Bile and acid reflux in long and short segment Barrett's esophagus, and in reflux disease.

Gastroesophageal acid reflux (GER) is the primary risk factor for gastroesophageal reflux disease (GERD). In long segment Barrett's esophagus (LSBE) duodenogastroesophageal reflux (DGER) parallels acid reflux. The role of GER and DGER in short segment Barrett's esophagus (SSBE) remains to be determined. The aim of the present prospective study was to investigate the esophageal bile and acid reflux in patients with LSBE, SSBE and patients with GERD. Three groups of patients were studied: Patients with LSBE (n = 12), SSBE (n = 20) and patients with GERD without intestinal metaplasia (n = 33). Subjects underwent esophageal manometry and simultaneous 24-h pH and bile monitoring (Bilitec 2000). The thresholds for GER and DGER were a deMeester score > 14.7 and an absorbance value > 0.2 for 10.9% of total period, respectively. GER did not differ between the groups (p > 0.05). However, DGER differed between patients with LSBE, SSBE and GERD (14.7 vs 2.1 vs 2.1, respectively; p < 0.05). H. pylori status did not influence GER and DGER significantly. In contrast to patients with LSBE the DGER does not seem to play an important role in patients with SSBE and patients with GERD. This result indicates a different etiopathology of both long and short segment Barrett's esophagus.

[Peptic ulcer in the elderly--endoscopy in suspected ulcer. Therapy always includes proton pump inhibitor]. / Peptisches Ulkus im Alter--bei Verdacht endoskopieren. Zur Therapie gehören in jedem Fall Protonenpumpenhemmer.

In the elderly patient, peptic ulcer disease is associated with increased morbidity and mortality. Abdominal pain is often absent, and the first sign is blood in the stools. The major risk factors are infection with Helicobacter pylori and the use of non-steroidal antiinflammatory drugs (NSAIDs). Endoscopic and medical treatment of peptic ulcer is independent of the age. The use of proton pump inhibitors is the treatment of choice. In the event of an infection with H. pylori, eradication treatment is usually carried out. Currently, however, H. pylori eradication is not recommended in patients with NSAID-associated ulcers; if possible, the NSAIDs should be discontinued. The development of a new generation of NSAIDs holds out the promise of a marked reduction in gastrointestinal side effects.

[Diverticulosis and diverticulitis in the elderly]. / Divertikulose und Divertikulitis beim alten Menschen.

Diverticulosis of the colon is a disease that mainly affects the elderly, presenting in 10 to 20% of this age group. The most common complication--painful diverticular disease, is usually treated conservatively with a high-fiber diet, intermittent use of antispasmodics and possibly regulation of the stools. Diagnostic differentiation is best performed using ultrasonography of the bowel wall, supplemented where necessary by computer tomography and colonoscopy (sigmoidoscopy) or, where this latter is not possible, barium enema using Gastrografin. Conservative treatment of diverticulitis with antibiotics, bowel rest, possibly including parenteral alimentation, is usually applied for three to ten days. In the absence of a response to this treatment, frequent recurrence, immunosuppression or complications (perforation, peritonitis, enterovesicular fistula), surgery is indicated.

[Diseases of the esophagus in the elderly. Deglutition disorders--intermittent thoracic pain--retrosternal burning pain]. / Erkrankungen des Osophagus im Alter. Schluckstörungen--intermittierende Thoraxschmerzen--retrosternales Brennen.

As a contribution to the polymorbidity of geriatric patients, gastrointestinal diseases are numerically of only minor importance, occurring four to five times less frequently than diseases of the cardiovascular system. However, a number of gastrointestinal diseases are more commonly found in the elderly than in the younger patient. The symptoms of esophageal diseases include dysphagia, odynophagia, pyrosis, and intermittent chest pain. New developments in the area of drug treatment, and minimally invasive endoscopic procedures usually now permit age adaptet therapeutic management to be offered.

[Reflux esophagitis--diagnosis and differential diagnosis]. / Refluxösophagitis--Diagnose und Differentialdiagnose.

The combination of the two typical symptoms - heartburn and regurgitation - is almost proving gastrooesophageal reflux disease (GORD). Further - atypical - symptoms are dysphagia, odynophagia, pharyngitis, reflux-induced pulmonary symptoms or intermittent chest-pain. Endoscopic signs of GORD are patchy reddening of the mucosa, erosions, ulcers and stricture. Barretts oesophagus is characterized by columnar epithelial metaplasia. Consequence: Typical symptoms of GORD may be treated without further diagnostic procedure whereas in the case of atypical symptoms diagnosis of GORD has to be established by endoscopy.

