High prevalence of asymptomatic esophageal motility disorders among morbidly obese patients.

BACKGROUND: Morbid obesity is becoming more prevalent in the industrialized world. Few data exist regarding the resting lower esophageal sphincter pressure (LESP) and esophageal motility in relationship to body mass index (BMI). METHODS: During a 3-year period, 111 of 152 morbidly obese patients seeking bariatric surgery completed esophageal manometric testing and questionnaire regarding esophageal symptoms. Manometric parameters included wave amplitude and duration of esophageal contractions, percentage of peristaltic function, and resting LESP. Questionnaire data included age, sex, medications, prior medical conditions, and esophageal symptoms. RESULTS: 88 (79%) of the patients were female; 23 (21%) were male. The mean age was 39.8 years (+/- 9.9), the mean BMI was 50.7 kg/m2 (+/- 9.4). There was a lack of correlation between BMI and LESP (r = 0.04). Abnormal manometric findings were observed in 68/111 (61%) patients: 28 (25%) had only hypotensive lower esophageal sphincter (LESP < 10 mm Hg); 16 (14%) had nutcracker esophagus (amplitude >180 mm Hg), 15 (14%) had nonspecific esophageal motility disorders, 8 (7%) had diffuse esophageal spasm (DES), and 1 (1%) had achalasia. Patients with DES had a significantly higher BMI than those with other motility disorders (P < 0.05). Dysphagia was reported in 7 (6%) patients and chest pain in 1 patient. Heartburn and/or regurgitation (gastroesophageal reflux disease, GERD) was noted in 35 patients (32%), of whom 18 (51%) had a hypotensive resting LES. 40 of 68 patients (59%) with abnormal motility tracings did not report any esophageal symptoms. CONCLUSION: Morbid obesity per se does not imply an abnormality of LESP. In addition, a majority of morbidly obese patients who were considering bariatric surgery had no esophageal symptoms but were found to have abnormal esophageal manometric patterns. These findings add support to the suggestion that morbidly obese patients may have abnormal visceral sensation.

Esophageal anatomy and function in laparoscopic gastric restrictive bariatric surgery: implications for patient selection.

BACKGROUND: The purpose of this study was to assess factors of clinical importance in morbidly obese patients having a laparoscopically adjustable gastric band (LAP-BAND) implanted in order to achieve weight loss. METHODS: Preoperative evaluation of hiatus hernia and esophageal (dys)motility were compared with the need for reoperation. Results are presented for the first 50 consecutive patients entered. RESULTS: Nine of the first 50 patients required reoperation (18%). Five (10%) were for LAP-BAND slippage on the stomach. Of these five, reoperation was required in four of 12 (33%) with hiatus hernia (P = 0.0093); three of nine (33%) with a motility disorder (P = 0.025); and three of six (50%) with both hiatus hernia and a motility disorder (P = 0.0076). CONCLUSIONS: We identify two factors, hiatus hernia and esophageal dysmotility, which are associated, both independently as well as in combination, with reoperation for LAP-BAND slippage. Both patients and their physicians should consider these data when considering the LAP-BAND as possible therapy for morbid obesity.

Fecal incontinence in scleroderma. Clinical features, anorectal manometric findings, and their therapeutic implications.

Fecal incontinence is an under-reported complication of scleroderma. Ten incontinent patients with scleroderma were evaluated through anorectal manometry and compared with 20 incontinent patients without scleroderma who were matched for age and sex as controls. The scleroderma patients had a higher voluntary external anal squeeze pressure, whereas the resting internal anal sphincter pressure was similar to that of the control group. The threshold for rectal sensation in the scleroderma group was significantly less than that in controls. Episodes of fecal incontinence, anal canal length, and maximal tolerable volume were not significantly different between the study groups. The rectoanal inhibitory response was abnormal in 80% of patients with systemic sclerosis but was normal in 70% of the controls. Stool consistency was significantly looser in the scleroderma patients. Treatment of fecal incontinence in scleroderma patients may be successful in many patients using a combination of dietary and pharmacologic manipulation because diarrhea is an important etiologic cofactor superimposed on reduced internal anal sphincter pressure.

