Management of gastroesophageal reflux disease by primary care physicians and gastroenterologists: a prospective study of patients' records.

BACKGROUND: We previously compared the perceptions and practices of primary care physicians (PCP) and gastroenterologists (GE) in the management of gastroesophageal reflux disease (GORD), but the data were only declarative statements. OBJECTIVE: The aim of the present study was to analyze the respective management of GORD by PCP and GE on the basis of patients' records, and to look for any discrepancies between the declared and actual practices in both groups of physicians in the management of GORD. METHODS: A representative sample of French physicians was asked to enroll two consecutive patients with frequent and typical symptoms of GORD into a prospective observational survey. RESULTS: A total of 136 PCP and 91 GE participated in the survey and enrolled 271 and 182 patients, respectively, with frequent GORD symptoms (453 patients in total). Patients consulting GE were slightly younger, and had waited longer before arranging a consultation despite having symptom severity and impact on daily life similar to those visiting PCP. Most patients enrolled by GE had undergone upper GI endoscopy (95% versus 64% from PCP, P<0.01). In both groups of physicians, recourse to endoscopy for their patients was more frequent than they estimated. Prescription therapies for GORD were usually Proton Pump Inhibitors (PPI) in both groups of physicians and were in keeping with the declared findings. CONCLUSIONS: Despite differences between patients' characteristics, the management of frequent GORD was similar by both groups of physicians. The reasons why both groups of physicians underrated their actual recourse to endoscopy for their patients warrant further investigation.

Perceptions and practices on the management of gastro-oesophageal reflux disease: results of a national survey comparing primary care physicians and gastroenterologists.

BACKGROUND: Literature comparing generalist and specialist care is accumulating in many disease areas, but very few studies focussed on gastrointestinal diseases and little is known about gastro-oesophageal reflux disease. AIM: To compare the management of gastro-oesophageal reflux disease (GERD) by French primary care physicians and gastroenterologists. METHODS: A postal survey was conducted in a representative sample of French physicians who were asked to complete a questionnaire that consisted of 44 questions relating to their usual medical practice for the diagnostic and therapeutic management of frequent GERD. RESULTS: 136 primary care physicians and 91 gastroenterologists participated in the survey (54%). Alarm symptoms were identified more frequently by primary care physicians than gastroenterologists, but the appraisal of their seriousness was less acute by primary care physicians than gastroenterologists. Upper endoscopy was prescribed more frequently by gastroenterologists (64% vs. 38%, P < 0.01). Physicians in both groups mainly recommended lifestyle modification. For GERD treatment, most respondents declared using a 'step-down' strategy with proton pump inhibitors, and only slight differences in drug prescription were identified between primary care physicians and gastroenterologists. Both groups of physicians also have similar perception of symptom persistence after treatment, but satisfaction with treatments was slightly higher for gastroenterologists than primary care physicians (7.6 vs. 7.1 on a scale from 0 to 10, P < 0.01). CONCLUSIONS: Overall patterns of GERD diagnosis and management are comparable between primary care physicians and gastroenterologists. Both groups perceive that GERD therapy can still be improved.

Comparative study of characteristics and disease management between subjects with frequent and occasional gastro-oesophageal reflux symptoms.

BACKGROUND: Little is known about the distinctive characteristics of subjects with frequent (at least weekly) and occasional gastro-oesophageal reflux symptoms. AIM: To compare the characteristics and disease management of subjects complaining of at least weekly and less frequent gastro-oesophageal reflux symptoms. METHODS: Population-based postal survey carried out in France in 2003 among a representative sample of 8000 subjects. RESULTS: The prevalence of frequent and occasional gastro-oesophageal reflux symptoms was 7.8% and 23.4%, respectively. Compared to subjects with occasional gastro-oesophageal reflux symptoms, those with frequent symptoms were older, suffered from more severe symptoms and felt greater impact on daily living, despite a slightly shorter duration of symptoms. These subjects more often sought medical advice. Most of them had treated the last episode of symptoms primarily with a proton-pump inhibitor and less often with antacids/alginates. The degree of treatment satisfaction was lower in subjects with frequent gastro-oesophageal reflux symptoms, in relation to a more frequently observed persistence of symptoms irrespective of the medication used except for proton-pump inhibitors. CONCLUSIONS: This survey suggests that subjects complaining of frequent or occasional gastro-oesophageal reflux symptoms constitute two distinctive groups. Despite greater healthcare use, the former group shows a lower level of satisfaction with disease management. Nevertheless, a substantial subset of subjects with occasional symptoms also complained of impaired health-related quality of life and sought health care.