Long-term clinical outcome of post-cholecystectomy patients with biliary-type pain: results of manometry, non-invasive techniques and endoscopic sphincterotomy.

OBJECTIVE: The purpose of the present study was to investigate prospectively the value of manometry, non-invasive techniques and endoscopic sphincterotomy in biliary type II and III patients with suspected sphincter of Oddi dysfunction. METHODS: All patients (n = 31) had undergone a cholecystectomy from 1 to 45 years before entry into the study, and had a history of biliary-type pain ranging from 4 to 156 months. In a primary diagnostic work-up, including ERCP, other causes of gastrointestinal disease were excluded. The width of the common bile duct, pain induced by the injection of contrast medium into the common bile duct, delayed contrast drainage and the results of a morphine-neostigmine test were analysed. Manometric measurements of basal sphincter of Oddi pressure were performed. Twenty-three patients with an elevated basal pressure (> 40 mmHg) underwent endoscopic sphincterotomy. RESULTS: During the follow-up period (8-62 months) 83% of the patients became symptom free or experienced an improvement. Basal sphincter of Oddi pressure and long-term clinical outcome of patients correlated to different degrees with the results of non-invasive techniques. CONCLUSIONS: Our data suggest that endoscopic sphincterotomy may be an effective therapeutic modality in group II and III patients with sphincter of Oddi dysfunction in whom other gastrointestinal disorders have previously been excluded.

The [13C]acetate breath test accurately reflects gastric emptying of liquids in both liquid and semisolid test meals.

BACKGROUND/AIMS: The current standard for gastric emptying studies are radioactive isotope methods. [13C]breath tests have been developed as a nonradioactive alternative. The aim of this study was to validate a [13C]acetate breath test as a measure of gastric emptying of the liquid phase both in liquid and semisolid test meals by simultaneous radioscintigraphy. METHODS: Thirty-five patients with dyspeptic symptoms and 20 healthy volunteers were tested using a semisolid oatmeal or a liquid test meal. Both test meals were labeled by 150 mg sodium [13C]acetate and (in patients) by 45 MBq 99mTc-albumin colloid. Half-time of gastric emptying was calculated after curve fitting of the 13C exhalation to a modified power exponential function. 99mTc-albumin emptying was measured by conventional radioscintigraphy. RESULTS: The half-emptying times for the [13C]acetate breath test closely correlated to those measured by radioscintigraphy both for semisolids (r = 0.87) and liquids (r = 0.95). The time of maximum 13CO2 exhalation was itself a reliable parameter compared with the half-emptying times obtained by scintigraphy (r = 0.85 for semisolids; r = 0.94 for liquids). CONCLUSIONS: The [13C]acetate breath test is a reliable and noninvasive tool for the analysis of gastric emptying rates of liquid phases without radiation exposure.

Ambulatory oesophageal pressure, pH and ECG recording in patients with normal and pathological coronary angiography and intermittent chest pain.

The present study was performed to compare pain-related oesophageal motility, gastro-oesophageal reflux and ST-segment deviations in patients with intermittent chest pain and normal or pathological coronary angiography. Thirty patients (11 males, 19 females; mean age 54.8 years) with normal and 15 patients (12 males, 3 females; mean age 66.7 years) with pathological coronary angiography were investigated by 24-h oesophageal pressure, pH and ECG recording. Chest pain correlated with motility abnormalities or gastro-oesophageal reflux occurred in 33% (10/30) of patients with normal coronary arteries and in 26% of patients with pathological coronary angiography. Symptomatic and asymptomatic ST-segment changes were less frequently observed in patients with normal angiography (4/30) than in patients with pathological coronary angiography (7/14; P = 0.02). Oesophageal dysfunction coincided with ST-segment deviation in 6.7% (2/30) of patients with normal and 40% (6/15) of patients with pathological coronary angiography (P = 0.02). The conclusions reached were: (1) pain-correlated abnormal motility or gastro-oesophageal reflux occurred in patients with normal and pathological coronary angiography at the same frequency; (2) ambulatory motility and pH recording alone does not appear to differentiate between cardiac and non-cardiac chest pain; (3) simultaneous ECG recording reveals a significant correlation of ST-segment deviation and gastro-oesophageal reflux or abnormal motility in patients with coronary artery stenosis.

