Real-time evaluation of dyspeptic symptoms and gastric motility induced by duodenal acidification using noninvasive transnasal endoscopy

Background  Although different pathophysiological mechanisms have been suggested to be involved in functional dyspepsia, a practical method to clarify them has not been established. The aim of this study was to evaluate dyspeptic symptoms and gastric motility induced by duodenal acidification using transnasal endoscopy. Methods  Fourteen healthy volunteers (mean age, 32 years) were enrolled. Transnasal endoscopy was performed on all fasting volunteers. Dyspeptic symptoms and antral contractions were evaluated before and after duodenal infusions of pure water (20 ml/min for 5 min) and acid (0.1 N HCl, 20 ml/min for 5 min). The severity of various symptoms was assessed by each subject using a 10-cm visual analog scale every 2 min. The maximum severity scale was calculated as the mean of the individual maximum values. The motility number was defined as the mean number of antral contractions in 1 min. Results  The maximum severity score for a heavy feeling in the stomach and other symptoms significantly increased after the acid infusion compared with after the pure water infusion. During pure water infusion, there were no changes in the motility number. On the other hand, the motility number significantly decreased after duodenal acidification (before vs. after, 2.93 ± 0.12 times vs. 1.11 ± 0.23 times, P < 0.0001). Conclusions  Duodenal acid exposure induces dyspeptic symptoms and inhibits antral motility. Transnasal endoscopy enabled us to evaluate both dyspeptic symptoms and gastric motility simultaneously.     

Dyspeptic symptoms associated with hypersensitivity to gastric distension induced by duodenal acidification

BACKGROUND AND AIM: Duodenal acidification might increase sensitivity to gastric distension, which seems to play a role in the genesis of dyspeptic symptoms in a subset of patients with functional dyspepsia. The aim of the present study was to investigate the characteristics of dyspeptic symptoms associated with hypersensitivity to gastric distension induced by duodenal acidification. METHODS: An infusion tube and a barostat bag were positioned in the duodenum and gastric fundus, respectively. Sensitivity to stepwise fundic distensions with severity scoring of the seven dyspeptic symptoms was assessed before and during duodenal acid infusion in 20 healthy subjects. RESULTS: Acid infusion significantly decreased the pressures and the corresponding wall tensions at the thresholds for discomfort. At the distending level of minimal distending pressure (MDP) + 2 mmHg, significantly higher scores of fullness and bloating were obtained during acid infusion. With distending stimuli of MDP + 4 and 6 mmHg, fullness, bloating, nausea, satiety, epigastric burning and epigastric pain were significantly more severe during acid infusion than before acid infusion. At the level of MDP + 8 mmHg, the severity of epigastric pain was significantly greater, compared with that before acid infusion. CONCLUSIONS: Duodenal acidification might aggravate dyspeptic symptoms through the induction of hypersensitivity to gastric distension in healthy individuals. Those symptoms are diverse and variable, depending on the strength of the distending stimuli.     

Effect of capsule placement with transnasal endoscopy

Aim: One of the prohibiting factors in achieving complete small bowel capsule endoscopy is slow gastric transit of the capsule. The present study retrospectively investigated the success rate of, and the time required for, transnasal endoscope‐assisted capsule placement to assess its clinical utility. Methods: In 24 of 27 patients who underwent capsule placement assisted by a transnasal endoscope, the capsule was successfully transported to and released in the duodenum (capsule placement group). For each patient in the capsule placement group, three age‐ and sex‐matched patients who underwent conventional capsule endoscopy were assigned as controls (n = 72). Gastric transit time, small bowel transit time, and rate of capsule arrival at the cecum within 8 h were compared between the two patient groups. Results: Among the 27 patients in whom capsule placement was carried out, the capsule was successfully placed in the duodenum in 24 patients (88.9% success rate). In the capsule placement group, gastric transit time was significantly shorter (10.5 vs 46.2 min, P = 0.0021), small bowel transit time was significantly longer (354.7 vs 301.3 min, P = 0.0134), and completion rate (capsule arrival at the cecum within 8 h) was significantly higher (83.3 vs 61.1%, P = 0.0455) than in the control group. There were no procedural accidents associated with capsule placement. Conclusion: Transnasal endoscope‐assisted capsule placement appears to be a safe and reliable procedure, achieving complete small bowel capsule endoscopy, and is considered clinically useful.     

