Hiatal hernia and Barrett's oesophagus impact on symptoms occurrence and complications.

UNLABELLED: The aim of the study was to evaluate the influence of sliding hiatal hernia over the Barrett's oesophagus, including symptoms rate and complications. METHODS: A total of 520 (4.6%) cases of Barrett's oesophagus were found out of 18.276 upper gastrointestinal endoscopies, performed in 11.276 patients at a single tertiary centre in a period from 1994 to 2004. RESULTS: Sliding hiatal hernia was found in 58% of patients with Barrett's oesophagus, more frequently in men (60%). The association between hernia and some complications of Barrett's oesophagus was significant (94% of Barrett's ulcer, 77% of low-grade dysplasia with p < 0.01). However, there was no significant association with adenocarcinoma (54%; p > 0.05). The other complications of Barrett's oesophagus (i.e. bleeding, stenosis, high-grade dysplasia) were identified in small number (less than 10), so they were not evaluated statistically. Association between the presence of hiatal hernia and occurrence of symptoms (reflux symptoms, dysphagia, odynophagia, dyspeptic and other symptoms) was significant with p < 0.01. CONCLUSIONS: Our study suggests that sliding hiatal hernia may play a significant role as a pathophysiologic factor in Barrett's oesophagus. Complications rate of Barrett's oesophagus were not equally frequent in particular cases with hiatal hernia. The occurrence of symptoms is getting more pronounced in those with sliding hiatal hernia.

Propofol-fentanyl anaesthesia at high altitude: anaesthetic requirements and haemodynamic variations when compared with anaesthesia at low altitude.

BACKGROUND: There are few published accounts of anaesthesia delivery at high altitude. Natives at high altitude are known to have altered cardiorespiratory reserve. This study seeks to demonstrate the safety of propofol-fentanyl anaesthesia at high altitude titrated to the bispectral index (BIS) (3505 metres above sea level) in native highlanders. It also shows the differential effects of anaesthesia and surgery on the haemodynamics of such individuals as compared with individuals living at low altitude. METHODS: Fifteen consenting adults scheduled to undergo general surgical/orthopaedic procedures under general anaesthesia using fentanyl, and propofol infusions titrated to the BIS along with nitrous oxide in oxygen after intubation, were recruited in the high-altitude arm. Their anaesthesia record was compared with retrospective data from low altitude with respect to anaesthetic requirements, recovery after anaesthesia and the haemodynamic responses to surgical stress. RESULTS: The high-altitude dwellers required significantly larger doses of propofol at anaesthetic induction (2.31+/-0.64 vs. 1.41+/-0.24 mg/kg, P<0.0001) and thereafter to maintain designated BIS than their low-altitude counterparts (6.22+/-1.14 vs. 4.61+/-1.29 mg/kg/h, P<0.01). They, however, had uneventful and short recovery times. The high-altitude population also had significantly lower baseline heart rates (72+/-9.83 vs. 88+/-12.1, P<0.04) as also the heart rate responses to noxious stimulation such as direct laryngoscopy or skin incision (P<0.04, P<0.005, respectively). CONCLUSIONS: High-altitude dwellers require significantly larger amounts of intravenous anaesthetic propofol. Heart rate at rest as also the heart rate responses to surgical stress were significantly attenuated at high altitude.

Isolated gastric tuberculosis presenting as massive hematemesis: report of a case.

Tuberculous involvement of the stomach is rare. We report herein the unusual case of a 25-year-old man in whom a benign gastric ulcer was found along the lesser curvature after he presented with massive upper gastrointestinal bleeding. Histopathological examination helped to confirm a diagnosis of tuberculosis. The granulomas typical of tuberculosis were caseation with epithelioid and giant cells. The patient was successfully treated by a combination of appropriate surgical therapy and prompt institution of antituberculosis medication.

Effects of long use of a beta-blocker, carteolol, on exercise hemodynamics in hypertensives.

The symptom limited maximal exercise was performed by a supine bicycle ergometer before and 12 weeks after oral carteolol therapy in 10 patients with essential hypertension of WHO Stage 1 and 2. At rest, arterial blood pressure (BP) and venous pressure (VP) significantly declined after therapy, while heart rate (HR), cardiac index (CI), stroke index (SI) and systemic vascular resistance (SVR) were not significantly changed. The maximal exercise work of post-therapy was similar to that of pre-therapy in 9 patients and increased in one. When compared with the pre-therapy values at each work load of exercise, carteolol caused significant decreases in systolic BP, mean BP, HR and CI, and a significant increase in SVR, while SI and VP were not significantly changed. Plasma levels of renin activity, aldosterone, and catecholamines were not altered by carteolol throughout the study at rest and with exercise. It may be concluded that the inhibition of HR increase by carteolol results in a reduced cardiac output during moderate and severe exercise and then suppresses the elevation of BP, so that carteolol makes it possible to achieve more exercise with less cardiac work.

[Early relaxation of the left ventricular wall in coronary artery disease].

