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Upper Endoscopy (upper + endoscopy)
Selected AbstractsPerceptions and practices on the management of gastro-oesophageal reflux disease: results of a national survey comparing primary care physicians and gastroenterologistsALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 7 2007J.-F. BRETAGNE Summary Background Literature comparing generalist and specialist care is accumulating in many disease areas, but very few studies focussed on gastrointestinal diseases and little is known about gastro-oesophageal reflux disease. Aim To compare the management of gastro-oesophageal reflux disease (GERD) by French primary care physicians and gastroenterologists. Methods A postal survey was conducted in a representative sample of French physicians who were asked to complete a questionnaire that consisted of 44 questions relating to their usual medical practice for the diagnostic and therapeutic management of frequent GERD. Results 136 primary care physicians and 91 gastroenterologists participated in the survey (54%). Alarm symptoms were identified more frequently by primary care physicians than gastroenterologists, but the appraisal of their seriousness was less acute by primary care physicians than gastroenterologists. Upper endoscopy was prescribed more frequently by gastroenterologists (64% vs. 38%, P < 0.01). Physicians in both groups mainly recommended lifestyle modification. For GERD treatment, most respondents declared using a ,step-down' strategy with proton pump inhibitors, and only slight differences in drug prescription were identified between primary care physicians and gastroenterologists. Both groups of physicians also have similar perception of symptom persistence after treatment, but satisfaction with treatments was slightly higher for gastroenterologists than primary care physicians (7.6 vs. 7.1 on a scale from 0 to 10, P < 0.01). Conclusions Overall patterns of GERD diagnosis and management are comparable between primary care physicians and gastroenterologists. Both groups perceive that GERD therapy can still be improved. [source] High accuracy and cost-effectiveness of a biopsy-avoiding endoscopic approach in diagnosing coeliac diseaseALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 1 2006G. CAMMAROTA Summary Background The ,immersion' technique during upper endoscopy allows the visualization of duodenal villi and the detection of total villous atrophy. Aim To evaluate the accuracy of the immersion technique in detecting total villous atrophy in suspected coeliac patients. The accuracy in diagnosing coeliac disease and the potential cost-sparing of a biopsy-avoiding approach, based on selection of individuals with coeliac disease-related antibodies and on endoscopic detection of absence of villi, were also analysed. Methods The immersion technique was performed in 79 patients with positive antibodies and in 105 controls. Duodenal villi were evaluated as present or absent. As reference, results were compared with histology. Diagnostic approaches, including endoscopy with or without biopsy, were designed to investigate patients with coeliac disease-related antibodies and total villous atrophy. A cost-minimization analysis was performed. Results All patients with positive antibodies had coeliac disease. The sensitivity, specificity, positive and negative predictive values of endoscopy to detect total villous atrophy was always 100%. The sensitivity, specificity, positive and negative predictive values of biopsy-avoiding or biopsy-including strategies in diagnosing coeliac disease when villi were absent was always 100%. The biopsy-avoiding strategy was cost-sparing. Conclusions Upper endoscopy is highly accurate in detecting total villous atrophy coeliac patients. A biopsy-avoiding approach is both accurate and cost-sparing to diagnose coeliac disease in subjects with marked duodenal villous atrophy. [source] Triple therapy with clarithromycin, omeprazole, and amoxicillin for eradication of Helicobacter pylori in duodenal ulcer patients in Asia and AfricaALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 11 2000B. C. Y. Wong Background: Studies assessing the efficacy of triple therapy containing clarithromycin and amoxicillin for the eradication of Helicobacter pylori infection and healing of duodenal ulcers in Asian and African countries are limited. Aim: To determine the efficacy and safety of 1-week triple therapy with omeprazole, amoxicillin and clarithromycin for eradicating H. pylori infection in patients with active duodenal ulcer living in Asian and African regions. Methods: This was an open-label, multicentre study in 11 centres in Asia and Africa. Patients with endoscopy-proven duodenal ulcer and who were H. pylori -positive were treated with clarithromycin 500 mg, omeprazole 20 mg, and amoxicillin 1000 mg, all given twice daily for 7 days. Upper endoscopy was repeated at week 6 to check for ulcer healing and H. pylori status. Results: A total of 117 patients were recruited. H. pylori eradication rates were 85% by per protocol analysis and 80% by intention-to-treat analysis. Ulcer healing was found in 94% of subjects (per protocol analysis). Clinical success, measured by change of pre-treatment ulcer symptoms, was strongly supported by complete resolution or improvement in 100% of the evaluable patients (per protocol analysis). Since treatment-related adverse events, when present, were largely mild or moderate, the triple therapy regimen was considered safe. Conclusion: Seven-day triple therapy with omeprazole, amoxicillin, and clarithromycin was efficacious for treating Asian and African patients with duodenal ulcer disease associated with H. pylori infection, and the treatment regimen was well-tolerated. [source] Comparison of lansoprazole-based triple and dual therapy for treatment of Helicobacter pylori -related duodenal ulcer: an Asian multicentre double-blind randomized placebo controlled studyALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 2 2000Wong Bakcground : In Asian countries with limited resources, clarithromycin-based triple therapy may not be readily available. There are also few direct comparisons of different regimens in Asia. Aim : To compare two lansoprazole-based non-clarithromycin triple therapies and one dual therapy in a prospective double-blind placebo-controlled