[A man with vomiting and retrosternal pain and dysphagia]. / Een brakende man met retrosternale pijn en dysfagie.

A 67-year-old male presents with complaints of severe retrosternal pain, frequent vomiting and dysphagia. Endoscopy revealed a very large intramural oesophageal hematoma, obliterating the lumen. Additional CT-imaging showed peri-oesophageal air collections, indicative for oesophageal perforation (compatible with Boerhaave's syndrome). Patient was treated successfully with intravenous antibiotics and fluid. Follow-up endoscopy after one year showed full recovery of the oesophageal wall.

Dutch guidance for the treatment of chronic hepatitis C virus infection in a new therapeutic era.

BACKGROUND: A new era for the treatment of chronic hepatitis C is about to transpire. With the introduction of the first-generation protease inhibitors the efficacy of hepatitis C treatment improved significantly. Since then, the therapeutic agenda has moved further forward with the recent approval of sofosbuvir and the expected approval of agents such as simeprevir and daclatasvir. This paper, developed parallel to the approval of sofosbuvir, is to serve as a guidance for the therapeutic management of chronic hepatitis C. METHODS: We performed a formal search through PubMed, Web of Science and ClinicalTrials.gov to identify all clinical trials that have been conducted with EMA-approved new agents in hepatitis C; for this version (April 2014) we focused on sofosbuvir. For each disease category, the evidence was reviewed and recommendations are based on GRADE. RESULTS: We identified 11 clinical trials with sofosbuvir and for each disease category recommendations for treatment are made. Not all disease categories were studied extensively and therefore in some cases we were unable to provide recommendations. CONCLUSION: The recent approval of sofosbuvir will most likely change the therapeutic landscape of chronic hepatitis C. The use of sofosbuvir-containing regimens can shorten the duration of therapy, increase efficacy and result in less side effects, compared with standard of care. The efficacy relative to standard of care needs to be weighed against the increased costs of sofosbuvir. With future approval of the other direct-acting antivirals, the outcome of hepatitis C treatment will likely improve further and this guidance will be updated.

The 2012 revised Dutch national guidelines for the treatment of chronic hepatitis B virus infection.

In 2008, the Netherlands Association of Gastroenterologists and Hepatologists (Nederlands Vereniging van Maag-Darm-Leverartsen) published the Dutch national guidelines for the treatment of chronic hepatitis B virus infection. New insights into the treatment of chronic hepatitis B with relevance for clinical practice have been adopted in these concise, revised guidelines. The most important changes include the choice of initial antiviral therapy, licensing of tenofovir for the treatment of chronic hepatitis B and the management of antiviral resistance.

Colonoscopic perforations: a review of 30,366 patients.

BACKGROUND: Although the incidence of perforation after endoscopic procedures of the colon is low, the rising number of procedures could pose relevant health problems. Recognizing risk factors and optimizing treatment may reduce perforation incidence and the probability of (severe) complications. This study aimed to determine perforation frequency and the management of endoscopic colonoscopic perforation. METHODS: A retrospective review of patient records was performed for all patients with iatrogenic colonic perforations after sigmoido/colonoscopy between 1990 and 2005. The patients' demographic data, endoscopic procedural information, perforation location, therapy, and outcome were recorded. RESULTS: In the 16-year period, 30,366 endoscopic colonic procedures were performed. In total, 35 colonic perforations occured (0.12%). All the patients underwent a laparotomy: for primary repair in 18 cases (56%), for resection with anastomosis in 8 cases (25%), and for resection without anastomosis in 6 cases (19%). In three patients (8.6%), no perforation was found. The postoperative course was uncomplicated in 21 cases (60%) and complicated in 14 cases (40%), including mortality for 3 patients (8.6% resulting from perforations and 0.01% resulting from total endoscopic colon procedures). The relative risk ratio of colonoscopic and sigmoidoscopic procedures for perforations was 4. Therapeutic procedures show a delay in presentation and diagnosis compared with diagnostic procedures. Of the 35 perforations, 26 (74%) occurred in the sigmoid colon. CONCLUSION: Iatrogenic colonic perforation is a serious but rare complication of colonoscopy. A perforation risk of 0.12% was found. The perforation risk was higher for colonoscopic procedures than for sigmoidoscopic procedures. The sigmoid colon is the area at greatest risk for perforation. Immediate operative management, preferably primary repair and sometimes resection, appears to be a good strategy for most patients.

Is there any association between referral indications for open-access upper gastrointestinal endoscopy and endoscopic findings?

BACKGROUND AND STUDY AIM: The total number of upper gastrointestinal endoscopies is increasing, and despite guidelines for endoscopy referral for general practitioners, the proportion of patients found to have no endoscopic abnormalities is still up to 60% (and increasing). The aim of this study was to assess the association between general practitioners' referral indications and endoscopic findings. PATIENTS AND METHODS: General practitioners of patients referred for an open-access endoscopy between January 2002 and December 2004 were asked to specify the reason for referral on a specially designed form. The relative frequency of patients actually having an endoscopic abnormality was assessed for each referral indication. RESULTS: A total of 1298 people were included in the study. A relevant endoscopic abnormality was found in 48% of patients. Patients with an endoscopic abnormality were not more often referred with "alarm" symptoms or failure of empirical treatment than patients without an abnormal endoscopic finding (31% with an endoscopic abnormality vs. 30% without an endoscopic abnormality had alarm symptoms; 57% of people in both groups experienced failure of empirical treatment). Referral with alarm symptoms had a positive predictive value of 4% for cancer (prevalence 2%; P < 0.01), and referral with reflux-like symptoms had a positive predictive value of 33% for finding reflux esophagitis (prevalence 22%; P < 0.01). CONCLUSIONS: General practitioners' referral indications for open-access endoscopy did not add any relevant predictive value for endoscopic findings in comparison with what might have been expected from overall prevalence. Only alarm symptoms slightly increased the probability of finding cancer and only reflux-like symptoms slightly increased the probability of finding reflux esophagitis.

