Prolonged clearance is the primary abnormal reflux parameter in patients with progressive systemic sclerosis and esophagitis

The purpose of this study is to determine if frequent reflux events from an incompetent LES or poor clearance from decreased peristalsis is the predominant abnormality in PSS patients with severe reflux esophagitis. Seven patients with both classic manometric findings of PSS and endoscopic findings of esophageal ulcerations and/or Barrett's esophagus were compared to nine patients with similar endoscopic findings but with no evidence of a connective tissue disorder. All patients underwent simultaneous intraesophageal pH monitoring and scintigraphy for a total of 40 min after a radiolabeled meal. Four of the PSS patients and all the non-PSS patients had simultaneous manometry. We found that PSS patients had significantly fewer reflux events (P<0.01), but the reflux events had significantly longer duration (P<0.01) compared to patients with similar severity of esophagitis and no connective tissue disease. We conclude that decreased smooth muscle peristalsis appears to be the primary contributor to acid exposure and esophageal injury in PSS.The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.     

Decreased esophageal peristaltic amplitude in response to prostaglandin E1 and prostacyclin in the baboon

Prostaglandins have been shown to produce significant decreases in lower esophageal sphincter pressure (LESP), although their effect on esophageal peristalsis is unknown. We studied the effect of injusion of prostaglandin E₁ (PGE₁) or prostacyclin (PI) on esophageal peristalsis in the proximal and distal esophagus in the awake baboon. Peristalsis was recorded using a polyvinyl catheter and a pneumohydraulic perfusion system and was induced by wet swallows. PGE₁ infusion significantly (P<0.01) diminished peristaltic amplitude in proximal and distal esophagus by 51% and 77%, respectively. The wave duration was significantly (P<0.001) shortened by PGE₁ in the distal esophagus, but not in the proximal esophagus. Similarly, prostacyclin significantly (P<0.05) decreased peristaltic amplitude in proximal and distal esophagus by 31% and 67%, respectively. As seen with PGE₁, PI decreased distal esophageal amplitude significantly (P<0.02) more than proximal esophageal amplitude. Equivalent decreases in mean arterial blood pressure seen during prostaglandin infusion were reproduced by bleeding with no changes in measurements of peristaltic activity. Decreased peristaltic wave amplitude and duration suggest that prostaglandins exert a modulating local effect on esophageal muscle. In addition, this effect appears to be more pronounced on distal smooth muscle than on proximal striated muscle in the baboon esophagus.The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of Defense or the Department of the Army.Supported by USUHS grant R08316.     

Esophageal hematoma

We report four cases of esophageal hematoma and emphasize that endoscopically and radiographically it may simulate a neoplasm. After a review of 26 cases, we found that patients with normal hemostasis often had esophageal hematoma occur distally after vomiting. Most of these hematomas probably originated from a Mallory-Weiss laceration. In contrast, patients with impaired hemostasis had esophageal hematoma occur proximally or at multiple sites. Many of these hematomas occurred spontaneously, without a history of vomiting, and probably resulted from impaired coagulation. Regardless of etiology most esophageal hematomas were associated with a benign course.The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army of Department of Defense.     

Congenital esophageal stenosis presenting as noncardiac,esophageal chest pain

Summary A case of a 31-year-old female with congenital esophageal stenosis presenting with symptoms of chest pain caused by esophageal dysmotility is described. The involved segment in congenital esophageal stenosis has a characteristic thickening of the muscularis propria layer, as seen by EUS examination. In these patients, symptoms of dysphagia can be managed with esophageal dilation and noncardiac esophageal chest pain responds to pharmacotherapy with diltiazem.The opinions and assertions contained herein are the private ones of the authors and are not to be construed as official policy or reflecting the views of the Army or the Department of Defense.     

