Assessment of oesophageal emptying in achalasia patients by intraluminal impedance monitoring

Oesophageal emptying can be assessed by radiographic and scintigraphic tests with radiation exposure or by multichannel intraluminal impedance monitoring (MII). The aim of this study was to evaluate the applicability of MII for the assessment of oesophageal emptying in achalasia patients. In 10 achalasia patients, impedance tracings were scored independently by three observers after ingestion of a 100-mL barium bolus. Bolus clearance time (BCT) and height of barium column were scored using fluoroscopic images acquired at 20-s intervals. All patients showed a low baseline impedance level in the distal oesophagus. Air trapping in the proximal oesophagus was detected in nine patients. BCT on MII was similar to that on fluoroscopy in 40-70% of the patients. Correlations between height of barium on fluoroscopy and fluid level on MII were poor to moderate at different time intervals. Concordance (Kendall's coefficient) between the three observers for assessment of fluid level on MII was 0.31 (P = 0.04) at 1 and 5 min, 0.26 (P = 0.08) at 10 and 0.44 (P = 0.01) at 15 min. We conclude that in achalasia patients, low baseline impedance levels and air entrapment in the proximal oesophagus limit the value of intraluminal impedance monitoring as a test of oesophageal emptying

Review article: the clinical relevance of transient lower oesophageal sphincter relaxations in gastro-oesophageal reflux disease

Background Transient lower oesophageal sphincter relaxations (TLOSR) are considered the physiological mechanism that enables venting of gas from the stomach and appear as sphincter relaxations that are not induced by swallowing. It has become increasingly clear that most reflux episodes occur during TLOSRs and therefore play a key role in gastro-oesophageal reflux disease (GERD). Aim To describe the current knowledge about TLOSRs and its clinical implications. Methods Search of the literature published in English using the PubMed database and relevant abstracts presented at international conventions. Results Several factors influence the rate of TLOSRs including anti-reflux surgery, meal, body position, nutrition, lifestyle and a wide array of neurotransmitters. Ongoing insights in the neurotransmitters responsible for the modulation of TLOSRs, as well as the neural pathways involved in TLOSR induction, have lead to novel therapeutic targets. These therapeutic targets can serve as an add-on therapy in patients with an unsatisfactory response to proton pump inhibitor by inhibiting TLOSRs and its associated reflux events. However, the TLOSR-inhibiting drugs that are currently available still have significant side effects. Conclusion It is likely that in the future, selected GERD patients may benefit from transient lower oesophageal sphincter relaxation inhibition when compounds are found without significant side effects

Increased Belching After Sleeve Gastrectomy

Contains fulltext : 172797.pdf (publisher's version ) (Open Access)INTRODUCTION: Laparoscopic sleeve gastrectomy (LSG) is considered to be an effective procedure for patients with morbid obesity. Belching is frequently reported after this procedure, but it has not been well studied in the bariatric population. This study aims to assess the changes in belching before and after sleeve gastrectomy, as measured with impedance monitoring. METHODS: In a prospective study, patients underwent 24-h pH-impedance monitoring before and 3 months after LSG. Using this technique, belches can be identified. Preoperative and postoperative upper gastrointestinal symptoms were assessed using the Reflux Disease Questionnaire (RDQ). RESULTS: Fifteen patients (1 M/14 F, mean age 42.2 +/- 11.0 years, mean weight 134.5 +/- 21.1 kg, mean BMI 46.4 +/- 6.0 kg/m(2)) participated in this study. Belching occurred significantly more often after LSG, with an increase in symptom score from 2.9 +/- 2.6 before to 5.3 +/- 3.5 3 months after LSG (p = 0.04). The total number of gastric belches increased from 29.7 +/- 11.7 before to 59.5 +/- 38.3/24 h 3 months after LSG (p = 0.03). The total number of supragastric belches did not change after LSG. The number of swallows decreased from 746.9 +/- 302.4 before to 555.7 +/- 172.5 3 months after the procedure (p = 0.03). The number of air swallows tended to decrease (p = 0.08). Esophageal acid exposure increased significantly, from 3.7 +/- 2.9 % before to 12.6 +/- 10.5 % after LSG (p = 0.01). CONCLUSION: Subjectively (as reported by patients) and objectively (as measured by impedance monitoring), an increase in gastric belches is seen after LSG, while the number of (air) swallows tends to decrease after the procedure and the incidence of supragastric belches remains constant. The altered anatomy as well as increased gastroesophageal reflux after LSG may play a role in the increase of belching

Assessment of bolus transit with intraluminal impedance measurement in patients with esophageal motility disorders

