Effectiveness of salivary stimulation using xylitol-malic acid tablets as coadjuvant treatment in patients with gastro-oesophageal reflux disease: early findings.

BACKGROUND: Besides dental erosion syndrome, other oral syndromes could benefit from the stimulation of salivary secretion, in patients with gastro-oesophageal reflux disease (GORD). Our aims is evaluate the improvement of oral extra-oesophageal manifestations in patients with GORD using xylitol-malic acid tablets to stimulate salivary secretion. MATERIAL AND METHODS: The effectiveness of salivary stimulation using xylitol-malic acid tablets (as a supplement to omeprazole 40 mg/day) was assessed in a clinical trial (n = 14) lasting six months with patients with prior positive pH-metry, through GORD extra-oesophageal clinical signs, GerdQ and RDQ questionnaires, odontological variables, basal salivary secretion, stimulated salivary secretion, pH and buffer capacity, mucosal erythema index and dental wear. STATISTICS: chi-square (Haberman post-hoc), ANOVA, and Mann-Whitney U; variables between visits were evaluated with McNemar's Student's t and Wilcoxon tests; p < 0.05. RESULTS: 100% of patients not taking xylitol-malic acid presented xerostomia, but only 14.3% of patients taking xylitol-malic acid (p < 0.01) did. The mean saliva-buffer capacity at the last visit for patients not taking xylitol-malic acid was 2.14 ± 0.38, versus 2.71 ± 0.49 for patients taking xylitol-malic acid (p < 0.05). Retro-sternal burning (p < 0.05), heartburn (p < 0.05) and regurgitation (p < 0.05) were also reduced. CONCLUSIONS: Xylitol-malic acid tablets improve quality of life among patients with GORD, by reducing dry mouth, increasing saliva buffering and reducing heartburn, retro-sternal burning and regurgitation.

Optimised empiric triple and concomitant therapy for Helicobacter pylori eradication in clinical practice: the OPTRICON study.

BACKGROUND: Empiric triple therapy for Helicobacter pylori should be abandoned when clarithromycin resistance rate is >15-20%. Optimisation of triple therapy (high-dose acid suppression and 14-day duration) can increase eradication rates by 10%. AIM: To compare the efficacy and safety of optimised triple (OPT-TRI) and nonbismuth quadruple concomitant (OPT-CON) therapies. METHODS: Prospective multicentre study in 16 Spanish centres using triple therapy in clinical practice. In a 3-month two-phase fashion, the first 402 patients received an OPT-TRI therapy [esomeprazole (40 mg b.d.), amoxicillin (1 g b.d) and clarithromycin (500 mg b.d) for 14 days] and the last 375 patients an OPT-CON treatment [OPT-TRI therapy plus metronidazole (500 mg b.d)]. RESULTS: Seven-hundred seventy-seven consecutive patients were included (402 OPT-TRI, 375 OPT-CON). The OPT-CON therapy achieved significantly higher eradication rates in the per-protocol [82.3% (95% CI = 78-86%) vs. 93.8% (91-96%), P < 0.001] and intention-to-treat analysis [81.3% (78-86%) vs. 90.4% (87-93%), P < 0.001]. Adverse events (97% mild/moderate) were significantly more common with OPT-CON therapy (39% vs. 47%, P = 0.016), but full compliance with therapy was similar between groups (94% vs. 92%, P = 0.4). OPT-CON therapy was the only significant predictor of successful eradication (odds ratio, 2.24; 95% CI: 1.48-3.51, P < 0.001). The rate of participating centres achieving cure rates ≥ 90% favoured OPT-CON therapy (OPT-TRI 25% vs. OPT-CON 62%). CONCLUSIONS: Empiric OPT-CON therapy achieved significantly higher cure rates (>90%) compared to OPT-TRI therapy. Addition of metronidazole to OPT-TRI therapy increased eradication rates by 10%, resulting in more mild adverse effects, but without impairing compliance with therapy.

Normal values in ambulatory oesophageal pH monitoring at two levels in Spain.