study of Helicobacter pylori eradication and duodenal ulcer healing. Methods : Fourteen centres in Asia participated in this study. Patients with acute duodenal ulcer who were H. pylori -positive were recruited. They were randomized to receive: (a) lansoprazole 30 mg b.d., amoxycillin 1 g b.d. and metronidazole 500 mg b.d. for 2 weeks (LAM-2 W), or (b) LAM for 1 week and placebo (LAM-1 W), or (c) lansoprazole 30 mg b.d., amoxycillin 1 g b.d. and placebo for 2 weeks (LA-2 W). Upper endoscopy was repeated at week 6 to check for duodenal ulcer healing. Symptoms and side-effects were recorded. Results : A total of 228 patients were recruited, and two patients took less than 50% of the drugs. H. pylori eradication rates (intention-to-treat) were 68 out of 82 (83%) with LAM-2 W, 55 out of 71 (78%) with LAM-1 W and 43 out of 75 (57%) with LA-2 W. There were significant differences (P=0.001) in eradication rates when comparing either LAM-2 W or LAM-1 W with LA-2 W. The eradication rate in patients with metronidazole resistant H. pylori strains were significantly lower than those with metronidazole sensitive strains (P=0.0001). The duodenal ulcer healing rates at week 6 were 85%, 85% and 72% in LAM-2 W, LAM-1 W and LA-2 W, respectively (P=0.065). Side-effects occurred in 13%, 11% and 9% in LAM-2 W, LAM-1 W and LA-2 W, respectively. H. pylori eradication and initial ulcer size were factors affecting duodenal ulcer healing. Conclusions : This Asian multicentre study showed that 1-week lansoprazole-based triple therapy without clarithromycin has similar efficacy in H. pylori eradication and ulcer healing compared with a 2-week regimen. Both triple therapies were significantly better than dual therapy in H. pylori eradication. Therefore, 1-week lansoprazole-based triple therapy is as safe and effective as 2-week therapy in eradication of H. pylori infection and healing of duodenal ulcer in these Asian centres. [source] Chronic mucocutaneous candidiasis may cause elevated gliadin antibodiesACTA PAEDIATRICA, Issue 10 2009Florian Brinkert Abstract We present a 4-year-old boy admitted to the hospital due to the typical symptoms of celiac disease with severe dystrophy, anaemia and elevated gliadin IgG antibodies. Upper endoscopy ruled out celiac disease but showed severe Candida esophagitis. Due to an impaired T-cell function especially following Candida antigen stimulation in vitro, plus recurrent Candida infections of the skin, the diagnosis of chronic mucocutaneous candidasis (CMC) was made. Under the treatment with fluconazol, trimethoprim/sulfmethoxazole and IVIG, the child improved impressively. Gliadin antibodies declined steadily. Conclusion:, The common symptoms growth retardation, anaemia and elevated gliadin antibodies are suggestive for celiac disease but very unspecific. The rare immunodeficiency CMC may cause elevated gliadin antibodies. [source] Association of prediagnosis endoscopy with stage and survival in adenocarcinoma of the esophagus and gastric cardia,CANCER, Issue 1 2002Gregory S. Cooper M.D. Abstract BACKGROUND Barrett esophagus, a consequence of chronic gastroesophageal reflux disease, is a premalignant condition for adenocarcinoma of the esophagus and, possibly, the gastric cardia. However, the actual use and clinical impact of upper gastrointestinal endoscopy in screening and surveillance for Barrett esophagus are unknown. METHODS A cohort included 1633 patients with adenocarcinoma (777 esophagus, 856 cardia) who were 70 years or older. They were diagnosed between 1993 and 1996 and were identified from the Surveillance, Epidemiology and End Results program registry. All claims for upper endoscopy and a diagnosis of Barrett esophagus from 1991 through 1 year before diagnosis were identified from linked Medicare files. RESULTS One or more upper endoscopies before diagnosis were performed in 9.7% of patients (13.0% esophagus, 6.8% cardia) and a diagnosis of Barrett esophagus was present in only 3.7% of patients. A shift toward earlier stage at diagnosis was observed in patients with previous endoscopy or Barrett diagnosis. For example, 62% of patients with esophageal and 49% of patients with cardia tumors who underwent previous endoscopy presented with in situ or local stage carcinoma, compared with 35% and 27% of other patients, respectively. Receipt of endoscopy was also associated with a reduced risk of death for esophageal adenocarcinoma (relative hazard 0.73, 95% confidence interval 0.57,0.93; P = 0.01), but not for adenocarcinoma of the cardia. CONCLUSIONS Receipt of upper endoscopy at least 1 year before diagnosis of adenocarcinoma, which may reflect prediagnosis screening, was associated with an earlier tumor stage and improved survival. These data support the role of endoscopic screening and surveillance for Barrett esophagus and highlight the underdiagnosis of populations at risk. Cancer 2002;95:32,8. © 2002 American Cancer Society. DOI 10.1002/cncr.10646 [source] DEXMEDETOMIDINE FOR SEDATION DURING UPPER GASTROINTESTINAL ENDOSCOPYDIGESTIVE ENDOSCOPY, Issue 4 2008Kazutoshi Hashiguchi Background:, A clinical study was conducted to investigate the safety and efficacy of dexmedetomidine for sedation of patients undergoing routine upper gastrointestinal (GI) endoscopy. Methods:, Forty middle-aged patients who were admitted for medical examination were randomized to receive an initial loading dose infusion of dexmedetomidine 6.0 µg/kg per h over 10 min followed by a maintenance infusion of 0.6 µg/kg per h (group A) or rapid infusion of midazolam 0.05 mg/kg (group B) as sedation for routine endoscopy. Sixty patients did not receive sedative agent (group C). Assessment included measurement of heart rate (HR), blood pressure (BP), oxygen saturation, and endoscopy duration. Results:, There were no statistically significant differences among the groups in baseline characteristics. The level of sedation was similar between groups A and B, and the gag response score was significantly lower in the sedated groups than in group C. Hemodynamic stability was also demonstrated in group A during and after the endoscopic procedure. Increased systolic/diastolic BP was significantly attenuated in group A compared with group C. Interestingly, HR was significantly suppressed in group A than in groups B and C. In groups A and B, SpO2 was decreased compared with group C during