BACKGROUND: The clinical management of patients with non-obstructive dysphagia is notoriously difficult. Esophageal impedance measurement can be used to measure esophageal bolus transit without the use of radiation exposure to patients. However, validation of measurement of bolus transit with impedance monitoring has only been performed in healthy subjects with normal motility and not in patients with dysphagia and esophageal motility disorders. The aim was, therefore, to investigate the relationship between transit of swallowed liquid boluses in healthy controls and in patients with dysphagia. METHODS: Twenty healthy volunteers and 20 patients with dysphagia underwent concurrent impedance measurement and videofluoroscopy. Each subject swallowed five liquid barium boluses. The ability of detecting complete or incomplete bolus transit by means of impedance measurement was assessed, using radiographic bolus transit as the gold standard. KEY RESULTS: Impedance monitoring recognized stasis and transit in 80.5% of the events correctly, with 83.9% of bolus transit being recognized and 77.2% of stasis being recognized correctly. In controls 79.8% of all swallows were scored correctly, whereas in patients 81.3% of all swallows were scored correctly. Depending on the contractility pattern, between 77.0% and 94.3% of the swallows were scored correctly. CONCLUSIONS & INFERENCES: Impedance measurement can be used to assess bolus clearance patterns in healthy subjects, but can also be used to reliably assess bolus transit in patients with dysphagia and motility disorders

Gastro-oesophageal reflux disease in The Netherlands. Results of a multicentre pH study.

Gastro-oesophageal reflux disease in The Netherlands. Results of a multicentre pH study. Smout AJ, Geus WP, Mulder PG, Stockbrugger RW, Lamers CB. Dept. of Gastroenterology, University Hospital Utrecht, The Netherlands. Information on the relationships between gastro-oesophageal reflux (GOR), reflux symptoms, hiatal hernia (HH) and oesophagitis, and the response to antisecretory treatment is lacking. In a multicentre study endoscopy, ambulatory 24-h pH monitoring and symptom assessment were carried out in 142 patients with symptomatic reflux disease before and during treatment with ranitidine. Using a randomized, double-blind design, patients took ranitidine 150 mg bid or 300 mg bid. Macroscopic oesophagitis (grade I or II) was found in 85 patients; the remaining 57 patients had normal oesophageal mucosa. A significant correlation was found between the presence of an HH and the presence of oesophagitis. Symptom scores were similar in patients with and without oesophagitis, and in patients with and without HH. Patients with oesophagitis had significantly greater oesophageal acid exposure during the night, and in the total 24-h period, but not during the day. Likewise, patients with HH had greater acid exposure during the night (p < 0.008). Both doses of ranitidine significantly decreased oesophageal acid exposure and the effect was independent of baseline acid exposure. Reflux symptoms cannot be used to differentiate between presence or absence of oesophagitis and/or HH. Reflux patients without oesophagitis have less night-time reflux. Ranitidine dose-dependently decreases oesophageal acid exposure, and the effect is independent of baseline reflux. Publication Types: Clinical Trial Multicenter Study Randomized Controlled Tria

Getting beneath the surface of marine mammal – fisheries competition

&lt;p&gt;1: In systems where marine mammals are perceived to compete with fisheries, the priorities of conservationists and wildlife managers can come into conflict. Resolution of these conflicts requires quantitative information on the intensity of competition, i.e. the expected reduction in resource acquisition by one competitor as a result of a given increase in resource acquisition by the other.&lt;/p&gt; &lt;p&gt;2: The intensity of competition will depend on the extent to which marine mammals and fisheries overlap in space and time with their shared resource, and the way in which individual competitors' preferences for particular prey or target species vary in response to variations in the population composition of these prey and the abundance of other components of the system.&lt;/p&gt; &lt;p&gt;3: We use two examples of marine mammals, Steller sea lions Eumetopias jubatus in Alaska and grey seals Halichoerus grypus in the UK, to illustrate these points and to challenge some intuitive notions about the nature of marine mammal–fisheries interactions.&lt;/p&gt; &lt;p&gt;4: We conclude that the four main sources of ecological complexity (spatial heterogeneity, individual variation, multi-species interactions and long-term dynamics) can have a substantial effect on scientific predictions of the likely outcome of different management actions.&lt;/p&gt; &lt;p&gt;5: We argue that a pragmatic approach, which considers the effect of ecological complexity while avoiding the indiscriminate addition of detail to mathematical models of competition, is the best way to provide scientific advice on issues that require urgent action.&lt;/p&gt

Reflux and belching after 270 degree versus 360 degree laparoscopic posterior fundoplication.