Effects of transdermal nicotine on lower esophageal sphincter and esophageal motility

Cigarette smoking has been shown to decrease lower esophageal sphincter pressure (LESP) by 19–42%. This decrease in LESP may be due to nicotine in the cigarette smoke or substances other than nicotine. The aim of this study was to evaluate the effects of a nicotine patch on esophageal motility since nicotine patches are devoid of all toxins present in the cigarette smoke except the nicotine. Ten healthy nonsmoking volunteers underwent baseline esophageal manometry. Esophageal manometry was repeated after placing a nicotine transdermal patch (Nicotrol) designed to deliver 15 mg of nicotine per day. The parameters that were compared included LESP by rapid pull-through (LESP-RPT) and station pull-through (LESP-SPT), LES relaxation, and velocity, amplitude, and duration of esophageal contractions. Plasma nicotine and cotinine levels were measured prior to baseline manometry and after 12 hr of placing the nicotine patch. the LESP-RPT decreased by 31% from 17.4±6.1 to 12.1±3.3 (P=0.013) and the LESP-SPT by 27% from 13.4±5.4 to 9.8±4.8 (P=0.029) after the nicotine patch. LES relaxation was present in 100% before and after nicotine patch. There were no significant differences in velocity, duration, and amplitude of esophageal contractions after the nicotine patch. Plasma nicotine and cotinine was absent in all subjects at baseline but was significantly elevated after 12 hr of nicotine patch. Transdermal delivery of nicotine results in a significant reduction in LESP in healthy subjects without effecting LES relaxation or esophageal body motility.The opinions and assertions contained herein are the private views of the authors and are not to be construed as reflecting the views of the Department of the Army or the Department of Defense.This work was published in an abstract form in Gastroenterology 106:A1047, 1994.     

Cycling,a manometric phenomenon due to repetitive episodes of gastroesophageal reflux and clearance

We studied intraesophageal pressure changes in patients with symptoms of gastroesophageal reflux and an abnormal 24-hr pH monitoring record (N=52). Our method was simultaneous esophageal manometry and pH monitoring. We observed a three-component esophageal manometric sequence (EMS). When this sequence recurred over and over, we termed this phenomenon cycling. We found cycling in 35% of the patients (18/52). Those with cycling had lower basal LES pressures, more acid exposure, and an increased incidence of endoscopic esophagitis. That cycling resulted from repeated reflux events and their esophageal clearance was documented by scintigraphy during simultaneous manometry and pH monitoring (N=7 patients). Cycling was found on the routine esophageal manometry record of 25% of symptomatic patients (N=112) with an abnormal 24-hr pH score. In conclusion, cycling represents an esophageal manometric phenomenon due to repetitive reflux events. Its recognition during esophageal manometry may denote a severe reflux diathesis.The opinions and assertions contained herein are the private views of the authors and are not to be construed as official policy or as reflecting the views of the Department of the Army or the Department of Defense.     

Prognostic grouping: the next step in tumor classification

Summary At present, staging of malignant tumors is based on the anatomical extent of disease defined by the T(umor) N(odes) M(etastasis) classification. The main objective of further efforts in classifying tumors is to identify additional independent prognostic factors and to create mathematical models that may predict disease progression by prognostic grouping. This article summarizes problems, methods and the design of coordinated studies on prognostic grouping.The opinions or assertions contained herein are the expressed views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense     

Meat Consumption Is Associated with Esophageal Cancer Risk in a Meat- and Cancer-Histological-Type Dependent Manner

Background

We conducted a systematic review and meta-analysis of meat intake and esophageal cancer risk, with subgroup analyses based on meat type and histological type of cancer.

Aims

The purpose of this study was to investigate the association between meat intake and risk of esophageal cancer.

Methods

We searched MEDLINE, EMBASE and Cochrane Library (April 2013) for cohort and case–control studies that assessed meat intake and esophageal cancer risk. Random-effect or fixed-effect models were used to pool relative risks (RRs) from individual studies with heterogeneity and publication bias analyses carried out. Seven cohort and 28 case–control studies were included.

Results

The summary RRs for esophageal cancer for the highest versus lowest consumption categories were 1.19 (95 % confidence interval [CI] 0.98–1.46) for total meat, 1.55 (95 % CI 1.22–1.96) for red meat, 1.33 (95 % CI 1.04–1.69) for processed meat, 0.72 (95 % CI 0.60–0.86) for white meat, 0.83 (95 % CI 0.72–0.96) for poultry, and 0.95 (95 % CI 0.76–1.19) for fish. When striated by histological subtype, positive associations were seen among esophageal squamous cell carcinoma and red meat, white meat and poultry, and esophageal adenocarcinoma with total meat and processed meat.

Conclusions

Meat consumption is associated with esophageal cancer risk, which depends on meat type and histological type of esophageal cancer. High intake of red meat and low intake of poultry are associated with an increased risk of esophageal squamous cell carcinoma. High meat intake, especially processed meat, is likely to increase esophageal adenocarcinoma risk. And fish consumption may not be associated with incidence of esophageal cancer.     

