Endoscopic incision as an alternative to bougienage in the treatment of peptic esophageal stricture

With the aim of suggesting incision of peptic esophageal strictures, as an alternative to bougienage, we report the results of the first 20 patients so treated. We included as candidates for this treatment all those patients with moderate or severe dysphagia in whom a stricture of the distal esophagus was confirmed on esophagoscopy that could not be negotiated despite continuous and vigorous pressure with the tip of the fiberscope. On the basis of radiological films, the minimum diameter of the stenotic ring (+/- SD) was 4.4 +/- 2.2 mm, increasing up to 10.05 +/- 1.5 mm once the endoscopic procedure was made. Dysphagia was initially relieved in all the cases. Four patients had recurrence within a few days after the incision. Later, another 4 patients had recurrence. Finally, a further 4 cases were lost by non-compliance. The remaining 8 patients who underwent a 6-months' follow-up did not show a later tendency to re-stenosis. In total, 5 patients were surgically treated for hiatal hernia. One case of emphysema in the mediastinum was noted and treated conservatively. We conclude that endoscopic incision is an alternative to esophageal dilatation as initial treatment for peptic esophageal stricture, despite the fact that a significant number of patients will require additional surgical correction for gastro-esophageal reflux.     

胃镜辅助胸腔镜改良Heller手术治疗贲门失弛缓症

目的探讨胃镜辅助胸腔镜改良Heller手术治疗贲门失弛缓症的效果及优势。方法对33例症状明显且保守治疗无效的的贲门失弛缓症患者采用胃镜辅助胸腔镜改良Heller手术治疗,观察术后食道梗阻解除的效果及并发症的发生情况,并术后随访半年,观察疗效。结果 33例贲门失弛缓症患者术后食道梗阻症状均有不同程度改善。其中1例由于胸腔粘连严重,改为开放手术;4例并发食管黏膜损伤,胸腔镜下修补食管。1例患者出现食管胸膜瘘,保守治疗1个月后瘘管愈合。1例患者术后出现胃食管返流,保守治疗后症状缓解。随访半年,仅1例于术后3个月再次出现食道梗阻,予扩张治疗后好转。结论胃镜辅助胸腔镜改良Heller手术治疗贲门失弛缓症手术效果明显,手术操作简单易行,并发症少,可在临床上推广应用。     

Barrett's oesophagus: a clinical study of 52 patients

This paper reports a series of 52 patients with Barrett's (or columnar-lined) oesophagus from one medical unit diagnosed over a six-year period. The commonest associated symptoms were heartburn, regurgitation and dysphagia but 10 patients had no oesophageal symptoms and two had no symptoms at all. Gastrointestinal bleeding (overt or occult) was observed in almost one-third of patients. At diagnosis, 26 patients had oesophagitis, 23 had oesophageal ulceration and 10 had benign oesophageal strictures. An association between oesophageal ulceration and non-steroidal anti-inflammatory drug ingestion was suggested by the data and patients with oesophageal ulceration were significantly older than patients with uncomplicated Barrett's oesophagus. No patient had adenocarcinoma of the oesophagus at diagnosis and neither carcinoma nor dysplasia were seen during a mean period of 16.4 months. However, 17 per cent of patients in the series had malignancies in other sites. Most patients did well on medical treatment and only two were referred for anti-reflux surgery (both for non-healing oesophageal ulcers). Barrett's oesophagus was seen in 10 per cent of patients with gastro-oesophageal reflux at endoscopy. Oesophageal ulceration in patients with Barrett's oesophagus made up 21 per cent of oesophageal ulcers seen and benign oesophageal stricture in patients with Barrett's oesophagus constituted 13 per cent of all benign strictures seen. Barrett's oesophagus is common in our population and despite complications, it can be managed successfully, at least in the short term, by conservative means.     