Item does not contain fulltextOBJECTIVE: To investigate differences in effects of 270 degrees (270 degrees LPF) and 360 degrees laparoscopic posterior fundoplication (360 degrees LPF) on reflux characteristics and belching. BACKGROUND: Three hundred sixty degrees LPF greatly reduces the ability of the stomach to vent ingested air by gastric belching. This frequently leads to postoperative symptoms including inability to belch, gas bloating and increased flatulence. Two hundred seventy degrees LPF allegedly provides less effective reflux control compared with 360 degrees LPF, but theoretically may allow for gastric belches (GBs) with a limitation of gas-related symptoms. METHODS: Endoscopy, stationary esophageal manometry, and 24-hour impedance-pH monitoring off PPIs was performed before and 6 months after fundoplication for PPI-refractory gastroesophageal reflux disease (n = 14 270 degrees LPF vs. n = 28 360 degrees LPF). GBs were defined as gas components of pure gas and mixed reflux episodes reaching the proximal esophagus. Absolute reductions (Delta) were compared. RESULTS: Reflux symptoms and the 24-hour incidence of acid (Delta -77.6 vs. -76.7), weakly acidic (Delta -9.4 vs. -6.6), liquid (Delta -59.0 vs. -49.8) and mixed reflux episodes (Delta -28.0 vs. -33.5) were reduced to a similar extent after 270 degrees LPF and 360 degrees LPF, respectively. The reduction in proximal, mid-esophageal and distal reflux episodes were similar in both groups as well. Persistent symptoms were not related to acid or weakly acidic reflux. Two hundred seventy degrees LPF had no significant impact on the number of gas reflux episodes (Delta -3.6; P = 0.363), whereas 360 degrees LPF significantly reduced gas reflux episodes (Delta -17.0; P = 0.002). After 270 degrees LPF, GBs (Delta -29.3 vs. -50.6; P = 0.026) were significantly less reduced and the prevalence of gas bloating (7.1% vs. 21.4%; P = 0.242) and increased flatulence (7.1% vs. 42.9%; P = 0.018) was lower compared to 360 degrees LPF. Twenty-eight patients (67%) showed supragastric belches (SGBs) before and after surgery. The increase in SGBs without reflux (Delta +32.4 vs. +25.5) and the decrease in reflux-associated SGBs (Delta -12.1 vs. -14.0) were similar after 270 degrees LPF and 360 degrees LPF. CONCLUSIONS: Two hundred seventy degrees LPF and 360 degrees LPF alter the belching pattern by reducing GBs (air venting from stomach) and increasing SGBs (no air venting from stomach). However, gas reflux and GBs are reduced less after 270 degrees LPF than after 360 degrees LPF, resulting in more air venting from the stomach and less gas bloating and flatulence, whereas reflux is reduced to a similar extent in the short-term.1 januari 201

Effects of anti-reflux surgery on weakly acidic reflux and belching

Item does not contain fulltextBACKGROUND: Laparoscopic Nissen fundoplication (LNF) is the most frequently performed operation for gastro-oesophageal reflux disease (GORD). However, 12% of the patients have persistent reflux symptoms and 19% develop gas-related symptoms after LNF. Weakly acidic reflux and inability to belch have been alleged to cause these symptoms, respectively. The effect of LNF on weakly acidic reflux and (supra) gastric belching was evaluated. METHODS: In 31 patients upper gastrointestinal endoscopy, stationary oesophageal manometry and 24-h impedance-pH monitoring off acid secretion inhibiting drugs was performed before and 6 months after primary LNF for GORD that was refractory to proton pump inhibitors. Patients filled out validated questionnaires on GERD-HRQoL before and 3, 6 and 12 months after surgery. RESULTS: LNF reduced reflux symptoms (18.6-->1.6; p = 0.015). The procedure drastically reduced the incidence (number per 24 h) of acid (76.0-->1.6; p 5.7; p = 0.001) as well as liquid (53.4-->5.4; p1.9; p 25.7; p = 0.022). Proximal, mid-oesophageal and distal reflux were reduced to a similar extent. Persistent GORD symptoms were neither preceded by acid nor by weakly acidic reflux. The number of air swallows did not change, but the number of gastric belches (GBs) was greatly reduced (68.5-->23.9; p 46.0; p = 0.036). Reflux-associated SGBs were abolished after surgery (14.0-->0.4; p < 0.001). CONCLUSIONS: LNF similarly controls acid and weakly acidic reflux, but gas reflux is reduced to lesser extent. Persistent reflux symptoms are neither caused by acid nor by weakly acidic reflux. LNF alters the belching pattern by reducing GBs (air venting from stomach) and increasing SGBs (no air venting from stomach). This explains the increase in belching experienced by some patients after LNF, despite the reduction in gastric belching. It can be hypothesised that the reduction in GBs after LNF incites patients to increase SGBs in a futile attempt to vent air from the stomach

The preoperative reflux pattern as prognostic indicator for long-term outcome after Nissen fundoplication.

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