Search

Objectives: Non-celiac gluten sensitivity (NCGS) is the presence of symptoms induced by gluten and relieved by a gluten-free diet (GFD) in patients without celiac disease or wheat allergy. Studies are mixed as to whether gluten is the main symptom trigger in patients with NCGS. Gluten immunogenic peptides (GIPs) in stool and urine are novel methods to monitor GFD compliance. Few studies have investigated their use in patients with NCGS. The aim of this study was to assess whether patients with NCGS have increased symptoms with gluten ingestion and to assess compliance with the GFD using stool and urine GIPs., Method: This was a prospective, randomized, double-blinded crossover trial evaluating symptoms in patients with NCGS. Thirty patients with NCGS and 43 healthy controls were placed on a GFD. Patients received 0.5 or 2 g/d of gluten for 7 d each. The remaining weeks, they received placebo for a total of 4 wk. Symptoms were evaluated weekly using the Celiac Symptom Index (CSI). Urine and stool samples were collected weekly and measured for the detection of GIPs to detect exposure to gluten., Results: There was no difference in symptom severity within the NCGS group whether receiving placebo or gluten (32.69 versus 31.54, P = 0.64). Patients with NCGS had significantly higher CSI scores at baseline than healthy controls. Patients with NCGS were less likely to have stool and urine GIPs than healthy patients., Conclusion: Patients with NCGS were more adherent to the GFD based on stool and urine GIP results. Patients with NCGS had increased symptom severity at baseline compared with healthy controls. Neither group had significantly increased symptoms after ingestion of gluten., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Gastroparesis is a complex and poorly understood disease. The literature is lacking with respect to the epidemiology of patient comorbidities and their effect on gastric emptying. We aimed to describe the most common comorbid conditions among patients with gastroparesis in an urban population and quantify the effect of these comorbidities on the severity of delayed gastric emptying (DGE)., Methods: We examined the medical records of all patients diagnosed with gastroparesis at a quaternary care center between 2014 and 2015. The severity of DGE was analyzed after patients were stratified for possible causative etiologies. Likelihood ratio tests were used to assess the significance of demographic and scintigraphic variation in this population., Results: Of the 221 patients, 56.1% were Caucasian and 31.7% were African American. Among these patients, 29.4% had evidence of medication-associated gastroparesis, 29.0% had diabetes-associated gastroparesis, and 31.7% had idiopathic disease. African American patients with gastroparesis were more likely to have diabetic gastroparesis than patients of other races (P=0.01). There was a statistically significant relationship between the number of major risk factors and the severity of a patient's DGE (P=0.004)., Conclusions: Among a diverse urban population, patients with DGE often carry multiple comorbid conditions that serve as risk factors for the development of gastroparesis, including prescriptions for narcotic medications. Greater numbers of these comorbid conditions are associated with more severe disease. Demographics are significantly associated with the etiology and severity of gastroparesis; in particular, African American patients are more likely to have diabetic gastroparesis than patients of other races., Competing Interests: Conflict of Interest: None, (Copyright: © Hellenic Society of Gastroenterology.)

Hepatitis B virus (HBV) is one of the most significant hepatocarcinogens. The ultimate goal of anti-HBV treatment is to prevent the development of hepatocellular carcinoma (HCC). During the last two decades, with the use of currently available anti-HBV therapies (lamivudine, entecavir and tenofovir disoproxil fumatate), there has been a decrease in the incidence of HBV-associated HCC (HBV-HCC). Furthermore, several studies have demonstrated a reduction in recurrent or new HCC development after initial HCC tumor ablation. However, during an observation period spanning 10 to 20 years, several case reports have demonstrated the development of new, subsequent new and recurrent HCC even in patients with undetectable serum HBV DNA. The persistent risk for HCC is attributed to the presence of covalently closed circular DNA (cccDNA) in the hepatocyte nucleus which continues to work as a template for HBV replication. While a functional cure (loss of hepatitis B surface antigen and undetectable viral DNA) can be attained with nucleos(t)ide analogues, these therapies do not eliminate cccDNA. Of utmost importance is successful eradication of the transcriptionally active HBV cccDNA from hepatocyte nuclei which would be considered a complete cure. The unpredictable nature of HCC development in patients with chronic HBV infection shows the need for a complete cure. Continued support and encouragement for research efforts aimed at developing curative therapies is imperative. The aims of this minireview are to highlight these observations and emphasize the need for a cure for HBV., Competing Interests: Conflict-of-interest statement: Hann HW receives Research grant from Gilead Sciences, Assembly Biosciences and TriHealth. Shinn BJ, Martin A, Coben RM, Conn MI, Prieto J, Kroop H and DiMarino AJ have no conflict of interest.

Since the discovery of the hepatitis B virus (HBV) by Blumberg et al. in 1965, its genome, sequence, epidemiology, and hepatocarcinogenesis have been elucidated. Globally, hepatitis B virus (HBV) is still responsible for the majority of hepatocellular carcinoma (HCC). HCC is the sixth-most common cancer in the world and the second-most common cancer death. The ultimate goal of treating HBV infection is the prevention of HCC. Fortunately, anti-HBV treatment with nucleos(t)ide analogues (NAs), which began with lamivudine in 1998, has resulted in remarkable improvements in the survival of patients with chronic hepatitis B and a reduced incidence of HCC. These results were documented with lamivudine, entecavir, and tenofovir. Nonetheless, as the duration of antiviral treatment increases, the risk for HCC still remains despite undetectable HBV DNA in serum, as reported by different investigators with observation up to 4⁻5 years. In our own experience, we are witnessing the development of HCC in patients who have received antiviral treatment. Some have enjoyed negative serum HBV DNA for over 12 years before developing HCC. Current treatment with NAs can effectively suppress the replication of the virus but cannot eradicate the covalently closed circular DNA (cccDNA) that is within the nucleus of hepatocytes. There still remains a great need for a cure for HBV. Fortunately, several compounds have been identified that have the potential to eradicate HBV, and there are ongoing clinical trials in progress in their early stages.

Background: Gastrointestinal tract (GIT) involvement is a common cause of debilitating symptoms in patients with systemic sclerosis (SSc). There are no disease modifying therapies for this condition and the treatment remains symptomatic, largely owing to the lack of a clear understanding of its pathogenesis., Aims: To investigate novel aspects of the pathogenesis of gastrointestinal involvement in SSc. To summarise existing knowledge regarding the cardinal clinical gastrointestinal manifestations of SSc and its pathogenesis, emphasising recent investigations that may be valuable in identifying potentially novel therapeutic targets., Methods: Electronic (PubMed/Medline) and manual Google search., Results: The GIT is the most common internal organ involved in SSc. Any part of the GIT from the mouth to the anus can be affected. There is substantial variability in clinical manifestations and disease course and symptoms are nonspecific and overlapping for a particular anatomical site. Gastrointestinal involvement can occur in the absence of cutaneous disease. Up to 8% of SSc patients develop severe GIT symptoms. This subset of patients display increased mortality with only 15% survival at 9 years. Dysmotiity of the GIT causes the majority of symptoms. Recent investigations have identified a novel mechanism in the pathogenesis of GIT dysmotility mediated by functional anti-muscarinic receptor autoantibodies., Conclusions: Despite extensive investigation, the pathogenesis of gastrointestinal involvement in systemic sclerosis remains elusive. Although treatment currently remains symptomatic, an improved understanding of novel pathogenic mechanisms may allow the development of potentially highly effective approaches including intravenous immunoglobulin and microRNA based therapeutic interventions., (© 2017 John Wiley & Sons Ltd.)