and after the procedures; however, there was no significant difference between the two groups. There was no significant difference among the groups with endoscopy duration. Conclusions:, For sedation during upper endoscopy, dexmedetomidine is as safe and effective as midazolam, and it significantly reduces HR and BP during and after the endoscopic procedures. [source] Original article: The prevalence of Barrett's esophagus in the US: estimates from a simulation model confirmed by SEER dataDISEASES OF THE ESOPHAGUS, Issue 6 2010T. J. Hayeck SUMMARY Barrett's esophagus (BE) is the precursor and the biggest risk factor for esophageal adenocarcinoma (EAC), the solid cancer with the fastest rising incidence in the US and western world. Current strategies to decrease morbidity and mortality from EAC have focused on identifying and surveying patients with BE using upper endoscopy. An accurate estimate of the number of patients with BE in the population is important to inform public health policy and to prioritize resources for potential screening and management programs. However, the true prevalence of BE is difficult to ascertain because the condition frequently is symptomatically silent, and the numerous clinical studies that have analyzed BE prevalence have produced a wide range of estimates. The aim of this study was to use a computer simulation disease model of EAC to determine the estimates for BE prevalence that best align with US Surveillance Epidemiology and End Results (SEER) cancer registry data. A previously developed mathematical model of EAC was modified to perform this analysis. The model consists of six health states: normal, gastroesophageal reflux disease (GERD), BE, undetected cancer, detected cancer, and death. Published literature regarding the transition rates between these states were used to provide boundaries. During the one million computer simulations that were performed, these transition rates were systematically varied, producing differing prevalences for the numerous health states. Two filters were sequentially applied to select out superior simulations that were most consistent with clinical data. First, among these million simulations, the 1000 that best reproduced SEER cancer incidence data were selected. Next, of those 1000 best simulations, the 100 with an overall calculated BE to Detected Cancer rates closest to published estimates were selected. Finally, the prevalence of BE in the final set of best 100 simulations was analyzed. We present histogram data depicting BE prevalences for all one million simulations, the 1000 simulations that best approximate SEER data, and the final set of 100 simulations. Using the best 100 simulations, we estimate the prevalence of BE to be 5.6% (5.49,5.70%). Using our model, an estimated prevalence for BE in the general population of 5.6% (5.49,5.70%) accurately predicts incidence rates for EAC reported to the US SEER cancer registry. Future clinical studies are needed to confirm our estimate. [source] Helicobacter pylori -Associated Chronic Gastritis and Unexplained Iron Deficiency Anemia: a Reliable Association?HELICOBACTER, Issue 6 2003Stéphane Nahon Abstract Background and aim., About 35% of iron deficiency anemia cases remain unexplained after a gastrointestinal evaluation. An association between Helicobacter pylori and iron malabsorption has been suggested. The aim of this study was to determine whether H. pylori -associated chronic gastritis is linked to unexplained iron deficiency anemia in adults. Methods., From 1996 to 2001, we identified 105 patients with unexplained iron deficiency anemia after upper endoscopy, colonoscopy, small bowel radiographic examination and duodenal biopsies. Two biopsies were obtained from the gastric antrum and two from the corpus of each patient. Gastritis status was described according to the Sydney System and H. pylori infection was assessed by an immunohistochemical test on biopsy specimens. This group was compared to a control group matched for sex and age. Results., There were 76 women and 29 men (mean age 57.4 ± 21.4 years) examined in the study. A H. pylori -associated chronic gastritis was identified in 63 cases (60%) vs. 45 cases (43%) cases in the control group (p < .01). Atrophic gastritis was significantly associated with iron deficiency anemia compared with the control group [16 (15%) vs. 6 (6%); p < .03]. In the unexplained iron deficiency anemia group, (1) patients with chronic gastritis were significantly younger (52 ± 22 vs. 64 ± 20 years; p < .005), and (2) chronic gastritis was not linked to sex [sex ratio (male/female): 0.5 vs. 0.34, p = .34]. The prevalence of H. pylori infection was similar between premenopausal and postmenopausal women [28 (27%) vs. 26 (25%); p = .7] with iron deficiency anemia. Conclusion.,H. pylori infection and chronic gastritis, especially atrophic gastritis, are significantly associated with unexplained iron deficiency anemia. Relationships between H. pylori -associated chronic gastritis and unexplained iron deficiency anemia should be considered. [source] Mucosal tissue transglutaminase expression in celiac diseaseJOURNAL OF CELLULAR AND MOLECULAR MEDICINE, Issue 2 2009Vincenzo Villanacci Abstract Tissue transglutaminase (tTG) plays an important role in celiac disease pathogenesis and antibodies to tTG are a diagnostic marker of gluten-sensitive enteropathy. The aim of this study was to investigate the localization of tTG in the duodenal mucosa in control tissues and in different histological stages of celiac disease by using a commercial and a novel set of anti-tTG monoclonal antibodies, to see whether this assessment can be useful for diagnostic purpose. The distribution of tTG was firstly evaluated in 18 untreated celiac patients by using a commercial monoclonal antibody (CUB7402) against tissue transglutaminase enzyme and directed against the loop-core region of the enzyme. Thereafter, in further 30 untreated celiac patients we employed three newly characterized anti-tTG monoclonal antibodies produced against recombinant human-tTG. The epitopes recognized are located in three distinct domains of the protein corresponding to the core, C1 and C2 protein structure. Eleven age- and sex-matched patients with chronic duodenitis acted as controls. All subjects underwent upper endoscopy to obtain biopsy samples from the duodenum. Overall, we