Hiatal hernia with severe reflux esophagitis: treatment by superselective vagotomy and Nissen fundoplication

Thirty-two patients had surgical treatment for severe reflux esophagitis due to sliding hiatal hernia. A superselective vagotomy was done as an adjunct to a Nissen fundoplication as the antireflux procedure. All patients had severe esophagitis; 16 patients (53%) had dysphagia, nine patients (28%) had esophageal stricture, and all had failed an intensive trial of medical treatment with antireflux measures, antacids, and histamine receptor blockers. Follow-up averaged 14.3 months (3 to 38). Three patients (9%) had significant postoperative esophagitis. The other 29 patients, including those with esophageal stricture, are now asymptomatic. We conclude that the combination of a superselective vagotomy and a Nissen fundoplication is a safe and effective operation for the treatment of severe reflux esophagitis.     

改良术式在胃肠吻合术的临床分析

目的探讨改良胃大部分切除术后胃与空肠的改良吻合,预防返流性胃炎的方法。方法回顾分析2005年3月至2008年3月收住院的43例消化道溃疡病患者,根据患者病变的部位、性质及程度,改良胃大部分切除术后吻合术式。一般取空肠配合肠襻20—40cm与进行正中Roux-Y吻合,重建消化道。结果术后经过随访3～12个月不等,同时进行胃镜观察、分析,本组病例对术后胃内食物的顺利缓慢进入肠道,防止逆道返流;又保持了胃内的生理环境,也有利于胃功能的早期恢复。无返流性胃炎的发生。结论经过临床分析,本术式无近期并发症,既解除溃疡术后残胃炎症状,又有效地预防返流性胃炎。     

Mucosal protective effects of ecabet sodium: pepsin inhibition and interaction with mucus

Pepsin, acid and Helicobacter pylori are major factors in the pathophysiology of peptic ulcer disease and reflux oesophagitis. Ecabet sodium reduces the survival of H. pylori in the stomach and inhibits pepsin activity in the gastric juice of experimental animals. Here we have investigated the effects of ecabet sodium on some of the factors involved in the dynamics of the mucosal barrier, i.e. pepsins and mucins. This study used gastric juice obtained from 12 non-symptomatic volunteers and nine patients with reflux oesophagitis. Ecabet sodium significantly inhibited pepsin activity in human gastric juice, with a maximum inhibition of 78%. Pepsin 1, the ulcer-associated pepsin, was inhibited to the greatest extent. The ability of gastric juice to digest mucin was significantly inhibited by ecabet. As with gastric juice proteolytic activity, the inhibitory effect of ecabet on mucolysis was greater in gastric juice from patients with reflux oesophagitis than in that from controls. Ecabet sodium showed a positive interaction with gastric mucin, as assessed by an increase in viscosity. Thus ecabet sodium may reduce the aggressive potential of gastric juice towards the mucosa, which may be relevant in the treatment of reflux oesophagitis and peptic ulcer disease. In addition, it may strengthen the mucus barrier in peptic ulcer disease and gastritis.     

HEARTBURN,OESOPHAGITIS AND BARRETT'S OESOPHAGUS IN SELF-MEDICATING PATIENTS IN GENERAL PRACTICE

SUMMARY A postal questionnaire on heartburn sent to 6760 randomly selected subjects yielded 3971 replies suitable for analysis. Heartburn had never been experienced by 1665 (42%) respondents. Significant symptoms of more than three months' duration that had occurred at least once a month in the preceding 12 months were reported by 1337 (34%) respondents. Of these, 875 had not consulted their general practitioner and were invited to attend for a structured interview with questionnaire and upper gastrointestinal endoscopy. A total of 177 were interviewed, and 143 underwent upper gastrointestinal endoscopy. Of those endoscoped, 106 (74%) experienced symptoms at least once a week. These were relieved by alginate consumption in 97 (68% of) cases. Just nine (6%) patients had been taking H₂-receptor antagonists. Macroscopic appearances of oesophagitis were seen in 46 cases [13 (6%) grade 1, 24 (11%) grade 2, five (2%) grade 3, two (1%) grade 4, and two (1%) grade 5]. Three patients had mild strictures and six patients had Barrett's oesophagus. There were no appearances suggestive of malignancy. Biopsies were taken in 122 cases, including all those in which abnormalities had been seen. Histological evidence of oesophagitis was seen in 47 cases. Gastric metaplasia was found in six cases and dysplasia seen in three. Patients who self-medicate for reflux symptoms have a low prevalence of pre-neoplastic and neoplastic pathology. A substantial proportion, however, have histological evidence of oesophagitis and a small number have metaplasia.     