Gastrointestinal dysmotility in systemic sclerosis (SSc) is associated with autoantibodies against muscarinic-3 receptor (M3-R). We investigated the temporal course of the site of action of these autoantibodies at the myenteric neurons (MN) vs. the smooth muscle (SM) M3-R in relation to disease duration, and determined the role of intravenous immunoglobulin (IVIG) in reversing these changes. Immunoglobulins purified from SSc patients (SScIgG) were used to assess their differential binding to MN and SM (from rat colon) employing immunohistochemistry (IHC). Effect of SScIgG on neural and direct muscle contraction was determined by cholinergic nerve stimulation and bethanechol-induced SM contraction. Effects of IVIG and its antigen-binding fragment F(ab')2 on SScIgG binding were studied by enzyme-linked immunosorbent assay (ELISA) of rat colonic longitudinal SM myenteric plexus (LSMMP) lysate and to second extracellular loop peptide of M3-R (M3-RL2). SScIgG from all patients demonstrated significantly higher binding to MN than to SM. With progression of SSc duration, binding at MN and SM increased in a linear fashion with a correlation coefficient of 0.696 and 0.726, respectively (P < 0.05). SScIgG-mediated attenuation of neural and direct SM contraction also increased with disease duration. ELISA analysis revealed that IVIG and F(ab')2 significantly reduced SScIgG binding to LSMMP lysate and M3-RL2. Dysmotility in SSc occurs sequentially, beginning with SScIgG-induced blockage of cholinergic neurotransmission (neuropathy), which progresses to inhibition of acetylcholine action at the SM cell (myopathy). IVIG reverses this cholinergic dysfunction at the neural and myogenic receptors by anti-idiotypic neutralization of SScIgG., (Copyright © 2016 the American Physiological Society.)

Hypogammaglobulinemia/common variable immunodeficiency (CVID) may lead to disruption of the gut mucosal immune barrier. Collagenous infiltrative disorders of the intestinal tract (colitis, gastritis, sprue) constitute a relatively new spectrum of gastrointestinal disorders. Our aims were (1) to determine the association between immunoglobulin deficiency state like CVID and collagenous infiltrative disorders of the gut and (2) to study the clinic-pathologic characteristics and treatment outcomes in these patients. A retrospective search was conducted to identify cases with concurrence of these two conditions at an academic center from 2007 to 2013. Four such patients were identified from our database: three with collagenous colitis and one with collagenous gastritis. All patients with collagenous colitis had normal colonic mucosa while the patient with collagenous gastritis had nodular gastric mucosa. Only one patient out of four had decreased plasma cells in the submucosa as expected in low immunoglobulin states. All patients had improvement in their symptoms on immunoglobulin therapy with considerable remission on budesonide. Literature search revealed reporting of four similar patients. In conclusion, (1) the association between collagenous infiltrative disorders of the gut and CVID and its prompt response to immunoglobulins with effective maintenance with budesonide are novel findings. Our study also shows that the presence of plasma cells should not rule out the possibility of CVID. (2) In patients with chronic diarrhea, hypogammaglobulinemia and collagenous colitis/sprue should be considered for the available effective treatments such as immunoglobulins and budesonide.

In patients with refractory heartburn while on proton pump inhibitor (PPI) therapy, changing drugs or increasing treatment to a twice a day (b.i.d.) dose has become a common practice. This study aims to study patients with persistent heartburn while on PPI therapy and to determine if persistent symptom indicates the need for more aggressive or different therapy. A retrospective review of impedance-pH tracings on PPI therapy (q.d. or b.i.d.) for patients with persistent heartburn was performed. DeMeester score, impedance, and symptom sensitive index (SSI) were used as indices. Statistical analyses were performed using chi-squared test with Yates correction and paired t-test. One hundred consecutive patients, (female 50%, male 50%, mean age 54 [range 16-83] years) were studied on q.d. (n = 45) or b.i.d. PPI (n = 55). Only 20% of the patients had abnormal DeMeester score; 41% had an abnormal impedance score and 56% had abnormal SSI; 29% had all indices normal. There was no difference between patients taking q.d. versus b.i.d. PPI for abnormal DeMeester score (22 vs. 18%), impedance (38 vs. 44%) and SSI (53 vs. 58%); P = 0.80, 0.69, and 0.77, respectively. In 56 patients with positive SSI, symptoms were due to acid reflux in 8 (14%) patients, nonacid reflux in 31 (55%) patients, and combined acid and nonacid reflux in 17 (30%) patients. Patients with persistent heartburn on PPI therapy show a variety of disorders: (i) acid reflux (20%); (ii) nonacid reflux (26%); (iii) positive SSI (56%); (iv) all normal indices (29%). These studies indicate that persistent heartburn on PPI therapy is a complex problem that may not respond to simply increasing acid inhibition., (© 2014 International Society for Diseases of the Esophagus.)

Aim: Screening first-degree relatives of celiac disease (CD) patients offers an opportunity to diagnose CD in a high-risk population.This study aims to determine how frequently CD patients receive a physician-issued recommendation for first-degree relative screening., Materials and Methods: A 12-question survey assessing whether CD patients receive a physician recommendation to screen first-degree relatives for CD, and the impact of such a recommendation, was validated with outpatients in a university gastroenterology practice ("University"). The 12-question survey was then distributed online to members of a celiac organization - the National Foundation for Celiac Awareness ("NFCA"). Results were collected over 3 months. Univariate analysis was used to compare cohort means and assess the association between demographic and diagnostic factors and first-degree relative screening recommendations., Results: 87 University patients participated in the validation phase. Test-retest reliability of 4 key survey questions was high (Kappa coefficient > 0.80). The main analyses were based on data from 677 NFCA and 82 University respondents. Respondents were predominantly female, with a mean age of 45 years. Significantly more University patients received a recommendation for screening (78% vs 44%, p < 0.001). Ninety-eight percent receiving a screening recommendation (both groups) discussed this with family members, leading to CD screening (University 71%, NFCA 79%) and, ultimately, a CD diagnosis (University 18%, NFCA 27%)., Conclusions: Physicians of CD patients often do not recommend screening first-degree family members. The high clinical impact of this recommendation suggests that greater physician compliance with screening may increase the diagnosis of CD in high risk individuals., Competing Interests: CONFLICT OF INTERESTS The authors state that they have no conflict of interest.

