[Rehabilitation for digestive and metabolic diseases. Quo vadis?]. / Rehabilitation bei Verdauungs- und Stoffwechselkrankheiten. Quo vadis?

The position of rehabilitation in gastroenterology, hepatology and metabolic diseases has changed little in the last 25 years. Initial improvements in quality are oriented more to the content of rehabilitative measures and less to organizational basic conditions. Nevertheless, there is an urgent need for action if rehabilitation medicine is to achieve an equivalent and recognized position in the interaction between primary care and other medical specialties. In this article suggestions for expedient prerequisites and utilization options of rehabilitation in the fields of hepatogastroenterology and metabolism will be presented, which are also oriented to the exemplary implemented concepts from Sweden and The Netherlands.

[Chronic pancreatitis: weight loss and poor physical performance - experience from a specialized rehabilitation centre]. / Chronische Pankreatitis: Gewichtsverlust und Leistungsschwäche - Erfahrungen aus einer spezialisierten Rehabilitationsklinik.

There are various potential explanations for weight-loss and poor physical performance in patients with chronic pancreatitis: In severe chronic pancreatitis the decline in enzyme secretion is an important cause for the malassimilation syndrome frequently seen in these patients. Occasionally, difficulties may arise in establishing this decline and in quantifying the secretory capacity of the gland. Many patients limit their food intake because of the pain caused by eating. In untreated patients with diabetes, glucosuria may contribute to their malnutrition. Insufficient funds for food due to alcoholism and anorexia may also be of some significance. Concomitant gastrointestinal diseases and malabsorption following gastrointestinal surgery are frequently found in patients with chronic pancreatitis. Neurological complications and traumatic lesions after accidents - often in connection to the underlying alcoholism - are joined by physical inactivity and thus contribute to the development of muscular atrophy and decreased physical performance. Consequently, rehabilitation of patients with chronic pancreatitis is challenging: They not only need expert medical treatment of both the symptoms of chronic pancreatitis and the concomitant disorders. Therapy must also include dietary support, careful physical training, and - in cases caused by alcoholism - psycho-social support. So far, the multi-professional competence required for these purposes can only be expected in a specialized rehabilitation centre.

The effect of pancreatic enzyme supplementation in patients with steatorrhoea after total gastrectomy.

OBJECTIVE: To assess the influence of pancreatic enzyme supplementation on symptoms, energy intake, bowel habits, and fat malassimilation in patients after total gastrectomy. DESIGN: A prospective, double-blind, randomized, parallel, placebo-controlled, multi-centre trial. SETTING: Institutionalized patients in three gastroenterological rehabilitation clinics. PARTICIPANTS: 52 institutionalized patients with a faecal fat output > or = 14 g/day, operated on for malignant gastric disease a median of 198 days (interquartile range (IQR) 47-608) previously, and free from recurrence and/or metastasis. INTERVENTIONS: Nine sachets of pancreatic enzymes per day (each containing lipase 36,000, amylase 27,000, protease 2400 FIP (Federation International Pharmaceutique)) or identical-looking placebo were given for 14 days. MAIN OUTCOME MEASURES: Abdominal symptoms, energy intake, bowel habits and fat malassimilation. RESULTS: After treatment, patients on enzyme therapy felt better overall (P = 0.006), but no improvement of a specific symptom could be identified. During the intervention, the median kilojoule intake per kilogram body weight was 9% higher in the placebo group (170.8 (IQR 146.9-202.6)) than in the enzyme-treated group (157.0 (IQR 134.8-170.4)) (P = 0.03). Enzyme treatment did not result in a significant difference between the placebo and the enzyme-treated group regarding bowel habits or fat malassimilation. CONCLUSIONS: The effect of high-dose pancreatic enzymes supplementation on symptoms and steatorrhoea after total gastrectomy is marginal and does not justify its routine use.

Determinants of medico-social functioning after total gastrectomy.

