CLO vs histology: optimal numbers and site of gastric biopsies to diagnose Helicobacter pylori.

OBJECTIVE: To determine the optimal numbers and sites of biopsies required for diagnosis of Helicobacter pylori by using the CLOtest and comparing the results with those of a routine histological assessment in a district general hospital (DGH) setting. METHODS: A prospective study comparing the sensitivity of the CLOtest containing one antral (CLO 1), two antral (CLO 2) and two antral and one body biopsy (CLO 3), and with histological examination for H. pylori. Consecutive patients undergoing upper gastrointestinal endoscopy (UGIE) at Stepping Hill Hospital, Stockport, UK, who had evidence of gastritis, gastric ulcer, duodenitis or duodenal ulcer were included in the study. RESULTS: Ninety-six patients were biopsied. Forty were positive on at least one of the CLOtests; of these, nine were negative on histological assessment. Of these nine, two were positive on all CLOtests and seven were positive only on CLO 3. One was positive on histology but negative on all CLOtests. This study showed that CLO 3 was more sensitive than CLO 1 (P = 0.004), CLO 2 (P = 0.016) and histology (P = 0.022). There was no significant difference between CLO 1 and CLO 2 (P = 0.500), CLO 1 and histology (P = 1.000), CLO 2 and histology (P = 1.00). CONCLUSION: We feel that in a busy clinical setting, taking two antral and one body biopsy in a single CLOtest is superior to routine histological assessment for the detection of H. pylori, with resulting cost saving.

Evaluation of gastric antral motor performance in patients with dysmotility-like dyspepsia using real-time high-resolution ultrasound.

Although manometric antral hypomotility and delayed gastric emptying have been reported separately in patients with dyspepsia, relationships between symptoms, antral contractility and emptying rate have not been sought. The present study therefore aimed to evaluate, simultaneously, gastric antral excursion characteristics and emptying in a sub-group of patients with severe functional dyspepsia using high-resolution real-time ultrasound. The circumference of the relaxed and contracted antrum was measured at 15-min intervals after ingestion of a 360 mL mixed nutrient meal in 36 chronic dyspepsia patients with symptoms of post-prandial bloating and epigastric distension, and in 25 healthy volunteers. Antral emptying (measured as the rate of decrease in circumference of the relaxed antrum) was slower in patients than normals (P = 0.02). In both groups, the average values for antral excursion were similar but the range of excursion in patients was significantly wider than in controls (F < 0.001), with 11 patients showing values above, and 8 showing values below the normal range. There was no relationship between antral emptying and antral excursion in either patients or volunteers. In conclusion, patients with severe functional dyspepsia show a wide range of antral performance characteristics, suggesting not only that the mechanisms responsible for the control of antral motor function are disturbed but also that the cause of the symptoms and the disturbed antral motor function are probably not directly related.

Effect of distension and feeding on phasic changes in human proximal gastric tone.

BACKGROUND: Proximal stomach by virtue of its property of accommodation acts as a reservoir for the ingested food, but its role in emptying and the factors modulating it remain unexplored. AIM: To assess the effects of distension and of feeding on proximal gastric tone. SUBJECTS: 14 healthy volunteers with no current or past history of any gastro-intestinal symptoms. METHODS: Isobaric changes in volume of the proximal stomach were recorded both during fasting and for the first 30 minutes after a meal. RESULTS: For a given degree of distension, the mean (SEM) intragastric pressure was consistently lower, immediately after meal ingestion (9.8 (1.1), mm Hg) than during fasting (12.9 (0.6) mm Hg; p < 0.01). Proximal gastric tone was continuously variable with a frequency of fluctuation of 0.9-1.3/minute and an amplitude of 16.8 (2.2) ml, superimposed upon slower higher amplitude fluctuations in baseline tone. These variations in tone were unaffected by the degree of gastric distension or by food. CONCLUSIONS: While proximal gastric tone decreases after meal ingestions consistent with accommodation, the fluctuations in tone are not an importance factor in the modulation of nutrient emptying from the proximal stomach in the immediate postprandial period.

Covert dysphagia in the mentally handicapped: two case reports and a review of published literature.