Background: Despite the surge of new medical and surgical approaches to treat fecal incontinence, the types of sphincter abnormalities in patients with incontinence have not been well characterized. We aimed to categorize anal sphincter dysfunction using anorectal manometry in patients with fecal incontinence as a potential guide for improved treatment., Methods: A retrospective review of 162 consecutive patients with fecal incontinence referred for anorectal manometry was performed. Resting anal pressure and maximal squeeze pressure were considered as measures of internal anal sphincter and external anal sphincter function respectively., Results: Mean age of the patients was 63 years (13-89); females (81.5%) and males (18.5%). 74% of the patients had sphincter dysfunction on anorectal manometry. Internal anal sphincter dysfunction was present in 62% patients vs. external anal sphincter dysfunction present in 44% patients. 80% females had abnormal manometry vs. 44% in males (P<0.0001). Internal anal sphincter dysfunction was present in 68% females vs. 37% in males (P=0.0026)., Conclusions: Overall, abnormal anorectal manometry studies revealed that internal anal sphincter dysfunction is the most common finding, alone or in combination with external anal sphincter dysfunction. We suggest that anorectal manometry may be important to delineate anal sphincter function prior to using newer therapeutic mechanical devices. Future studies using pharmacological agents to increase internal anal sphincter tone may be of clinical importance. Finally, the classification of fecal incontinence based on the type of sphincter dysfunction may be an improved guide in the selection of newer agents in treating fecal incontinence.

Background: Celiac disease is an immune-mediated small bowel disorder that develops in genetically susceptible individuals upon exposure to dietary gluten. Celiac disease could have extra-intestinal manifestations that affect women's reproductive health. The aim of this study was to investigate fertility and outcomes of pregnancy among women with celiac disease., Methods: In a retrospective cohort study, we analyzed information collected from patients at a tertiary care celiac center and from members of 2 national celiac disease awareness organizations. Women without celiac disease were used as controls. Women completed an anonymous online survey, answering 43 questions about menstrual history, fertility, and outcomes of pregnancy (329 with small bowel biopsy-confirmed celiac disease and 641 controls)., Results: Of the 970 women included in the study, 733 (75.6%) reported that they had been pregnant at some point; there was no significant difference between women with celiac disease (n=245/329, 74.5%) and controls (488/641, 76.1%; P=0.57). However, fewer women with celiac disease than controls (79.6% vs. 84.8%) gave birth following 1 or more pregnancies (P=0.03). Women with celiac disease had higher percentages of spontaneous abortion than controls (50.6% vs. 40.6%; P=0.01), and of premature delivery (23.6% vs. 15.9% among controls; P=0.02). The mean age at menarche was higher in the celiac disease group (12.7 years) than controls (12.4 years; P=0.01)., Conclusions: In a retrospective cohort analysis examining reproductive features of women with celiac disease, we associated celiac disease with significant increases in spontaneous abortion, premature delivery, and later age of menarche.

The ultimate goal of antiviral therapy for chronic hepatitis B (CHB) is prevention of hepatocellular carcinoma (HCC). Earlier we reported favorable effects of antiviral therapy on survival of HCC patients following curative tumor ablation (Int J Cancer online 14 April 2010; doi: 10.1002/ijc.25382). It was the first observation made in the United States. We now report 12 year follow-up of this patient group. CHB patients with no prior antiviral therapy with a single HCC (≤ 7 cm) were studied. All patients underwent local tumor ablation as their first option. Patients diagnosed before 1999 received no antiviral treatment while those diagnosed after 1999 received antiviral treatment. Survival between the treated and untreated groups was compared. Among 555 HCC patients seen at our clinic between 1991 and 2013, 25 subjects were eligible. Nine subjects (all male patients, median age 53 years [46-66]) did not receive antiviral therapy while 16 (14 male patients, median age 56 years [20-73]) received treatment. Between the two groups, there was no difference in their median tumor size and levels of alpha-fetoprotein and albumin. However, the survival was significantly different (P = 0.001): the median survival of the untreated was 16 months (3-36 months) while that of the treated was 80 months (15-152 months). Fourteen of 16 treated patients are alive to date with two longest survivors alive for ≥ 151 months. In conclusion, concomitant antiviral therapy for CHB patients with HCC reduces and prevents new/recurrent tumor and improves survival. This novel treatment strategy offers an alternative to liver transplantation in patients with HBV-associated HCC., (© 2014 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.)

A 19-year-old young male presented with abdominal pain and constipation. Subsequent EGD showed nodular gastric mucosa with simple gastric aspirate demonstrating acidic pH of 2.0. The gastric biopsy showed thick subepithelial band of about 15 microns that was confirmed to be collagen on Masson's trichrome stain along with inflammatory infiltrate. Colonoscopy and capsule endoscopy findings were unremarkable as well as the biopsy of the colon. Collagenous gastritis is a rare histopathological entity characterized by the presence of thick subepithelial collagen band of thickness greater than 10 microns along with intraepithelial lymphocytes and lamina propria lymphoplasmacytic and eosinophilic infitrates. Clinical presentation varies and depends more on the age of the patient with anemia or epigastric pain with nodular gastric mucosa being more common in children while diarrhea being more common in adults due to its increased association with collagenous colitis. The purpose of this case report is; (A) To define the endoscopic and histopathological features and progression of collagenous gastritis in this patient; (B) To compare these findings to those of collagenous sprue and collagenous colitis.

Background: Prior studies report esophageal rupture following endoscopy or bolus impaction in eosinophilic esophagitis (EoE). The purpose of this study is to add new information to available evidence defining the clinical spectrum of spontaneous rupture (Boerhaave's syndrome) associated with vomiting in EoE., Methods: A retrospective search of inpatient and outpatient records was conducted from January 2001 to January 2011. A faculty member in pathology blindly reviewed all esophageal biopsy specimens. EoE was defined as 15 or more eosinophils in at least 2 high-power fields (hpfs) or 25 or more eosinophils in any single HPF., Results: In ten years, 447 patients were identified with a diagnosis of EoE. Of these, four patients presented with Boerhaave's syndrome in the setting of EoE. None of the patients had an established diagnosis of EoE prior to presentation. All cases presented with a triad of vomiting, chest pain and pneumomediastinum. In two patients, water-soluble contrast extravasation prompted surgical intervention (50%). Full thickness surgical specimen provides a unique opportunity to show eosinophils in the muscularis propria. Intraepithelial eosinophil infiltration was seen on all mucosal biopsies (>25/hpf) with significant improvement after steroid (topical or systemic) treatment., Conclusions: Spontaneous esophageal rupture is a rare (4/447, less than 1%) but critical presentation of EoE manifesting with vomiting, chest pain and pneumomediastinum. Surgery is required if extravasation is seen with water-soluble contrast. We suggest that EoE may be a transmural disease in some patients, thus making the esophageal wall susceptible to spontaneous rupture with vomiting (Boerhaave's syndrome).