AIM: To describe medico-social functioning after total gastrectomy and the factors determining it. PATIENTS AND METHODS: In three medical rehabilitation centres, 173 consecutive patients (female/male = 62/111) after potentially curative total gastrectomy for gastric malignancy 206 days earlier (median, interquartile range = IQR 56-644) were evaluated for different pre- and post-operative parameters with potential influence on post-operative medico-social functioning as measured with the Edinburgh Rehabilitation Status Scale (ERSS). Parameters evaluated were: gender, age, time since operation, tumour stage, type of operation, clinical centre of admittance, haemoglobin, ferritin, albumin, presence of small bowel bacterial overgrowth, rapid oro-coecal transit, dyspepsia, early satiety, reflux, dysphagia, vomiting, a symptom based score, body mass index in health, at operation and on admission, weight loss since operation, calorie intake, bowel habits, and fat malassimilation. Independent influential factors for the ERSS were identified in a linear regression analysis. RESULTS: The median ERSS-score was 4 (IQR 2-6) on a scale from 0 (best) to 28 (worst). There was a significant difference in the ERSS-scores between the three different clinics. The ERSS-scores improved significantly with time since operation (ca. 22% per year). ERSS-scores were higher in patients with intestino-oesophageal reflux (+71%), with dyspepsia (+65%), or with dysphagia (+62%). CONCLUSION: Medico-social functioning was acceptable in this patient population. After total gastrectomy, dyspepsia, dysphagia, and intestinal reflux into the oesophagus need special attention.

Treatment of reflux oesophagitis of moderate and severe grade with ranitidine or pantoprazole--comparison of 24-hour intragastric and oesophageal pH.

BACKGROUND: Proton pump inhibiting drugs strongly decrease gastric acid secretion and have proven more effective in the treatment of reflux oesophagitis than H2-receptor antagonists. METHODS: In a double-blind randomized trial, 24 patients with oesophagitis grade II (n = 15) and III (n = 9) were treated for 4 weeks with either ranitidine 150 mg b.d. (n = 13) or pantoprazole 40 mg o.m. (n = 11). Before the trial and on the last day of medication, 24-h intragastric pH and oesophageal pH profiles were performed. Healing was assessed by endoscopy. RESULTS: Pantoprazole increased median gastric pH from 1.7 to 3.9. Virtually no change in gastric pH was seen in the ranitidine group. Pantoprazole reduced the fraction time of pH < 4 in the oesophagus from 21% to 3% (P = 0.0005), and the median number of refluxes from 206 to 56 (P = 0.022). Oesophageal acid exposure was not decreased by ranitidine. Healing of the oesophagitis was seen in 6/11 cases after pantoprazole and in 3/13 cases after ranitidine (N.S.) CONCLUSION: In patients with oesophagitis of moderate and severe grade, pantoprazole 40 mg o.m. decreases intragastric acidity and gastro-oesophageal acid reflux more effectively than ranitidine 150 mg b.d.

Total gastrectomy: the influence of preserved duodenal transit and of pouch reconstruction on abdominal symptoms, nutrient assimilation, and medico-social functioning.

BACKGROUND/AIMS: The aim of this retrospective study was to establish whether patients with different reconstruction after total gastrectomy (duodenal bypass without pouch (subgroup Ia, n = 88); duodenal bypass with pouch (subgroup Ib, n = 27); continuous duodenal transit (subgroup II, n = 27)) differ concerning abdominal symptoms, nutrient assimilation, and medico-social functioning. METHODS: The 142 patients (49 females, 93 males; mean age 57.2 years, (95% confidence interval 55 to 59)) after potentially curative total gastrectomy for gastric malignancy 500 days earlier (mean: 95% confidence interval 334 to 666) were evaluated for abdominal symptoms, biochemical and haematological parameters, endoscopic findings, small intestinal bacterial overgrowth, oro-caecal transit time, objective signs of malassimilation, and the degree of medico-social functioning. RESULTS: There were no significant differences between the subgroups in any of the parameters examined. CONCLUSION: In this study, neither subjective nor objective patient data support preference for any single mode of the examined reconstructions after total gastrectomy. However, small patient numbers, unstandardised reconstruction procedures and a recruitment bias might influence these findings.

Small bowel bacterial overgrowth in patients after total gastrectomy.

