Eosinophilic Esophagitis in Saudi Children: Symptoms, Histology and Endoscopy Results

Background/Aim:

Eosinophilic esophagitis (EE) is a clinicopathologic entity characterized by esophageal symptoms in association with a dense eosinophilic infiltrate currently defined as >15 eosinophils per high power field in the appropriate clinical context. This is the first pediatric study in Saudi Arabia to give the experience with EE and examine its symptom, histology and endoscopy results.

Materials and Methods:

Retrospective chart review of all patients diagnosed with EE at National Guard Hospital, Jeddah Between 2007 and 2009. The authors identified EE on histologic criteria (≥15 eosinophils per high-power field) together with their clinical context. The authors reviewed medical records for details of clinical presentation, laboratory data, radiologic, endoscopic, and histologic findings, and the results of treatment.

Results:

We identified 15 patients in our database in the last three years. 100% of the patients were males. The median age at presentation was 10 years (range, 3-17 years). The commonly reported symptoms were failure to thrive (86%), epigastric abdominal pain (53%), poor eating (40%), dysphagia with solid food (26%), food impaction (13%), and vomiting (20%). Asthma was reported in 46% and allergic rhinitis in 40%. Peripheral eosinophilia (>0.7 × 10/l) was found in 66%. High serum IgE Level (>60 IU/ml) was found in 60%. Upper endoscopic analysis revealed esophageal trachealization in 46%, esophageal erythema in 46%, white specks on the esophageal mucosa in 33%, esophageal narrowing in 13%, and normal endoscopy in 13%. The mean eosinophils per high-power field was 30.4 (range, 20–71). Histologic characteristics included degranulated eosinophils (86%), basal cell hyperplasia (93%) and eosinophils clusters (micro-abscess) in 73%. The treatment of EE revealed that they used swallowed corticosteroid in 50%, proton pump inhibitors in 66%, elemental diet/ food elimination in 13% and systemic corticosteroid in 13%.

Conclusions:

Failure to thrive and abdominal pain in a male, atopic school-aged child was the most common feature of EE. Peripheral eosinophilia, high serum IgE and endoscopic esophageal erythema and trachealization should significantly raise the clinical index of suspicion for the diagnosis of EE.     

The Effect of Sedation During Upper Gastrointestinal Endoscopy

Background/Aim:

We aimed to study whether sedation reduces discomfort during endoscopy and a comparison of longer-acting diazepam with shorter-acting midazolam.

Patients and Methods:

A prospective, randomized, single-blinded study was conducted at the Department of Medicine at Government Medical College and Hospital, Chandigarh, and was completed over a period of 6 months. The patients were randomized to receive either placebo or sedation with midazolam or diazepam before endoscopy. The endoscopist and the observer recording patient’s/physician’s responses were blinded to the drugs administered. Two hundred and fifty two consecutive patients undergoing diagnostic or therapeutic upper gastrointestinal endoscopy were recruited. The patient’s discomfort and the physician’s comfort during the procedure were recorded on a visual analogue scale rated from 1-10 with-in 10 minutes of the procedure by an independent observer. The Patient’s discomfort ratings were further divided into 3 groups, comfortable (score, 1-3), satisfactory (score, 4-7) and uncomfortable (a score of >7). Similarly the physician’s ease of performing the procedure was also recorded on the same scale. This was again divided into 3 groups: easy (score, 1-3), satisfactory (score, 4-7) and difficult (a score of >7).

Results:

Out of the total of 252 patients, 82 patients received no sedation (group I), 85 received diazepam (group II) and 85 received midazolam (group III). There was no statistical difference in the discomfort experienced by the patients during endoscopy when sedation was used (P=0.0754). Out of 252 patients, 49 underwent endoscopic procedures. Nineteen patients were included in group I, 18 in group II and 12 in group III. Only 10 (20%) patients undergoing endoscopic procedures complained of significant discomfort, but there was no difference in the ones undergoing interventions with or without sedation (P=0.854). The physicians were more comfortable in performing endoscopic procedure in sedated patients, however, the difference between patients in group II and group III was not statistically significant (P=0.0461). Both diazepam and midazolam fared equally well in increasing physician’s comfort (P=0.617).

Conclusion:

There was no difference in the patient’s discomfort with regard to the sedative used (midazolam or diazepam). Although endoscopy was easy or satisfactory in the majority of patients in the unsedated as well as the sedated groups, more often the endoscopist found it difficult to do endoscopy on the unsedated patients.     