found that (i) tTG is equally expressed in CD at different stages of disease; (ii) tTG is expressed, at similar level, in CD and controls with duodenitis. Assessment of tTG level in biopsy samples by immunohistochemical methods is not useful in the clinical diagnostic work-up of CD. [source] Unusual hepatic-portal-systemic shunting demonstrated by Doppler sonography in children with congenital hepatic vein ostial occlusionJOURNAL OF CLINICAL ULTRASOUND, Issue 4 2004Maha Barakat MD Abstract Purpose This report describes unusual changes in the hepatic vasculature in 3 children presenting with upper gastrointestinal hemorrhage. Methods The study included 3 children (ages 5,8 years) who presented with hematemesis. All had mild hepatosplenomegaly and normal liver function. Esophageal varices were demonstrated in all on upper endoscopy. Color and spectral Doppler sonography was performed to assess the hepatic vasculature, including the hepatic veins (HVs), portal vein (PV), hepatic artery (HA), and inferior vena cava (IVC). Results The HVs were all patent but with ostial occlusion at the point of their communication with the IVC. Complete flow reversal was shown inside the HVs, with blood draining into collateral vessels at the liver surface and paraumbilical vein. In one patient, the paraumbilical vein could be traced to its communication with the right external iliac vein. In all children, the direction of flow in the PV, HA, and IVC was normal. After endoscopic sclerotherapy, all children were shown to be in good general condition and to have normal liver function for a follow-up period of 15,36 months. Conclusions Ostial occlusion of the HV is a rare cause of hepatic outflow obstruction in children. Doppler sonography is a valuable, noninvasive imaging technique for evaluation of the hepatic vasculature and the accompaning shunting pathways in such cases. © 2004 Wiley Periodicals, Inc. J Clin Ultrasound 32:172,178, 2004; Published online in Wiley InterScience (www. interscience.wiley.com). DOI: 10.1002/jcu.20019 [source] Clinical application of wireless capsule endoscopyJOURNAL OF DIGESTIVE DISEASES, Issue 2 2003Zhi Zheng GE BACKGROUND: Diagnostic modalities for identifying lesions within the small bowel have been quite limited. Wireless capsule endoscopy (WCE) is a new, innovative technique that can detect very small mucosal lesions in the entire small bowel and can be used in the outpatient setting. The present study explored the diagnostic value, tolerance and safety of WCE in the identification of small bowel pathology that was not detected with conventional small bowel imaging studies. METHODS: From May through September 2002, 15 patients with suspected small bowel diseases were prospectively examined, Of them, 12 presented with persistent obscure gastrointestinal bleeding and negative findings on upper endoscopy, colonoscopy, small bowel radiography, and bleeding-scan scintig-raphy or mesenteric angiography. RESULTS: Wireless capsule endoscopy identified pathologic small bowel findings in 11 of the 15 patients (73%): angioectasias, Dieulafoy's lesion, polypoid lesion, submucosal mass, Crohn's disease, carcinoid tumor, lipoma, aphthous ulcer, and hemorrhagic gastritis; four of the patients had two lesions. The images displayed were considered to be good. The capsule endoscopes remained in the stomach for an average of 82 min (range 6,311 min) and the mean transit time in the small bowel was 248 min (range 104,396 min). The mean time of recording was 7 h 29 min (from 5 h to 8 h 30 min). The mean time to reach the cecum was 336 min (180,470 min). The average number of the images transmitted by the capsule was 57 919 and the average time the physician took to review the images transmitted by the capsule was 82 min (range 30,120 min). The average time of elimination of the capsule was 33 h (range 24,48 h). All 15 patients reported that the capsule was easy to swallow, painless, and preferable to conventional endoscopy. No complications were observed. CONCLUSIONS: Wireless capsule endoscopy is safe, well tolerated, and useful for identifying occult lesions of the small bowel, especially in patients who present with obscure gastrointestinal bleeding. [source] Esophageal perforation as a complication of esophagogastroduodenoscopyJOURNAL OF HOSPITAL MEDICINE, Issue 3 2008Nisha L. Bhatia MD Abstract Fifty years ago, esophageal perforation was common after rigid upper endoscopy. The arrival of flexible endoscopic instruments and refinement in technique have decreased its incidence; however, esophageal perforation remains an important cause of morbidity and mortality. This complication merits a high index of clinical suspicion to prevent sequelae of mediastinitis and fulminant sepsis. Although the risk of perforation with esophagogastroduodenoscopy alone is only 0.03%, this risk can increase to 17% with therapeutic interventions in the setting of underlying esophageal and systemic diseases. A wide spectrum of management options exist, ranging from conservative treatment to surgical intervention. Prompt recognition and management, within 24 hours of perforation, is critical for favorable outcomes. Journal of Hospital Medicine 2008;3:256,262. © 2008 Society of Hospital Medicine. [source] Duodenal mastocytosis, eosinophilia and intraepithelial lymphocytosis as possible disease markers in the irritable bowel syndrome and functional dyspepsiaALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 7 2009M. M. WALKER Summary Background, Irritable bowel syndrome (IBS) and functional dyspepsia (FD) are common functional disorders without defined pathology. Mast cells and eosinophils interact with T lymphocytes and may alter enteric nerve and smooth muscle function. Aim, To examine mast cell, eosinophil and intraepithelial lymphocyte populations in duodenal biopsies of subjects with IBS and FD. Methods, A random sample of an adult Swedish population (n = 1001; mean age 54 years; 51% female) underwent upper endoscopy and biopsy; 51 cases with FD and 41 cases with IBS were compared with 48 randomly selected controls. Eosinophils were identified by light microscopy; mast cells by immunocytochemistry (CD117). Intraepithelial lymphocytes were counted per 100 enterocytes. Cell counts were quantified by counting the number per high power field (HPF) in 5HPFs in the bulb (D1) and second part