were excluded for inadequate pH tests. Twenty-seven subjects had abnormal conventional pH. The remaining 91 subjects (37 M; 18-72 yrs age range) formed the reference group for normality. At the level of the upper oesophagus, the 95th percentile of the total number of reflux events was 30, after eliminating the meal periods 22, and after eliminating also the pseudo-reflux events 18. Duration of the longest episodes was 5, 4 and 4 min, respectively (3.5 min in upright and 0.5 min in supine). The upper limit for the percentage of acid exposure time was 1.35, 1.05 and 0.95%, respectively. No reflux events were recorded in the upper oesophagus in 8 cases. CONCLUSION: This is the largest series of normal values of proximal oesophageal reflux that confirm the existence of acid reflux at that level in healthy subjects, in small quantity and unrelated to age or gender. Our data support the convenience of excluding pseudo-reflux events and meal periods from analysis.

Hemorragia digestiva baja secundaria a tumor estromal rectal (GIST rectal) / Lower GI bleeding secondary to a stromal rectal tumor (rectal GIST)

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Non-complicated cholelithiasis associated with GERD. Results of combined laparoscopic surgery in low risk patients.

BACKGROUND: the aim of this study was to evaluate the efficacy of combined laparoscopic surgery for non-complicated cholelithiasis and gastroesophageal reflux disease (GERD) in patients with low surgical risk. METHODS: a total of 680 cholecystectomies performed by means of laparoscopic surgery were retrospectively studied from February 1991 to February 2002. A total of 442 patients that fulfilled the inclusion criteria were divided into two groups: group A: non-complicated cholelithiasis (cholecystectomy alone), consisting of a total of 362 patients, and group B: non-complicated cholelithiasis and GERD (cholecystectomy and Toupet's fundoplication in all cases) in 80 patients. Demographic and clinical data, intraoperatory incidences, and post-surgical complications were prospectively collected and compared for all patients. The results of reflux surgery (group B) were evaluated at 6 months by means of 24-hour pH-metry. RESULTS: in spite of the fact that the group undergoing combined surgery consisted of patients with greater weight and older age (p < 0.05), no significant differences were found in the number of intraoperative incidences and post-surgical complications between both groups (NS). Significant differences were only found in the duration of surgery: 48 +/- 25 min (10-150) in group A compared to 112 +/- 23 min (80-180) in group B (p<0.001), and in the return to normal daily activities (5.8 +/- 0.9 days vs 6.5 +/- 1 days in group B) (p< 0.001). In the latter group a normalization of 24-hour pH-metry values and an absence of symptoms associated with reflux were observed in all cases. CONCLUSIONS: in patients younger than 75 years with low surgical risk and non-complicated cholelithiasis and GERD, both illnesses can be resolved during the same surgical procedure by laparoscopy with no increased risk or postoperative complications.

Clinical efficacy of the Toupet technique performed by laparoscopic surgery. Medium-term follow-up in 122 cases.

BACKGROUND: We present the results obtained in a series of patients with gastroesophageal reflux disease (GERD) who underwent the same type of laparoscopic surgery (Toupet technique). METHODS: A total of 122 patients with symptomatic hiatal hernia and GERD were submitted to laparoscopic surgery between March 1993 and March 1999. In all patients, we performed a preoperative gastroduodenal radiological study, an upper gastrointestinal (GI) endoscopy, esophageal manometry, and 24-h pH monitoring. The same studies were repeated at 3 months. All patients were followed up clinically for ?1 year. The only laparoscopic technique used was the Toupet (270 degrees posterior fundoplication). RESULTS: In 117 patients (95.9%), the clinical results were good, with complete disappearance of the symptoms. Two patients suffered a relapse, which was resolved by reintervention with laparoscopy. One patient experienced dysphagia and frequent chest pain for 5 months. Another two patients had moderate difficulty in belching. The endoscopic and radiological barium studies at 3 months were normal in all patients. Significant differences were seen in functional studies performed prior to and 3 months after the operation in all patients (p < 0.05). CONCLUSIONS: Surgical laparoscopic treatment with the Toupet technique is effective both clinically and functionally. In cases of relapse, a new repair is possible with laparoscopy. Long-term follow-up of these patients is necessary to show whether these results are maintained over time.

Ambulatory liver biopsy: complications and evolution in 264 cases.