Sleep Stage Coordination of Respiration and Swallowing: A Preliminary Study

Swallowing is an important physiological response that protects the airway. Although aspiration during sleep may cause aspiration pneumonia, the mechanisms responsible have not yet been elucidated. We evaluated the coordination between respiration and swallowing by infusing water into the pharynx of healthy young adults during each sleep stage. Seven normal subjects participated in the study. During polysomnography recordings, to elicit a swallow we injected distilled water into the pharynx during the awake state and each sleep stage through a nasal catheter. We assessed swallow latency, swallow apnea time, the respiratory phase during a swallow, the number of swallows, and coughing. A total number of 79 swallows were recorded. The median swallow latency was significantly higher in stage 2 (10.05 s) and stage 3 (44.17 s) when compared to awake state (4.99 s). The swallow latency in stage 3 showed a very wide interquartile range. In two subjects, the result was predominantly prolonged compared to the other subjects. There was no significant difference in the swallow apnea time between sleep stages. The presence of inspiration after swallowing, repetitive swallowing, and coughing after swallowing was more frequent during sleep than when awake. This study suggests that the coordination between respiration and swallowing as a defense mechanism against aspiration was impaired during sleep. Our results supported physiologically the fact that healthy adult individuals aspirate pharyngeal secretions during sleep.     

Electronic Endoscopy and Biopsy Findings During the Course of Reflux Esophagitis

Abstract: We observed the esophageal mucosa in 90 patients with reflux, esophagitis using a zoom-type electronic endoscope and clarified the endoscopic characteristics of each stage of the disease as well as the response to treatment. It was possible to differentiate between white slough, erosions and regenerating epithelium from observations of the magnified mucosa. The white slough appeared uniform and featureless, the erosions appeared irregular and had featureless reddish areas, and regenerating epithelium were noted in the reddish areas in addition to various types of mucosal surface structure. Biopsies obtained after the disappearance of the white sloughs of reflux esophagitis from the mucosal membrane of the discolored esophagitis generally showed the “accessory findings” of the diagnostic criteria of the Japanese Society of Esophageal Diseases. Even in the early scarring stage (S1), the inflammation persisted under the regenerating mucosa, and it was necessary to continue treatment until the late scarring stage (S2) to prevent recurrence. Regarding treatment, H₂ receptor antagonists were effective, but 19.4% of the patients showed resistance to them. Intractable esophagitis was often seen in stage III and IV of the Savary & Miller classification and in the elderly patients. Intractable esophagitis was associated with a high incidence of hiatus hernia, a reduced lower esophageal sphincter pressure, and a reduction in primary peristalsis in the lower esophagus.     

Changes of Emphysema Parameters over the Respiratory Cycle During Free Breathing: Preliminary Results Using Respiratory Gated 4D-CT

The purpose of this research was to evaluate respiratory gated CT of the lung in patients with COPD for analysis of parenchymal characteristics who were potential candidates for volume reduction surgery.

Eleven patients with clinically known emphysematous disease underwent a respiratory gated, free-breathing 64-multislice-CT (Aquilion 64, Toshiba). Retrospective image reconstruction was performed similar to cardiac CT at every 10% of the respiratory loop, resulting in 10 complete volumetric datasets at 10 equidistant time points. All images were transferred onto a PC for calculation of the total lung volume, emphysema volume, emphysema index, and mean lung density.

Complete datasets could be successfully reconstructed in all patients. The mean lung volume increased from 6.9 L to 7.5 L over the respiratory cycle. Emphysema volume increased from 1.6 L to 2.0 L and emphysema index from 22.6% to 26.5% from expiration to inspiration.

In conclusion, respiratory gated chest 4D-CT allows for combined morphologic and functional image analysis, which can provide new insight into functional impairment and individual treatment planning.     

Ring-Shaped Pulse Oximeter and Its Application: Measurement of SpO2 and Blood Pressure During Sleep and During Flight

Respiratory and cardiovascular functions show circadian and day-to-day changes. We have developed a wireless ring-shaped pulse oximeter in collaboration with MC Medical Inc. and Advanced Medical Inc. We investigated the accuracy of this pulse oximeter and its application in daily life. Percutaneous arterial oxygen saturation (SpO₂) of 47 volunteers was measured simultaneously with the ring-shaped pulse oximeter and a standard pulse oximeter. A total of 103 volunteers underwent measurement of SpO₂ for 24 hr, and 11 healthy volunteers underwent measurement of SpO₂ and blood pressure (BP) during flight. SpO₂ and heart rate (HR) were measured and recorded every 20 sec, cabin barometric pressure and cabin oxygen concentration equivalent to sea level were measured minute-to-minute, and BP was measured every 3 min with a portable BP recorder during each flight. The SpO₂ values measured with the ring-shaped pulse oximeter were similar to those measured with the standard method. The mean SpO₂ during sleep was significantly lower in the group with high-normal BP or mild hypertension than in the group with normal BP. During flight, the mean change in SpO₂ was ? 2.4 ± 1.7% during nose-up flight, and 2.1 ± 2.6% during nose-down flight. There was a significant correlation between change in SpO₂ and change in systolic BP during nose-up flight. The wireless ring-shaped pulse oximeter was useful for investigating changes in SpO₂ and its effect on BP in daily life during sleep and during air travel.     