A mechanism for the genesis of early relaxation of the left ventricle was assessed. For 18 patients with coronary artery disease, biplane left coronary cineangiography was performed and the coordinates (x, y, z) of the points of the artery were measured by frame to frame basis throughout one cardiac cycle. The spatial distance (segment length) between any two points was calculated on each frame as (Formula: See text) to investigate shortening and relaxation characteristics of the ischemic and nonischemic segments. Coronary angiography was repeated during right atrial pacing to aggravate ischemia, and following nitroglycerin administration to ameliorate ischemia. From data of six normal subjects, 43 segments were calculated. All showed shortening during systole and lengthening in diastole. Right atrial pacing caused early relaxation in only two of the 43. Two hundred and fifteen segments were calculated for 18 patients with coronary artery disease. All but eight segments showed normal relaxation on control angiography. Following pacing, 115 segments showed early relaxation, and in 107 of the 115, normal relaxation were restored after nitroglycerin. Among the 107 segments, 44 were ischemic and 63 were normal. For 34 segments with early relaxation by pacing, pacing was repeated after administering nitroglycerin, and 15 did not reproduce early relaxation. The present study showed that early relaxation was observed in patients with coronary artery disease, which was effectively ameliorated by nitroglycerin, suggesting this phenomenon is closely related to the development of myocardial ischemia. The decreased active tension, reduced duration of tension, development and delay in electrical depolarization in the ischemic segment can be a reasonable inducement to early relaxation.(ABSTRACT TRUNCATED AT 250 WORDS)

Reduction of left ventricular size following oxygen inhalation in patients with coronary artery disease as measured by biplane coronary cineangiograms.

Left ventricular size is one of the major determinants of myocardial oxygen consumption, therefore if oxygen inhalation reduces myocardial oxygen demand, such might be beneficial in the treatment of acute myocardial infarction. Routine diagnostic biplane left coronary cineangiograms were obtained during air or oxygen breathing in 11 patients with old myocardial infarction or angina pectoris. Coordinates of the points on the left coronary artery were measured and throughout one cardiac cycle frame by frame. The spatial distance (segment length: L) between any two of these points was calculated. Segment length at R wave on the electrocardiogram (LECG R) and minimum value (Lmin) for each segment were calculated. Arterial pO2 was elevated by oxygen breathing from 91 +/- 4 (+/- SE) to 427 +/- 18 mmHg. Left ventricular segment length was significantly reduced by oxygen breathing: LECG R being reduced following oxygen breathing from 62.3 +/- 3.0 to 60.6 +/- 3.0 mm (a decrease of 3.3 +/- 0.8%) and Lmin also being reduced from 55.9 +/- 2.8 to 54.4 +/- 2.8 mm (a decrease of 3.1 +/- 1.0%). These figures indicate that left ventricular size was reduced. Reduction in left ventricular size through oxygen inhalation, by reducing myocardial oxygen demand, should therefore be beneficial in coronary artery disease.

Coronary artery constriction by oxygen breathing in patients with coronary disease.

This study was conducted to find whether or not oxygen breathing induces coronary vasoconstriction in diseased as well as in normal coronary arteries. Coronary angiograms were repeated in 14 patients with coronary artery disease during successive air and oxygen breathings and the diameters of the coronary arteries as displayed by film projection were measured and compared. Arterial oxygen tension was elevated from 91.3 +/- 16.8 to 457.2 +/- 26.5 mmHg by oxygen breathing but was not accompanied by any significant changes in mean arterial pressure. The diameters of coronary arteries without significant narrowing were reduced from 2.89 +/- 1.05 to 2.65 +/- 1.02 mm by oxygen breathing (a decrease of 8.9 +/- 7.0%) and that of coronary arteries distal to a narrowing of more than 50% was reduced from 2.24 +/- 0.53 to 2.02 +/- 0.57 mm (a decrease of 10.1 +/- 10.7%). These findings suggest that oxygen breathing and constrict a large coronary artery even if it has atherosclerotic lesions and the myocardium needs more flow.

[Change of left ventricular segment length by nitroglycerin measured by biplane coronary cineangiography in man (author's transl)].

Left ventricular size at different portions was evaluated following the administration of nitroglycerin to find whether there is any regional difference in the amount of shortening. In 6 patients with old myocardial infarction, biplane coronary cineangiograms were obtained before and after sublingual administration of nitroglycerin of 0.3 mg. The coordinates of the bifurcations of the left coronary artery at multiple sites were measured on the postero-anterior and lateral films and the spatial lengths (L) between any paired two points were calculated frame by frame covering one cardiac cycle. The maximum length (Lmax) was 63.2 +/- 3.1 (SE) mm before nitroglycerin as a whole and was 61.4 +/- 2.9 mm after nitroglycerin, showing no significant change. The minimum length (Lmin) also showed no significant change after nitroglycerin; from 56.1 +/- 2.9 to 54.9 +/- 2.6 mm. However, at the free wall, Lmax after nitroglycerin was reduced by 4.5 +/- 2.5%, and Lmax at the anterior septum was also reduced by 3.0 +/- 1.3%. Lmax at the base was unchanged after nitroglycerin. Lmin at the free wall and at the anterior septum were also reduced after nitroglycerin, 4.4 +/- 2.6 and 2.9 +/- 1.2%, respectively, and it was unchanged at the base. Since a reduction in the left ventricular size is effective in reducing myocardial oxygen demand and is effective in treating myocardial ischemia, it was suggested that nitroglycerin is more effective in relieving ischemia at the free wall and septum and less effective at the base.