of duodenum (D2), summed over 5HPFs at each site. Results, Cases and controls showed similar demographics. Compared to controls, IELs in IBS-constipation were significantly increased (P = 0.005). Mast cells were significantly increased in IBS in D2 (P < 0.001), while eosinophils were significantly increased in FD in D1 and D2 (P < 0.001). Conclusion, Duodenal mast cell hyperplasia is linked to IBS and eosinophilia to FD, and duodenal biopsy may identify subsets of these disorders. [source] Clinical trial: the effect of Johrei on symptoms of patients with functional chest painALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 1 2009A. GASIOROWSKA Summary Background, Patients with functional chest pain (FCP) represent a therapeutic challenge for practising physicians. Aim, To determine the efficacy of Johrei as compared to wait-list in improving symptoms of FCP patients. Methods, Patients with chest pain of noncardiac origin for at least 3 months were enrolled into the study. All patients had to have negative upper endoscopy, pH testing and oesophageal manometry prior to randomization. Subsequently, patients were randomized to either Johrei or wait-list control. Patients received 18 Johrei sessions from a Johrei practitioner for 6 weeks. Results, A total of 21 FCP patients enrolled into the Johrei group and 18 into the wait-list group. There was no difference in symptom intensity score between Johrei group and wait-list group at baseline (20.28 vs. 23.06, P = N.S.). However, there was a significant pre- and post-treatment reduction in symptom intensity in the Johrei group (20.28 vs. 7.0, P = 0.0023). There was no significant reduction in symptom intensity score between baseline and at the end of the study in the wait-list group (23.06 vs. 20.69, P = N.S.). Conclusion, This pilot study shows that Johrei may have a role in improving FCP symptoms; however, future studies are needed to compare Johrei treatment with sham Johrei or supportive care. [source] Review article: moderate sedation for endoscopy: sedation regimens for non-anaesthesiologistsALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 2 2006D. K. REX Summary Background Moderate sedation is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands with or without light tactile stimulation. Moderate sedation is typically accepted in the anaesthesia community as an appropriate target for sedation by non-anaesthesiologists. Aim To describe drug regimens that can be successfully and safely targeted to moderate sedation for endoscopy by non-anaesthesiologists. Results Moderate sedation can be achieved using narcotics and benzodiazepines. There is interest in some countries in propofol for endoscopy, which is often viewed as an agent for deep sedation. Indeed, propofol cannot be targeted to moderate sedation for endoscopy as a single agent because of coughing during upper endoscopy and pain withdrawal responses during colonoscopy. Pre-treatment with low doses of narcotic and/or benzodiazepine blocks these effects, allowing propofol to be targeted to moderate sedation. Fospropofol, a prodrug of propofol in clinical development, can also be targeted to moderate sedation if co-administered with narcotic. Conclusion Moderate sedation provides a safety margin when compared with deep sedation and general anaesthesia. Development of protocols that target agents such as propofol to moderate sedation will expand the sedation agents available to non-anaesthesiologists and help ensure that this expansion occurs safely. [source] High accuracy and cost-effectiveness of a biopsy-avoiding endoscopic approach in diagnosing coeliac diseaseALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 1 2006G. CAMMAROTA Summary Background The ,immersion' technique during upper endoscopy allows the visualization of duodenal villi and the detection of total villous atrophy. Aim To evaluate the accuracy of the immersion technique in detecting total villous atrophy in suspected coeliac patients. The accuracy in diagnosing coeliac disease and the potential cost-sparing of a biopsy-avoiding approach, based on selection of individuals with coeliac disease-related antibodies and on endoscopic detection of absence of villi, were also analysed. Methods The immersion technique was performed in 79 patients with positive antibodies and in 105 controls. Duodenal villi were evaluated as present or absent. As reference, results were compared with histology. Diagnostic approaches, including endoscopy with or without biopsy, were designed to investigate patients with coeliac disease-related antibodies and total villous atrophy. A cost-minimization analysis was performed. Results All patients with positive antibodies had coeliac disease. The sensitivity, specificity, positive and negative predictive values of endoscopy to detect total villous atrophy was always 100%. The sensitivity, specificity, positive and negative predictive values of biopsy-avoiding or biopsy-including strategies in diagnosing coeliac disease when villi were absent was always 100%. The biopsy-avoiding strategy was cost-sparing. Conclusions Upper endoscopy is highly accurate in detecting total villous atrophy coeliac patients. A biopsy-avoiding approach is both accurate and cost-sparing to diagnose coeliac disease in subjects with marked duodenal villous atrophy. [source] Review article: the management of heartburn in pregnancyALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 9 2005J. E. RICHTER Summary Heartburn is a normal consequence of pregnancy. The predominant aetiology is a decrease in lower oesophageal sphincter pressure caused by female sex hormones, especially progesterone. Serious reflux complications during pregnancy are rare; hence upper endoscopy and other diagnostic tests are infrequently needed. Gastro-oesophageal reflux disease during pregnancy should be managed with a step-up algorithm beginning with lifestyle modifications and dietary changes. Antacids or sucralfate are considered the first-line drug therapy. If symptoms persist, any of the histamine2 -receptor antagonists can be used. Proton pump inhibitors are reserved for women with intractable symptoms or complicated reflux disease. All but omeprazole are FDA category B drugs during pregnancy. Most drugs are excreted in breast milk. Of systemic agents, only the histamine2 -receptor antagonists, with the