Prospective randomized trial of transnasal versus peroral endoscopy using an ultrathin videoendoscope in unsedated patients

AIM: The aim of this study was to compare the acceptance and tolerance of transnasal and peroral esophagogastroduodenoscopy (EGD) using an ultrathin videoendoscope in unsedated patients. METHODS: A total of 124 patients referred for diagnostic endoscopy were assigned randomly to have an unsedated transnasal EGD (n = 64) or peroral EGD (n = 60) with local anesthesia. An ultrathin videoendoscope with a diameter of 5.9 mm was used in this study. A questionnaire for tolerance was completed by the patient (a validated 0-10 scale where '0' represents no discomfort/well tolerated and '10' represents severe discomfort/poorly tolerated). RESULTS: Of the 64 transnasal EGD patients, 60 patients (94%) had a complete examination. Four transnasal EGD examinations failed for anatomical reasons; all four patients were successfully examined when switched to the peroral EGD. All 60 peroral EGD patients had a complete examination. Between the transnasal and peroral groups, there was a statistically significant difference in scores for discomfort during local anesthesia (1.5 +/- 0.2 vs 2.6 +/- 0.3, P = 0.003), discomfort during insertion (2.3 +/- 0.3 vs 4.3 +/- 0.3, P = 0.001), and overall tolerance during procedure (1.6 +/- 0.2 vs 3.8 +/- 0.2, P = 0.001). In all, 95% of transnasal EGD patients and 75% of peroral EGD patients (P = 0.002) were willing to undergo the same procedure in the future. Four patients in the transnasal EGD group experienced mild epistaxis. CONCLUSION: For unsedated endoscopy using an ultrathin videoendoscope, transnasal EGD is well tolerated and considerably reduces patient discomfort compared with peroral EGD.     

老年冠心病患者经鼻胃镜检查的安全性分析

目的探讨老年冠心病患者经鼻胃镜检查的安全性。方法选择2012年1月至2012年12月在北京老年医院接受胃镜检查的65岁以上老年患者100例,分为经鼻胃镜及普通胃镜组（各50例）,每组再分为冠心病及非冠心病（各25例）,比较各组胃镜检查中心率、血压、血氧饱和度、心肌耗氧量及心电图变化。结果普通胃镜检查中,冠心病患者心率、血压、心肌耗氧量增加较非冠心病患者明显（P＜0.05）,血氧饱和度下降值较非冠心病患者高（P＜0.05）,冠心病患者心律失常及ST段下移发生率较非冠心病患者高（P＜0.05）;冠心病患者经鼻胃镜检查中,心率、血压、心肌耗氧量增加值较普通胃镜明显低（P＜0.05）,血氧饱和度下降值低（P＜0.05）,心律失常及ST段下降发生率低（P＜0.05）。结论老年冠心病患者经鼻胃镜检查耐受性好,对心血管影响小,安全性高。     

Unsedated transnasal percutaneous endoscopic gastrostomy carried out by a single physician

Aim: The present prospective observational study investigates the safety of transnasal percutaneous endoscopic gastrostomy (T‐PEG) carried out by a single physician using an ultrathin endoscope. Methods: A single endoscopist attempted the unsedated transnasal insertion of a 20‐Fr PEG tube using a pull‐method in 31 dysphagic patients: 11 females and 20 males aged 76.5 ± 10.6 (46–96) years, using a 5‐mm‐diameter endoscope. The indications for PEG, cardiopulmonary function before and after T‐PEG, operation time, success or failure, and any immediate adverse events that occurred during each procedure were recorded. Complications, including peristomal infection, systemic infection, tube lifespan, and patient mortality were monitored throughout the post‐T‐PEG follow‐up period. Results: Thirty (96.8%) of the transnasal PEG insertions were successful. The mean operation time was 14.7 ± 2.9 (10–20) min, and cardiopulmonary function did not change before and after T‐PEG. Complications included three (10%) cases of epistaxis, eight (26.6%) cases of minor Pseudomonas wound infection and two cases of Foley‐related urinary tract infection (UTI). No self‐extubation was observed, and the mean lifespan of the PEG tubes was 10.7 ± 2.2 months. Four patients died from pneumonia 10 months after T‐PEG insertion. Conclusion: Unsedated T‐PEG insertion carried out by a single physician is a feasible and safe procedure. No major complications or mortality were observed following the procedures; only minor Pseudomonas aeruginosa wound infections were noted. It is an alternative method for dysphagic patients when transoral insertion of endoscopy is impossible.     

Evaluation of esophageal function in patients with gastroesophageal reflux disease using transnasal endoscopy

Background and Aims:  To investigate the utility of a new method of carrying out esophageal manometry using a narrow gauge manometry catheter via a transnasal endoscope.
Methods:  The Frequency Scale for the Symptoms of gastroesophageal reflux disease (GERD) (FSSG), a GERD-specific questionnaire, was given to 45 subjects. Subjects 
underwent transnasal endoscopy with three dry and three wet (3 mL water) swallows. Direct observations of the primary peristaltic wave and peristaltic pressure measurement were conducted simultaneously.
Results:  Endoscopic observation of lower esophageal motility associated with swallowing revealed dilatation of the esophageal lumen after swallowing, followed by contraction in association with the primary peristaltic wave. The peristaltic pressure was significantly lower with increased FSSG scores for dry swallows ( r  = −0.347, P  = 0.0212), but no significant correlation was seen for wet swallows.
Conclusions:  The significant negative correlation between reflux symptoms and peristaltic pressure in dry swallows was thought to be that reduced pressure immediately rostral to the lower esophageal sphincter leads to decreased clearance following gastric acid reflux, playing a large part in the onset of symptoms.     