Background: Nocturnal acid reflux is associated with symptomatic and asymptomatic sleep arousals, leading to fragmented sleep. The frequency and influence of acid reflux in patients with various forms of insomnia has not been reported. The aim of this study was to quantify nocturnal acid and nonacid reflux in patients with primary sleep disorders as previously diagnosed by polysomnography., Methods: THIRTY ONE SUBJECTS WERE STUDIED: (A) 9 subjects with a polysomnographically diagnosed sleep disorder (1 with restless legs syndrome, 4 with narcolepsy, 4 with periodic limb movement disorder); (B) 12 subjects with primary insomnia (PI) and unrevealing polysomnography; and (C) 10 controls without disturbed sleep. All subjects underwent a physical examination and 24 h transnasal pH and impedance monitoring to detect acid and non-acid reflux., Results: The 21 subjects with fragmented sleep due to a primary sleep disorder had significantly more recumbent acid exposure (>1.2% of time) as compared with control subjects (33% versus 0%). When fragmented sleep subjects were divided into two groups, 17% of PI subjects and 55% of subjects with a diagnosed sleep disorder had significant recumbent acid exposure (P=0.009). Likewise, the median recumbent nonacid events were increased in the sleep disordered group (P=0.011)., Conclusions: This study indicates that patients with primary sleep disorders have prominent nocturnal acid reflux without symptoms of daytime acid reflux. Acid reflux is most prominent in patients with polysomnographic findings of disturbed sleep as compared to patients with PI; while non acid reflux is increased minimally in these patients.

Various esophageal motor disorders including achalasia have been sporadically reported in patients with eosinophilic esophagitis (EoE). The aim of this study was to determine the association between achalasia and EoE and to review the treatment outcomes in patients having both conditions. A retrospective search was conducted to identify the cases of achalasia having EoE over the last 10 years at a tertiary care hospital in the United States. Subsequently, a review of the literature was performed to search for cases of achalasia that have concurrent EoE. The retrospective study showed that 4 out of 512 patients of achalasia (<1 %) had concomitant EoE. The eosinophil counts were high (80-100/hpf) but the classic endoscopic features of EoE were present in only one patient. Long term outcome following treatment including botox, myotomy and corticosteroids was generally poor. Sixteen patients have been reported in the literature out of which five patients were reported in detail. Patients had good short term response to various therapies. The long term outcomes have not been reported. These studies suggest that a concurrence of these two conditions, although rare, may occur and may not be recognized by usual endoscopic features of EoE. Long term treatment outcomes, distinct from short term in the literature, may be poor.

Background & Aims: Patients with systemic sclerosis (SSc) have impairments in gastrointestinal smooth muscle function. The disorder has been associated with circulating antibodies to cholinergic muscarinic the type-3 receptor (M(3)-R). We investigated whether it is possible to neutralize these antibodies with pooled human IgGs (pooledhIgG)., Methods: We studied the effects of IgGs purified from patients with SSc (SScIgGs) on cholinergic nerve stimulation in rat colon tissues. We also examined the effects of SScIgGs on M(3)-R activation by bethanechol (BeCh), M(3)-R occupancy, and receptor binding using immunofluorescence, immunoblot, and enzyme-linked immunosorbent analyses of human internal anal sphincter (IAS) smooth muscle cells, before and after administration of pooledhIgG. Functional displacement of M(3)-R occupancy by the SScIgGs was compared with that of other IgGs during the sustained phase of BeCh-induced contraction of intact smooth muscles from rats., Results: SScIgG significantly attenuated neurally mediated contraction and acetylcholine release in rat colon as well as BeCh-induced sustained contraction of the IAS smooth muscle. In immunofluorescence analysis, SScIgG co-localized with M(3)-R. In immunoblot and enzyme-linked immunosorbent analyses, M(3)-R loop-2 peptide and human IAS SMC membrane lysates bound significant amounts of SScIgG, compared with IgGs from healthy individuals and pooledhIgG. Binding was attenuated significantly by application of pooledhIgG, which by itself had no significant effect. Incubation of samples with pooledhIgG, or mixing pooledhIgG with SScIgG before administration to tissues, significantly reduced binding of SScIgG, indicating that pooledhIgG prevents SScIgG blockade of M(3)-R., Conclusions: In studies of rat and human tissues, pooled human IgG prevent and reverses the cholinergic dysfunction associated with the progressive gastrointestinal manifestations of SSc by neutralizing functional M(3)-R antibodies present in the circulation of patients with SSc., (Copyright © 2012 AGA Institute. Published by Elsevier Inc. All rights reserved.)

A 74-year-old male with a history of dysphagia for 3 years presented with acute food impaction. Endoscopy showed a tight distal stricture with course rings at the middle third of the esophagus. Biopsies taken from the middle third of the esophagus showed marked infiltration of the intraepithelial lymphocytes mainly in a peripapillary distribution. The immunostains showed presence of CD3 and CD5 lymphocytes (T cell markers) in the epithelium. Lymphocytic esophagitis is a histologic phenotype of esophagitis diagnosed by marked esophageal lymphocytosis mostly in a peripapillary distribution with no or only rare intraepithelial granulocytes and presenting similar to eosinophilic esophagitis with dysphagia and esophageal rings.

Aim: Colonoscopy to detect and remove polyps has contributed to a reduction in colorectal carcinoma. Three-year follow up is recommended for patients considered to be at high risk (at least three adenomas, adenoma ≥ 1 cm, villous or high-grade features). Our study focused on patients diagnosed with high-grade dysplasia with regard to initial management and follow up., Method: A search of patients who had had endoscopic removal of a high-grade adenoma was carried out. Patients with the following were excluded: follow up of < 1 year, polyposis syndromes, prior colon cancer and a diagnosis of adenocarcinoma within 6 months following initial diagnosis., Results: Eighty-three patients treated between 1999 and 2007 for high-grade dysplasia (HGD) in a colorectal adenoma were identified. Over a median follow-up period of 4 years, 53 (64%) developed further adenomatous polyps. Among these, 7% had an adenoma with HGD or an adenocarcinoma. In all these patients, the initial high-grade adenoma was > 1 cm in diameter. Initial follow-up colonoscopy was performed on average 7 months following the initial diagnosis. Ten per cent of patients underwent prophylactic segmental resection, and 6% received argon laser therapy., Conclusion: The study demonstrates that patients who have a colorectal adenoma > 1 cm with HGD may be at high risk of developing further adenomas with HGD or carcinoma. Close follow up is warranted., (© 2011 The Authors. Colorectal Disease © 2011 The Association of Coloproctology of Great Britain and Ireland.)