AIM: Upper oesophageal pH monitoring may play a significant role in the study of extra-oesophageal GERD, but limited normal data are available to date. Our aim was to develop a large series of normal values of proximal oesophageal acidification. METHODS: 155 healthy volunteers (74 male) participated in a multi-centre national study including oesophageal manometry and 24 hours oesophageal pH monitoring using two electrodes individually located 5 cm above the LOS and 3 cm below the UOS. RESULTS: 130 participants with normal manometry completed all the study. Twelve of them were excluded for inadequate pH tests. Twenty-seven subjects had abnormal conventional pH. The remaining 91 subjects (37 M; 18-72 yrs age range) formed the reference group for normality. At the level of the upper oesophagus, the 95th percentile of the total number of reflux events was 30, after eliminating the meal periods 22, and after eliminating also the pseudo-reflux events 18. Duration of the longest episodes was 5, 4 and 4 min, respectively (3.5 min in upright and 0.5 min in supine). The upper limit for the percentage of acid exposure time was 1.35, 1.05 and 0.95%, respectively. No reflux events were recorded in the upper oesophagus in 8 cases. CONCLUSION: This is the largest series of normal values of proximal oesophageal reflux that confirm the existence of acid reflux at that level in healthy subjects, in small quantity and unrelated to age or gender. Our data support the convenience of excluding pseudo-reflux events and meal periods from analysis.

Disease-specific health-related quality of life in patients with esophageal achalasia before and after therapy.

BACKGROUND: To evaluate disease-specific health-related quality of life (HRQoL) in patients with symptomatic esophageal achalasia before and after therapy. METHODS: Symptoms and disease-specific HRQoL were evaluated before and 3 months after therapy. Therapy selection, either dilatation or myotomy, depended exclusively on the opinion of the physician on charge of the patient. Symptom severity was graded from 0 to 3, using a scoring system. A disease-specific questionnaire for achalasia developed and validated in Spanish language with 18 items and four subscales (AE-18) was used to evaluate HRQoL. Changes after therapy in HRQoL and its association with clinical improvement were analyzed. KEY RESULTS: Sixty-five patients were prospectively included in eight hospitals in Spain. Of them, 47 were treated with dilatation, and 18 with laparoscopic Heller myotomy. After therapy, AE-18 global and subscales scores improved significantly. Changes in HRQoL were associated with improvement in symptoms. An important improvement in symptoms (>or=50%) was needed to obtain a minimal clinically important improvement (>or=20%) in HRQoL. CONCLUSIONS & INFERENCES: Disease-specific HRQoL improves in patients with symptomatic achalasia after therapy with dilatation or myotomy. The degree of improvement of HRQoL depends on the degree of improvement of esophageal symptoms.

[Is capsule endoscopy useful in children with chronic abdominal pain?]. / Es útil la cápsula endoscópica en niños con dolor abdominal crónico?

Chronic abdominal pain is highly prevalent in school-aged children and is one of the most frequent disorders in our environment. The aim of the present study was to evaluate the usefulness of capsule endoscopy (CE) in patients with chronic abdominal pain. Sixteen patients (nine boys and seven girls), aged between 5 and 16 years old, with chronic abdominal pain for at least 12 months were studied. In all patients the results of hemograms, biochemical investigations, urine sediment test, Helicobacter pylori breath test and celiac serology were normal. In all children, gastroscopy, small bowel follow-through, abdominal ultrasound and colonoscopy were normal. All patients received CE by mouth. In 43.75 % of the patients studied (7/16), the capsule showed evidence of nodular lymphoid hyperplasia, mainly located in the ileum. In one girl, oxyuriasis was observed in the cecum and in another girl aphthous lesions were observed in the ileum. These lesions suggested small bowel Crohn's disease. CE mainly showed images compatible with nodular lymphoid hyperplasia, with unknown clinical significance. Consequently, we conclude that CE does not provide useful information in patients with abdominal pain without other symptoms.

¿Es útil la cápsula endoscópica en niños con dolor abdominal crónico? / Is capsule endoscopy useful in children with chronic abdominal pain?