Autonomic nervous function in upper gastrointestinal endoscopy: A prospective randomized comparison between transnasal and oral procedures

Background. Transnasal esophagogastroduodenoscopy (EGD) using an ultrathin endoscope is less stressful to the cardiovascular system with less elevation of systolic blood pressure (BP) than oral procedures. To elucidate the mechanism of such beneficial cardiovascular responses, we performed a prospective patient-centered randomized study in which BP and pulse rate (P), as well as autonomic nervous functions, were estimated during transnasal EGD compared with those in oral procedures using the same ultrathin endoscope. Methods. The study involved 781 patients, among whom 55 and 56 cases were assigned to transnasal and oral EGD groups, respectively. The autonomic nervous responses were determined employing power spectral analysis (PSA) of heart-rate variations on electrocardiogram. PSA data were based on two peaks in lowfrequency (LF) and high-frequency (HF) ranges. HF power and the ratio of LF power/HF power represented parasympathetic and sympathetic nervous activities, respectively. Results. Our study confirmed the lesser elevation of BP and P in patients undergoing transnasal EGD than in those undergoing oral procedures. PSA revealed a lower increase in LH power/HF power in transnasal EGD than in oral EGD. However, both endoscopic procedures equally suppressed HF power. Significant correlations were found between the parameters of cardiovascular response (P and BP) and autonomic functions (LF power/HF power ratio and HF power). Conclusions. This is the first study demonstrating less sympathetic stimulation in patients undergoing transnasal EGD, leading to lesser elevation of BP and P.     

Role of duodenal lipid and cholecystokinin A receptors in the pathophysiology of functional dyspepsia

BACKGROUND/AIMS: We aimed to evaluate the role of fat and cholecystokinin (CCK) in the pathophysiology of functional dyspepsia (FD) by investigating symptoms and plasma CCK levels following increasing doses of duodenal lipid during gastric distension, and the effect of CCK-A receptor blockade. SUBJECTS/METHODS: In study A, six FD patients were studied on three occasions during duodenal infusion of saline or lipid (1.1 (L-1) or 2 kcal/min (L-2)) and proximal gastric distensions. Six healthy subjects were also studied as controls during L-2 only. In study B, the effect of the CCK-A antagonist dexloxiglumide (5 mg/kg/h) on L-2 induced symptoms was studied in 12 FD patients. Changes in gastric volume at minimal distending pressure and plasma CCK (study A) were assessed, gastric distensions were performed using a barostat, and dyspeptic symptoms were monitored. RESULTS: Lipid increased gastric volume compared with saline (DeltaV (ml): saline 15 (20), L-1 122 (42), L-2 114 (28)) in patients and even more so in controls (221 (37); p<0.05). During distensions, symptoms were greater during L-2 than during saline or L-1, and greater in patients than in controls, while gastric compliance was smaller in patients than in controls (p<0.05). Lipid increased plasma CCK levels in patients and controls (p>0.05). Dexloxiglumide abolished the increase in gastric volume (DeltaV (ml): dexloxiglumide 17 (9), placebo 186 (49)) and dyspeptic symptoms (sum of scores: dexloxiglumide 24 (7), placebo 44 (19)) during duodenal lipid infusion. Dexloxiglumide also reduced gastric compliance (ml/mm Hg: dexloxiglumide 51 (7), placebo 72 (11)) and symptoms (sum of scores: dexloxiglumide 101 (17), placebo 154 (21)) during gastric distension. CONCLUSION: CCK-A receptors are involved in the generation of dyspeptic symptoms by duodenal lipid during gastric distension.     