Comparative study of Riflux Forte and Riflux in cases of reflux oesophagitis

In an open, randomised, comparative study of 68 endoscopically proven cases of reflux oesophagitis, one antacid with relatively high acid-neutralising capacity (Riflux Forte) and another with lower acid-neutralising capacity (Riflux) were compared. Except for a relatively higher number of cases of severe oesophagitis in the Riflux Forte group (31 vs 19), the patient populations were homogeneous. A consistent trend of rapid and increased diminution in severity of symptoms was seen with both Riflux and Riflux Forte. Although differences between the two groups were not statistically significant, the trend towards a better response was reflected in symptomatic improvement (score difference 14.2 vs 12.0 between one and eight weeks), percentage improvement (93.0 vs 83.7), global assessment (2.9 vs 2.7) and oesophagitis grading on endoscopic assessment (2.5 vs 1.9). These data indicate that, while Riflux and Riflux Forte will produce equivalent results in cases of mild to moderate reflux oesophagitis, the additional acid-neutralising capacity of Riflux Forte provides it with the potential to be more useful in severe cases.     

Efficacy of once-daily cimetidine in preventing recurrence of duodenal ulcer

In a prospective multicenter trial, 88 patients with acute duodenal ulcers that were healed with ranitidine were randomly assigned to receive maintenance treatment with either cimetidine 400 mg (n = 45) or placebo (n = 43) at bedtime for six months. Ten percent of the patients experienced moderate or severe pain both during the day and at night while on placebo during the maintenance phase. The average proportion of cimetidine patients experiencing moderate or severe pain during the day or night was 50% and 80% lower than placebo, respectively. Ulcer-like symptoms prompted endoscopy in 44% (19 of 43) of the placebo patients compared with 18% (eight of 45) of patients receiving cimetidine (P = 0.009). At the completion of the maintenance study, cumulative symptomatic ulcer recurrence rates were 28% (12 of 43) for those on placebo compared with 13% (six of 45) for cimetidine patients. The adverse drug effects noted were similar between treatment groups, with no unexpected reactions reported. A low dose of cimetidine (400 mg) at bedtime effectively reduced the incidence of gastrointestinal symptoms that were severe enough to prompt endoscopy as well as the actual recurrence of ulcers in those patients who had responded to initial therapy with ranitidine, but who continued to be at increased risk of reulceration.     

胆汁反流和幽门螺杆菌感染在胆汁反流性胃炎和消化性溃疡发病中的作用

目的探讨胆汁反流和幽门螺杆菌感染在胆汁反流性胃炎和消化性溃疡发病中的作用。方法采用病理组织学检查和快速尿素酶试验对76例胆汁反流性胃炎及22例兼有胆汁反流性胃炎和消化性溃疡的患者行幽门螺杆菌检测,并与29例消化性溃疡患者作对照。结果胆汁反流性胃炎组幽门螺杆菌阳性率为31.6%(24/76例),兼有胆汁反流性胃炎和消化性溃疡组幽门螺杆菌阳性率为59.0%(13/22例),消化性溃疡组幽门螺杆菌阳性率为72.4%(21/29例),前二组比较,差异有显著意义(P<0.05),后二组比较,差异无显著意义(P>0.05)。结论胆汁反流在胆汁反流性胃炎的发病中起主要作用,幽门螺杆菌感染在消化性溃疡的发病中起主要作用。胆汁反流和幽门螺杆菌感染在胆汁反流性胃炎和消化性溃疡的共同发病中互不明显影响,幽门螺杆菌感染所起的作用可能更大一些。     