exception of nizatidine, are safe to use during lactation. [source] Non-invasive diagnosis of large oesophageal varices with FibroTest in patients with cirrhosis: a preliminary retrospective studyLIVER INTERNATIONAL, Issue 3 2006Dominique Thabut Abstract: Background and aims: Primary prevention of variceal bleeding with ,-blockers improves survival in patients with large oesophageal varices (LOV). Therefore, cirrhotic patients frequently undergo screening endoscopy. As portal hypertension is related to liver fibrosis, this study aimed to assess the predictive value of FibroTest, a non-invasive marker of liver fibrosis, for the diagnosis of LOV in cirrhotic patients. Methods: Ninety-nine cirrhotic patients had clinical examination, blood sample (liver function tests, platelet count, FibroTest) and upper endoscopy. Measurements of endoscopic and biochemical parameters were made blindly. Sensitivity, specificity, predictive values and area under the receiver operating characteristic curves were assessed for FibroTest, platelet count and Child,Pugh score. The main endpoint was the presence of LOV. Results: Platelet count, prothrombin time, ascites, FibroTest and Child,Pugh class were significantly different among patients with or without LOV. FibroTest had the highest discriminative power with an area under receiver operating characteristics curves of 0.77 (SE=0.06), compared with 0.64 (0.08) and 0.68 (0.08) for platelet count and Child,Pugh score, respectively (P=0.08). A cut-off at 0.80 had a 86% negative predictive value for the diagnosis of LOV (Se=92%, Sp=21%). Conclusion: FibroTest could aid in the diagnosis of LOV and may therefore reduce the indication of endoscopic screening in cirrhotic patients. [source] Clinical, virological and histopathological features: long-term follow-up in patients with chronic hepatitis C co-infected with S. mansoniLIVER INTERNATIONAL, Issue 4 2000Sanaa Kamal Abstract:Background/Aims: Infection with Schistosoma mansoni is endemic in Egypt leading to hepatic schistosomiasis and eventually portal hypertension. The prevalence of antibodies against hepatitis virus C among Egyptians is 14,51%. The aim of the present study was to investigate the influence of schistosomiasis on chronic hepatitis C with respect to the natural course of the disease, immunology, virology and histology. Patients and Methods: One hundred and twenty-six Egyptian patients classified into three groups: group A: chronic hepatitis C (n=33); group B: chronic schistosomiasis (n=30) and group C: chronic hepatitis C and chronic schistosomiasis (n=63) were enrolled and prospectively followed for 62.7±22 months. Patients infected with other hepatic viruses and/or parasites were excluded. Detailed history, clinical examination, CD4+ and CD8+ lymphocyte counts in blood, hematological and blood chemical values, abdominal ultrasonography, upper endoscopy, HCV RNA titer by RT/PCR, genotype and histological activity index in the liver biopsy were determined. Results: Thirty patients (48%) with HCV and schistosomiasis had liver cirrhosis and Child-Pugh class C vs. five (15%) in HCV patients and none in the schistosomal group. HCV RNA levels ranged between 0.07 and 13×105 copies/ml in group A, and between 1 and 25×105 copies/ml in group C. HCV genotype 4 was detected in 58 patients with co-infection (92%) and 21 patients with HCV alone (64%). Patients with coinfection showed higher grading and staging scores in their liver biopsies. Hepatocellular carcinoma was detected only in patients with coinfection. During follow-up, the mortality rate was 12%, 3% and 48% in group A, B and C, respectively. Conclusions: Patients with concomitant HCV and schistosomiasis infection were characterized by more advanced liver disease, higher HCV RNA titers, predominance of HCV genotype 4, higher histologic activity, higher incidence of cirrhosis and hepatocellular carcinoma as well as a much higher mortality rate. [source] The effect of an empirical trial of high-dose lansoprazole on symptom response of patients with non-cardiac chest pain , a randomized, double-blind, placebo-controlled, crossover trialALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 10 2004J. Bautista Summary Background :,Empirical trial with high-dose omeprazole has been shown to be a sensitive tool for diagnosing patients with gastro-oesophageal reflux disease-related non-cardiac chest pain. Aim :,To determine the clinical value of an empirical trial of high-dose lansoprazole in detecting patients with gastro-oesophageal reflux disease-related non-cardiac chest pain. Methods :,Patients who were referred by a cardiologist after a comprehensive evaluation, with at least three episodes per week of unexplained chest pain as the predominant symptom, were enrolled into the study. Oesophageal mucosal disease was determined by upper endoscopy followed by 24-h oesophageal pH monitoring to assess acid exposure. Patients were then randomized to either placebo or lansoprazole 60 mg am and 30 mg pm for 7 days. After a washout period of 1 week, patients crossed over to the other arm of the study for an additional 7 days. Patients completed a daily diary assessing severity and frequency of chest pain as the predominant symptom throughout the baseline treatment and washout periods. The lansoprazole empirical trial was considered diagnostic if chest pain score improved ,50% than baseline. Results :,Of the 40 patients with non-cardiac chest pain that were enrolled, 18 (45%) had erosive oesophagitis and/or abnormal pH test (gastro-oesophageal reflux disease-positive) and 22 (55%) had both tests negative (gastro-oesophageal reflux disease-negative). Of the gastro-oesophageal reflux disease-positive patients, 14 (78%) had significantly higher symptom improvement on lansoprazole than on placebo (22%) (P = 0.0143). Of the gastro-oesophageal reflux disease-negative group, two (9.1%) markedly improved on the medication and eight (36.3%) on placebo (P = 0.75). The sensitivity and specificity of the lansoprazole empirical trial was 78 and 80%, respectively. By day 2, 12 (85.7%) of the gastro-oesophageal reflux disease-related non-cardiac chest pain responders had either complete or almost complete symptom resolution. Conclusions :,The lansoprazole empirical trial is highly sensitive and specific for diagnosing gastro-oesophageal reflux disease-related non-cardiac