AIM: To determine the safety and acceptance of outpatient liver biopsies. PATIENTS AND METHODS: Data from all liver biopsies were collected in a prospective way over a period of 18 months. Information was gathered on complications, evolution of patients outside the hospital and opinion relating to the test. All patients were required to previously present: platelet count > 60.000/mm3 prothrombin time within 4 seconds of control and absence of ascites or encephalopathy. Criteria for outpatient liver biopsy also included cooperative patient, a partner or friend who stayed with the patient during 12-24 hours following the test and easy access to the hospital. Out of a total of 378 biopsies, 264 (70%) were ambulatory. RESULTS: Five of the 264 outpatients were hospitalized (1.9%), due to a subcapsular hematoma in one case, persistent pain in 3 cases and sever hypotension in the other; all of them evolved favorably in the first 24 hours. Among the inpatients, 2 had complications (1.7%): one subcapsular hematoma resolved without treatment and one abdominal hemorrhage requiring transfusion. Of the ambulatory patients, 46 (18%) presented pain whilst at home, being more frequent in females than in males (30% vs 15%, p = 0.004) and in those who needed more than one attempt to obtain histological material compared with those of a single attempt (33% vs 17%; p = 0.008). Twenty four hours after the test, 83% of the patients had returned to their normal activities. Ninety five percent of the patients questioned considered that the test was not traumatic, and 88% stated a preference for liver biopsy as a day case procedure. CONCLUSIONS: Liver biopsy performed on an ambulatory basis is safe, well tolerated and acceptable by the majority of patients.

Colonoscopic findings in patients with lower gastrointestinal bleeding send to a hospital for their study. Value of clinical data in predicting normal or pathological findings.

BACKGROUND: Lower gastrointestinal bleeding is a highly frequent clinical problem that may reflect serious pathology in the colon. Colonoscopy is generally accepted as the diagnostic procedure of choice. Decisions as to whether to carry out colonoscopy or not, are not well defined. METHODS: 536 colonoscopies, made to discover the cause of lower gastrointestinal bleeding were analyzed and a final 457 included in the study. All of these patients came to the hospital because they had presented at least in one occasion, one episode of rectal bleeding, and were send by the specialist of the zone, in order to achieve a correct diagnosis of its process. In all cases the following associated symptoms were analyzed: the presence of diarrhea, constipation, abdominal pain and rectal mass on examination. The characteristics of lower gastrointestinal bleeding were analyzed in a subset of 150 consecutive patients. RESULTS: Mean age was 59 +/- 16.9 years. 54.5% were male and 45.5% female. The exploration was normal until the cecum in 146 patients (32%). In the remaining 311, the findings were: polyps (25.1%), diverticular disease (24%), neoplasia (12.6%), inflammatory bowel disease (9.4%), unspecific proctitis (2.4%), ischemic colitis (2.4%), angiodysplasia (1.9%), infectious colitis (1.1%), and miscellaneous (0.7%). An age of less than 40 years and the existence of anal pathology were significantly more frequent among patients with a normal examination (p < 0.001), but with a sensitivity of only 66%. No differences were found among patients with disordered bowel frequency or abdominal pain in relation to the colonoscopic findings. Previous presence of a rectal mass when the examination proved abnormal (p=0.06). Intermittent bleeding and the presence of blood in the stools were more frequent in patients with normal examination (p= 0.07 and p< 0.05, respectively). No significant differences in relation to colour, duration of bleeding, or to whether toilet paper was stained with blood were found. CONCLUSIONS: 1) The more frequent endoscopic findings were polyps and diverticular disease. 2) Clinical data are of little value in predicting a normal examination. 3) Total colonoscopy appears to be the first procedure of choice in all patients with lower gastrointestinal bleeding, irrespective of the clinical data and the presence of anal pathology.

Clinical efficacy of intramuscular human interferon-beta vs interferon-alpha 2b for the treatment of chronic hepatitis C.

We have conducted a randomized study to compare the efficacy and tolerance of human interferon (IFN) beta vs recombinant IFN-alpha 2b in patients with chronic active hepatitis C. Forty patients were included: 21 received IFN-alpha (group A) and 19 IFN-beta (group B). IFN was administered intramuscularly at a dose of 6 MU three times a week (tiw) for 2 months (induction phase), followed by 3 MU tiw for 4 months. Clinical, epidemiological and pathological features were similar in the two groups. Normal alanine aminotransferase (ALT) values at the end of treatment was regarded as a response to therapy and the response rate was 57% (12/21) in group A and 5.2% (1/19) in group B (P < 0.01). Both types of IFN induced a significant decrease in mean ALT values by the end of the induction phase (P < 0.01). When the dose was reduced to 3 MU, a marked, but not significant increase in ALT, was seen in group B, whereas no increase was seen in group A. IFN-beta was better tolerated and haematological adverse effects (platelet and leucocyte decrease) were less pronounced with IFN-beta. Hence, human IFN-beta was less effective than IFN-alpha in treating chronic hepatitis C virus (HCV). Doses of IFN-beta of 3 MU intramuscular (IM) tiw were clearly insufficient and it remains to be established whether higher doses of intramuscularly IFN-beta can be useful.

[Esophageal carcinosarcoma: morphologic and cytometric study]. / Carcinosarcoma esofágico: estudio morfológico y citométrico.

Carcinosarcoma of the esophagus is a rare malignant neoplasm composed by both carcinomatous (epithelial) and sarcomatous (mesodermal) elements. We report a case, diagnosed by biopsy an endoscopic brushing. Cytometric analysis was also performed.