Significance of occult gastrointestinal bleeding during anticoagulation therapy.

A prospective study was undertaken to determine the effect of anticoagulation therapy on the prevalence of occult gastrointestinal bleeding and to ascertain the causes of bleeding. During a six-month period, 256 patients who had received anticoagulants were screened for occult bleeding with guaiac-impregnated cards. Twenty-one (12 percent) of the 175 patients who had received anticoagulants and who voluntarily completed the cards had occult gastrointestinal bleeding compared with only two (3 percent) of 74 control patients who had not received anticoagulants. The mean prothrombin time and partial thromboplastin time did not differ significantly in the patients who had received anticoagulants with and without subsequent bleeding. Fifteen of 16 patients who had received anticoagulants and who underwent diagnostic evaluation had previously undiagnosed lesions in the intestinal tract. These results indicate that occult gastrointestinal bleeding in a patient who has received an anticoagulant should not be attributed to the anticoagulant; instead, such bleeding often indicates the presence of significant intestinal disease.

The prognosis of gastric outlet obstruction.

A retrospective study was undertaken to examine the prognosis of gastric outlet obstruction with specific reference to patients with obstruction due to peptic ulcer. During the 10-year period 1970-1979, 68 patients with gastric outlet obstruction were admitted to our hospital. Obstruction was caused by peptic ulceration in 55 of these patients, all of whom initially were managed conservatively. Thirty-four, however, required surgical decompression during their first admission for obstruction, and 11 needed surgery for a subsequent episode of obstruction. Of the ten patients who have not undergone surgery, six died within 3 years of their first episode of obstruction and three of the four survivors continue to have recurrent obstructive symptoms. Overall, 92% (45/49) of patients who have lived for more than 3 years after their presentation with gastric outlet obstruction due to peptic ulcer have required surgery for relief of obstruction.

Aneurysm of the pulmonary artery as a cause of severe chest pain.

A 35-year-old man came to the emergency room with severe prolonged precordial chest pain. Serial chest roentgenograms obtained over a ten-year period revealed gradual development of marked aneurysmal dilatation of the pulmonary artery. Impending rupture of the artery was feared in spite of the presence of normal pulmonary artery pressure. At surgery, a markedly dilated pulmonary artery without evidence of rupture was found and the size was reduced by aneurysmorrhaphy. Prompt and continued relief of symptoms was achieved thereafter. Severe chest pain can be an initial symptom of pulmonary artery aneurysm in the absence of rupture, such pain arising either from pain receptors in the wall of the pulmonary artery or possibly from pressure on contiguous mediastinal structures.

Induction of the phosphoenolpyruvate: hexose phosphotransferase system associated with relative anaerobiosis in an obligate aerobe.

Arthrobacter pyridinolis possesses alternative transport systems for D-fructose: a respiration-coupled transport system whereby D-fructose transport occurs with concomitant oxidation of L-malate, and a phosphoenolpyruvate: D-fructose phosphotransferase system. Studies of D-fructose uptake by whole cells in the presence and absence of cyanide demonstrate that respiration-coupled transport is used almost exclusively during the first half of logarithmic growth, after which it accounts for only 15-20% of D-fructose uptake. Phosphotransferase levels are low during log phase, peak during late log, and then slowly decline. In a mutant of A. pyridinolis which requires delta-aminolevulinic acid for growth, the growth rate, cell cytochrome content, and activity of the respiration-coupled transport system increased with increasing concentrations of delta-aminolevulinic acid up to 50 microgram/ml. By contrast, phosphotransferase activity was highest in cells grown on limiting delta-aminolevulinic acid. L-Malate, which stimulates respiration-coupled transport, repressed the phosphotransferase system. The respiratory activity and the ability to release CO2 from internalized d-fructose was consistently low in D-fructose-grown cells. A cyanide-resistant cytochrome, tentatively identified as cytochrome d, appeared in the late exponential phase of growth. Isocitrate lyase activity, required for aerobic growth of this organism, declined markedly during the late exponential phase. Thus the phosphotransferase system is maximally induced, in this obligate aerobe, under conditions of relative anaerobiosis during which metabolism is primarily fermentative.