Congenital esophageal stenosis

Esophageal stenosis is a rare congenital anomaly (1 per 25,000 live births), which usually presents during infancy (1). The stenosis is typically aperistaltic, and the onset of symptoms depends upon the degree of deformity. In severe stenosis, symptoms of vomiting or r'egurgitation occur at birth or with the introduction of solids (2, 3). In mild cases, patient adaptation may delay the diagnosis (1,4). We report an unusual case of congenital esophageal stenosis, where abnormal peristalsis was preserved within the stenotic segment and presentation as acute food impaction was delayed until adulthood. Endoscopic, radiographic, and esophageal manometric findings of congenital esophageal stenosis are described, and the therapeutic alternatives discussed.The opinions and assertions contained herein are the private ones of the authors and are not to be construed as official policy or reflecting the views of the Army or the Department of Defense.     

Esophageal acid clearance during sleep in patients with Barrett's esophagus

Sleep-related gastroesophageal reflux and esophageal acid clearance have been shown to be important components in the pathogenesis of reflux esophageal disease. Previous studies have suggested that patients with more severe esophagitis are distinguished by an accumulation of acid mucosal contact time during sleep. These data would suggest that patients with Barrett's esophagus should have particularly severe impairment of acid clearance, most notable during sleep. To address this issue, 16 asymptomatic healthy volunteers and 13 patients with Barrett's esophagus were studied. Acid clearance was assessed by timing the reestablishment of an esophageal pH of 4 following the infusion of 15 ml 0.1 N HCl. Sleep was poly graphically monitored in order to objectively determine sleep and waking. The results indicated that while patients with Barrett's esophagus had a marked increase in the frequency of spontaneous gastroesophageal reflux during sleep, they unexpectedly demonstrated faster acid clearance times during both waking and sleep. A greater percentage of arousal responses to acid infusion during sleep was noted in the Barrett's group. It is concluded from these results that patients with Barrett's esophagus can adequately clear acid from the distal esophagus but experience considerable acid mucosal contact through repeated episodes of spontaneous reflux during sleep.The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.     

Effects of verapamil and diltiazem on gastric emptying in normal subjects

It has been suggested that calcium-channel blockers may delay gastric emptying by inhibiting gastric smooth muscle contraction. Most reports in man, however, reveal no significant delay in gastric emptying after using nifedipine; other calcium-channel blockers have not been studied in humans to date. We studied the effects of verapamil and diltiazem on solid-phase gastric emptying in 10 healthy volunteers. Each subject underwent a radionuclide gastric emptying determination (1) without preadministered medication, (2) after verapamil 80 mg orally every 6 hr for 10 doses, and (3) after diltiazem 60 mg by mouth given as one dose. Results revealed no significant difference in gastric emptying rates after pretreatment with verapamil or diltiazem when compared with no premedication (P>0.37). We conclude that verapamil and diltiazem do not significantly delay gastric emptying in normal subjects. These data may be of clinical significance when prescribing calcium-channel blockers to patients with diseases associated with altered gastric emptying.The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the views of the Department of the Army or the Department of Defense.     

Suture granuloma masquerading as malignancy of the biliary tract

Summary Eighteen years after having a duodenal leiomyosarcoma resected, a patient presented with weight loss, pruritus, and abdominal pain. ERCP was consistent with a cholangiocarcinoma with proximal hepatic duct stricture and nonfilling of the cystic duct. CAT scan revealed no extrinsic masses compressing the gallbladder or biliary tract. At surgical exploration, the patient was found to have a suture granuloma with surrounding fibrosis within the common bile duct. There was no evidence of malignancy.The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.     

The clinical prognosis of HIV-1 infection

Thirty-two follow-up studies of patients with HIV-1 infection, but without AIDS at baseline, were examined for information on the risk of developing AIDS or other conditions. Disease progression in asymptomatic groups was similar to that found in patients with persistent generalized lymphadenopathy (PGL) without other symptoms. Among these asymptomatic and PGL groups, the risk of developing AIDS reached 10% to 15% between 24 and 36 months of follow up. The risk of progression to AIDS continued to increase in the studies with longer follow-up periods, reaching 36% at 88 months. However, more than 40% of “high-risk” groups (characterized by the presence of constitutional symptoms, oral thrush, herpes zoster, and/or low T4 counts) developed AIDS after only 36 months of follow-up. Reliable information about progression to other states (e.g., AIDS-related complex) has not been consistently provided. Received from the Division of General Internal Medicine, Department of Medicine, Uniformed Services University of Health Sciences, Bethesda, Maryland, and Walter Reed Army Medical Center, Washington, DC. The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.     