[Congenital hepatic fibrosis disclosed late by hepatic encephalopathy]. / Fibrose hépatique congénitale tardivement révélée par une encéphalopathie hépatique.

A case of hepatic encephalopathy revealing congenital hepatic fibrosis in a 47-year-old woman is reported. The characteristic features of this observation were: a) the long clinical latency of a congenital disease usually discovered in childhood or in adolescence; b) the existence of hepatocellular insufficiency which appeared without any other reason than an ordinary infection; c) the absence of digestive bleeding or portacaval shunt, factors always found in the rare, previously described cases of encephalopathy in congenital hepatic fibrosis.

[Changes in circulating lymphocyte subsets in alcoholic hepatopathies. Respective role of alcohol, hepatocellular insufficiency and malnutrition]. / Etude des modifications des sous-populations lymphocytaires circulantes au cours des hépatopathies alcooliques. Rôle respectif de l'alcool, de l'insuffisance hépato-cellulaire et de la dénutrition.

Peripheral lymphocyte subpopulations have been quantified by a direct and indirect, immunofluorescence technique, using monoclonal antibodies, in 22 patients with continued heavy drinking, hepatocellular dysfunction (spider angiomata, ascites, and factor V decrease) (group I), in 16 patients with a history of heavy drinking and abstinence maintained for at least 6 months and hepatocellular dysfunction (group II) and in 28 patients admitted for continued heavy drinking, without hepatocellular dysfunction (group III). Sixteen normal subjects were studied as controls. The total number of lymphocytes and T lymphocytes (OKT3+) were significantly reduced (p less than 0.001) in groups I and II. A significant decrease of B lymphocytes was observed in group II (p less than 0.02). The OKT8+ lymphocytes were significantly reduced in group I (p less than 0.01) and in group II (p less than 0.001); the decrease of the OKT4+ lymphocytes was significant in group II (p less than 0.01) only. The OKT4/OKT8 ratio was higher in group I (p less than 0.05) and group II (p less than 0.01) than in the control group. Normal values of total lymphocytes, B lymphocytes, T lymphocytes subsets and OKT4/OKT8 ratio were observed in group III. In group III, the lymphocyte subpopulations and OKT4/OKT8 ratio were similar in patients with or without abnormalities of liver function tests. In group I and II, no correlation was found between the lymphocyte subpopulations or the OKT4/OKT8 ratio and factor V or nutritional status assessed by anthropometrical and biological tests. T-cell imbalance in alcoholic liver disease does not seem to be related to alcohol consumption, factor V decrease or malnutrition.

[Evolution of serum gammaglutamyl transpeptidase activity in treated hyperthyroid and hypothyroid patients]. / Evolution de l'activité sérique gammaglutamyl transpeptidase (GGT) au cours des hyperthyroïdies et des hypothyroïdies traitées.

