Esophageal pH testing in patients refractory to proton pump inhibitor therapy.

BACKGROUND: Proton pump inhibitors (PPIs) are the most potent drugs available for the management of gastroesophageal reflux disease (GERD). Ambulatory 24 h pH monitoring is often recommended for patients experiencing symptoms despite PPI therapy. Recent pivotal data suggest that pH studies are predictably normal in this setting, casting doubt on the clinical utility of the current practice. OBJECTIVE: To describe 24 h pH findings in patients referred by gastrointestinal specialists for the indication of GERD refractory to PPI therapy. METHODS: A retrospective review was performed, examining all patients undergoing ambulatory esophageal pH monitoring at the St Boniface General Hospital Motility Laboratory, between January 2002 and June 2005. Tests performed in patients clinically suspected of having GERD who were not responding to PPI therapy formed the study group. pH data were analyzed for the total, upright and supine periods. Abnormal reflux parameters were defined by applying three criteria: DeMeester score greater than 14.72; pH less than 4.0 more than 5.5% of the total time, more than 8.3% of the time upright or more than 3% of the time in the supine position; and pH less than 4.0 for more than 1.6% of the total time. RESULTS: A total of 417 patients underwent pH monitoring during the time of the review. One hundred seven patients (mean age 51.7 years; 37 men and 70 women) met study criteria. Sixty-eight (63.6%) were referred by a gastroenterologist and 39 (36.4%) were referred by a gastroenterologist surgeon. Sixty-one patients were on twice-daily PPIs and 46 were on once-daily dosing. Using the most stringent pH criteria, namely criteria 2, pH readings were abnormal in 30% of patients on once-daily PPIs and in 25% of patients on twice-daily dosing. The prevalence of abnormal pH readings were even higher if criteria 1 or 3 were applied. CONCLUSIONS: In a patient population assessed by a specialist as having clinically suspected GERD that is not responding to PPI therapy, a substantial number of patients will have abnormal esophageal pH test results. The role of pH testing in the algorithm of GERD is evolving; however, our data suggests that an abandonment of pH testing is premature.

A randomized-controlled trial comparing an educational intervention alone vs education and biofeedback in the management of faecal incontinence in women.

Biofeedback (BF) training is an accepted therapy in the treatment of faecal incontinence (FI) despite a paucity of data demonstrating benefit. This study aims to determine whether BF has any specific effect above and beyond an educational intervention. Twenty-three women with regular and frequent idiopathic FI were randomized to education and pelvic exercise vs education and BF therapy. Complete data is available for 18 women. Overall, 61% of participants demonstrated a complete response. There was no difference in response rate between treatment arms. Women with FI demonstrate a good response to treatment with education and exercise and education plus BF thus questioning the specific effect of BF.

Therapeutic value of a gastroenterology consultation in irritable bowel syndrome.

BACKGROUND: Functional patients comprise the largest group in gastroenterology practice. Pharmacological therapy of irritable bowel syndrome is disappointing. One treatment strategy for irritable bowel syndrome emphasizes the physician's role; the physician is promoted as the therapeutic modality. AIM: To determine the therapeutic value of the contemporary approach to irritable bowel syndrome by examining health care utilization and patient morbidity. METHODS: We performed an observational study over 4 years using an administrative database and morbidity scales. Health care utilization was assessed for 2 years pre- and post-intervention. Patient morbidity was assessed at baseline and 1 and 2 years post-intervention. The participants included 70 irritable bowel syndrome patients referred by primary physicians. A structured consultation was performed, establishing a positive diagnosis of irritable bowel syndrome and providing disease conceptualization. RESULTS: Health care utilization for gastrointestinal diagnoses increased in the year prior to the intervention and declined immediately after to baseline; psychiatric and other visits remained unchanged for 4 years. Pain was reduced but other morbidity persisted. CONCLUSIONS: A consultation itself is a therapeutic intervention in irritable bowel syndrome with regard to its impact on societal economic burden. It is associated with a durable decrease in illness-specific health care utilization. It may not address all aspects of irritable bowel syndrome; multiple domains of morbidity demonstrated persistent distress.

Clinical evaluation and management of acute infectious diarrhea in adults.

Acute infectious diarrhea is a major global health problem. Issues for the developed and developing regions of the world differ. Awareness of disease pathophysiology and epidemiology are essential, however, for clinical evaluation and management. The immense human and economic burden imposed by acute diarrhea illness can be addressed only by thoughtful strategies aimed at prevention as well as cost-efficient evaluation and treatment.

Crohn's disease and the Melkersson-Rosenthal syndrome.

A 30-year-old woman with a 10-year history of recurrent bloody diarrhea and documented colitis of the descending colon, consistent with Crohn's disease, presented with an exacerbation of her gastrointestinal disease and an 18-month history of recurrent facial and genital swelling. Her course evolved to include severe ear pain, dysphagia and colonic dysmotility. She was diagnosed with Melkersson-Rosenthal syndrome and treated with multiple agents. The neurological aspects of her presentation are highlighted, and the Melkersson-Rosenthal syndrome is reviewed.

Quantification of the placebo response in ulcerative colitis.

BACKGROUND & AIMS: There is consistently a measurable benefit noted among placebo users in treatment trials of ulcerative colitis (UC). The aim of this study was to define the placebo response in active UC and identify study features that influence the placebo response. METHODS: MEDLINE database was searched for placebo-controlled treatment studies of active UC. Data extraction was performed by two reviewers, and one separate investigator reviewed all trials and data extraction before data tabulation. Placebo remission and benefit rates were determined for clinical, endoscopic, and histological outcomes. Synthesis analysis on the weighted proportions from the different studies explored the placebo response as it related to eight study variables. RESULTS: Thirty-eight of 44 studies identified were included in the analysis. The clinical remission rate was 9.1% (confidence interval [CI], 6.6-11.6) and the benefit rate was 26.7% (CI, 24.1-29.2). Similar rates were observed endoscopically and histologically. The number of study visits (< or =3 vs. >3) modified placebo response as assessed by clinical benefit (P = 0.05), endoscopic remission (P = 0.02), and histological remission (P = 0.04). Other study variables were not significant placebo response modifiers. CONCLUSIONS: In trials of active UC, the placebo remission rate is approximately 10% and the placebo benefit rate is approximately 30%. These rates are consistent regardless of assessment end point. The placebo response is greater in trials with more frequent study visits (more than three).

Escherichia coli O157:H7 infection mimicking Crohn's disease.

Two patients presented with abdominal pain, diarrhea, and tender right lower-quadrant masses. Both patients had computerized tomographic scans showing cecal thickening and mass effects with multiple mesenteric lymph nodes and sparing of the rest of the colon. Colonoscopy in each patient also revealed disease confined to the right colon, and the mucosal pattern was consistent with that of Crohn's disease. The patients were both treated as having Crohn's disease until stool testing showed the presence of Escherichia coli O157:H7 serotype and follow-up computerized tomography scans and endoscopies revealed no evidence of chronic inflammatory bowel disease. E. coli O157:H7 is an increasingly recognized enteric infection, and these cases highlight how this infection may mimic right colonic Crohn's disease in its presentation. Furthermore, the submucosal nature of the clinical findings is discussed. Patients presenting with acute bloody diarrhea and displaying clinical and computerized tomographic features of Crohn's disease should have E. coli O157:H7 infection excluded before therapy for Crohn's disease is initiated.