The aim of this study was to elucidate the consequences of small bowel bacterial overgrowth (SBBO) after total gastrectomy. A total of 127 patients, evaluated for SBBO with a radiographically controlled H2-breath test (subgroup I, without SBBO, n = 80; subgroup II, with SBBO, n = 47) after potentially curative total gastrectomy for gastric malignancy, were uniformly evaluated. Mean time since operation was significantly shorter in subgroup II than in subgroup I [370 days, confidence interval (CI) 96-645 days, vs. 687 days, CI 397-976 days; P < 0.01]. Controlling for this difference, there were no other significant differences in symptoms and signs between the subgroups except for the medico-social functioning measured with the Edinburgh Rehabilitation Status Scale (ERSS). The mean ERSS showed significantly better medicosocial functioning in subgroup I than in subgroup II [3.7 (CI 2.2-5.2) vs. 5.1 (CI 3.0-7.0); P < 0.05]. After total gastrectomy, patients without SBBO did not differ significantly from patients with SBBO in most parameters. Medicosocial functioning was significantly poorer in the latter.

The risk factor profile of recto-sigmoid adenomas: a prospective screening study of 665 patients in a clinical rehabilitation centre.

During a prospective screening study for recto-sigmoid adenomatous polyps, the influence of the following risk factors was evaluated: age; gender; body mass index; heredity for colorectal malignancy; diabetes; hypertension; constipation; previous gastric surgery; previous gastric acid inhibition; alcohol and cigarette consumption; serum cholesterol; serum triglycerides; and serum gastrin. Screening fibre-sigmoidoscopy of 665 patients (aged between 50 and 60 years) at a clinical rehabilitation centre for gastrointestinal and metabolic diseases showed that 146 had one or several adenomas. The study population was overweight by a mean of about 15%. Comparison of those with and those without adenoma using univariate analysis, showed that the group with adenomas had higher serum triglyceride values, drank more alcohol on a regular or excessive basis, were more frequent smokers, and had a tendency to raised fasting serum glucose. In a multivariate analysis, age, high serum triglycerides and high alcohol consumption were risk factors for recto-sigmoid adenomas. The risk factor profile identified in this study may help in the selection of individuals for screening sigmoidoscopy from a similar background population. It also identifies target conditions for primary prevention of colorectal neoplasia.

[Effect of elevated head position in bed in therapy of gastroesophageal reflux]. / Effekt der kopferhöhten Bettlage in der Therapie der gastroösophagealen Refluxkrankheit.

In a randomized multicentric trial the effect of sleeping with the bed-head raised was studied in inpatients with reflux symptoms. All patients underwent an endoscopic and pH-metric examination. As a result from the diagnostic procedures three groups were formed: group 1 - refluxlike dyspepsia (endoscopic and pH-metric examination normal), group 2 - reflux disease without esophagitis (endoscopy normal, pH-metric examination abnormal), group 3 - refluxesophagitis (endoscopy abnormal). All patients were randomly assigned to either sleeping with horizontal bed-head or having the bed-head raised (15 cm). Furthermore, the patients in group 3 were put on treatment with omeprazole (20 mg twice a day) those in group 2 were treated with a procinetic drug (cisapride 30 mg). The patients in group 1 had no drug therapy. However, antacids were allowed in all patients. For a two-week-period reflux symptoms and use of antacids were registered. No difference was seen in the symptom-score or use of antacids. Also sub-group analysis (sex, age, body-mass-index, severity of esophagitis and nocturnal reflux) did not reveal any impact of sleeping with the bed-head raised on reflux symptoms or use of antacids.

Screening for gastrointestinal neoplasia: efficacy and cost of two different approaches in a clinical rehabilitation centre.