El dolor abdominal crónico afecta a un alto porcentaje de niños en edad escolar, lo que la convierte en una de las patologías más frecuentes en nuestro medio. El objetivo es valorar si la cápsula endoscópica (CE) permite identificar lesiones intestinales en estos pacientes. Se han incluido 16 pacientes (9 niños y 7 niñas) con edades comprendidas entre los 5 y 16 años con dolor abdominal crónico de más de 12 meses de evolución. Todos tenían realizados hemograma, bioquímica, sedimento de orina, test de aliento para Helicobacter pylori y serología para enfermedad celíaca, que eran negativos. A todos se les había realizado una gastroscopia, y una colonoscopia que resultaron negativas, así como un tránsito gastrointestinal y una ecografía abdominal, sin hallazgos de interés. En el 43,75 % de los pacientes estudiados (7/16) la CE mostró imágenes compatibles con hiperplasia folicular linfoide localizadas en el íleon. En una niña se observaron oxiuros en ciego y en otra, lesiones aftosas ileales compatibles con enfermedad de Crohn. La CE muestra en la mayoría de los casos imágenes compatibles con hiperplasia nodular linfoide intestinal, con dudosa significación clínica, por lo que podemos concluir que la CE no aporta nada específico en niños con dolor abdominal crónico

Chronic abdominal pain is highly prevalent in school-aged children and is one of the most frequent disorders in our environment. The aim of the present study was to evaluate the usefulness of capsule endoscopy (CE) in patients with chronic abdominal pain. Sixteen patients (nine boys and seven girls), aged between 5 and 16 years old, with chronic abdominal pain for at least 12 months were studied. In all patients the results of hemograms, biochemical investigations, urine sediment test, Helicobacter pylori breath test and celiac serology were normal. In all children, gastroscopy, small bowel follow-through, abdominal ultrasound and colonoscopy were normal. All patients received CE by mouth. In 43.75 % of the patients studied (7/16), the capsule showed evidence of nodular lymphoid hyperplasia, mainly located in the ileum. In one girl, oxyuriasis was observed in the cecum and in another girl aphthous lesions were observed in the ileum. These lesions suggested small bowel Crohn's disease. CE mainly showed images compatible with nodular lymphoid hyperplasia, with unknown clinical significance. Consequently, we conclude that CE does not provide useful information in patients with abdominal pain without other symptoms

Modification of pepsinogen I levels and their correlation with gastrointestinal injury after administration of dexibuprofen, ibuprofen or diclofenac: a randomized, open-label, controlled clinical trial.

OBJECTIVE: To assess the effect of a 2-week treatment with dexibuprofen, in comparison with ibuprofen and diclofenac, on pepsinogen plasma concentrations and gastrointestinal mucosa, as well as the correlation of these changes with gastrointestinal mucosal injury. METHODS: 60 patients with rheumatologic disease in chronic therapy with NSAID, were included. After a 7-day run-in period patients were randomly assigned to receive a 14-day treatment with dexibuprofen (Group A; Day 1 - 3 = 400 mg t.i.d; Day 4 - 14 = 400 mg b.i.d.), ibuprofen (Group B; Day 1 - 3 = 800 mg t.i.d; Day 4 -14 = 800 mg b.i.d.) or diclofenac (Group C; Day 1 - 3 = 50 mg t.i.d; Day 4 - 14 = 50 mg b.i.d.). Upper gastrointestinal endoscopy (Day 15), capsule-endoscopy (Day 16, 7 patients of each group) and determination of pepsinogen plasma concentrations were performed (basal and Day 15). A semiquantitative scale was designed for the assessment of the gastrointestinal mucosa. RESULTS: No differences in plasma pepsinogen were found between treatment groups or gastrointestinal injury grades or between basal and post-therapy determinations. Dexibuprofen showed gastroduodenal mucosal injury in fewer patients (42.1%) than was the case with ibuprofen (5%; p = 0.003) and diclofenac (30%; p = N.S.). Dexibuprofen administration was also associated with more patients having no intestinal mucosal damage (42.86% vs. 28.7% in the diclofenac group and 14.29% in the ibuprofen group; p = 0.0175). The rate of clinical adverse events was similar in Groups A, B and C (28%, 38% and 34%). CONCLUSIONS: Dexibuprofen showed a lower rate of gastroduodenal and intestinal mucosal injury. This effect was not mediated by modifications of plasma pepsinogen levels.

Previously unknown stricture due to radiation therapy diagnosed by capsule endoscopy.