Systemic sclerosis (SSc) IgGs affecting the M(3)-muscarinic receptor (M(3)-R) have been proposed to be responsible for the gastrointestinal (GI) dysmotility in this disease. However, the effect of SSc IgGs on smooth muscle cell (SMC) function has not been studied. We determined the effect of SSc IgGs on the muscarinic receptor activation by bethanechol (BeCh; methyl derivate of carbachol) in SMC and smooth muscle strips from rat internal anal sphincter. IgGs were purified from GI-symptomatic SSc patients and normal volunteers, with protein G-Sepharose columns. SMC lengths were determined via computerized digital micrometry. The presence of M(3)-R and IgG-M(3)-R complex was determined by Western blot. IgGs from SSc patients but not from normal volunteers caused significant and concentration-dependent inhibition of BeCh response (P < 0.05). The maximal shortening of 22.2 +/- 1.2% caused by 10(-4) M BeCh was significantly attenuated to 8.3 +/- 1.2% by 1 mg/ml of SSc IgGs (P < 0.05). Experiments performed in smooth muscle strips revealed a similar effect of SSc IgG that was fully reversible. In contrast to the effect on BeCh, the SSc IgGs caused no significant effect (P > 0.05) on K(+) depolarization and alpha(1)-adrenoceptor activation by phenylephrine. Western blot studies revealed the specific presence of SSc IgG-M(3)-R complex. SSc IgGs attenuated M(3)-R activation, which was reversible with antibody removal. These data suggest that SSc GI dysmotility may be caused by autoantibodies that inhibit the muscarinic neurotransmission. Future treatment of SSc patients may be directed at the removal or neutralization of these antibodies.

Background & Aims: Nocturnal acid reflux is associated with complicated gastroesophageal reflux (GER) disease. Nocturnal GER initiates a protective arousal reflex, which induces a swallow to clear esophageal acid. The purpose of this study was to determine the effect of zolpidem on the sleep arousal mechanism and acid clearance in patients with documented GER, compared with control subjects with normal acid exposure., Methods: Eight controls and 16 GER patients were enrolled in a randomized, double-blind, placebo-controlled study. Zolpidem or placebo was given on separate nights. Reflux events and reflux-associated arousals or awakenings were recorded using simultaneous esophageal pH recording and standard polysomnography., Results: Nocturnal acid exposure resulted in a sleep arousal 89% of the time in participants (with and without GER) given placebo but only 40% in those given zolpidem (P < .01). In controls given placebo, acid reflux events lasted 1.15 +/- 0.28 seconds; in controls given zolpidem, they lasted 15.67 +/- 12.42 seconds (P < .01). In GER patients given placebo, the acid reflux events lasted 37.8 +/- 17.2 seconds compared with 363.3 +/- 139.3 seconds with zolpidem (P < .01). With zolpidem reflux events lasted 630.6 +/- 236.5 seconds when no arousal occurred and 49.2 +/- 19.11 seconds when an arousal was recorded (P < .001)., Conclusions: Zolpidem reduced the arousal response to nocturnal acid exposure and increased the duration of each esophageal acid reflux event in healthy individuals and patients with GER. Because nocturnal acid exposure was prolonged, hypnotic use by patients with GER could lead to increased risk for complicated disease.

Esophageal adenocarcinoma (EAC), one of the fastest growing cancers in the United States, is increasingly recognized in younger patients in whom the clinicopathologic features have been poorly described. We aim to compare clinical presentation between early (i.e.,

Purpose: To evaluate the utility of selective esophageal manometry in clinical practice., Results: Retrospective data from 200 subjects was reviewed. Manometry was considered to be (1) high clinical utility when specific abnormality was identified resulting in therapeutic intervention, (2) low clinical utility when specific abnormality was identified without alteration of therapy, (3) limited clinical utility when manometry was normal. High, low, and limited clinical utility was noted in 47, 40, and 13% of instances. Manometry was of high utility in patients with dysphagia or non-cardiac chest pain (P < 0.05), and low utility in gastroesophageal reflux (P < 0.05)., Conclusions: (1) Esophageal manometry has high clinical utility in dysphagia after exclusion of structural disorders; and non-cardiac chest pain after careful exclusion of reflux. (2) Ineffective motility disorder has high association with gastroesophageal reflux disease but low clinical utility except in preoperative assessment for fundoplication. (3) Esophageal manometry is of high utility in clinical practice when used in conjunction with other diagnostic exclusions.

Background & Aims: Eosinophilic esophagitis (EoE) in adults, characterized by the triad of dysphagia, a ringed esophagus, and mucosal eosinophilic infiltration, has associated complications that include vertical mucosal lacerations, instrumental perforation, and emesis-induced rupture. The aim of this study was to determine whether clinical, endoscopic, and histologic features can be used to predict the risk for development of these complications., Methods: A review was conducted of 36 patients with EoE. Complications were defined as mucosal lacerations or radiographic evidence of perforation., Results: The mean age at presentation was 33.9 years. Twenty-eight (78%) patients were men. Complications occurred in 11 patients (31%). There were 7 mucosal lacerations, 3 perforations, and 1 emesis-induced rupture. Strictures were reported in 7 of 11 complicated cases compared with 2 of 25 of uncomplicated cases. Dilatation procedures had been performed in 6 of 7 complicated cases associated with stricture. Biopsy specimens obtained from 7 of 9 patients with complications showed 40 or more eosinophils/high-power field. There were no statistical differences between complicated and uncomplicated patients regarding demographics, clinical features, endoscopic characteristics, or histopathologic findings., Conclusions: EoE is a high-risk disorder with a range of complications. Although demographics, clinical presentation, and endoscopic features cannot distinguish risk, the presence of stricture, a longer duration of symptoms, and a greater density of eosinophilic infiltration suggest increased risk. The density of eosinophilic infiltration cannot be determined prospectively; therefore, the performance of endoscopy and subsequent dilatation should be deferred until biopsy specimens are reviewed or treatment is completed.

Background: Oesophageal adenocarcinoma is the sixth leading cause of cancer-related mortality worldwide. Previously, oesophageal cancer was mainly squamous cell, presenting late with dysphagia and weight loss., Aims: To examine the distribution of oesophageal cancer histopathology at a large, urban hospital; to determine the tumour stage and symptoms at presentation; and to evaluate the impact of endoscopic surveillance in Barrett's oesophagus., Methods: From 1999 to 2004, all patients diagnosed with oesophageal cancer were evaluated retrospectively for demographics and tumour stage at presentation using endoscopic ultrasonography and computerized tomography., Results: A total of 131 patients were included. 81% of tumours were adenocarcinomas; most localized to the distal oesophagus (97%). Patients presented with dysphagia (56%), pain (30%) and/or weight loss (16%). Irrespective of histology, locally advanced lesions accounted for most cases. Thirteen patients had lesions detected in Barrett's surveillance; these were early or intermediate stage in nine patients, but late stage in four patients., Conclusions: Adenocarcinoma has become the dominant histologic subtype, comprising 81% of proven malignancies. Despite a change in histopathology, most cancers are diagnosed at an advanced stage, presenting with dysphagia, pain and/or weight loss. Endoscopic surveillance of Barrett's oesophagus allows earlier diagnosis of cancer in most, but not all, patients.