Mortality from colorectal cancer (CRC) can be reduced by screening of asymptomatic individuals and by removal of colorectal adenomas (CRA). It is still under debate which screening method should be used. In a clinical rehabilitation centre we compared two widely different approaches: faecal occult blood testing (FOBT) with subsequent endoscopy of test-positives in an unselected patient group, and primary sigmoidoscopy of asymptomatic persons between 50 and 60 years of age. Between January 1988 and October 1991 a FOBT was offered to all--symptomatic and asymptomatic--6,500 in-patients of a clinical rehabilitation centre and lower/upper GI-endoscopy was suggested to test-positives (study A). In the latter half of this period 1,166 persons without bowel symptoms and/or disease and aged 50-60 years were invited to a screening sigmoidoscopy (study B). In study A 95% of the patients (n = 6,234) returned a complete FOBT, which was positive in 186 (2.98%). 126 of these 186 patients (68%) accepted further investigation, and a total of 78 sigmoidoscopies, 78 colonoscopies and 47 gastroscopies were performed. Six patients in whom a malignancy was detected (1 gastric, 1 rectal and 4 colonic; all in a curable stage) underwent surgery. In 28 patients CRA were identified and removed by snare excision. In study B 658/1,166 asymptomatic in-patients accepted the screening sigmoidoscopy (56%). Rectosigmoid adenomas were identified in 153 (23%). One rectal cancer was found. Of these cases, 116 underwent an additional colonoscopy, disclosing proximal adenomas in 39 patients (33.6%). The cost of identifying one CRA-bearer was $1,436 in study A and $271 in study B (assuming: FOBT = $3.00; sigmoidoscopy = $63.00; colonoscopy = $135; gastroscopy = $108). In study A, the cost of identifying one patient with cancer would have been $5,435, if the cost of identifying one CRA-bearer was set to $271 as in study B. Screening for CRC was well-accepted in the health-orientated environment of a rehabilitation centre. The cost of identifying a CRA-bearer with screening sigmoidoscopy was about one-fifth of that using preselection with a FOBT. However, with FOBT a higher number of cancers was found. For the discovery of CRA, mass-screening with sigmoidoscopy of persons above the age of 50 years can be advised. For the detection of both CRA and CRC, screening with FOBT and subsequent endoscopy is an acceptable and cost-effective method.

Nutrient malassimilation following total gastrectomy.

BACKGROUND: The aim of the study was to elucidate the degree and the pathophysiology of abdominal symptoms, malnutrition and malassimilation after total gastrectomy. METHODS: In 174 consecutive patients, with potentially curative total gastrectomy for gastric malignancy, subjective symptoms and objective parameters of malassimilation were evaluated. RESULTS: Abdominal symptoms were present in 86% of the patients. In spite of a high daily calorie intake (median 37.8 kcal/kg body weight) mean body mass index had been decreasing since good health. Anaemia was found in 46%, sideropenia in 31% and oesophagitis in 26%. Mean faecal fat excretion was 17.4 (1.4) g/day and mean fat malassimilation 14.8% (1.1) of the intake. A shortened small-bowel transit was measured in 21.7% of the patients, and bacterial overgrowth was present in 37.7%. CONCLUSIONS: Malassimilation post total gastrectomy seems to be multifactorial. Shortened small-bowel transit and subsequent dyssynchrony of pancreatic enzyme supply seem to be of major importance.

Observation of gastric glandular cysts in the corpus mucosa of the stomach under omeprazole treatment.

In patients undergoing long-term treatment with omeprazole, tiny gastric polyps, described histologically as glandular cysts, have occasionally been reported. We report on a further nine patients (5 women and 4 men) undergoing omeprazole treatment who developed endoscopically visible and histologically verified glandular cysts. Eight patients were on long-term treatment with omeprazole for reflux oesophagitis, and the glandular cysts were observed between 8 and 60 months after the start of treatment. In one patient with an NSAID-induced ulcer, a tiny polyp was found only three weeks after initiation of treatment. None of the patients had Helicobacter pylori-associated gastritis. The cysts, which measured between 0.25 and 0.7 mm in diameter, were mostly lined with flattened parietal and chief cells, but in three cases also with foveolar epithelium, so that they could not be reliably distinguished from Elster's gastric glandular cysts. These glandular cysts are harmless, and do not require further diagnostic or therapeutic measures. They probably develop spontaneously independently of the omeprazole therapy.

[Mexiletine in treatment of painful diabetic neuropathy]. / Mexiletin in der Behandlung der schmerzhaften diabetischen Neuropathie.

