ABSTRACT
Proton pump inhibitors are the reference standards for the treatment of acid-related diseases. Acid suppression in gastroesophageal reflux disease is associated with a high rate of mucosal cicatrization, but symptom response differs among endoscopic phenotypes. Extraesophageal manifestations have a good clinical response in patients that present with abnormal acid exposure (diagnostic test) in the esophagus. Proton pump inhibitors have shown their effectiveness for reducing symptom intensity in nighttime reflux and sleep disorders, improving quality of life and work productivity. That can sometimes be achieved through dose modifications by splitting or increasing the dose, or through galenic formulation. Proton pump inhibitors are not exempt from controversial aspects related to associated adverse events. Technological development is directed at improving proton pump inhibitor performance through increasing the half-life, maximum concentration, and area under the curve of the plasma concentrations through galenic formulation, as well as creating safer and more tolerable drugs. The present review is focused on the mechanisms of action, pharmacokinetic properties, and technological advances for increasing the pharmacologic performance of a proton pump inhibitor.
Subject(s)
Gastric Acid/chemistry , Proton Pump Inhibitors/pharmacology , Animals , Esophageal pH Monitoring , Gastroesophageal Reflux , Humans , Proton Pump Inhibitors/chemistry , Proton Pump Inhibitors/pharmacokinetics , Proton Pump Inhibitors/therapeutic useABSTRACT
Laparoscopic Nissen fundoplication is currently considered the surgical treatment of choice for gastroesophageal reflux disease (GERD) and its long-term effectiveness is above 90%. Adequate patient selection and the experience of the surgeon are among the predictive factors of good clinical response. However, there can be new, persistent, and recurrent symptoms after the antireflux procedure in up to 30% of the cases. There are numerous causes, but in general, they are due to one or more anatomic abnormalities and esophageal and gastric function alterations. When there are persistent symptoms after the surgical procedure, the surgery should be described as "failed". In the case of a patient that initially manifests symptom control, but the symptoms then reappear, the term "dysfunction" could be used. When symptoms worsen, or when symptoms or clinical situations appear that did not exist before the surgery, this should be considered a "complication". Postoperative dysphagia and dyspeptic symptoms are very frequent and require an integrated approach to determine the best possible treatment. This review details the pathophysiologic aspects, diagnostic approach, and treatment of the symptoms and complications after fundoplication for the management of GERD.
Subject(s)
Fundoplication , Gastroesophageal Reflux/surgery , Postoperative Complications , Fundoplication/methods , Humans , Laparoscopy , Postoperative Complications/diagnosis , Postoperative Complications/physiopathology , Postoperative Complications/therapy , Recurrence , Treatment OutcomeABSTRACT
Inadequate function of Oddi sphincter is a clinical entity of difficult diagnosis and controversial treatment. The diagnosis can be suspected by the clinical history, biochemical tests, ultrasonography and endoscopy but can only be proved by manometry. We studied 35 patients, 23 women and 12 men with a mean age of 56.4 years. They were all cholecystectomized and had pain as before they were operated. 33 had elevation of alkaline phosphatase all of them had dilatation of the main bile duct over 12 mm and delayed contrast emptying over a 45 minutes period. Manometry demonstrated high pressure of Oddi sphincter above 30 mmHg. We performed endoscopic sphincterotomy in all cases without complications. We did a clinical, biochemical and endoscopic evaluation every 3 months during the first year and every 6 months during the second and third year. Thirty one patients (81.6%) remained asymptomatic after the procedure, with improvement of the biochemical tests in all cases. We concluded that endoscopic sphincterotomy is a good alternative in the management of these patients.
Subject(s)
Sphincter of Oddi/physiopathology , Sphincterotomy, Endoscopic , Common Bile Duct Diseases/physiopathology , Common Bile Duct Diseases/surgery , Female , Follow-Up Studies , Humans , Male , Manometry , Middle Aged , Sphincter of Oddi/surgeryABSTRACT
We studied 30 patients. 20 were males and 10 females. Mean age was 48 year old. Esophageal disease was not present neither gastro-esophageal reflux. Biopsy was taken between 24 hours and 25 days after nasogastric tube (NG) was put into place. Endoscopic findings were: hyperemic mucosa, submucosal hemorrhage, clots, erosions and ulcers near Esophago-gastric junction. Intraepithelial edema, vessel congestion, polymorphonuclear infiltration, fibrin thrombosis of submucosal vessels, ischemia, epithelial regeneration and ulcer were common histologic findings. All endoscopic and histologic alterations were related to the length of time of NG tube contact with the esophageal mucosa. We concluded that NG tube damages the esophageal mucosa by two mechanisms: a) Local irritation that favors b) gastric reflux by decreasing lower esophageal sphincter pressure.
Subject(s)
Esophagus/injuries , Intubation, Gastrointestinal/adverse effects , Biopsy , Esophagoscopy , Esophagus/pathology , Female , Humans , Male , Middle Aged , Mucous Membrane/injuries , Mucous Membrane/pathology , Postoperative Period , Time FactorsABSTRACT
From April to June 1990, five female patients with a mean age of 47 years, with previous cholecystectomy and the presence of bile duct stones, were treated by extracorporeal shock wave lithotripsy. Pain and jaundice was present in 4, one patient only had jaundice. In 3 patients the stones were located in the intrahepatic bile ducts, in the other 2 they were located in the common bile duct but were judged to be to large for endoscopic treatment. In all patients a sphincterotomy was performed and a nasobiliary catheter was inserted, after which extracorporeal shock wave lithotripsy was performed. Saline solution was infused through the nasobiliary tube (1 ml per minute) for 24 hours. In all the patients except one, the problem was solved in one session. Saline infusion through a nasobiliary catheter was useful as a complement of shock wave lithotripsy of bile duct stones to prevent the obstruction of the bile duct by fragments.