The pattern of gammaglutamyl transpeptidase levels was studied in the sera of 25 subjects with hyperthyroidism and 11 subjects with hypothyroidism, before and after treatment, and in 14 age- and sex-matched control subjects. Gammaglutamyl transpeptidase levels were significantly increased in hyperthyroidism (65 +/- 59 U/l) (p less than 0.01) and significantly decreased under treatment (40 +/- 27 U/l) (p less than 0.001). Before treatment, gammaglutamyl transpeptidase levels correlated with alkaline phosphatase levels and 5'-nucleotidase levels, the correlation persisting after treatment with 5'-nucleotidase. Alkaline phosphatase levels significantly increased under treatment (p less than 0.01). The percentages of gammaglutamyl transpeptidase variation correlated with thyroxine (r = 0.44, p less than 0.03), triiodothyronine (r = 0.47, p less than 0.02) and latent fixation capacity (r = 0.44, p less than 0.03) variations. Subjects with hypothyroidism had significantly decreased gammaglutamyl transpeptidase levels before treatment (18 +/- 9 U/l, p less than 0.01). Alkaline phosphatase levels were significantly decreased before treatment, and significantly increased after treatment. For all subjects with hyperthyroidism of hypothyroidism, the percentages of gammaglutamyl transpeptidase variations correlated with thyroxine (r = 0.48, p less than 0.003) and triiodothyronine (r = 0.39, p less than 0.016) variations. These results suggest that variations in gammaglutamyl transpeptidase levels in hyperthyroidism and hypothyroidism are, at least in part, in relation with variations in thyroid hormone levels.

[Pharmacokinetics of alcohol after 3-hour intravenous infusion with and without cimetidine in 10 healthy non-alcoholic subjects]. / Pharmacocinétique de l'alcool après perfusion intraveineuse de trois heures avec et sans cimétidine chez dix sujets sains non alcooliques.

Ethanol metabolism was studied in ten male non-alcoholic subjects following the constant intravenous infusion of ethanol (1.2 g/kg) administered during three hours with and without cimetidine. Pharmacokinetic analysis was performed on the pseudolinear portion of the elimination curve. The mean peak ethanol concentrations were not significantly different with and without cimetidine. There was no acceleration of ethanol metabolism at high concentrations: the ethanol elimination rate was similar above and under 17 mM, with and without cimetidine. Cimetidine administration had no effect on pharmacokinetic parameters of ethanol (area under the curve, Km and Vm). The fact that the ethanol elimination rate is similar whatever be its concentration and the absence of modifications of the pharmacokinetic parameters by cimetidine are not in favor of an important role of the microsomal ethanol oxidizing system (MEOS) in the ethanol metabolism of nonalcoholic subjects. The data do not allow to examine the role of MEOS in ethanol metabolism after chronic alcohol consumption.

High density lipoprotein cholesterol and apoprotein A1 in healthy volunteers during long-term moderate alcohol intake.

Moderate alcohol consumption is associated with lower cardiovascular mortality. The effect of moderate alcohol intake during 5 weeks on lipoproteins, especially on the high density lipoprotein (HDL) cholesterol total (of which the levels are inversely predictive of coronary heart disease) and apoproteins A, A1 and B, was studied in 7 normal men. HDL cholesterol total appreciated by the heparin manganese precipitation method and phosphotungstate magnesium method increased (p less than 0.01) during alcohol consumption. The composition of HDL was modified by alcohol consumption: increase of the esterified/total cholesterol ratio (p less than 0.05) and phospholipids (p less than 0.05) without significant modification of triglycerides. Low density lipoprotein and very low density lipoprotein did not vary significantly. Apoprotein A1 increased during alcohol consumption (p less than 0.05) with a transitory increase of apoprotein A. There was no significant modification of apoprotein B.

[Chronic vomiting disclosing a pheochromocytoma]. / Vomissements chroniques révélateurs d'un phéochromocytome.

Emesis is a common symptom in pheochromocytoma. It occurs in 26% of cases with permanent secretion, and 43% of cases with paroxystic secretion. Emesis may be the initial manifestation as in the present report of a 54-year-old female patient. For more than 15 years she experienced emesis which was ascribed to biliary dyskinesia. Bilateral pheochromocytoma was then diagnosed. With reference to this case, digestive manifestations of pheochromocytoma are reviewed.