The objective of this double-blind placebo controlled multicenter study was to prove the efficacy of mexiletine in painful diabetic neuropathy. Treatment was provided for in three dosages. For pain measurements a visual analogue scale (VAS) and McGill's verbal rating scale were chosen. 95 patients were included. A global assessment of the VAS showed no differences in treatment. The total evaluation (PRIT = Pain Rating Index Total) of the McGill scale just failed the level of significance. More specific exploratory evaluation of subclasses of the McGill scale, representing different qualities of pain, gave remarkable differences between mexiletine and placebo. According to types of complaints an evaluation showed substantial advantages of the mexiletine treatment with both the VAS and the McGill scale. There is strong evidence that particularly patients with stabbing or burning pain, heat sensations or formication will benefit most by mexiletine therapy. Concerning the dosage, a medium regimen of 450 mg per day seems to be appropriate in this indication. With an increase in dosage the efficacy does not rise proportionally. Mexiletine proved a very safe therapy with negligible side effects at the medium dose range, even less than placebo. There were no cardiovascular side effects. Further investigations should pay more attention to the variety of the complaints and include the quality of life.

Acceptance and outcome of endoscopic screening for colonic neoplasia in patients undergoing clinical rehabilitation for gastrointestinal and metabolic diseases.

Our purpose was to study the acceptance and the outcome of endoscopic screening investigations of the colon in patients between 50 and 60 years of age in a clinical rehabilitation center. A total of 1,166 patients (m = 691, f = 475) entered the study. After guaiac testing all patients for fecal occult blood loss (FOBT), 667 patients (57%; m = 407, 61%; f = 260, 39%; n.s.) accepted a sigmoidoscopy. Of 658 (m = 403, f = 255) patients with complete investigation, 153 (23%) (m = 104, 26%; f = 49, 19%; n.s.) had a total of 272 neoplastic polyps, including 1 carcinoma. Adenomas = /> 10 mm were found exclusively in male patients (n = 25, p < 0.001). In comparing patients aged 50-55 years (n = 386) with those aged 56-60 years (n = 272), prevalences of neoplasia were found to be 19%/29% (p < 0.01), and prevalences of adenomas = /> 10 mm were 2%/10% (p < 0.05). The acceptance of a colonoscopy in patients with neoplastic polyps at sigmoidoscopy was 116/153 (m = 78, 75%; f = 38, 78%; n.s.). In 39 of these patients (34%) (m = 31, 40%; f = 8, 21%; p < 0.05), 68 further adenomas were detected but no carcinoma or adenoma with severe dysplasia. Multiple adenomas in the proximal colon were seen in 17 cases (15%) (m = 16, 21%; f = 1.3%; p < 0.01). The FOBT was positive in 10/658 patients, including the case with a carcinoma, but only in 4/25 with adenomas = /> 10 mm. In 5 cases with positive FOBT sigmoidoscopy and complementary colonoscopy did not reveal any pathology.

Determination of faecal chymotrypsin concentration and 72-hour faecal chymotrypsin output in the detection of pancreatic steatorrhoea.

In 96 consecutive patients who underwent a 72-h faecal fat determination because of suspected nutrient malassimilation (maldigestion and/or malabsorption) faecal chymotrypsin (F-Chym) was estimated with a commercial photometric test (Monotest Chymotrypsin), comparing F-Chym concentrations in the first 24-h stool with the total 72-h F-Chym output. In the first 24-h faeces, the F-Chym concentration, calculated as a mean of three random samples, did not significantly differ from a single value obtained after homogenization. In known pancreatic disease, a F-Chym concentration less than 3.0 U/g wet faeces distinguished well between steatorrhoic patients (n = 12) and nonsteatorrhoic (n = 13) (positive predictive value (PV), 91%; negative PV, 86%) but was less suitable as a screening test for pancreatic steatorrhoea in the unselected patient group (positive PV, 61%; negative PV, 98%). Although the estimation of 72-h F-Chym output could differentiate between various subgroups of patients to a certain extent, the positive PV for discovery of pancreatic steatorrhoea in a single patient was low. Four patients had excessively high F-Chym output and increased bile acid excretion after ileal resection (n = 3) and radiation ileitis (n = 1), respectively, possibly indicating the removal of an inhibitory mechanism of pancreatic and biliary secretion in these conditions.