Evaluation of elevation of the head of the bed,bethanechol, and antacid foam tablets on gastroesophageal reflux

To ascertain how elevation of the head of the bed, bethanechol, and antacid foam tablets affect gastroesophageal reflux, we used prolonged intraesophageal pH monitoring in 55 symptomatic patients. Acid exposure was separated into reflux frequency and esophageal acid clearance time and recorded during the day in the upright posture and recumbent at night. Values before and during each therapy were compared to physiologic reflux in 15 asymptomatic controls. Ten patients slept with the head of the bed elevated and had a 67% improvement in the acid clearance time (P<0.025); however, the frequency of reflux episodes remained unchanged. Twelve patients given 25 mg of bethanechol 4 times a day had a 50% decrease in recumbent acid exposure only (P<0.05), due to a trend towards decreased reflux episodes and acid clearance time. Bethanechol combined with head of bed elevation in 19 other patients decreased both reflux frequency (30%) and acid clearance time (53%, allP<0.05). Antacid foam tablets failed to significantly diminish acid exposure. Nocturnal reflux responded the best to those therapies tested.This paper was presented in part at the Clinical Research Forum of the American Gastroenterological Association 78th Annual Meeting, May 24, 1977, Toronto, Canada.The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.     

Dysphagia lusoria caused by persistent right aortic arch with aberrant left subclavian artery and diverticulum of kommerell

Sammary It requires a high index of suspicion to make the diagnosis of dysphagia lusoria. Clinically, these adults will present with symptoms of intermittent solid food dysphagia, and a mediastinal abnormality may be seen on chest x-ray. Noninvasive imaging of the chest with either computerized tomography or magnetic resonance scanning are excellent methods for evaluating the mediastinum for solid tumors or vascular anomalies that can cause extrinsic esophageal compression. Dysphagia lusoria caused by a persistence of the right embryologic aortic arch and diverticulum of Kommerell with an aberrant left subclavian artery may be satisfactorily managed by dietary modification when the symptoms are mild.The opinions and assertions contained herein are the private ones of the authors and are not to be construed as official policy or reflecting the views of the Army or the Department of Defense.     

Prospective evaluation of gastrointestinal tract in patients with iron-deficiency anemia

Gastrointestinal bleeding is believed to cause iron-deficiency anemia (IDA). The information concerning ideal evaluation of the gastrointestinal tract and exact findings in patients with IDA is scant. The aim of this study was to prospectively evaluate patients with IDA for gastrointestinal lesions potentially causing IDA at a US Army Teaching Medical Center with Gastroenterology Fellowship. Seventy patients with IDA had esophagogastroduodenoscopy (EGD) and colonoscopy, and if this evaluation was unremarkable, then small bowel biopsy was obtained at EGD to evaluate for celiac disease. Enteroclysis was done if endoscopic evaluation was negative. At endoscopy, at least one lesion potentially accounted for the IDA in 50 (71%) patients. At colonoscopy, 21 (30%) patients had 22 lesions (four colon cancer, seven adenoma>1 cm, six vascular malformation, four severely bleeding hemorrhoids, one ileal Crohn's); at EGD, 39 (56%) patients had 43 lesions (11 gastric erosion, 10 esophagitis, four vascular malformation, four celiac disease, three gastric cancer, three gastric ulcer, three duodenal ulcer, two gastric polyp>1 cm, one duodenal lymphoma, one esophageal cancer, and one duodenal Crohn's). Twelve (17%) patients had both upper and lower gastrointestinal tract lesions. Twenty-four of 32 (75%) patients with positive fecal occult blood test had potentially bleeding lesions compared to 24 of 38 (63%) patients with negative fecal occult blood test (P>0.05). Six of nine patients with malignancy had positive fecal occult blood test. Twenty patients with normal endoscopy and small bowel biopsy had normal enteroclysis. It is concluded that the combination of colonoscopy and EGD identifies potential bleeding sources in most patients with IDA. In the absence of a potential bleeding lesion, small bowel biopsy at EGD is essential to diagnose celiac disease.The opinions and assertions contained herein are the private views of the authors and are not to be construed as reflecting the views of the Department of the Army or the Department of Defense.     