Barrett's Oesophagus: A Clinical Study of 52 Patients

This paper reports a series of 52 patients with Barrett's (orcolumnar-lined) oesophagus from one medical unit diagnosed overa six-year period. The commonest associated symptoms were heartburn,regurgitation and dysphagia but 10 patients had no oesophagealsymptoms and two had no symptoms at all. Gastrointestinal bleeding(overt or occult) was observed in almost one-third of patients.At diagnosis, 26 patients had oesophagitis, 23 had oesophagealulceration and 10 had benign oesophageal strictures. An associationbetween oesophageal ulceration and non-steroidal anti-inflammatorydrug ingestion was suggested by the data and patients with oesophagealulceration were significantly older than patients with uncomplicatedBarrett's oesophagus. No patient had adenocarcinoma of the oesophagusat diagnosis and neither carcinoma nor dysplasia were seen duringa mean period of 16.4 months. However, 17 per cent of patientsin the series had malignancies in other sites. Most patientsdid well on medical treatment and only two were referred foranti-reflux surgery (both for non-healing oesophageal ulcers).Barrett's oesophagus was seen in 10 per cent of patients withgastro-oesophageal reflux at endoscopy. Oesophageal ulcerationin patients with Barrett's oesophagus made up 21 per cent ofoesophageal ulcers seen and benign oesophageal stricture inpatients with Barrett's oesophagus constituted 13 per cent ofall benign strictures seen. Barrett's oesophagus is common inour population and despite complications, it can be managedsuccessfully, at least in the short term, by conservative means.     

硬输尿管镜术并发症及其防治

目的 探讨硬输尿管镜术并发症发生的原因和防治措施。方法 对804例输尿管镜术中发生的并发症进行了回顾性研究。结果 1994年10月前后入镜成功率分别67．07％和96．68‰输尿管口撕裂假道形成12例（1．49％）、浅层撕裂47例（5．85％），无输尿管断裂及黏膜撕脱、输尿管穿孔14例（1．74％）、输尿管嵌顿7例（0．87％），术中因出血中止手术10例（1．24％），术后524例获得随访，输尿管口狭窄5例（0．95％），输尿管狭窄8例（1．53％）。中转开放手术2例。术后行ESWL96例，第2次输尿管镜术47例，输尿管气囊扩张7例，输尿管口再植术2例。榆尿管端端吻合术4例。该组所有并发症患者经过处理后均得到治愈和明显改善。结论 对于严重输尿管镜术并发症应高度重视，采用正确的方法，大部分并发症是可以防治的。     

Severe reflux esophagitis after vertical banded gastroplasty for treatment of morbid obesity.

Herein we describe two patients with medically refractory, severe reflux esophagitis after vertical banded gastroplasty for morbid obesity. Neither patient had symptoms of reflux preoperatively. Both patients underwent conversion to a vertical Roux-en-Y gastric bypass, an operation that prevents acid and peptic reflux and maintains a weight-reducing anatomy. Symptoms of gastroesophageal reflux are common (they occur in approximately 38% of patients) after vertical banded gastroplasty has been performed. Patients with unusually severe reflux may require operative management.     

经口内镜下肌切开术治疗贲门失弛缓症临床疗效和并发症的分析

目的探讨经口内镜下肌切开术(POEM)治疗贲门失弛缓症(AC)的临床疗效和并发症。方法对2013年1月-2015年1月该院消化内镜中心的38例AC患者进行POEM治疗,观察手术相关并发症和胃食管反流情况,并对比分析治疗前后贲门失弛缓症临床症状评分系统(ECKARDT)评分和食管下段括约肌(LES)压力变化。结果 38例均成功实施POEM手术,无1例出现与POEM相关的严重并发症,出血、气体相关并发症均保守治疗成功。术后随访时间10.4个月(9~12个月),所有患者症状缓解,ECKARDT评分平均分从术前的8.7分降至术后的1.2分(P0.01),食管括约肌压力明显降低,平均压从术前的(33.40±11.80)mm Hg下降至术后的(13.50±4.30)mm H(g P0.01),气体相关并发症6例(15.78%),食管反流总发生率为23.68%(9/38)。结论 POEM用于AC的治疗是安全、有效的,并且具有较好的远期疗效。     

