Diagnosis and treatment of gastroesophageal reflux disease in the mentally retarded: guidelines of a multidisciplinary consensus work group. Dutch Association of Physicians in Care of Mentally Handicapped

Gastroesophageal reflux disease (GORD) is more frequent among people with intellectual disability than among the intellectually normal population. Also GORD is more serious in this population. The diagnosis is often missed, because most intellectually disabled cannot express their complaints of GORD. For that reason a multidisciplinary working group of the Dutch Association of physicians active in the care of persons with a mental handicap has developed guidelines. The working group recommends endoscopy in case of a (alarm) symptoms: haematemesis, prolonged vomiting, irondeficiency anaemia e.c.i., and a 24 hour oesophageal pH test in case of b (aspecific) symptoms: recurrent pneumonia, refusal of food, regurgitation, rumination, dental erosions. In general most patients are cured with drug treatment (omeprazol or another proton pump inhibitor). If symptoms are not improved after 6 months of optimal treatment, surgical treatment may be considered.     

早期胃癌的超声内镜诊断及内镜下治疗效果观察

目的:观察早期胃癌的超声内镜诊断及内镜下治疗效果。方法:选取本院2017年1月~2018年12月收入的90例早期胃癌患者,均实施超声内镜诊断以及CT检查,以病理结果为参照,对其诊断价值进行分析。利用随机数字表法将其分为实施内镜治疗的观察组及实施开腹手术治疗的对照组各45例,对比两组治疗效果。结果:病理结果证实,90例早期胃癌患者T0期10例、T1期45例、T2期25例、T3期10例,超声内镜诊断符合率>CT检查,差异有统计学意义(P<0.05);观察组手术相关指标优于对照组、并发症发生率低于对照组,差异有统计学意义(P<0.05)。结论:在早期胃癌诊断中超声内镜能够取得理想的效果,内镜治疗更有助于降低并发症发生率。     

78例青年人胃癌的临床诊断过程分析

目的总结青年人胃癌早期诊断困难的原因,并探讨其改善的办法。方法对78例青年人胃癌的诊疗全过程进行回顾性分析和总结。结果青年人胃癌临床表现无特异性,首发症状多样化,但以上腹不适为主。早期诊断困难的原因主要有四点:一是首诊医生滥用抗酸制剂而不重视胃镜和上消化道钡餐检查等;二是内镜医生对可疑早期癌的细微病变活检不规范;三是医生对溃疡型早期胃癌可有“溃疡-愈合-溃疡”的临床过程认识不足;四是对胃粘膜癌前病变认识不充分。结论对20岁以上出现上腹隐痛不适、纳差、乏力、黑便或不明原因呕吐等一项或一项以上者,均须早行胃镜和病检。重视“溃疡复发”患者的胃镜和规范活检,对溃疡疤痕或新形成的溃疡要予以多点、多块和深掘取材活检,每年1~2次,以持续3年为宜。对胃粘膜癌前病变至少密切胃镜随访3年。     

Open access endoscopy in an epidemiological situation of high prevalence of Helicobacter pylori infection: applicability of the guidelines of the European Society for Primary Care Gastroenterology

BACKGROUND: Dyspepsia is a common syndrome and provides primary care physicians with a significant workload. To optimize the management of dyspepsia, several guidelines have been developed. OBJECTIVE: The aim of this study was to determine the incidence of upper gastrointestinal diseases and their relationship to Helicobacter pylori infection in dyspeptic patients referred for upper endoscopy by family physicians, as well as to assess the applicability of the guidelines of the European Society for Primary Care Gastroenterology (ESPCG). METHODS: A total of 168 unselected dyspeptic out-patients (mean age 38 years, range 18-75), 88 male and 80 female, were included. Two biopsies from the antrum and two from the corpus were taken for histological assessment, and one from the antrum and one from the corpus were taken for culture. RESULTS: Half of the patients had clinically significant findings at endoscopy: peptic ulcer which occurred in 35% of the patients under the age of 30 years, in 45% of the patients in the age group 30-44 years and in 36% of the patients over 45 years of age. The prevalence of H. pylori infection in these age groups was 67, 87 and 89%, respectively. Duodenal ulcer was 12 times more common than gastric ulcer. CONCLUSIONS: The overall incidence of upper gastrointestinal disease, especially among young dyspeptic patients, was high compared with that observed in Western countries. The characteristics of dyspeptic patients, consulted in primary care, should be used for adaptation of the ESPCG guidelines to local needs.     

