Randomised clinical trial: the effect of baclofen in patients with gastro-oesophageal reflux--a randomised prospective study.

BACKGROUND: Baclofen, a GABA(B) agonist, has been shown to reduce transient lower oesophageal sphincter relaxations (TLESRs), a major cause of gastro-oesophageal reflux disease (GERD). AIM: To examine the effect and tolerability of baclofen in GERD patients over a 2-week period. METHODS: Forty-three GERD patients with abnormal 24-h pH tests were prospectively randomised to receive baclofen or placebo in a double-blind fashion for 2 weeks. Oesophageal manometry, 24-h pH monitoring, and a standard questionnaire was administered, before and after treatment. RESULTS: Thirty-four patients completed the study. In the baclofen group there were significant decreases in 24-h pH score (P = 0.020), percent of upright reflux episodes (P = 0.016), percent total time pH <4 (P = 0.003), number of reflux episodes (P = 0.018), number of reflux episodes longer than 5 min (P = 0.016), number of postprandial reflux episodes (P = 0.045), and percentage of time pH <4 (P = 0.003). No significant changes in reflux parameters were noted in the placebo group. Patients receiving baclofen had significantly less belching (P = 0.038), regurgitation (P = 0.036) and overall symptom score (P = 0.004) whereas placebo patients had less heartburn (P = 0.001), chest pain (P = 0.002), regurgitation (P = 0.017) and overall symptom score (P = 0.000). However, there were no significant differences in changes of reflux parameters or symptoms when comparing the two groups. Drowsiness did not limit baclofen use. CONCLUSIONS: Baclofen was associated with a significant decrease in percent upright reflux by 24-h pH monitoring and a significant improvement in belching, regurgitation and overall symptom score. Baclofen may be more effective in patients with predominantly upright reflux and belching.

Correlation between eosinophilic oesophagitis and aeroallergens.

BACKGROUND: Aeroallergens have been implicated in the pathogenesis of eosinophilic oesophagitis. AIM: To determine whether a seasonal variation exists in the diagnoses of eosinophilic oesophagitis and whether there is a correlation with seasonal pollen count. METHODS: A retrospective review was performed from January 2006 to November 2008 to identify eosinophilic oesophagitis patients. Cases were classified by endoscopic date. Daily pollen counts for grass, trees and weeds were obtained from a certified counting station. Per cent of eosinophilic oesophagitis cases were collated seasonally and compared with mean pollen counts for grass, trees and weeds during the same time period. RESULTS: A total of 127 eosinophilic oesophagitis cases were identified (median age 41, range 19-92 years, 84% men). The highest percentage of cases (33.0%; Binomial P = 0.022) was diagnosed in the spring, while the least percentage (16%; Binomial P = 0.0.010) occurred in the winter. There was a significant association between per cent eosinophilic oesophagitis cases diagnosed seasonally and mean grass pollen count (r(s) = 1.000, P < 0.01), but not with trees (r(s) = 0.400, P = 0.600) or weeds (r(s) = 0.800, P = 0.200). CONCLUSIONS: A seasonal variation was seen in the diagnosis of eosinophilic oesophagitis which correlated with pollen counts. These findings have important implications regarding the pathogenesis of eosinophilic oesophagitis, suggesting a potential role for aeroallergens.

Review article: the management of achalasia - a comparison of different treatment modalities.

BACKGROUND: Achalasia is an uncommon primary oesophageal motor disorder with an unknown aetiology. Therapeutic options for achalasia are aimed at decreasing the lower oesophageal sphincter pressure, improving the oesophageal empting, and most importantly, relieving the symptoms of achalasia. Modalities for treatment include pharmacologic, endoscopic, pneumatic dilatation and surgical. The decision of which modality to use involves the consideration of multiple clinical and economic factors. AIM: To review the management strategies currently available for achalasia. METHODS: A Medline search identified the original articles and reviews the published in the English language literature between 1966 and 2006. RESULTS: The results reveal that pharmacotherapy, injection of botulinum toxin, pneumatic dilatation and minimally invasive surgical oesophagomyotomy are variably effective at controlling the symptoms of achalasia but that each modality has specific strengths and weaknesses which make them each suitable in certain populations. Overall, pharmacologic therapy results in the shortest lived, least durable response followed by botulinum toxin injection, pneumatic dilatation and surgery, respectively. CONCLUSION: The optimal treatment for achalasia remains an area of controversy given our lack of complete understanding about the pathophysiology of the disease as well as the high numbers of clinical relapse after treatment. Further research focusing on optimal dosing of botulinum toxin injection and optimal timing of repeated graduated pneumatic dilatations could add to our knowledge regarding long-term therapy.

Testing for Helicobacter pylori in the clinical setting.

There are a variety of tests available to identify Helicobacter pylori infection. These tests can be divided into those that do not require and those that do require endoscopy. This review provides a detailed discussion of the available diagnostic tests for H. pylori infection. Special attention is paid to the role of diagnostic testing in the management of patients with H. pylori-related disease. The potential advantages and disadvantages of various tests and the role of testing to confirm eradication after treatment for H. pylori is also discussed.