Mentally handicapped patients with esophageal pathology may present a diagnostic challenge, as they may not complain of any specific symptoms or be able to give a clear history of either dysphagia or odynophagia. This paper reports 2 such patients who recently presented to the Royal Wolverhampton Hospitals. In the first case, upper gastrointestinal endoscopy under general anesthesia enabled both the identification and removal of a large esophageal foreign body. In the second case, repeated upper gastrointestinal endoscopy facilitated both the identification and nonsurgical management of a paraesophageal abscess.

Relations between upper abdominal symptoms and gastric distension abnormalities in dysmotility like functional dyspepsia and after vagotomy.

Postprandial bloating and fullness are commonly found both in dysmotility like functional dyspepsia, and after vagotomy but the relation between gastric accommodation and symptom production has not been investigated. Intragastric pressure levels and symptoms developed during controlled distension of the gastric fundus were recorded in nine patients with functional dyspepsia, in seven patients after truncal vagotomy, and in 11 healthy volunteers. The procedure was repeated after ingestion of a liquid nutrient meal (250 ml; 250 kcal). Gastric tone, expressed as the average value of pressure over the distension period was lower in controls (median: 11.3 mm Hg) than in either the dyspeptic patients (median: 16.48 mm Hg) or postvagotomy patients (median: 19.12 mm Hg) (p < 0.05). Meal ingestion reduced gastric tone in controls, but no significant change occurred in either the dyspepsia or the postvagotomy patients. Volumes at which discomfort was elicited by distension during fasting were lower both in dyspeptic patients (median: 210 ml) and in postvagotomy patients (median: 180 ml) than in healthy volunteers (median: 660 ml) (p < 0.05). Discomfort thresholds were unaffected by meal ingestion. These results suggest that a disturbance of gastric relaxation may be related to symptom development in dysmotility like functional dyspepsia, while similarities between dyspeptic patients and postvagotomy patients suggest that the impaired gastric accommodation in functional dyspepsia may be due to an underlying vagal defect.

Beta adrenergic modulation of human upper intestinal propulsive forces.

beta Adrenoceptor blockade is known to accelerate transit through the small intestine without changing either the number or pattern of intestinal contractions. This study therefore tested the hypothesis that an increase in intraluminal aboral propulsive force may contribute to this transit acceleration. Twenty paired studies were performed, in 10 healthy volunteers, after oral administration of either 100 mg atenolol (a selective beta 1 antagonist) or matched dummy tablets according to a double blind, randomised protocol. The frequency of occurrence of, and the propulsive force exerted by, traction events related to intestinal contractions were measured, using a combined traction force detector and manometry assembly. After atenolol, a consistent increase in the force generated per traction event was noted, both for propagating contractions mean (SEM) (12.0 (1.8) g v control 5.9 (0.07) g; p < 0.05) and for stationary (11.6 (1.4) g v control 7.0 (0.7) g; p < 0.05). In contrast no change in the number of traction events was noted (control v atenolol = 1.6 (0.3) v 1.64 (0.4) per min for propagating and 0.7 (0.1) v 0.85 (0.16) per min for stationary contraction; p > 0.05). beta Adrenoceptor blockade thus increases the propulsive force generated by intestinal contractions, possibly by removing a sympathetic neural inhibition of intestinal tone.

Relaxation responses of the human proximal stomach to distension during fasting and after food.

The responses of the human proximal stomach to distension were studied in 22 healthy volunteers using an intragastric polyethylene bag, inflated progressively in 30-ml steps until the limit of tolerated volume was reached. Three successive inflations were carried out during the fasting state followed by a fourth inflation after ingestion of 250 ml of either a nutrient meal or isosmolar saline. The first inflation showed an initial nonlinear pressure rise (slope of logged pressure vs. volume = 114.6 +/- 10.0 log mmHg/ml x 10(-5)), which was then followed by the development of a plateau phase, in which further distension did not increase intragastric pressure. The slopes of the subsequent fasting inflations were significantly lower than that of the first inflation (P < 0.01) but were similar to each other (slope 83.0 +/- 5.4 and 79.8 +/- 5.7 log mmHg/ml x 10(-5)), indicating that distension-induced gastric relaxation had occurred. After saline ingestion, responses to distension were similar to those during the fasted state. After the nutrient meal ingestion, however, the slope decreased to 60.3 +/- 7.7 log mmHg/ml x 10(-5) (P < 0.01 vs. saline), indicating nutrient-induced gastric relaxation. Our study demonstrates that the pressure-volume characteristics of the proximal stomach are modulated both by distension and by the presence of nutrients in the upper gut, which appear to operate independently.