Background: Although studies suggest that inflammatory bowel disease (IBD) has a significant impact on an individual's health-related quality of life, the added weight of other health conditions and comorbidities has not been investigated. The purpose of this study was to expand on prior research by taking into account the impact of other chronic health conditions on the health-related quality of life of individuals with IBD, and to develop a model to help clinicians understand the relative impact of various predictors of their patients' physical and mental health-related quality of life., Methods: 615 patients from the gastroenterology outpatient practice of a large, urban university hospital received a self-administered survey including questions about their health conditions, the severity of their bowel symptoms, and their health-related quality of life (measured using the SF-36 instrument)., Results: 314 completed surveys were returned, resulting in a response rate of 51.1%. Two regression analyses were conducted to identify the role of patient demographic variables and other chronic conditions on the 2 primary outcomes of interest: the SF-36 Physical Component and Mental Component Summary scores. Statistically significant predictors of physical quality of life included IBD disease severity, arthritis, heart disease, age, anemia, back/shoulder pain, and hypertension; statistically significant predictors of mental health-related quality of life were IBD disease severity, depression/anxiety, age, and headaches., Conclusions: IBD disease severity is the most important predictor of both physical and mental health-related quality of life in patients with this condition despite the presence of other chronic conditions.

Background: The effect of gastro-oesophageal reflux on sleep and sleep quality is highly controversial., Aim: To determine the temporal relationship of abnormal objective sleep parameters to gastro-oesophageal reflux during acid suppression in patients with self diagnosed sleep disorders., Methods: Polysomnography during oesophageal pH monitoring was conducted in 16 subjects with and without gastro-oesophageal reflux as determined by a standardized questionnaire. Subjects were studied before and after omeprazole., Results: All reflux events were followed by a sleep arousal or awakening. Nocturnal acid reflux events were not predicted by the Carlsson score. Omeprazole reduced acid reflux-associated arousals from 11.6 +/- 3.8 to 1.5 +/- 0.8 (P < 0.01) and awakenings from 7.7 +/- 1.2 to 3.7 +/- 0.5 (P < 0.05). Sleep efficiency improved from 70.2% to 81.6% in a small subset of subjects with decreased sleep (P < 0.05); rapid eye movement sleep increased from 55.0 +/- 4.5 to 94.5 +/- 18.9 min (P < 0.05); total sleep time increased from 294.0 +/- 15.9 to 345.6 +/- 55.6 min (P < 0.05). Apnoea, hypopnoea and hypoxaemia were not associated with reflux., Conclusions: In subjects with gastro-oesophageal reflux, sleep arousals and awakenings are closely related to acid reflux events. Reflux-related arousals and awakenings are decreased by acid suppression. Acid suppression in selected subjects with reflux events and reduced sleep efficiency is associated with increased total sleep time, rapid eye movement sleep and sleep efficiency.

Background: Acute diverticulitis is increasingly being recognized in younger patients, but its management remains controversial., Aim: To compare long-term outcomes of young patients treated with surgery vs. medical therapy for their first episode of diverticulitis., Methods: A retrospective chart analysis at a university and an affiliated community hospital between 1991 and 2002 revealed 149 patients < or = 40 years of age with confirmed diverticulitis. Forty-nine patients (38 males, 11 females) were contacted at least 1 year after their first episode of diverticulitis. Outcomes were compared based on initial therapy--antibiotics or surgical resection. The groups were compared by outcomes, gender, age, white blood cell count, temperature and diet., Results: Three (15%) of 20 surgical patients (mean follow-up 6.89 years), and 16 (55%) of 29 medical patients had a recurrence of diverticulitis (mean follow-up 5.72 years; P = 0.01). The treatment groups did not differ in age, white blood cell count, or temperature., Conclusions: (i) Surgical treatment is effective initial therapy but disease may recur in a minority of patients; (ii) medical treatment is less effective initial therapy, with recurrence in half of the patients; (iii) initial presentation is not a strong predictor of disease recurrence.

Background: The effect of ageing on oesophageal motility in patients with achalasia is not well described. Oesophageal contraction amplitude is decreased in otherwise healthy elderly subjects., Aim: To evaluate whether ageing influences the motor function of the oesophagus in achalasia., Methods: Initial manometry studies of patients with achalasia were reviewed and findings (lower oesophageal sphincter basal and residual pressures and oesophageal body contraction amplitudes) were compared between two groups of patients, those 65 years of age or older (49 patients) and those younger than 65 years (68 patients). The older group was further divided into those > or =70 years and those <70 years., Results: Patients 65 years and older had significantly higher lower oesophageal sphincter basal pressures compared with younger patients (65.6 +/- 4.9 vs. 52.3 +/- 2.7, P = 0.02). At an age cut-off of 70 years, older patients had significantly higher basal (70.7 +/- 1.6 vs. 53.0 +/- 2.4, P = 0.02) and residual (19.7 +/- 1.6 vs. 15.9 +/- 0.7, P = 0.03) lower oesophageal sphincter pressures compared with younger patients. Amplitude of oesophageal contractions was not different between the groups. Across all age groups, there was no linear correlation between age and basal or residual lower oesophageal sphincter pressures (r = 0.28 and 0.12, respectively)., Conclusions: Older patients with achalasia have higher lower oesophageal sphincter pressures, however there is no linear correlation between age and lower oesophageal sphincter pressures. Unlike healthy subjects, advanced age is not associated with a decrease in oesophageal contraction amplitude in patients with achalasia.

Background: Gastro-esophageal reflux disease (GERD) is a highly prevalent disease caused by the exposure of the esophagus to refluxed gastric contents. Proton pump inhibitors (PPIs) are the mainstay of current treatment. At present, the assessment of the efficacy of different PPIs in the treatment of GERD employs two measures: esophageal and gastric pH monitoring. Esophageal pH monitoring is the most accurate method of detecting reflux episodes and, therefore, its role as a diagnostic modality is well accepted. Gastric pH monitoring, on the other hand, is an accurate measure of gastric acid pH, but its relevance to patients with GERD is questionable, since recordings correlate poorly with esophageal acid exposure., Objective: This paper reviews (based on a Medline literature search, 1980-2004) the clinical relevance of esophageal and gastric pH measurements in both the management of GERD and in the evaluation of the efficacy of PPI therapy., Findings and Conclusions: Evidence presented suggests that the assessment of esophageal pH yields data of greater relevance to patients with GERD than does data from gastric pH. This largely arises from the fact that esophageal pH monitoring assesses the pH of the refluxate and the frequency of reflux episodes at the mucosal site affected by the disease. The use of esophageal pH monitoring is recommended in patients who fail to present with endoscopic evidence of esophagitis, those with extra-esophageal symptoms, those who have failed traditional anti-reflux therapies, and those who are potential candidates for anti-reflux surgery. In recent years, the technique has benefited from the development of a wireless pH probe, and there is also an increasing body of evidence supporting its use in combination with other emerging technologies, such as Bilitec monitoring and multichannel intraluminal impedance. Such an approach is anticipated to aid both the diagnosis of GERD and the characterization of gastro-esophageal reflux (GER) in these patients.

This is a report of a patient who manifests all of the features of Carney's syndrome, including gastrointestinal stromal tumors (GISTs), extra-adrenal paragangliomas, and pulmonary chondromas. The patient underwent surgical resection of a gastric GIST; a retroperitoneal, nonfunctional paraganglioma; and a mediastinal, catecholamine-secreting paraganglioma (pheochromocytoma). Recently, new gastric GISTs were diagnosed by endoscopic, ultrasound-guided, fine-needle aspiration (EUS-FNA) biopsy and were resected. Recurrence of stromal tumors following complete resection is common in Carney's syndrome and presents considerable management challenges. This case illustrates several important points: (1) Carney's syndrome, although rare, should be considered in patients with foregut GISTs; (2) GISTs associated with Carney's syndrome, like sporadic gastric GISTs, may have a more indolent clinical course; and (3) EUS-FNA may be useful for the diagnosis and management of GISTs in this syndrome.