Gastrointestinal disorders and symptoms: does body mass index matter?

BACKGROUND: Recent studies have shown inconsistent results about the association between body mass index (BMI) and gastrointestinal disorders. The aim of this study was to assess the association between BMI and gastrointestinal disorders in patients referred for endoscopy. METHODS: Consecutive patients received a questionnaire about gastrointestinal symptoms prior to upper gastrointestinal endoscopy. The association between BMI and gastrointestinal disease and related symptoms was determined by adjusted logistic regression analyses. RESULTS: A total of 1023 subjects were included, 303 (35%) subjects were overweight (BMI 25 to 30 kg/m2), an additional 118 (14%) subjects were obese (BMI >30 kg/m2). Overall, 42% of the patients experienced symptoms of gastro-oesophageal reflux disease (GERD ), 70% dyspepsia and 55% lower abdominal symptoms. In obese patients the prevalence of GERD was higher (52%) compared with normal weight (44%) and overweight (44%) (ns). Reflux oesophagitis was found in 13, 17 and 19% for normal weight, overweight and obese, hiatus hernia in 7, 9 and 11% and Barrett's oesophagus in 6, 7 and 8%, respectively. CONCLUSION: More than half the patients undergoing upper gastrointestinal (GI ) endoscopy were overweight or obese. In this patient population, no relation between BMI and GI disorders and symptoms was found. However, a small but statistically insignificant trend was observed toward obesity for patients with GERD-associated symptoms.

Anxiety, depression and psychotropic medication use in patients with persistent upper and lower gastrointestinal symptoms.

BACKGROUND: Limited information is available about anxiety, depression and psychotropic medication use in patients referred for gastrointestinal endoscopy. AIM: To determine anxiety and depression and its association with endoscopic findings in a representative sample of patients with persistent gastrointestinal symptoms prior to endoscopy. METHODS: Patients referred to the hospital for endoscopy between February 2002 and February 2004 were asked to score anxiety and depression on the Hospital Anxiety and Depression Scale 2 weeks prior to endoscopy. Information about endoscopic diagnoses was obtained from medical files. RESULTS: A total of 1298 subjects was studied (600 upper gastrointestinal endoscopies and 698 lower gastrointestinal endoscopies). Patients referred for upper gastrointestinal endoscopy used most psychotropic agents (24%; odds ratio = 3.1; 95% confidence interval = 2.3-4.2), especially patients with an organic abnormality when compared with patients without an organic abnormality (42% versus 8%; odds ratio = 8.6; 95% confidence interval = 5.4-14.0). Patients with colonic polyps were more anxious (odds ratio = 1.7; 95% confidence interval = 1.0-2.9) and depressed (odds ratio = 1.8; 95% confidence interval = 1.1-3.1) than other patients referred for lower gastrointestinal endoscopy. CONCLUSIONS: There is no difference in anxiety nor depression between patients with and without organic abnormalities at endoscopy. Patients with colonic polyps are more anxious and depressed than other patients referred for lower gastrointestinal endoscopy. Psychotropic medication use is highest among patients with an organic abnormality in the proximal gastrointestinal tract.

Health-related quality of life of patients with gastrointestinal symptoms.

BACKGROUND: Little is known about the variation in health-related quality of life among patients with different presentations of gastrointestinal symptoms. AIM: To study the association between health-related quality of life and presentations of gastrointestinal symptoms. METHODS: Health-related quality of life and demographic information was obtained from 873 patients referred to the hospital for endoscopy, using a questionnaire. RESULTS: A total of 436 patients (50%) reported predominantly upper gastrointestinal symptoms, 344 (39%) predominantly lower symptoms, and 93 (11%) patients reported both upper and lower symptoms. Patients with mild, moderate and severe symptoms, reported mean scores on a 100-point visual analogue scale (95% CI) of 90 (79-100), 75 (64-86) and 64 (53-76), respectively (P < 0.001). Mean visual analogue scale scores (95% CI) almost linearly declined from 81 (77-85) to 49 (46-52) for those with one to those with more than eight symptoms. Patients who reported upper gastrointestinal symptoms and in particular epigastric pain, bloating and vomiting had significantly impaired health status in comparison to patients without these symptoms (P < 0.05). CONCLUSIONS: Severity of gastrointestinal symptoms is the most important factor in affecting health status, followed by the numbers and type of gastrointestinal symptoms.

Acute fatty liver in pregnancy.

When confronted with liver abnormalities during the third trimester of pregnancy, one should consider acute fatty liver of pregnancy. The differential diagnosis with (pre-)eclampsia and HELLP syndrome is sometimes difficult. In these cases a liver biopsy is helpful though rarely performed during pregnancy. After delivery of the child the liver test abnormalities will ultimately disappear. Recent publications reveal that a dysfunction in the beta-oxidation of mitochondrial fatty acids may contribute to the aetiology of this rare disorder. We describe a case of acute fatty liver in pregnancy, with liver dysfunction (decreased albumin, prolonged prothrombin time) slowly returning to normal after delivery. Testing for disorders in beta-oxidation of mitochondrial fatty acids did not reveal abnormalities in mother or child.