Gastrostomy, esophagitis, and gastrointestinal bleeding in older adults

INTRODUCTION: Percutaneous endoscopic gastrostomy tubes (PEG) are commonly used in older adults with dysphagia and poor nutrition. The association of PEG with upper gastrointestinal bleeding (UGIB) and role of gastroesophageal reflux disease (GERD) in relation to UGIB in patients with PEG are not well known. METHODS: We conducted a retrospective analysis of older patients with PEG, hospitalized for UGIB, during a 1-year period between 1997 and 1998. The study was performed in a university teaching hospital involving residents from long-term care facilities (LTCF) of the Bronx. RESULTS: A total of 38 patients with PEG were admitted for UGIB; 28 were evaluated with upper endoscopy. The mean age of the group who underwent endoscopy was 83.4 +/- 9.2 years, with 18 females and 10 males. In the same group, 13 patients were on H2 blockers and 4 patients used nonsteroidal antiinflammatory drugs before hospitalization. None of the residents were on proton pump inhibitors. The most common upper endoscopic findings were esophagitis, either alone (11 patients) or in association with other lesions (10 patients). Esophagitis predominantly involved the lower third of the esophagus. Other significant findings on endoscopy were gastric and duodenal ulcers, gastritis, and gastric erosions either alone or in combinations. CONCLUSIONS: Esophagitis is a common occurrence and a significant contributor for UGIB in patients with PEG. Use of H2 blockers does not appear to be an effective preventive measure for UGIB in these patients.     

Cost-effectiveness analysis of two management strategies for dyspepsia

OBJECTIVES: To compare the cost-effectiveness of endoscopy and empirical proton pump inhibition (PPI) therapy for management of dyspepsia in primary care. METHODS: A randomized controlled trial, including prospective collection of economic resource data, was conducted in general practice from June 2000 to August 2002, Aarhus County, Denmark. We randomly assigned 368 dyspeptic patients from thirty-two general practices to treatment with omeprazol 40 mg for 2 weeks (n=184) or endoscopy (n=184). The study adopted a societal perspective, and the year of costing was 2006. Outcome measures: days free of dyspeptic symptoms and proportion of patients with dyspepsia after 1 year based on patients' and general practitioners' (GPs) assessment. Costs were estimated from patient and GP questionnaires and from medical records. RESULTS: The incremental cost-effectiveness (CE) ratio for 1 day free of dyspeptic symptoms using the endoscopy strategy was euro/day 154 compared with the PPI strategy. The incremental CE ratio for one person free of dyspeptic symptoms after 1 year using the endoscopy strategy was euro13,905 based on the patients' evaluation, and the incremental CE ratio for one person free of predominant symptoms after 1 year was euro5,990 according to the GPs' evaluation. The PPI strategy was both cheaper and more effective than the endoscopy strategy when reflux was the predominant symptom. CONCLUSIONS: A strategy using empirical antisecretory PPI therapy should be recommended if the alternative is an endoscopy strategy for managing dyspeptic patients in general practice, especially if reflux was the predominant symptom.     