chest pain patients. The trial enables diagnosing most of the responders within the first 2 days and thus a shorter duration of therapy may be considered in a subset of non-cardiac chest pain patients. [source] Serum pepsinogen and gastrin levels in HIV-positive patients: relationship with CD4+ cell count and Helicobacter pylori infectionALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 4 2002P. Fabris Background: The relationship between serum parameters of gastric function and Helicobacter pylori infection in human immunodeficiency virus (HIV)-positive patients is almost unknown. Aims: To investigate in HIV-infected patients: (i) the relationship between serum gastrin and serum pepsinogens over the progressive phases of HIV-related disease; (ii) the impact of H. pylori infection on gastrin and pepsinogen serum levels and its relation to antral histology; (iii) the prevalence of parietal cell autoantibodies. Methods: Fifty-nine HIV-positive patients were studied by upper endoscopy plus gastric antral biopsy. Serum samples were tested for gastrin, pepsinogen A, pepsinogen C and parietal cell autoantibodies. Results: In patients without overt acquired immunodeficiency syndrome (AIDS), or with a CD4+ count of > 100 × 106 cells/L, mean serum levels of gastrin and pepsinogen C were higher than in subjects with AIDS or with a CD4+ count of < 100 × 106 cells/L (P < 0.01). Only one patient was found to be positive for parietal cell autoantibodies. H. pylori infection was associated with increased values of gastrin and pepsinogen C only in HIV-positive patients without AIDS or with a CD4+ count of > 100 × 106 cells/L. Atrophy was more frequent in patients with overt AIDS than in those without overt AIDS (57% vs. 33%, P=N.S.), and/or in patients with a CD4+ count of < 100 × 106 cells/L than in those with a CD4+ count of > 100 × 106 cells/L (62% vs. 26%, P < 0.05). Conclusions: HIV-positive patients without overt AIDS have increased serum levels of gastrin and pepsinogen C compared with HIV-positive patients with overt AIDS. [source] An evaluation of invasive and non-invasive tests for the diagnosis of Helicobacter pylori infection in ChineseALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 4 2001B. C. Y. Wong Background: Different tests are available for diagnosing Helicobacter pylori infection. Aim: To compare the most commonly used tests either alone or in combination in Chinese patients with respect to routine clinical use or research purpose. Methods: A total of 294 consecutive dyspeptic patients without previous H. pylori treatment were recruited. During upper endoscopy, biopsies were taken from the antrum and corpus, for a commercially available CLO-test, an in-house rapid urease test, culture, polymerase chain reaction and histological examination. Patients then received a 13C-urea breath test. The H. pylori status of each patient was determined by a concordance of test results. Results: For routine clinical use, histology (antral plus corpus biopsies) had an accuracy of 100%, whilst the rapid urease test had an accuracy of 99.7%. The 13C-urea breath test was equally reliable, with an accuracy of 94.5%. Combinations of two tests did not confer additional advantage over the most accurate single test. For research purposes, the accuracy of using the criteria of two positives out of three diagnostic tests was 100% and equivocal results were not found. Conclusion: Histology with or without a rapid urease test was highly accurate for routine clinical use. Alternatively, the 13C-urea breath test was an equally reliable non-invasive test. The two positives out of three tests approach was highly reliable in predicting H. pylori status of untreated Chinese patients in a research setting. [source] Diagnosis and treatment of gastroesophageal reflux disease in Ohio Medicaid patients: practice patterns and temporal trends,PHARMACOEPIDEMIOLOGY AND DRUG SAFETY, Issue 1 2004Gregory S. Cooper MD Abstract Purpose There is a paucity of data about the use of procedures and prescription medications in the treatment of gastroesophageal reflux disease (GERD) in actual clinical practice. Methods Outpatient Ohio Medicaid claims from 1994 to 1998 were searched to identify patients with an initial diagnosis of GERD along with associated prescriptions and gastrointestinal procedures. Complications of GERD and comorbid illnesses were also determined. Results A total of 5579 patients were identified. Histamine-2 receptor antagonists (H2RA') were prescribed in 59%, followed by proton pump inhibitors (PPI's) (30%) and prokinetic drugs (17%). PPI's were more frequently prescribed to patients with GERD-related complications, peptic ulcer disease and major comorbidities, and patients who received PPI's were also more likely to undergo upper gastrointestinal endoscopy. The frequencies of upper endoscopy and barium studies were 20% and 11% respectively, with no change over the study period. There was an increased frequency of PPI therapy (17,43%) and decreased frequency of H2RA therapy (72,47%) from 1994 to 1998 which persisted after adjusting for potential differences in case mix. Conclusions In this population-based study, prescription of PPI's increased over time which likely reflected changes in clinician practice rather than patient mix. Despite a greater awareness of GERD complications, use of upper endoscopy did not increase. Although the cohort consists of predominantly low socioeconomic status, female patients, further studies should be conducted in other populations to confirm these findings. Copyright © 2003 John Wiley & Sons, Ltd. [source] Transnasal Esophagoscopy: A High-Yield Diagnostic Tool,THE LARYNGOSCOPE, Issue 6 2005Jennifer G. Andrus MD Abstract Objectives: Transnasal esophagoscopy (TNE) reveals a wide range of esophageal findings. TNE technique, indications, outcomes, advantages, limitations, and impact on patient care are described. Study Design: Retrospective chart review. Methods: Charts of the first 30 patients to undergo TNE in an academic otolaryngology practice were reviewed. Technique details, patient demographics, and procedure indications and findings as well as the disposition of patients in this series are described. TNE limitations are discussed with areas for future development. Results: Thirty patients who underwent unsedated outpatient TNE by their otolaryngologist