Development of gastric dysplasia in pernicious anaemia: a clinical and endoscopic follow up study of 80 patients.

The development of gastric dysplasia and neoplasia in patients with pernicious anaemia has been evaluated in a prospective clinical and endoscopic follow up study. After initial screening of 80 patients between 1978 and 1980, one patient underwent total gastrectomy for a gastric malignancy and 12 were kept under surveillance and underwent endoscopy at a mean interval of 14 months. In the remaining 67 patients further investigation was attempted six to seven years after the initial investigation. The continuous follow up study identified carcinoids in one patient and an adenoma with severe dysplasia in a further patient. The grade and site of mucosal dysplasia differed from one investigation to the next, but no overall progression was observed. Of the 79 patients, eight had died by the time of the reinvestigation, two of unknown cause and six of causes unrelated to pernicious anaemia. In 38 of the remaining 71 patients, clinical data only were available, with no evidence of new gastric malignancy. In 27 patients it was possible to perform an upper gastrointestinal endoscopy, when no change in the degree of dysplasia was detected. In six patients no follow up information was obtainable. In conclusion, patients with pernicious anaemia should be investigated by upper gastrointestinal endoscopy soon after diagnosis. Polyps should be removed wherever possible. In the presence of severe mucosal dysplasia or polyps that are not removed, frequent reinvestigation should be performed, provided the patient is eligible for gastric surgery. In the remaining patients, follow up endoscopies at about five year intervals would seem sufficient.

The influence of telenzepine on gastrointestinal transit: comparison with placebo and domperidone.

In a placebo controlled trial, the effect of the M1-antagonist telenzepine (3 mg in the morning) and of the dopamine antagonist domperidone (10 mg t.d.s.) was studied on bowel habits, on oro-caecal and on oro-anal transit time. The study was carried out on healthy subjects double-blind, multiple cross-over. The test periods were seven days each interrupted by wash-out periods of seven days. Stool weight, frequency and consistency as well as side-effects were recorded daily. The oro-anal transit time was estimated by evaluating the excretion of orally ingested radiopaque markers. The oro-caecal transit time was studied by means of a hydrogen breath test after a standard meal. The oro-caecal transit time was significantly prolonged during medication with telenzepine, both compared with placebo (p less than 0.05) and with domperidone (p less than 0.01). Bowel habits and the oro-anal transit time remained statistically unchanged during treatment with the active drugs. It is concluded that telenzepine has a dissociate effect on intestinal motility, delaying transit through the upper gastrointestinal tract without affecting the oro-anal transit time.

The effect of cisapride on defaecation in normal human subjects--lack of effect on faecal excretion of water, fat, and bile acids.

In order to elucidate whether or not the increased stool frequency that occurs during cisapride treatment is a result of malabsorption of water, fat, and bile acids, 12 healthy volunteers were dosed with either tablets of placebo q.d.s. or tablets of 10 mg cisapride q.d.s. during two periods of 5 days in a double-blind, crossover study. Stool frequency, stool consistency, and side-effects were recorded each day. Total faecal mass, faecal water content, and faecal excretion of fat and bile acids were determined during the last 72 h of each study period. Mean daily stool frequency was 18.8% higher during cisapride [1.68 +/- 0.12 (S.E.M.)] administration than during placebo (1.42 +/- 0.12); P = 0.038. The stool consistency score increased by 11.8% towards softer stools during cisapride dosing (N.S.). There were no significant differences in total faecal mass (placebo 399.4 g/72 h; cisapride; 414.5 g/72 h), faecal water content (placebo; 75.6%: cisapride 76.2%), or faecal excretion of fat (placebo; 12.7 g/72 h: cisapride; 11.6 g/72 h) and total bile acids (placebo; 2212 mumol/72 h: cisapride; 2261 mumol/72 h). The side-effects reported during placebo were constipation (n = 3), and during cisapride meteorism (n = 4) and increased appetite (n = 2). The increased stool frequency during cisapride treatment is not caused by malabsorption of water, fat, or bile acids, but seems to be the consequence of a direct motor effect.