Barrett's esophagus: endoscopic treatment of high-grade dysplasia and early cancer

In a Barrett's oesophagus without dysplasia, endoscopic control every 3-5 years is sufficient. If low-grade dysplasia is encountered in the surveillance biopsies, then endoscopy should be repeated within 3-6 months and yearly thereafter if the low-grade dysplasia persists. Antacid medication must be prescribed in cases with extensive inflammation. The endoscopic treatment of patients with high-grade dysplasia and/or early cancer of the mucosa in a Barrett's oesophagus (tissue ablation and/or mucosa resection) seems a promising alternative to surgery in view of the combination of effectiveness, limited invasiveness compared to surgical resection, and the preservation of a functional oesophagus. Data from long-term follow-up are still limited. Strict endoscopic surveillance will probably detect metachronic abnormalities in an early and still curable stage, creating a new opportunity for endoscopic treatment.     

Dietary antioxidants and DNA damage in patients on long-term acid-suppression therapy: a randomized controlled study

Free radicals and reactive species produced in vivo can trigger cell damage and DNA modifications resulting in carcinogenesis. Dietary antioxidants trap these species limiting their damage. The present study evaluated the role of vitamins C and E in the prevention of potentially premalignant modifications to DNA in the human stomach by supplementing patients who, because of hypochlorhydria and possible depletion of gastric antioxidants, could be at increased risk of gastric cancer. Patients undergoing surveillance for Barrett's oesophagus (n 100), on long-term proton pump inhibitors were randomized into two groups: vitamin C (500 mg twice/d) and vitamin E (100 mg twice/d) for 12 weeks (the supplemented group) or placebo. Those attending for subsequent endoscopy had gastric juice, plasma and mucosal measurements of vitamin levels and markers of DNA damage. Seventy-two patients completed the study. Plasma ascorbic acid, total vitamin C and vitamin E were elevated in the supplemented group consistent with compliance. Gastric juice ascorbic acid and total vitamin C levels were raised significantly in the supplemented group (P=0.01) but supplementation had no effect on the mucosal level of this vitamin. However, gastric juice ascorbic acid and total vitamin C were within normal ranges in the unsupplemented group. Mucosal malondialdehyde, chemiluminescence and DNA damage levels in the comet assay were unaffected by vitamin supplementation. In conclusion, supplementation does not affect DNA damage in this group of patients. This is probably because long-term inhibition of the gastric proton pump alone does not affect gastric juice ascorbate and therefore does not increase the theoretical risk of gastric cancer because of antioxidant depletion.     

对住院病人中胃癌患者的回顾性调查

综合性医院181 055例住院病人中1079例胃癌患者的调查结果:胃癌患者占住院病人总数的0.59%,其中进行癌与早欺癌分别占胃癌总数的98.24%与1.76%。男女之比约6:1。胃癌的多发年龄范围为40~70岁,多发年龄高峰是50~60岁。入院前病程1年以上者多有胃病史。早期癌病理回顾:有溃疡癌变者占早期癌总数的78.94%。胃癌病变的分布、癌灶大小、数目、大体分型等与有关文献相比不尽相同。常规法,低张双重法,内窥镜法对进行癌的病变发现率与诊断正确率相似,经统计学处理:P值均大于0.05,即无显著差异。多相胃肠造影技术相结合,胃肠造影与内窥镜相结合,具有互相印证补偿作用。此外,在上述调查结果的基础上,还就在现有的医疗设备等条件下提高胃癌的诊断准确性做了有关的扼要探讨。     

Guideline "Dyspepsia"

