True adenomas of the cardia: a case series of 3 patients.

BACKGROUND/AIM: True adenomas of the cardia appear to be extremely rare lesions. There are no data on the natural history and histopathological background of these lesions. We report 3 patients with true adenomas of the cardia. METHODS AND RESULTS: Three patients with polypoid masses at the cardia below the Z-line were submitted to a tertiary referral center for further diagnosis and therapy. In 2 of the 3 cases Barrett's esophagus with low-grade intraepithelial neoplasia was assumed on the basis of histopathological examination of biopsy specimens taken from the surface of the lesions. Polypectomy was performed in all 3 cases. In 2 of the 3 cases the final histopathological diagnosis of low-grade adenoma of the cardia could only be established after complete removal of the polypoid masses. CONCLUSIONS: Adenomas of the cardia can be mistaken for dysplasia arising from Barrett's esophagus, if the diagnosis is based on endoscopic biopsies only. It is, therefore, reasonable to completely remove any suspicious lesions by endoscopy not only for therapeutic but also for diagnostic reasons.

A prospective randomized comparison of unsedated ultrathin versus standard esophagogastroduodenoscopy in routine outpatient gastroenterology practice: does it work better through the nose?

BACKGROUND AND STUDY AIMS: In an outpatient gastroenterological practice setting, highly effective diagnostic procedures and patient satisfaction play an important role. Ultrathin endoscopy in unsedated patients has been shown to be more cost-effective and time-efficient in comparison with standard endoscopy. A prospective randomized study was carried out in unsedated patients to compare performance, feasibility, safety, and patient tolerance between ultrathin transnasal (UT), ultrathin oral (UO), and standard (SO) esophagogastroduodenoscopy (EGD). PATIENTS AND METHODS: A total of 200 of 600 eligible patients consented to participate in the study, and were randomly assigned to undergo UT, UO, or SO. Patients reported their tolerance of the procedure (anxiety, pain, gagging, and overall satisfaction; Likert scale 1-10), and the endoscopists reported the effectiveness of the procedure (handling, picture quality, and overall performance; Likert scale 1-10). Statistics were calculated using the Kruskal-Wallis test. RESULTS: After randomization, 65, 67, and 68 patients were allocated to the UT, UO, and SO groups, respectively. Failure to achieve complete EGD by the intended route occurred in 14 patients (22 %) in the UT group. Compared to the SO group, patients in the UT and UO groups rated anxiety before the procedure as being more intense - median score (10 % quantile estimate; 90 % quantile estimate): UT, 2.0 (1.0; 4.0); UO, 2.0 (1.0; 4.0); SO, 0.0 (0.0; 2.0); p < 0.0001), whereas SO patients experienced a higher level of anxiety during the procedure ( P < 0.0001). Pain during insertion of the endoscope was the least intense in the UO group: UT, 2.0 (1.0; 5.0); UO, 1.0 (1.0; 3.0); SO, 2.0 (1.0; 4.0); P < 0.001). Gagging during insertion was more pronounced in the UO group: UT, 2.0 (1.0; 4.0); UO, 3.0 (1.0; 7.0); SO, 2.0 (1.0; 5.0); P < 0.01). The patients' score for the overall assessment was better in the SO group ( P < 0.0001). The endoscopists' overall assessment for ultrathin EGD was poorer than for standard EGD: UT, 3.0 (2.0; 5.0); UO, 3.0 (2.0; 5.0); SO, 2.0 (1.0; 3.0); P < 0.0001). CONCLUSIONS: Ultrathin endoscopy through both the transnasal and oral routes has limited use in routine outpatient practice. Techniques for reducing pain and gagging may improve patient tolerance. Further technical improvements are needed to allow routine implementation.

Are guidelines followed in Helicobacter pylori diagnosis and therapy? An inquiry among gastroenterologists, referring physicians and patients in Munich.

BACKGROUND AND STUDY AIMS: Attempts to standardize Helicobacter pylori (Hp) diagnosis and therapy have led to the publication of guidelines by various national gastroenterological societies in Europe and the USA. However, little information is available either regarding the compliance of gastroenterologists and referring physicians with these guidelines, or regarding the patients' perspective. PATIENTS AND METHODS: A retrospective analysis was conducted of all outpatient upper gastrointestinal endoscopy reports for a one-month period in eleven different centers (two university hospitals and nine private practice gastroenterology offices) with a total of 24 gastroenterologists. Endoscopy reports from patients wit the indications of reflux, diarrhea, and tumors were excluded. Diagnoses and treatment recommendations given by gastroenterologists were recorded. Questionnaires concerning Hp diagnosis, treatment indications and performance, and follow-up were sent to referring physicians and patients. RESULTS: A total of 772 endoscopy reports were included in the study; analyzable questionnaires were returned by 287 referring physicians (47%) and by 265 patients (59%). Gastroenterologists recommended Hp eradication in all ulcers and in 29% of gastritis/nonulcer dyspepsia (NUD) cases. Referring physicians thought that 94% of ulcers should be treated by Hp eradication, which was also considered to be an absolute and relative indication in NUD by 15% and 53% of the referring physicians, respectively. Among the patients who replied, 52% had received Hp eradication regimens; ulcers were found in 22% of the total patient group. Check-up examinations after Hp therapy were considered necessary by 75% of the referring physicians, but only 22% of the responding patients actually underwent some form of check-up (upper gastrointestinal endoscopy in 91%). CONCLUSIONS: Gastroenterologists and (to a somewhat lesser extent) referring physician appear to be following the current guidelines for Hp treatment. As expected, two thirds of referring physicians consider NUD to be absolute or relative indication for Hp eradication. Check-up examinations are apparently being performed less frequently than recommended.

Clinical response to dietary fiber treatment of chronic constipation.

OBJECTIVES: To determine the clinical outcome of dietary fiber therapy in patients with chronic constipation. METHODS: One hundred, forty-nine patients with chronic constipation (age 53 yr, range 18-81 yr, 84% women) at two gastroenterology departments in Munich, Germany, were treated with Plantago ovata seeds, 15-30 g/day, for a period of at least 6 wk. Repeated symptom evaluation, oroanal transit time measurement (radiopaque markers), and functional rectoanal evaluation (proctoscopy, manometry, defecography) were performed. Patients were classified on the basis of the result of dietary fiber treatment: no effect, n = 84; improved, n = 33; and symptom free, n = 32. RESULTS: Eighty percent of patients with slow transit and 63% of patients with a disorder of defecation did not respond to dietary fiber treatment, whereas 85% of patients without a pathological finding improved or became symptom free. CONCLUSION: Slow GI transit and/or a disorder of defecation may explain a poor outcome of dietary fiber therapy in patients with chronic constipation. A dietary fiber trial should be conducted before technical investigations, which are indicated only if the dietary fiber trial fails.