Improving meat inspection and control in resource-poor communities: the Nepal example

Meat is an important source of protein and a valuable commodity in resource-poor communities. In many developing countries, lack of appropriate slaughtering facilities and unsatisfactory slaughtering techniques are causing unnecessary losses of meat as well as invaluable by-products from animal carcasses. Slaughtering places are frequently contaminated and may not be protected against dogs, rodents and insects. Meat products coming from such conditions are often deteriorated due to bacterial infection or contaminated, which may cause food poisoning or diseases in consumers. In many developing countries, regulations concerning meat inspection and/or control are inadequate or non-existent allowing consumers to be exposed to pathogens including zoonotic parasites. In Nepal, buffaloes contribute about 64% of the meat consumed, followed by goat meat (20%), pork (7%), poultry (6%) and mutton (2%). Goat and poultry meat is acceptable to all castes of people while buffalo meat is consumed mainly by the Newar ethnic group. Previously, pork was consumed only by people belonging to low castes, however, in recent years, the consumption of pork has increased in higher castes as the caste system has become more relaxed. Until recently, there were no official meat inspection regulations in the country, however, in 1999, the national government legislated an as-yet-to-be implemented Animal Slaughtering and Meat Inspection Act which mandates slaughterhouse construction and meat inspection and control. Due to the lack of implementation of the Meat Inspection Act and resultant absence of meat inspection, meat from sick or parasite-infected animals is serving as a source of infection to humans as well as other animals. In addition, meat quality is adversely affected by careless handling conditions in the slaughtering places as well as in the meat markets or shops. For improvement in animal slaughtering and meat inspection in both rural and urban areas of Nepal, several strategies are to be recommended. Sustainable capacity building should be introduced including training of veterinarians, meat inspectors and butchers as well as building of slaughter facilities. Government policies on slaughter procedures including ante-mortem examination, meat inspection and stamping of meat should be implemented. Programmes should be instituted with strong focus on prevention and control of meat-borne diseases to reduce infection risk of consumers and meat handlers and to avoid contamination of the environment. Lastly, emphasis should be put on improving the animal husbandry system in Nepal. These same actions can be undertaken in other developing countries to assist with improving meat inspection and control, thus helping with prevention and control of cysticercosis as well as other important meat-borne diseases.     

Contribution of trypsin and cholate to the pathogenesis of experimental alkaline reflux esophagitis

Previous studies suggest that trypsin and bile salts are the causative agents in alkaline reflux esophagitis. However, their individual effects on the esophageal mucosa is relatively weak when used alone. Since these agents seem to have different sites of action in the esophageal mucosa, we have investigated whether they might have a synergic action when used in combination. Rabbit esophagus was perfused in situ with a test solution containing trypsin and cholate, alone or in combination, at pH 7.0. The severity of mucosal damage was assessed, using as indicators of mucosal integrity transmucosal potential difference, net flux of Na+, and mucosal permeability to two neutral molecules of different sizes, 3H-H2O and 14C-erythritol. Cholate (in its conjugated and deconjugated form) was chosen as the bile salt test agent, because it is quantitatively important but almost inert on the esophageal mucosa when used alone. The results indicate that trypsin significantly decreased potential difference and increased mucosal permeability to Na+, 3H-H2O and 14C-erythritol. Cholate and taurocholate had no influence on the mucosa when used alone, but cholate, especially in its deconjugated form, increased significantly mucosal damage caused by trypsin. The findings suggest that trypsin and bile salts do have a synergic effect on esophageal mucosa, which may have pathogenetic significance in clinical alkaline reflux esophagitis.     

Massive abdominal wall desmoid tumor

The management of a massive abdominal wall desmoid tumor in a young woman with Gardner's syndrome is discussed. Treatment options included primary radiation, subtotal excision with radiation, primary chemotherapy or radical resection with abdominal wall reconstruction. The advantages and disadvantages of the various treatment options are discussed, and the technique of resection and reconstruction is explained. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense. No reprints are available.     

Sclerosing mesocolitis

A case report of sclerosing mesocolitis is presented. This is an unusual and poorly understood entity. A 49-year-old woman presented with episodic abdominal pain and a palpable abdominal mass. A fibrotic mass causing extensive compression of her cecum and transverse colon was found at laparotomy. The pathologic findings and treatment of sclerosing mesocolitis are discussed. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.