For the management of patients with dyspepsia a multidisciplinary working party has made recommendations, i.e. about indications for prompt endoscopy, the management of dyspeptic complaints of recent onset, the application of diagnostic tests and treatment of recurrent dyspepsia and the indications for long term use of acid suppressants. Endoscopy is indicated in every patient with alarm symptoms, i.e. blood loss, dysphagia, weight loss or anemia in combination with dyspepsia. Age alone is not a decisive factor in this. Given the good prognosis of recent onset dyspepsia, the application of diagnostic tests is generally not required. Treatment should be restricted to antacids or H2 receptor antagonists. Only in case of persistent or recurring complaints, diagnostic tests or another treatment (Helitobacter pylori diagnostic tests, empirical treatment or endoscopy) should be considered. Testing for H. pylori is especially effective in patients at risk for peptic ulcer disease: those with recurrent complaints, and those with a history of peptic ulcer, without typical reflux symptoms or those with a history ofpeptic ulcer. Short term empirical treatment with a proton pump inhibitor is especially effective in patients with typical reflux symptoms. Endoscopy is the only way to rule out malignancy, and should be used to solve serious diagnostic uncertainty in patient or physician. The only indication for continuous proton pump inhibitor treatment is severe oesophagitis. All other patients with less severe reflux disease should preferably be treated on either on demand or intermittent basis. Long term proton pump inhibitor treatment is not indicated for patients with peptic ulcer disease or functional dyspepsia.     

早期内镜诊断和治疗隐匿型胆源性胰腺炎

目的 探讨早期内镜诊断和治疗隐匿型胆源性胰腺炎的临床价值.方法 2007年1月至2009年12月完成的93例急性胰腺炎早期内镜治疗,常规进行内镜乳头切开,观察治疗后症状缓解和复发情况.结果 急性胆源性胰腺炎占62.4%(58/93),其中经内镜诊治隐匿型胆源性胰腺炎占27.6%(16/58),内镜治疗缓解率93.8%(15/16),无手术和复发病例.结论 隐匿型胆源性胰腺炎占有一定的比例,容易漏诊和复发,内镜是目前最有效的诊断和治疗方法.     

早期胃癌诊断与治疗研究进展

胃癌是世界范围内高居第二位的癌症死亡原因,但是由于各种原因发现时已是中晚期,并常伴有转移,总体预后不良。因此,早期诊断和治疗仍然是改善预后的关键。早期胃癌的诊断和治疗方法很多,而我国目前早期胃癌诊断率严重低于韩日等发达国家,同时,目前早期胃癌的治疗也已经从传统的外科手术转向内镜局灶切除。现结合近年来国内外有代表性的早期胃癌诊断与治疗方面的文献,对早期胃癌诊断与治疗现状进行综述,以期为我国早期胃癌的诊断与治疗提供理论依据。     

Early gastric cancer--two case reports

Gastric cancer is a serious disease with a high mortality rate. Early diagnosis of the disease improves its prognosis. We report two cases of early gastric cancer and we specify the clinical, endoscopic, histologic and therapeutic aspects of the disease. This study is about two female patients, respectively, 36 and 70 years old. The diagnosis of early gastric cancer was based on pathologic examination of the resected stomach. The two patients are in remission 2 years and 6 months later, respectively. The diagnosis of early gastric cancer is often made on nonspecific symptoms. Oeso-gastro-duodenoscopy shows gastric mucosal anomalies. Pathologic examination of gastric biopsies confirm the diagnosis of adenocarcinoma. Endoscopic ultrasound is essential; it specifies the submucosal infiltration and evaluates the lymph node invasion. Surgery is the primary treatment but in some cases endoscopic mucosal resection provides good long-term results. Early diagnosis of adenocarcinoma improves the prognosis of the disease, which remains poor nowadays.     