Cimetidine usage for unlabeled conditions in an ambulatory care service

With the intent of cost containment, we conducted a survey of cimetidine usage in the Ambulatory Care Service of our Veterans Administration Medical Center. During a period of six months, this drug was prescribed for 132 patients. Only about 20% received cimetidine for FDA approved conditions. Treated conditions not approved by the FDA (unlabeled) included undiagnosed abdominal pain, past peptic ulcer disease, reflux esophagitis, and a variety of other conditions. Fourteen percent of the patients had demanded the drug. Irrespective of whether a confirmed diagnosis was present or not, most patients taking cimetidine had symptomatic relief. It is unclear whether more regulations or improved physician education would be the better method to control improper and unnecessary use of a drug that is generally safe but has potentially serious side effects.     

Erosive reflux-esophagitis and its treatment

Altogether 78 patients were examined over time. They had erosive reflux esophagitis that complicated the course of duodenal ulcer (in 42 patients, hypersecretion of hydrochloric acid was the leading mechanism of the disease development) and chronic gastroduodenitis (36 persons manifested failure of the inferior sphincter of the esophagus with or without excess acid output). In patients with peptic ulcer exacerbation, the four-week treatment with cimetidine or gastrozepine compared very favourably with almagel and vicalin as regards the treatment efficacy. In chronic gastroduodenitis, the combination of almagel, vicalin and cerucal produced a therapeutic effect that did not yield to the effect of cimetidine or gastrozepine. In 1/5-2/5 of cases, erosive esophagitis was not amenable by the four-week treatment. In 17 out of 18 such patients, the two-week therapy with sucralfat (venter) resulted in the disappearance of esophagitis with multiple erosions. During 1-2 years, erosive reflux esophagitis recurred in 11 out of 34 patients with peptic ulcer and in 2 out of 17 suffering from chronic gastroduodenitis. In all the cases, the disease recurred in those patients who had not received systematic treatment with antisecretory and cytoprotector agents.     

自发性孤立性肠系膜上动脉夹层的治疗

目的:探讨自发性孤立性肠系膜上动脉夹层(SISMAD)治疗方法的选择。方法:回顾性分析2008-02-2014-01收治的29例SISMAD患者的临床资料。最初保守治疗25例,其中5例保守治疗无效后改行血管腔内治疗;急诊手术4例,均行小肠切除,其中1例行肠系膜上动脉切开取栓+内膜部分切除术,1例小肠切除前行肠系膜上动脉溶栓+支架植入术。结果:20例保守治疗有效;CTA随访显示假腔血栓部分或大部溶解(14例)或夹层无变化(2例)。血管腔内治疗获满意效果,CTA随访显示假腔消失或血栓形成,真腔通畅。4例开放手术中,1例死亡,其余3例均恢复良好。结论:大多数SISMAD保守治疗有效,若腹痛持续或加重,应适时中止保守治疗,改行腔内治疗;外科手术适合于夹层所致肠缺血坏死或动脉瘤破裂。     

Les sténoses peptiques de l’œsophage : expérience d’un centre hospitalier marocain

Introduction

Peptic stricture is a benign complication of gastroesophageal reflux that still remains common in developing countries. Endoscopy plays a vital role, not only as a diagnostic tool, but also in treatment. The aim of our study is to assess the frequency of this disease in our context, establish its clinical and endoscopic profile and compare our results with those from national and international series.

Equipment and method

Over a period of eleven years (July 2002 to March 2013), we collated all patients with peptic stricture treated with endoscopic oesophageal dilation.