[Gastroesophageal reflux. Pathophysiology, diagnosis and rational therapy]. / Gastroösophageale Refluxkrankheit. Pathophysiologie, Diagnostik und rationelle Therapie.

A combination of the typical symptoms heartburn and regurgitation may be considered virtual proof of gastroesophageal reflux disease. In the case of the atypical symptoms dysphagia, odynophagia, pharingitis, reflux-induced attacks of respiratory distress and intermittent chest pain further diagnostic investigation is indicated. Endoscopy reveals patchy reddening and possibly erosions, ulcers and strictures. Although the decisive pathophysiological factor in reflux disease is motility, the use in particular of acid suppressors represents an important part of treatment; in more severe reflux esophagitis (grades III and IV), proton pump inhibitors are the drugs of first choice. Gastro-esophageal reflux disease is a chronic condition with a recurrence rate of 60-80 percent. For prophylaxis, the minimum dose of antacids required to treat the stage must be administered.

[Diagnostic strategy in constipation, including irritable bowel syndrome]. / Diagnostische Strategie bei Obstipation einschliesslich irritablem Darmsyndrom.

Constipation is not a disease but a symptom. Underlying causes include side effects of drugs, metabolic, endocrine, neurologic, psychiatric and intestinal diseases. Constipation is part of the so-called irritable bowel syndrome. The diagnosis is based on history, physical examination and a few laboratory tests. Second-line diagnostic procedures include endoscopy, colonic transit time and physiological investigations of the anorectum like anorectal manometry or defecography.

[Gastrointestinal motility in the elderly]. / Motilität des Magen-Darm-Kanals im Alter.

The existence of specific, age-related changes in gastrointestinal motility with clinical significance is controversial. Beside the more infrequent primary motility disorders, secondary motility disturbances associated with collagen vascular diseases, endocrinopathies, and neuromuscular diseases are prominent in the older and often multimorbid patients. Especially in geriatric patients, motility associated symptoms are undesired side-effects of drug therapy. The pathophysiology, clinical syndromes, and therapeutic principles of motility disorders in the elderly are discussed. The major symptoms of esophageal dysfunction are dysphagia, chest pain, heartburn, and regurgitation. Oropharyngeal dysphagia, mostly caused by cerebrovascular accidents and other neurologic disorders, leads to disturbances in food intake, and is often complicated by broncho-pulmonary infections arising from recurrent aspiration of food or saliva. Gastrointestinal reflux disease and spastic motility disorders of the esophagus are regarded as possible causes of angina-like chest pain after exclusion of cardiac diseases. Motility disturbances of the stomach and small bowel are often related to systemic disease (i.e., diabetes mellitus, chronic intestinal pseudo-obstruction) of drug side-effects. Mental and physical decline, reduced fluid intake, and constipating drugs are the most relevant factors for idiopathic constipation in the elderly. Fecal incontinence means a great psychological strain for older patients and leads to social isolation.

Ultrastructure of megakaryocytes in the human bone marrow of patients with primary (essential) thrombocythemia.

An ultrastructural study was performed on bone marrow specimens in 10 patients (5 males/5 females, median age 53 years) with primary (essential) thrombocythemia (PTH) and an excessive elevation of the platelet count (1,625 +/- 783 x 10(9)/l). In contrast to a not severely altered neutrophilic granulo- and erythrocytopoiesis, megakaryocytes showed conspicuous large to giant forms. These were characterized by a highly lobulated nucleus containing several nucleoli and an extensive intermediate zone of the cytoplasm with many Golgi fields, numerous profiles of the so-called demarcation membrane system and an abundance of alpha-granules and some dense bodies. Our results demonstrate that ultrastructure of the megakaryocytes in PTH does not reveal gross abnormalities, but features which are compatible with an enforced thrombocytogenetic activity in accordance with the excessively elevated platelet count. Similar changes have been described in animal experiments with induced thrombocytopenia and stimulation of platelet shedding. Evaluation of thrombocytogenesis suggests that it may be mediated by a process of fragmentation with partitioning of the extensive intermediate zone into numerous prospective platelet territories followed by segregation.