内镜窄带成像筛查早期胃癌、癌前病变的应用分析

目的观察内镜窄带成像技术（NBI）筛查癌前病变、早期胃癌的特点。方法对74例患者进行了研究,同一病例自身对照,在无痛麻醉状态下,先进镜至十二指肠降段,用普通模式退镜观察至贲门,记录发现病灶,低倍放大病灶（1．4、1．6、1．8倍）。再次进镜至十二指肠降段,用NBI模式退镜观察至贲门记录所发现病灶,对病灶低倍放大（1．4、1．6、1．8倍）,可疑病灶行活检。把图片转化为Word文档,按需放大图片。结果慢性胃炎以A型、AB型较多;轻度肠化、轻度不典型增生：以BC、AB较多,总体分析是以含C型的混合型居多;中度不典型增生：CD型、AC型;重度不典型增生：CD型、D型;早期胃癌（浅表凹陷）：BC型＋不规则粗A型;进展期胃癌：CD型、D型、C型;幽门螺杆菌感染：A型、B型较多;隆起型、凹陷型病灶普通内镜、NBI下病灶没有漏诊。但对于平坦型病灶普通内镜易漏诊,NBI较少漏诊。结论NBI具有操作简单、安全,能够较为清晰发现癌前病变、早期胃癌的病灶。使活检病理检查阳性率明显提高,从而提高癌前病变、早期胃癌、平坦型病灶的诊断率。     

Functional dyspepsia: the past, the present and the Rome III classification

The author summarizes the historical development of our knowledge about functional dyspepsia and overviews the so-called "road to Rome" process. Between 1988 and 2006, expert committees developed using the Delphi method subsequent classifications of functional gastrointestinal disorders (Rome I-III). The Rome III classification reassessed the diagnostic criteria for functional dyspepsia and distinguished new subgroups as the postprandial distress and epigastric pain syndrome. The rationale for the proposed new classification was based on the inadequacy of prior approaches such as the predominant symptom, the results of factor analyses in tertiary care and in the general population, clinical experience and new observations in the peer-reviewed literature. Epidemiologic data suggest that dyspeptic symptoms date back to the 1730s and their prevalence increased markedly subsequently, remaining the commonest diagnosis even in the endoscopic era. The current worldwide prevalence of functional dyspepsia is 7-45%, with large geographic variations. The role of Helicobacter pylori and Salmonella infection as etiologic factors is discussed. Amongst the pathophysiological features, the recent data on the role of phenotypic changes of acid secretion, alterations of fundic accommodation and antro-duodenal motility and gastric emptying, gastric hypersensitivity and hormonal disturbances are presented, but all these abnormalities are present only in a small part of the patients. The possible role of the polymorphism of alpha-adrenoceptor gene was also raised. The treatment of functional dyspepsia led to equivocal results and the high rate of placebo response makes difficult any interpretation. According to the recent meta-analyses, proton pump inhibitors and H 2 -histamine receptor blockers are superior to placebo. In spite of good results, cisapride was withdrawn in 2004. Eradication of Helicobacter pylori can induce sustained remission in a small but significant minority of patients. However, it might prevent further development of peptic ulcer and gastric carcinoma and from public health view, eradication of the infection must be performed by using a test-and-treat or test-and-scope strategy and the benefits and risks of this approach must be discussed with the patient. Each of the above treatments achieves transient symptomatic improvement only and follow-up of dyspeptic patients for 5-7 years showed the benign, but recurrent nature of the disease in 50% of the cases. The aim of the Rome III classification is the identification of pathophysiological changes associated with the new subgroups of functional dyspepsia which will permit their targeted pharmacologic treatment leading to better and cost-efficient results.     

21例早期胃癌患者的临床病理特点

目的分析早期胃癌的临床病理特点。方法选择本院21例经内镜活检及病理诊断为胃癌、手术后病理确诊为早期胃癌的患者,分析并总结其内镜下的特点、部位及病理类型。结果21例患者中,病灶位于胃窦12例,胃体4例,胃角4例,胃底1例。早期胃癌镜下分型中,Ⅰ型1例,Ⅱ型12例,Ⅲ型8例。黏膜内癌13例,黏膜下层癌8例,其中黏膜内癌淋巴结转移2例,黏膜下层癌淋巴结转移1例;高、中低分化管状腺癌10例,腺癌6例,印戒细胞癌4例及乳头状腺癌1例。结论内镜检查是诊断早期胃癌的首选方法,增强对内镜表现及病理认识,有助于提高早期胃癌检出率。     