Combined Pancreas-Kidney Transplantation: Preliminary Results and Metabolic Effects

Vascularized pancreas transplantation (PT) results in a self-regulating endogenous source of insulin. In the last 18 months, we have performed combined pancreas-kidney transplantation in 25 type I diabetics with nephropathy. The mean age of the recipient group was 35 yr (range 24-51) with a mean duration of diabetes of 22 yr (range 13-41). All patients received quadruple immunosuppression with OKT3 induction. All patients remained normoglycemic and insulin independent with a mean glycosylated hemoglobin level of 6.0 +/- 1.1% and a mean serum creatinine of 1.7 +/- 0.5 mg/dl. Metabolic control and hormonal profiles were assessed by intravenous glucose challenge followed by arginine stimulation. Metabolic effects of PT included fasting hyperinsulinemia and hyperglucagonemia with exaggerated insulin and glucagon responses to glucose and arginine, respectively. Patient and graft survival is 100% after a mean follow-up interval of 8 months. Conclusion: combined pancreas-kidney transplantation is a valid treatment option for diabetic nephropathy, and results in near-complete normalization of glucose metabolism.     

Feasibility of Forward-Viewing Upper Endoscopy for Detection of the Major Duodenal Papilla

Background and Aim  

The purpose of this study was to assess the feasibility of forward-viewing upper endoscopy for detection of the major duodenal papilla (MDP) as an indicator of the descending duodenum.     

Sleep Quality in Asthma: Results of a Large Prospective Clinical Trial

Rationale. Previous studies have suggested that asthmatics have an increased incidence of sleep disturbances. However, these studies have been limited by reliance on population surveys or small numbers of participants. Objectives. We sought to measure sleep quality and daytime sleepiness in a cohort of symptomatic asthmatics and to measure the effects of improved asthma control on sleep quality. Methods. Data were collected in sub-study of a large multi-center randomized double-masked controlled trial of mild-moderate asthmatics evaluating the effect of low-dose theophylline on asthma control in comparison to montelukast and placebo. Each participant was administered sleep symptom questionnaires at randomization and at the final visit (6 months after randomization). These included the Pittsburgh Sleep Quality Questionnaire (PSQI) and the Epworth Sleepiness Scale (ESS). Measurements and main results. Data were available for 487 participants. Baseline mean values were: age 40 ± 15 years, 74% female, forced expiratory volume in 1 second (FEV₁) 79 +16 percent predicted, Juniper Asthma Control Questionnaire (ACQ) score 2.35 ± 0.63, PSQI 7.8 ±4, and ESS 8.5 ±4.9. There were no significant differences in the PSQI or ESS between the three treatment groups. Significant correlations were found at baseline between the global PSQI score and ACQ and quality of life and marginally with lung function. Significant correlation existed between improvements in PSQI and ESS with improved asthma control and quality of life. Conclusions. Sleep disturbances are common in asthmatics and are associated with asthma control and quality of life. Clinicians caring for asthmatics may need to complete a more detailed sleep history in patients with poorly controlled asthma. In addition, low-dose theophylline does not seem to impair sleep quality in asthmatics.     

A Preliminary Study of Patients' Concerns Related to GI Endoscopy

Objectives: In addition to the well known complications of bleeding and perforation, GI endoscopy also can produce discomfort, anxiety, and dissatisfaction. In this pilot study, our objective was to obtain information on the fears and concerns of patients about to undergo endoscopy and to assess the relationship of such worries to patient satisfaction and difficulty with the procedure. Methods: At our two referral hospitals, 793 unsedated patients (45% men, 55% women, average 58 yr) were interviewed by GI nurses before the intended procedure. Information on procedure-related concerns and difficulty/satisfaction with the procedure was obtained. Results: Sixty percent of our sample reported preprocedure concerns, most often: 1) finding out what is wrong (18%); 2) pain (12%); and 3) finding cancer (4%). New York patients were more concerned than North Carolina patients with finding out what was wrong (23 vs 12%) although patients at both sites were equally concerned about having pain during the procedure (12%); women (16%), younger patients (16%), and those about to have their first procedure (17%) reported more concerns about pain. Regression analysis indicated that women and persons having no or fewer procedures were more likely to report a concern. Having had previous endoscopic procedures predicted greater satisfaction with subsequent endoscopies. Finally, a high level of preprocedure concerns was associated with perceived difficulties related to the procedure. Conclusions: We believe that, by considering patient demographics, asking about previous experiences with endoscopy, and eliciting special concerns, the nurse or physician can focus patient education in a fashion that may reduce anticipatory anxiety.     

Accidental Occupational Injuries to Endoscopy Personnel in a High-Volume Endoscopy Suite During the Last Decade: Mechanisms,Workplace Hazards,and Proposed Remediation

Introduction  

Scant data exist about accidental occupational injuries in endoscopy suites. This work systematically analyzes injuries, identifies workplace hazards, and proposes hazard remediation to potentially reduce risks.