Results

Seventy-four patients were included, with a mean age of 50 years. They were predominantly male and 47.5% had a history of chronic gastroesophageal reflux. All patients had dysphagia at the time of the consultation appointment, 10% had pyrosis and 45% had regurgitation issues. Patients were seen at an advanced stage in their condition, on average 18 months after the start of dysphagia. An oesophageal transit study was performed in 30 patients and stricture was in the lower third of the oesophagus in 92.5% of patients. The endoscopy procedure was performed without sedation and often in the out-patient department. On average, two sessions of dilation were required for long-term remission and no complications, such as haemorrhaging or perforation, were observed. All patients received a double dose of proton pump inhibitors. Two patients were offered anti-reflux surgery.

Conclusion

Peptic stricture remains a rare condition. In our context, the combination of endoscopic dilation and medical treatment enabled us to achieve good results.     

RANITIDINE—PHARMACOLOGY AND CLINICAL USE

Ranitidine is a new histamine H₂-receptor antagonist which differs in chemical structure from both histamine and cimetidine. Animal studies have shown that it is a potent, specific competitive antagonist with a highly effective inhibitory action upon the release of acid and pepsin in gastric secretion invoked by a wide range of secretory stimulants. Similar pharmacological properties have been shown in man. It has no other measurable pharmacological effect resulting from blockade of histamine H₂-receptors, nor does it appear to exert any other biological effects in man. The gastric secretory inhibitory effects of ranitidine are qualitatively similar to those of cimetidine but are 4–9 times more potent on a weight-for-weight basis. The pharmacodynamics and pharmacokinetics are such that by administering ranitidine 150 mg morning and night, effective inhibition of intragastric acidity is achieved. Ranitidine has a greater selectivity of action than cimetidine so avoiding certain unwanted effects such as interference with enzymic degradation of a wide range of drugs metabolised by the liver mixed function oxygenase system, antiandrogenic effects and the propensity to cause confusion in the elderly. In short term treatment of duodenal ulceration, ranitidine 150 mg twice daily relieves symptoms and heals ulcers with an expected rate of approximately 80% over four weeks rising to over 90% during eight weeks of treatment, compared with placebo healing rates of around 30%. Similarly, the gastric ulcer healing rate of 60–70% at four weeks and 85% at three months was superior to placebo rates of 40–50%. In both duodenal and gastric ulcer, responses were similar to those previously reported with cimetidine. Nightly maintenance treatment with ranitidine 150 mg significantly reduces the rate of recurrence in patients with duodenal or gastric ulceration. In reflux oesophagitis, ranitidine 150 mg twice daily for six weeks reduces symptoms, and improves endoscopic appearances. Higher doses of ranitidine have been shown to control patients with the Zollinger-Ellison syndrome resistant to cimetidine. There are some reports of beneficial effects of ranitidine on acute upper gastrointestinal haemorrhage. Administered before anaesthesia, ranitidine decreases the volume and elevates the pH of gastric juice and may reduce morbidity and mortality arising from aspiration pneumonitis.     

经尿道钬激光手术治疗尿道狭窄与闭锁

目的探讨钬激光尿道内切开治疗尿道狭窄与闭锁的疗效。方法总结52例经尿道钬激光手术治疗尿道狭窄与闭锁的经验。结果该组52例,手术治疗成功50例,占96.15%。其中一次手术成功41例(78.84%),二次手术6例,三次手术2例,四次手术1例。手术失败2例,占5.77%。失败原因为,狭窄段长、感染严重各1例。术后均定期进行尿道扩张。术后50例(96.15%)排尿通畅。37例随访4～28个月,平均18个月。37例术后3～12个月尿流率检查,最大尿流率13～36(17.2±8.9)mL/s,平均尿流率11～26(15.8±5.8)mL/s,其余病例未行尿流率检查。结论经尿道钬激光手术治疗尿道狭窄与闭锁是安全、有效的治疗方法。