大剂量质子泵抑制剂治疗上消化道溃疡出血患者止血后再出血的临床效果分析

目的：观察两种质子泵抑制剂（PPI）治疗内镜下止血后再出血的胃十二指肠溃疡的效果。方法：将2010年5月-2012年7月118例在本院住院的符合入选标准的胃十二指肠溃疡出血胃镜下止血后再出血的患者,按入院先后次序半随机分成试验组和对照组各59例,试验组与对照组分别采用大剂量口服雷贝拉唑、奥美拉唑静脉恒速泵入治疗,治疗72 h后稳定的患者,第4天两组患者再继续10 mg/d雷贝拉唑口服,至第6周胃镜检查,判断治疗效果。结果：两组患者6周内失访人数试验组3例（5.08%）,对照组6例（10.17%）（P〉0.05）。两组患者治疗后试验组再出血率为1.79%、手术1.79%,对照组再出血率为5.66%、手术3.77%、输血1.89%（P〉0.05）。结论：大剂量口服雷贝拉唑与奥美拉唑静脉恒速泵入治疗内镜下止血后再出血的胃十二指肠溃疡均有比较好的疗效,但大剂量口服雷贝拉唑治疗安全、费用相对低、患者能接受,值得临床推广应用。     

Reasons for proton-pump-inhibitor failure in the treatment of gastroesophageal reflux disease

The introduction of proton pump inhibitors (PPI) has facilitated the successful management of patients with gastroesophageal reflux disease (GERD). In a minor, but still relevant proportion of patients with GERD-like symptoms, PPI therapy has also proved to be ineffective. In such cases, the first question to be answered is if the symptoms and complaints are related to GERD indeed, or another disorder should be searched for. If GERD is still the most likely diagnosis, patients' compliance should be thoroughly investigated before any further diagnostic and therapeutic measure is taken. If PPI failure is not a result of inadequate management of GERD, there are several other disorders to be ruled out. In our review, we summarize the most important differential diagnostic issues of PPI failure.     

Drug-induced tubulointerstitial nephritis

Three patients were diagnosed with drug-induced tubulointerstitial nephritis: a 72-year-old woman who was using a proton pump inhibitor, an 83-year-old woman who had recently been treated with antibiotics and an 83-year-old man who was using omeprazole. Discontinuation of the medications in question and the initiation of glucocorticoids resulted in improved renal function. In two of these patients, the diagnosis was established by renal biopsy. Acute tubulointerstitial nephritis is an important cause of renal insufficiency. It is characterized by inflammatory changes in interstitial tissue. Frequently prescribed medications such as proton pump inhibitors, antibiotics and nonsteroidal anti-inflammatory drugs may cause acute tubulointerstitial nephritis. Other causes are infections and auto-immune diseases. Renal failure may be reversible when use of the offending drug is discontinued. Partial or total renal insufficiency may, however, persist. Early treatment with steroids seems to improve the recovery of renal function in patients with drug-induced tubulointerstitial nephritis, although the evidence is not conclusive.     

内镜介入治疗溃疡性上消化道出血的临床应用效果分析

目的:研究探讨内镜介入治疗溃疡性上消化道出血的临床应用效果分析。方法:该研究选择本院2018年1月~2019年1月溃疡性上消化道出血的患者,总计80例,使用随机数字表法,将患者均分为对照组以及研究组,各40例。对照组给予质子泵抑制剂治疗,研究组在此基础上给予内镜介入治疗。分析两组患者治疗后12、24、48h止血状况和空腹胃液pH值,对比两组患者临床疗效以及不良反应状况。结果:研究组治疗疗效和对照组比较明显更高,治疗后患者的止血状况明显优于对照组,治疗前后空腹胃液pH值对比,差异有统计学意义,P<0.05。两组患者并没有严重不良反应出现。结论:针对溃疡性上消化道出血患者予以内镜介入治疗,能够改善临床症状,提升治疗疗效,值得应用。