Pyoderma gangrenosum (PG) is an ulcerating noninfectious disease of the skin seen in 1 to 5% of patients with inflammatory bowel disease. The pathogenesis of PG has yet to be determined but may be related to abnormal T cell responses and the production of TNF-alpha, a powerful proinflammatory cytokine. Infliximab, a chimeric monoclonal antibody to TNF-alpha, has been approved for the treatment of Crohn's disease. We present four patients with PG treated with Infliximab for fistulizing Crohn's in whom complete healing of PG was achieved. Four patients with active fistulizing Crohn's disease and PG were treated. All patients were females ranging in age from 48 to 60 years, with a mean age of 54 years. Three of four patients had PG lesions located on the lower extremities; one patient had peristomal disease. All patients had at least colonic involvement of their Crohn's. The patients received either a single infusion or a series of three 5 mg/kg Infliximab infusions. All four patients demonstrated rapid healing of PG within 4 weeks of the first infusion of Infliximab. PG healing followed improvement in bowel disease. Complete resolution without recurrence was noted in all patients. Rapid resolution of PG was noted in four female patients with fistulizing Crohn's disease treated with Infliximab. Healing was complete, without recurrence. The anti-TNF-alpha properties of Infliximab suggest that healing may be mediated by the drug's effect on cytokine pathways, perhaps by blunted T cell activation early in the inflammatory cascade. We suggest an independent effect of Infliximab on PG.

Gastrointestinal abnormalities in systemic sclerosis (SSc) involve both myogenic and neural mechanisms. The aims of this study were to evaluate the rectoanal inhibitory response (RAIR) in SSc patients and to correlate RAIR with duration and subtype of disease, antibody status, and lower gastrointestinal symptoms. Thirty-five patients with SSc completed a questionnaire and underwent anorectal manometry (ARM). Forty-five patients without SSc served as controls. In the 35 SSc patients, 62.3% reported diarrhea, 57.1% reported constipation, and 37.1% reported fecal incontinence. Twenty-five of the 35 scleroderma patients (71.4%) demonstrated an impaired or absent RAIR, compared with none of the 45 controls (P < 0.001). Eleven of 13 incontinent SSc patients (84%) had an impaired RAIR. No correlation was found between RAIR and duration or subtype of SSc, antibody status, or presence of diarrhea or constipation. Impaired RAIR was closely correlated with fecal incontinence, suggesting a possible neural mechanism for maintenance of continence.

We investigated the effects of (R,R)-5-[2-[2-3-chlorophenyl)-2-hydroxyethyl] - amino]propyl] - 1,3 - benzodioxole - 2, 2 - dicarboxylate (CL 316243) (a typical beta3-agonist) on the spontaneously tonic smooth muscle of the lower esophageal sphincter (LES). Studies were carried out in smooth muscle strips and smooth muscle cells (SMCs) of opossum LES. Isometric tension was recorded in the basal state and after CL 316243, and before and after beta3-antagonist (S)-N-[4-[2-[[3-[-(acetamidomethyl)phenoxy]-2-hydroxypropyl]amino]ethyl]phenyl]benzenesulfonamide (L 748337) and nonselective antagonist propranolol. In some experiments, the effects of nonadrenergic noncholinergic (NANC) nerve activation by electrical field stimulation (EFS) were also examined. The effects of CL 316243 were compared with those of nonselective beta-agonist isoproterenol. CL 316243 caused a concentration-dependent relaxation of the LES smooth muscle. The relaxant action of CL 316243 was determined to be directly at the smooth muscle because it remained unmodified by the neurotoxin tetrodotoxin and other neurohumoral antagonists, and also was observed in the SMCs. L 748337 selectively antagonized the relaxant effect of CL 316243 and, conversely, had no significant effect on the inhibitory actions of isoproterenol. CL 316243 (1 x 10(-8) M) caused an augmentation of NANC relaxation in the LES. Another beta3-agonist, (S)-4-[hydroxy-3-phenoxy-propylamino-ethoxy]-N-(2-methoxyethyl)-phenoxyacetamide (ZD 7114), also caused concentration-dependent full relaxation of the LES that was selectively antagonized by beta3-anatagonist 3-(2-ethylphenoxy)-1-[(1S)1,2,3,4-tetrahydronaphth-1-ylaminol]-(2S)-2-propanol oxalate (SR 59230A). These studies defined the effects of characteristic inhibitory beta3-adrenoceptors in the spontaneously tonic LES smooth muscle and suggested a potential therapeutic role in the esophageal motility disorders characterized by hypertensive LES.

Background & Aims: Previous studies have identified adrenergic receptor sites in the lower esophageal sphincter (LES) of animals and humans. A beta3 adrenoceptor has been identified and cloned. The binding site for this receptor has been found in the rat LES in vitro. The aim of the study was to assess the role of a specific beta3 agonist (CL316243) on LES pressure (LESP) in vivo., Methods: Anesthetized adult opossums were given CL316243 and isoproterenol intravenously as boluses before and after continuous infusion of L748337 (a specific beta3 antagonist), propranolol, and bethanechol. Blood pressure, heart rate, and LESP were continuously recorded., Results: CL316243 caused a dose-dependent maximal inhibition of LESP of 88.5% +/- 4.8%. The mean duration of inhibition was 62.2 +/- 9.2 minutes with minimal change in cardiovascular parameters. Isoproterenol caused dose-dependent maximal inhibition of 89.4% +/- 4.7% with mean duration of action of 5.1 +/- 0.9 minutes but was associated with significant hypotension and tachycardia. L748337 and propranolol significantly blocked the effects of CL316243 and isoproterenol, respectively. CL316243 and isoproterenol inhibited the bethanechol-mediated hypertensive LES., Conclusions: (1) A selective beta3 agonist, CL316243, caused significant, prolonged, and dose-dependent inhibition of LESP and, unlike isoproterenol, had minimal effect on heart rate and mean arterial pressure. (2) The beta3 antagonist, L748337, selectively inhibited CL316243 without altering the isoproterenol response. (3) CL316243 and isoproterenol both caused inhibition of cholinergic-mediated hypertensive LESP.