Radiation enteritis is a complex clinical entity secondary to the affectation of intestinal epithelial cells as a result of radiation in the management of pelvic malignancies that may occasionally cause intestinal strictures. We present the case of a 60 year-old woman who had been diagnosed ten years before with endometrial adenocarcinoma, and who underwent hysterectomy with double adnexectomy and subsequent radiation therapy. The patient consulted for abdominal pain and ferropenic anemia of several years standing, and had negative results following radiographic and endoscopic conventional techniques, reason why she was subjected to a capsule endoscopy study that revealed the presence of an ulcerated ileal stricture, which caused the asymptomatic retention of the capsule within the ileum. A laparotomy was subsequently performed--the strictured segment was resected and the capsule retrieved. The histologic examination of the resected segment confirmed the capsule endoscopy-raised suspicion of radiation enteritis. This case shows the role capsule endoscopy may play in the diagnosis of this condition.

Estenosis de origen actínico no conocida diagnosticada mediante capsuloendoscopia / Previously unknown stricture due radiation therapy diagnosed by capsule endoscopy

La enteritis actínica es una entidad producida por la afectaciónde las células intestinales como consecuencia del tratamiento radioterápicode tumores abdomino-ginecológicos, que en ocasionespuede causar áreas estenóticas.Presentamos el caso de una mujer de 60 años, diagnosticadadiez años antes de adenocarcinoma de endometrio, que fue tratadacon resección intestinal y radioterapia abdomino-pélvica. Lapaciente acudió por dolor abdominal y anemia ferropénica deaños de evolución, con técnicas radiológicas y endoscópicas convencionalesnegativas. La realización de una capsuloendoscopiareveló la presencia de una estenosis ileal ulcerada, que causó la retenciónasintomática de la cápsula en íleon. Se indicó de formaelectiva la realización de una laparotomía con resección del segmentoestenótico y extracción de la cápsula, confirmándose histológicamentela sospecha capsuloendoscópica de enteritis actínica.Este caso ilustra el papel que la capsuloendoscopia puede jugaren esta entidad de difícil diagnóstico

Radiation enteritis is a complex clinical entity secondary to theaffectation of intestinal epithelial cells as a result of radiation in themanagement of pelvic malignancies that may occasionally causeintestinal strictures.We present the case of a 60 year-old woman who had been diagnosedten years before with endometrial adenocarcinoma, andwho underwent hysterectomy with double adnexectomy and subsequentradiation therapy. The patient consulted for abdominalpain and ferropenic anemia of several years’ standing, and hadnegative results following radiographic and endoscopic conventionaltechniques, reason why she was subjected to a capsule endoscopystudy that revealed the presence of an ulcerated ilealstricture, which caused the asymptomatic retention of the capsulewithin the ileum. A laparotomy was subsequently performed – thestrictured segment was resected and the capsule retrieved. Thehistologic examination of the resected segment confirmed thecapsule endoscopy-raised suspicion of radiation enteritis. Thiscase shows the role capsule endoscopy may play in the diagnosisof this condition

The value of capsule endoscopy in pediatric patients with a suspicion of Crohn's disease.

BACKGROUND AND STUDY AIMS: The aim of this study was to assess the safety and usefulness of capsule endoscopy (CE) in pediatric patients with a suspicion of Crohn's disease. PATIENTS AND METHODS: CE was used in 12 patients (four girls, eight boys; age 12-16; weight range 43-87 kg). The indication was a clinical suspicion of Crohn's disease not confirmed with traditional methods. Gastroscopy, colonoscopy, and small-bowel follow-through examinations were carried out in all of the patients, without any diagnostic findings. Ileoscopy was possible in 50 % of the patients, and the ileal mucosa and biopsies were normal in all cases. RESULTS: The capsule was easily swallowed by all of the patients. They all excreted the capsule normally, and no complications were observed in any case. CE identified lesions suggestive of Crohn's disease in seven of the 12 (58.3 %), and the majority of the lesions were in the ileum. CONCLUSIONS: CE is safe in pediatric patients over 12 years of age. The procedure appears to be a very useful diagnostic tool in children with Crohn's disease.

Usefulness of capsule endoscopy in patients with suspected small bowel disease.