are described. TNE was directed toward select indications: dysphagia, screening esophagoscopy given long-standing gastroesophageal reflux (GER) or laryngopharyngeal reflux (LPR), and esophageal surveillance with a new diagnosis of head and neck squamous cell carcinoma. Positive findings included mucosal cobblestoning, Barrett's esophagus, esophagitis, gastritis, candidal esophagitis, esophageal diverticulum, postcricoid mass, patulous esophagus, and absence of secondary esophageal peristalsis. Outcomes included referral to a gastroenterologist for evaluation, with or without biopsy; direct laryngoscopy or esophagoscopy with biopsy by the otolaryngologist; planned cancer resection by the otolaryngologist; and medical management of GER/LPR by the otolaryngologist. Conclusions: With appropriate selection criteria, TNE yields a high percentage of positive findings and wide range of esophageal abnormalities, directly impacting patient management. Available to otolaryngologists in the outpatient setting, TNE expedites interventions by providing a safe, effective alternative to rigid esophagoscopy under general anesthesia and flexible upper endoscopy with sedation. Patients will benefit from the integration of TNE into otolaryngologists' outpatient diagnostic armamentarium. [source] Association of prediagnosis endoscopy with stage and survival in adenocarcinoma of the esophagus and gastric cardia,CANCER, Issue 1 2002Gregory S. Cooper M.D. Abstract BACKGROUND Barrett esophagus, a consequence of chronic gastroesophageal reflux disease, is a premalignant condition for adenocarcinoma of the esophagus and, possibly, the gastric cardia. However, the actual use and clinical impact of upper gastrointestinal endoscopy in screening and surveillance for Barrett esophagus are unknown. METHODS A cohort included 1633 patients with adenocarcinoma (777 esophagus, 856 cardia) who were 70 years or older. They were diagnosed between 1993 and 1996 and were identified from the Surveillance, Epidemiology and End Results program registry. All claims for upper endoscopy and a diagnosis of Barrett esophagus from 1991 through 1 year before diagnosis were identified from linked Medicare files. RESULTS One or more upper endoscopies before diagnosis were performed in 9.7% of patients (13.0% esophagus, 6.8% cardia) and a diagnosis of Barrett esophagus was present in only 3.7% of patients. A shift toward earlier stage at diagnosis was observed in patients with previous endoscopy or Barrett diagnosis. For example, 62% of patients with esophageal and 49% of patients with cardia tumors who underwent previous endoscopy presented with in situ or local stage carcinoma, compared with 35% and 27% of other patients, respectively. Receipt of endoscopy was also associated with a reduced risk of death for esophageal adenocarcinoma (relative hazard 0.73, 95% confidence interval 0.57,0.93; P = 0.01), but not for adenocarcinoma of the cardia. CONCLUSIONS Receipt of upper endoscopy at least 1 year before diagnosis of adenocarcinoma, which may reflect prediagnosis screening, was associated with an earlier tumor stage and improved survival. These data support the role of endoscopic screening and surveillance for Barrett esophagus and highlight the underdiagnosis of populations at risk. Cancer 2002;95:32,8. © 2002 American Cancer Society. DOI 10.1002/cncr.10646 [source] Barrett's esophagus and Cornelia de Lange SyndromeACTA PAEDIATRICA, Issue 9 2010Francesco Macchini Abstract Aim:, To review the records of Cornelia de Lange Syndrome (CDLS) children, affected by Gastro-oesophageal reflux disease (GERD), to detect the presence of Barrett's Esophagus (BE). Methods:, A total of 62 CDLS patients were investigated for GERD (1 month,35 years). In all of them a pH-metry, an upper endoscopy with multiple biopsies and a complete radiologic digestive evaluation were carried out. BE was diagnosed in case of replacement of oesophageal mucosa by specialized intestinal-type columnar mucosa. Anti-reflux surgery was considered in case of persistence of BE after medical therapy. Follow-up (mean 3.5 years) consisted in endoscopy every 6 months . Results:, Gastro-oesophageal reflux disease was found in 50 CDLS patients (80%) and BE in six of them (12% of the GERD group, 9.6% of the entire population, mean age 17 years, range 6,32 years). A short segment BE was observed in three patients, a long one in two patients and an infiltrating adenocarcinoma of the lower oesophagus in one patient. Conclusions:, A higher frequency of BE in CDLS patients than in a normal population is found. A delayed diagnosis because of atypical GERD symptoms and an altered intestinal motility as a result of neurological impairment can be recognized as the main cause. [source] Is there a relationship between Helicobacter pylori infection and erosive reflux disease in children?ACTA PAEDIATRICA, Issue 1 2010Halil Haldun Emiroglu Abstract Aim:, The aim of this study was to investigate the relationship between Helicobacter pylori infection and erosive reflux disease in children. Methods:, A total of 206 children [mean age 8.4 ± 4.9 (0.16,18) years] who underwent diagnostic upper endoscopy were tested for H. pylori infection between 2002 and 2005 and the relationship between H. pylori infection and gastro-oesophageal reflux disease was investigated retrospectively. Endoscopic and histopathological findings were examined retrospectively. When reflux-related oesophageal damage was identified as a result of the histological examination of endoscopic biopsy samples collected from distal oesophagus, the patients were diagnosed with gastro-oesophageal reflux disease and divided into two groups: those with macroscopic erosions or ulceration constituted the erosive oesophagitis group; those without constituted the non-erosive reflux disease group. Results:, Prevalence of H. pylori infection was 31.3% in the patients with gastro-oesophageal reflux disease and 36.7% in the control group (p > 0.05). Prevalence of erosive oesophagitis was found to be 23.8% in the patients with H. pylori infection and 41.3% in those without (p > 0.05). Conclusion:, No negative significant association was found between the prevalence of H. pylori infection and erosive oesophagitis. Presence of H. pylori infection did not influence the severity of oesophagitis either. [source] | |||||||||||||||||||||||||