Background: Whether an opiate-benzodiazepine combination is superior to benzodiazepine alone for sedation in upper endoscopy is controversial. The purpose of this study was to compare the effectiveness of intravenous midazolam alone versus the combination of intravenous midazolam and intravenous meperidine for the sedation of patients undergoing upper endoscopy., Methods: One hundred seven patients scheduled for outpatient diagnostic esophagogastroduodenoscopy were randomly assigned to receive 50 mg intravenous meperidine (53 of 107) or placebo (54 of 107). All patients received topical lidocaine spray and as much midazolam as the endoscopist thought the patient needed. Patients and endoscopists were blinded as to assignment. Data collected included intubation time (seconds), procedure time (minutes), pulse, blood pressure, complications, and the need for reversal agents. The endoscopist evaluated the quality of sedation immediately after the procedure (1 = excellent, 2 = good, 3 = fair, and 4 = poor). The patient evaluated the procedure the next day by phone (1 = no discomfort or did not remember, 2 = slightly uncomfortable, 3 = extremely uncomfortable, and 4 = unacceptable). Patients were also asked whether they would agree to another esophagogastroduodenoscopy if their doctor thought it was medically necessary., Results: The intubation time, procedure time and blood pressure were not significantly different between the 2 groups. In comparing the meperidine group versus placebo group, the highest pulse (82.3 vs. 93.7, p = 0.0010), lowest pulse (67.2 vs. 72.3, p = 0.0194) and amount of midazolam used (4.0 vs. 4.8 mg, p = 0.0185 or 0.53 vs. 0.67 mg/kg, p = 0.0083) were significantly different by using a t test analysis. Patient evaluations comparing meperidine versus placebo showed responses of 1 (52 vs. 49), 2 (1 vs. 3), 3 (0 vs. 2) and 4 (0 vs. 0), which were not significantly different. The endoscopists'evaluation comparing meperidine versus placebo gave responses of excellent (44 vs. 27), good (6 vs. 22), fair (3 vs. 5) and poor (0 vs. 0), which were highly significantly different (p < 0.001) by using chi-square statistical techniques., Conclusion: The addition of meperidine to midazolam in sedating patients undergoing upper endoscopy adds no benefit from the patient viewpoint, whereas endoscopists favored the use of both medications.

Three cases of esophageal Crohn's disease (CD) are described, each with dysphagia and/or odynophagia caused by esophageal ulceration. All three patients had associated ileocolitis. One patient followed for a prolonged period responded to treatment with sulfasalazine and prednisone. A computer search back to 1967 produced 72 additional cases of esophageal CD. Among these 75 patients (total), who were, on average, 34 years old, esophageal disease was the presenting disease symptom in 41 patients (55%). The diagnosis was difficult in 13 patients, in whom no distal bowel disease was detected at the time of initial esophageal presentation. The most common presentation was dysphagia associated with aphthous or deeper ulcerations (52 patients). In 11 of these patients, oral aphthous ulcerations were also present. Esophageal stenosis or fistulas to surrounding structures were present in 27 patients and led to surgery in 17 patients. Most of the unfavourable outcomes were in this group of 27 patients with esophageal complications, including five deaths. Fourteen additional patients required surgery for CD of other areas. Responses of uncomplicated ulcerative disease of the esophagus tended to be favourable if the medical regimen included prednisone. Clinical patterns of esophageal CD were divided into three categories: ulcerative, stenosing and asymptomatic (acute disease in children).

Flexible endoscopic instruments are very valuable in the diagnosis and treatment of patients with gastrointestinal diseases. Current guidelines for reprocessing these instruments between patient use are appropriate. Rigid adherence to these guidelines, however, will be necessary to reassure governmental authorities, other medical authorities, and the public that the risk of infection from these procedures is minimal.

Adequate endoscope reprocessing is one of the most essential functions in any endoscopy setting. Standards and guidelines for reprocessing endoscopes have been established by the Society of Gastroenterology Nurses and Associates (SGNA) and the American Society for Gastrointestinal Endoscopy (ASGE). These standards pertain to any setting in which gastrointestinal endoscopy is performed. Endoscope reprocessing that meets the established standard of practice helps to ensure a patient-ready instrument for all patients, reduces the risk of disease transmission to practitioners and staff, and helps to prolong the life of the endoscope.

Background/aims: Two ways popularly used to measure lower esophageal sphincter pressure are the mid-respiratory and end-expiratory methods. The aim of this study was to compare the suitability of these methods in the manometric assessment of patients with endoscopically documented esophagitis., Methods: Manometry was performed on 22 consecutive patients to determine whether medical therapy or surgery was the more appropriate treatment strategy. Lower esophageal sphincter pressure was measured during a slow station pull-through. End-expiratory lower esophageal sphincter pressure was assessed by measuring the highest trough which coincided with end expiration. Mid-respiratory lower esophageal sphincter pressure was assessed by bracketing the highest pressure over >/=3 respiratory cycles and measuring the mid point., Results: Mid-respiratory lower esophageal sphincter pressure (25.6 mm Hg) was higher (p < 0.0001) than end-expiratory lower esophageal sphincter pressure (15.7 mm Hg). Nine (41%) end-expiratory lower esophageal sphincter pressures were abnormally low (i.e., <10 mm Hg), whereas three (14%) mid-respiratory lower esophageal sphincter pressures were abnormally low (i.e., <14 mm Hg; p = 0.042). CONCLUSIONS Mid-respiratory lower esophageal sphincter pressure measurement includes respiratory artifact and does not accurately measure lower esophageal sphincter pressure. End-expiratory sphincter pressure better identifies potential surgical candidates., (Copyright 2000 S. Karger AG, Basel)

Background: Patient infection from contaminated gastrointestinal (GI) endoscopes can generally be attributed to failure to follow appropriate reprocessing guidelines. Recently, the Food and Drug Administration recommended a 45-minute exposure of GI endoscopes to 2.4% glutaraldehyde solutions heated to 25 degrees C. Simultaneously, the American Society for Gastrointestinal Endoscopy (ASGE), the American Gastroenterological Association, and the Society of Gastroenterology Nurses and Associates endorsed a reprocessing guideline that emphasized manual precleaning and recommended a 20-minute exposure to a 2.4% glutaraldehyde solution at room temperature. Since then, little information has become available regarding actual reprocessing practices in the United States., Methods: A previously developed questionnaire regarding endoscopic disinfection practices was mailed to randomly selected members of the ASGE., Results: The survey was sent to 730 members and 294 responded (40.3%). Appropriate manual cleaning (suctioning detergent through the accessory channel and brushing the channel and valves) is performed by 90.7% of respondents; 69.9% then use automated reprocessors for disinfection or sterilization. Glutaraldehyde is the most widely used chemical disinfectant; 85.3% use glutaraldehyde as one of their primary disinfectants. The most commonly used disinfection time with 2.4% glutaraldehyde is 20 minutes (83.9%) followed by 45 minutes (11.4%). Only 23.8% of users of 2.4% glutaraldehyde heat their solution; 59.6% of centers test disinfectant concentration daily or more frequently; 74.0% sterilize nondisposable forceps before use; 29.2% of centers re-use disposable endoscopic accessories (which are more frequently disinfected rather than sterilized). Twelve respondents reported cases of endoscopic cross infection., Conclusions: A significant minority of endoscopy centers still do not completely conform to recent ASGE, American Gastroenterological Association, and the Society of Gastroenterology Nurses and Associates guidelines on disinfection, and they may not be appropriately disinfecting GI endoscopes. Rigid adherence to recommended guidelines is strongly encouraged to ensure patient safety.