AIM: To study the usefulness and safety of capsule endoscopy as a diagnostic tool in various small bowel disorders. DESIGN: A retrospective analysis of a series of cases. MATERIAL AND METHODS: Between August 2001 and August 2002, 92 capsule endoscopy procedures were performed in 88 patients (53M/39F, age: 43.87 +/- 16.78). Indications included: chronic diarrhea (n=33); unknown abdominal pain (n=29); occult gastrointestinal bleeding or iron-deficiency anemia (n=13); abdominal discomfort in NSAID takers (n=7); staging of gastrointestinal tumors (n=4), and asymptomatic controls (n=2). Previously performed gastroscopy, colonoscopy, and small-bowel follow-through were not conclusive in all patients. RESULTS: Most frequently relevant findings included: jejuno-ileal aphtas and ulcerations (29 patients), vascular malformations (13 patients), and intestinal neoplasm (6 patients). The groups with a higher rate of findings related to this indication were occult gastrointestinal bleeding (76.92%) and chronic diarrhea (67.85%), with the lowest rate in the abdominal pain group (34.48%). Therapeutic strategy was directly changed in 36 of 88 patients (40.90%) because of capsule-endoscopic findings. The only observed complication was the failed excretion of one of the capsules because of an unknown ulcerated intestinal stricture. CONCLUSIONS: Capsule endoscopy is a safe procedure which can study the entire small bowel, meaning a valuable tool for the management of patients with suggestive signs and symptoms of intestinal disorders.

Utilidad de la cápsula endoscópica en gastroenterología pediátrica / Utility of capsule endoscopy in pediatric gastroenterology

La cápsula endoscópica es un nuevo método de diagnóstico no invasivo que permite visualizar de forma nítida posibles lesiones en el intestino delgado. Su tamaño es pequeño y porta una batería y una videocámara que permite tomar dos fotos por segundo del interior del tubo digestivo. Está indicada en casos de hemorragia digestiva de causa no clara y en el diagnóstico de enfermedad inflamatoria intestinal, entre otros. Hasta la fecha se ha utilizado principalmente en adultos. Creemos que en la edad pediátrica puede tener un papel muy importante, por tratarse de una prueba no invasiva, porque permite el diagnóstico de procesos intestinales, y así evitar la realización de numerosas pruebas diagnósticas inútiles. Aportamos el caso de una paciente en edad pediátrica con alta sospecha de enfermedad de Crohn no confirmada mediante las técnicas endoscópicas habituales. La cápsula muestra lesiones intestinales compatibles con esta enfermedad. Tras tratamiento corticoideo la paciente mejora clínicamente y con una evolución favorable de su proceso (AU)

[Utility of capsule endoscopy in pediatric gastroenterology]. / Utilidad de la cápsula endoscópica en gastroenterología pediátrica.

Wireless endoscopy is a new noninvasive diagnostic method that is able to visualize small bowel lesions. The instrument is small and carries a battery and microcamera that takes two photographs per second. It is indicated in cases of bleeding of unknown origin and for the diagnosis of inflammatory bowel disease, among other disorders. To date, it has mainly been used in adults. We believe that this instrument could play an important role in the pediatric age group since it is noninvasive and can be used to diagnose small bowel lesions, thus avoiding unnecessary diagnostic tests. We report the case of a girl with suspicion of Crohn's disease that was unconfirmed by conventional endoscopic techniques. The capsule showed small bowel lesions compatible with Crohn's disease. Corticosteroid treatment was initiated and the patient is now in clinical remission.

Capsule endoscopy in patients with suspected Crohn's disease and negative endoscopy.

BACKGROUND AND STUDY AIMS: The aim of the present study was to assess the value of capsule endoscopy in the diagnostic work-up of patients in whom there is a clinical suspicion of small bowel Crohn's disease that cannot be confirmed using traditional techniques. PATIENTS AND METHODS: A total of 21 patients (14 men, seven women; mean age 43 +/- 8 years) with a clinical and biochemical suspicion of Crohn's disease were included in the study. Conventional imaging work-up, including upper and lower endoscopy, as well as a small-bowel follow-through, was carried out in all of the patients. RESULTS: Pathological findings were not observed in 12 of the 21 patients (57 %). In the other nine patients (43 %), lesions supporting the diagnosis of Crohn's disease were seen. The most frequent findings were located in the distal ileum and included aphthae, lineal and serpiginous ulcers, and fissures. Four patients had lesions in the jejunum. One patient showed erosions in the distal duodenum, jejunum, and ileum. No adverse effects of the technique were observed in any of the patients. CONCLUSIONS: Capsule endoscopy is a valuable diagnostic tool in patients with suspected Crohn's disease that has not been confirmed using standard imaging techniques.

