How to Interpret Ambulatory 24 hr Esophageal pH Monitoring

Newer developing techniques for esophageal functional testing such as wireless pH capsule monitoring and esophageal impedance testing are currently available. However, ambulatory 24 hr esophageal pH monitoring is still widely used and provides quantitative data on esophageal acid exposure and the ability to correlate symptoms with acid exposure events. To properly analyze the result of pH monitoring, it is recommended to interpret in the order presented: visual inspection, computer calculation and symptom correlation

Colonic stenting as bridge to surgery versus emergency surgery for management of acute left-sided malignant colonic obstruction: a multicenter randomized trial (Stent-in 2 study)

Background. Acute left-sided colonic obstruction is most often caused by malignancy and the surgical treatment is associated with a high mortality and morbidity rate. Moreover, these operated patients end up with a temporary or permanent stoma. Initial insertion of an enteral stent to decompress the obstructed colon, allowing for surgery to be performed electively, is gaining popularity. In uncontrolled studies stent placement before elective surgery has been suggested to decrease mortality, morbidity and number of colostomies. However stent perforation can lead to peritoneal tumor spill, changing a potentially curable disease in an incurable one. Therefore it is of paramount importance to compare the outcomes of colonic stenting followed by elective surgery with emergency surgery for the management of acute left-sided malignant colonic obstruction in a randomized multicenter fashion. Methods/design. Patients with acute left-sided malignant colonic obstruction eligible for this study will be randomized to either emergency surgery (current standard treatment) or colonic stenting as bridge to elective surgery. Outcome measurements are effectiveness and costs of both strategies. Effectiveness will be evaluated in terms of quality of life, morbidity and mortality. Quality of life will be measured with standardized questionnaires (EORTC QLQ-C30, EORTC QLQ-CR38, EQ-5D and EQ-VAS). Morbidity is defined as every event leading to hospital admission or prolonging hospital stay. Mortality will be analyzed as total mortality as well as procedure-related mortality. The total costs of treatment will be evaluated by counting volumes and calculating unit prices. Including 120 patients on a 1:1 basis will have 80% power to detect an effect size of 0.5 on the EORTC QLQ-C30 global health scale, using a two group t-test with a 0.05 two-sided significance level. Differences in quality of life and morbidity will be analyzed using mixed-models repeated measures analysis of variance. Mortality will be compared using Kaplan-Meier curves and log-rank statistics. Discussion. The Stent-in 2 study is a randomized controlled multicenter trial that will provide evidence whether or not colonic stenting as bridge to surgery is to be performed in patients with acute left-sided colonic obstruction. Trial registration. Current Controlled Trials ISRCTN46462267

Noncardiac Chest Pain: Epidemiology, Natural Course and Pathogenesis

Noncardiac chest pain is defined as recurrent chest pain that is indistinguishable from ischemic heart pain after a reasonable workup has excluded a cardiac cause. Noncardiac chest pain is a prevalent disorder resulting in high healthcare utilization and significant work absenteeism. However, despite its chronic nature, noncardiac chest pain has no impact on patients' mortality. The main underlying mechanisms include gastroesophageal reflux, esophageal dysmotility and esophageal hypersensitivity. Gastroesophageal reflux disease is likely the most common cause of noncardiac chest pain. Esophageal dysmotility affects only the minority of noncardiac chest pain patients. Esophageal hypersensitivity may be present in non-GERD-related noncardiac chest pain patients regardless if esophageal dysmotility is present or absent. Psychological co-morbidities such as panic disorder, anxiety, and depression are also common in noncardiac chest pain patients and often modulate patients' perception of disease severity

Transanal endoscopic microsurgery versus endoscopic mucosal resection for large rectal adenomas (TREND-study)

Background: Recent non-randomized studies suggest that extended endoscopic mucosal resection (EMR) is equally effective in removing large rectal adenomas as transanal endoscopic microsurgery (TEM). If equally effective, EMR might be a more cost-effective approach as this strategy does not require expensive equipment, general anesthesia and hospital admission. Furthermore, EMR appears to be associated with fewer complications. The aim of this study is to compare the cost-effectiveness and cost-utility of TEM and EMR for the resection of large rectal adenomas. Methods/design. Multicenter randomized trial among 15 hospitals in the Netherlands. Patients with a rectal adenoma 3 cm, located between 115 cm ab ano, will be randomized to a TEM- or EMR-treatment strategy. For TEM, patients will be treated under general anesthesia, adenomas will be dissected en-bloc by a full-thickness excision, and patients will be admitted to the hospital. For EMR, no or conscious sedation is used, lesions will be resected through the submucosal plane i

Oncological outcome of malignant colonic obstruction in the Dutch Stent-In 2 trial

Cellular mechanisms in basic and clinical gastroenterology and hepatolog

The symptom sensitivity index: a valuable additional parameter in 24-hour esophageal pH recording

Twenty-four-hour esophageal pH monitoring is useful for the quantitative measurement of gastroesophageal reflux and for the demonstration of a temporal relationship between symptoms and reflux. The symptom index, a numerical score, was developed to quantify the association between symptoms and reflux. Because the symptom index primarily assesses the specificity of a patient's reflux symptoms, we propose to refer to this score as the symptom specificity index. Because of certain limitations of this score, we developed and evaluated a new score, the symptom sensitivity index, that quantifies the subject's sensitivity for reflux. Fifty-two consecutive patients, referred to our laboratory for ambulatory 24-h pH recording were studied. Beside the conventional reflux variables, both indexes were calculated. Although a statistically significant correlation between the indexes was found, discordance between the specificity and sensitivity indexes was seen in 17 patients (33%). Based on the findings in this study we advocate that the symptom sensitivity index should be used, in addition to the symptom specificity index, and incorporated in future pH studies to optimalize the interpretation of the result

The value of 24-hour combined esophageal pressure and pH recording in the detection of esophageal function abnormalities

Gastroesophageal reflux and esophageal motor abnormalities are suspected of being the source of chest pain when a cardiac origin of the pain has been excluded. Because of the usually intermittent character of the motility disturbances, short conventional manometry, with or without provocation tests, often fails to establish the diagnosis. Therefore, 24-h esophageal pressure and pH recording was developed and has been proposed as a diagnostic tool in the study of patients who suffer from intermittent substernal pain. In this paper the value of 24-h combined esophageal pressure and pH recording in detecting disordered esophageal function in noncardiac chest pain and other esophageal disorders is discusse