Human small intestinal contractions and aboral traction forces during fasting and after feeding.

Small intestinal intraluminal pressure activity and aboral traction forces were explored in 19 healthy volunteers using a combined manometry and traction force detecting assembly sited in the upper small intestine. Each aboral traction event was classified as being associated with either a propagating or a stationary contraction and its force measured. During phase I no contractions or traction events were seen. During phase II, traction events related to propagating contractions mean (SEM) (2.2 (0.2)/min) and to stationary contractions (0.3 (0.1)/min) generated similar force/event (7.5(0.9 g v 8.7 (1.4) g, p > 0.05). During phase III, all traction events were related to propagating contractions and generated 9.3 (2.4) g force/event (p > 0.05 v phase II). After feeding, traction events related to propagating contractions generated similar force/event to those related to stationary contractions (5.9 (1.0) g v 9.3 (2.7) g, p > 0.05 v each other and v fasting). No consistent pattern was seen in the temporal distribution of the traction events or in the pattern of the amplitude of the force of successive traction events.

Abnormal intragastric distribution of food during gastric emptying in functional dyspepsia patients.

Although delayed gastric emptying is found in some patients with functional dyspepsia, there seems to be little relation between rate of emptying and symptoms. This study examined the hypothesis that food maldistribution rather than gastric stasis may equate to symptoms in such patients and used scintigraphic techniques to quantify the partition of gastric contents between proximal and distal stomach during gastric emptying. Eleven patients with functional dyspepsia characterised by chronic severe postprandial bloating without organic abnormality, and 12 healthy volunteers, ingested a standard meal labelled with technetium-99M (99mTc). Serial images of the gastric area in anterior and posterior projections were taken for 90 minutes, regions of interest for proximal, distal, and total stomach were defined, and activity time curves were derived from the geometric means of anterior and posterior counts. Total emptying in patients (median: 46 minutes; range: 30-76) was not significantly different from controls (45 minutes; 28-58) and only three showed delayed gastric emptying. In controls, food remained predominantly in the proximal half of the stomach after ingestion and then redistributed to the distal half. In the patients, however, initial activity in the proximal half after ingestion (48%; 40-65) was significantly lower (p < 0.05) than in controls (60%; 39-73) and distributed more fully to the distal half of the stomach with a peak distal activity (56%; 34-58), which was consistently higher than in controls (36%; 33-42) (p < 0.05). It is concluded that this subgroup of functional dyspepsia patients show abnormal intragastric distribution of food, independent of gastric emptying rate.

Evaluation of human postprandial antral motor function using ultrasound.

We used high-resolution ultrasound to characterize postprandial antral excursion characteristics in 15 healthy volunteers. Antral circumference was repeatedly measured in the sagittal plane anterior to the abdominal aorta, at 15-min intervals following ingestion of a standard meal. At each recording period, the maximal and minimal antral circumference was noted. In seven volunteers, antral circumference was studied continuously for 5 min at each 15-min recording period to assess the frequency and regularity of antral excursions. Antral circumference increased immediately after meal ingestion from preprandial values of 64 +/- 2.6 (means +/- SE) to 138 +/- 3.1 mm and then gradually decreased with meal emptying to 72 +/- 2.6 mm at 90 min. The continuous recordings of antral images revealed that antral circumference transiently decreased at regular intervals; the interval between successive excursions was 20.1 +/- 0.2 s. There was no change in the excursion interval with emptying. The excursion amplitude decreased from 33 +/- 3.9 mm immediately post-meal ingestion to 13 +/- 1.5 mm at 90 min (r2 = 0.62 +/- 0.07). The ratio between the excursion amplitude and circumference of the relaxed antrum changed only slightly with time (slope = 0.0009 +/- 0.00003). Comparison of repeat studies in 10 volunteers showed a low intra-individual variation for postprandial antral circumference and excursion amplitude.