The personality patterns in patients with duodenal ulcer and ulcer-like dyspepsia and their relationship to the course of the diseases

Abstract. Objectives. To compare personality characteristics in duodenal ulcer patients and patients with ulcer-like dyspepsia from the primary health sector with duodenal ulcer patients from a hospital and to evaluate the relationship of the personality characteristics to the course of the diseases. Design. A prospective study using the Minnesota Multiphasic Personality Inventory (MMPI) with retesting of a subgroup of patients after a median observation period of 14 months. Setting. Departments of Medical and Surgical Gastroenterology, Hvidovre University Hospital, and the primary health sector in Roskilde County, Denmark. Subjects. Sixty hospital patients with duodenal ulceration and 17 patients with duodenal ulceration plus 2 5 patients with ulcer-like dyspepsia from the primary health sector. Main outcome measures. MMPI scores. Results. The hospital patients differed from the two other groups of patients by having higher scores of depression and anxiety (P < 0.05). Twenty-eight of the patients were retested with MMPI. Contrary to the patients with persisting complaints, abnormal personality characteristics disappeared in patients without complaints (P < 0.05-0.001). Conclusions. The results indicate that abnormal personality characteristics in patients with functional and organic upper dyspepsia are consequential rather than causal factors.     

Evaluation of a new referral system for the management of dyspepsia in Hong Kong: role of open-access upper endoscopy

BACKGROUND: In the management of dyspepsia, upper endoscopy is an important component. In our locality, patients requiring upper endoscopy are conventionally referred to specialist clinics by family physicians. We have introduced the first open-access upper endoscopy service in Hong Kong, which has allowed family physicians to arrange endoscopy without prior specialist consultation. A study on the outcome of open-access upper endoscopy in contrast with the conventional referral system was conducted. METHODS: For patients presenting with dyspepsia, family physicians in our region were given the option to arrange upper endoscopy directly with our Medical Endoscopy Unit in addition to the conventional referral to specialist clinics. The results were compared with those from the specialist clinic. A detailed prospective follow up was performed from June to September 1997 to evaluate the outcome and impact of open-access upper endoscopy. RESULTS: From November 1996 to September 1999, 978 referrals for open-access upper endoscopy were received. The service significantly reduced the waiting time for the procedure by 16 weeks. Open-access upper endoscopy had similar detection rates for peptic ulcers and cancers compared with referrals from specialist clinics. Seventy-five percent of patients did not require further consultation with their family physicians within 2 months after endoscopy. It is a safe and effective procedure in establishing a definitive diagnosis. All family physicians were satisfied with the open-access upper endoscopy service. CONCLUSIONS: This is the first Asian report on this service. Open-access upper endoscopy reduced waiting time from the patient perspective, decreased subsequent consultations with family physicians and reduced referral to specialist clinics as well as increased patient and doctor satisfaction. Both referral systems for endoscopy were similar in terms of the diagnostic yield.     

全景胃镜对十二指肠主乳头观察的随机对照研究

目的 探讨全景胃镜对十二指肠主乳头观察的效果和安全性。 方法 2017年3月至2017年12月在解放军总医院消化内镜中心接受无痛胃镜检查的患者按照随机化分组、自身对照原则，将符合入选标准的研究对象按就诊顺序编号，采用随机数字表法随机分为两组，分别进行普通胃镜检查（A组）或者全景胃镜检查（B组）。以十二指肠主乳头的观察情况作为主要评价指标，比较两组对十二指肠主乳头的观察率。 结果 根据入组标准共纳入100例患者，其中A组51例、B组49例。B组十二指肠主乳头全部观察率优于A组[7959%(39/49)比4118%(21/51),χ2=15366，P=0000]，而对十二指肠主乳头的总体观察率（全部、部分观察率之和）与A组比较差异无统计学意义[10000%(49/49)比9216%(47/51),χ2=2221，P=0136]。 所有患者顺利完成检查，无出血、穿孔、死亡等并发症发生。 结论 全景胃镜广阔的视野有效提高了十二指肠主乳头观察的有效性和安全性。     

Gastric metaplasia of the duodenum: in vivo diagnosis by endomicroscopy and its relationship with functional dyspepsia

Background and Aim: Gastric metaplasia (GM) of the duodenum is difficult to assess because of its patchy distribution, and the role of GM in functional dyspepsia (FD) is not clear. The aims of this study were to determine if endomicroscopy could identify GM of the duodenum and whether GM has associations with FD. Methods: A series of 51 patients with FD and 25 asymptomatic controls were enrolled. Confocal laser endomicroscopy was performed to evaluate villi changes in vivo. Targeted biopsy specimens were then compared with histopathological results. Results: The accuracy of the endomicroscopy diagnosis of GM during endoscopy was 92.8%, and the sensitivity, specificity, and positive and negative predictive values were 86.2%, 97.4%, 89.3%, and 96.6%, respectively. The mean κ‐value for interobserver agreement was 0.89. GM in the duodenal bulb was more frequent in patients with FD than in the controls (33.3% vs 12%, P < 0.05), especially in patients with epigastric pain syndrome (47.6% vs 12%, P < 0.01). Conclusions: Endomicroscopy is useful for identifying GM, and GM might be related to FD. These findings could have potential applicability for duodenal screening, and suggest a possible targeting therapy in FD.