Short- and medium-term clinical efficacy of three endoscopic therapies for achalasia: a single-blinded prospective study.

OBJECTIVE: to compare the efficacy of three endoscopic therapies for achalasia and to identify predictors of response. DESIGN: prospective, single-blinded study at short and medium term. MATERIAL AND METHODS: 22 patients (9M/13 F; mean age: 47.45 +/- 21.01 years) with confirmed clinical and manometric achalasia were randomised in three groups: intrasphincteric injections of botulinum toxin (group 1: 10 patients ), injections of 1% polidocanol (group 2:6 patients), and a combined therapy with both of them (group 3: 6 patients). Clinical response was evaluated by a score (0-5) of tested symptoms (dysphagia, regurgitation and chest pain) at 1 and 24 weeks post-treatment. RESULTS: at 24 weeks post-treatment group 2 had the best complete response (CR) rate (33.33%), whereas CR in both the botulinum toxin and combined therapy groups was 10 and 0%, respectively. Groups 1 and 2 got an overall improvement in clinical score at 1 (p= 0.02) and 24 weeks (p= 0.04). Five patients (50%) in group 1, two patients (33.33%) in group 2, and three patients (50%) in group 3 needed other therapies (dilation or surgery) because of treatment failure. Separately, neither age nor sex, time from diagnosis or type of therapy could distinguish responders from non-responders in these three groups. However, absence of response within the first week, and an initial clinical score above 7 were predictive factors of poor response at six months. CONCLUSIONS: short- and medium-term clinical response to these endoscopic therapies was limited. The absence of response at seven days and a severe initial clinical score were predictive factors of poor medium-term response.

Estudio de la eficacia de tres modalidades de terapia endoscópica en la acalasia / Short and medium-term clinical efficacy of three endoscopic therapies for achalasia: a single-blinded prospective study

Objetivo: comparar la eficacia de tres terapias endoscópicas para la acalasia, e identificar predictores de respuesta. Diseño: estudio simple-ciego y prospectivo a corto y medio plazo.Material y métodos: 22 pacientes (9H/13M; 47,45ñ21,01 años) con acalasia confirmada clínica y manométricamente, fueron asignados a 3 grupos: inyección intraesfinteriana de toxina botulínica (grupo 1: 10 pacientes), de polidocanol 1 per cent (grupo 2: 6 pacientes), o una terapia combinada de ambas (grupo 3: 6 pacientes). La respuesta clínica fue valorada por una escala semicuantitativa de síntomas (disfagia, regurgitación y dolor torácico), en las semanas 1 a 24 post-tratamiento. Resultados: a las 24 semanas post-tratamiento, el grupo 2 obtuvo una tasa de respuesta completa del 33,33 per cent, mientras que fue del 10 y 0 per cent en los grupos 1 y 3, respectivamente. Los pacientes de los grupos 1 y 2 tuvieron una mejoría clínica global tanto a la semana (p=0,02), como a las 24 semanas (p=0,04) de haber comenzado el tratamiento. Cinco pacientes (50 per cent) en el grupo 1, dos en el grupo 2, y tres en grupo 3 precisaron terapia de rescate (cirugía o dilatación) por fallo del tratamiento. La ausencia de respuesta en la primera semana, así como un score clínico inicial superior a 7 fueron factores predictivos de una pobre respuesta a medio plazo. Conclusiones: la respuesta clínica a corto y medio plazo de las tres modalidades estudiadas fue limitada. La ausencia de respuesta a los 7 días y una clínica inicial más severa fueron factores predictivos de mala respuesta a medio plazo (AU)

Role of capsule endoscopy in the management of patients with obscure gastrointestinal bleeding.

The recent emergence of capsule endoscopy has entailed a relevant diagnostic imaging advance for gastrointestinal conditions, especially those involving the small bowel. Gastrointestinal haemorrhage of obscure origin is probably the most widely accepted indication for this new technique, and promising results have been reported from series extant to date. In view of data available on this new modality, and looking forward to having wide, well designed studies fr corroboration, this paper suggests a tentative algorithm for the management of this patient group.