Helicobacter pylori is not associated with the manifestations of gastroesophageal reflux disease.

HYPOTHESIS: Helicobacter pylori is not associated with gastroesophageal reflux disease and its complications, including adenocarcinoma of the esophagus and the gastroesophageal junction (GEJ). DESIGN: Retrospective analysis. SETTING: University tertiary referral center. PATIENTS: Two hundred twenty-nine patients with symptoms suggestive of foregut disease underwent esophageal manometry, 24-hour pH monitoring, and upper gastrointestinal tract endoscopy, with biopsy specimens obtained from the gastric antrum, the GEJ, and the distal esophagus. In these and in an additional 114 patients with adenocarcinoma of the esophagus and the GEJ, the presence of H. pylori was determined by Giemsa stain. The presence of gastroesophageal reflux disease, defined by abnormal esophageal acid exposure, and its manifestations (carditis, erosive esophagitis, intestinal metaplasia limited to the GEJ, Barrett esophagus, and adenocarcinoma of the esophagus and GEJ) were correlated with the presence of H. pylori. RESULTS: Helicobacter pylori was found on the biopsy specimens of the gastric antrum in 14.0% (32/229) of the patients with benign disease. It was not related to the features of gastroesophageal reflux disease, including abnormal esophageal acid exposure, erosive esophagitis, or Barrett esophagus. The presence of inflamed cardiac mucosa at the GEJ or carditis was inversely related to H. pylori infection and strongly associated with increased esophageal acid exposure. There was no association between the presence of intestinal metaplasia and H. pylori infection. Helicobacter pylori was found in 22 (19.3%) of the 114 patients with esophageal adenocarcinoma, which was not different from the prevalence of H. pylori in patients with benign disease. CONCLUSION: Helicobacter pylori plays no role in the pathogenesis of gastroesophageal reflux disease or its complications.     

Cat-scratch disease: Otolaryngologic manifestations and management.

OBJECTIVE: The bacteria Bartonella henselae has been known as the principal causative agent of cat-scratch disease (CSD) since 1992. It is an important cause of infectious lymphadenopathies in the head and neck. Nevertheless, CSD often remains unrecognized in cases of cervicofacial lymph node enlargement. STUDY DESIGN: Between January 1997 and May 2003, we conducted a prospective clinical study including 721 patients with primarily unclear masses in the head and neck. RESULTS: CSD was diagnosed by serology and molecular investigations in 99 patients (13.7%; median age 33 years). Cervicofacial lymphadenopathy was the most common manifestation. Atypical manifestation of CSD including Parinaud's oculoglandular syndrome, swelling of the parotid gland and erythema nodosum were diagnosed in 8.1%, 8.1%, and 2.0% of cases, respectively. CONCLUSIONS: Our results demonstrate that CSD is a major cause of enlarged cervicofacial lymph nodes and should therefore be included in the differential diagnosis of lymphadenopathy in the head and neck region.     

Gastroesophageal reflux disease pathophysiology.

Gastroesophageal reflux disease is common in the Western world and affects a heterogeneous population. Structural and physiologic factors contribute to its pathophysiology, but the relative contribution of these individual factors varies between patients. Three main factors are generally central to the condition: TLESR, hypotensive LES tone, and hiatal hernia. In addition, several other factors (e.g., esophageal and gastric motility, salivary secretion, and mucosal defense mechanisms) modulate the extent of the injury produced by acid reflux.     

Autonomic dysfunction, vasomotor rhinitis, and extraesophageal manifestations of gastroesophageal reflux.

OBJECTIVE: Several recent reports suggest there may be a relationship between chronic rhinitis and extraesophageal manifestations of gastroesophageal reflux (EER). It is hypothesized that this relationship is a result of autonomic nervous system (ANS) dysfunction. STUDY DESIGN: Patients with isolated vasomotor rhinitis (VR), both VR and EER, and a control group were studied by a battery of tests designed to objectively evaluate ANS function. In addition all 3 groups underwent barium esophagogram and 4-site (proximal pharynx, distal pharynx, proximal esophagus, and distal esophagus) ambulatory pH monitoring. Adult patients fulfilling diagnostic criteria for VR, and with both VR and EER underwent objective ANS testing in a recently developed ANS testing laboratory. The control group consisted of age- and sex-matched adults without diagnostic criteria for VR or EER. RESULTS: In patients with VR only (n = 9), 2 patients had a positive esophagogram, whereas a positive pharyngeal reflux probe was found in 1 and an abnormal composite autonomic scoring scale (CASS) was found in 8 (mean VR CASS = 1.750 vs control CASS 0.556, P =.02). The group with VR and EER (n = 12) had a positive esophagogram in 10 patients, positive pharyngeal reflux by probe in 9, and all 12 had an abnormal CASS (mean CASS VR/EER = 2.909 vs CASS control = 0.556, P =.001 and vs VR CASS = 1.750, P =.05). The control patients (n = 9) had normal transesophageal gastroduodenoscopy in 8, 1 had a positive pharyngeal probe study, and all 9 had a normal CASS. In addition ANS testing in patients with diagnostic criteria for both VR/EER revealed statistically significant evidence of an adrenergic deficit as compared with control patients on the basis of mean phase II blood pressure response to Valsalva maneuver (mean phase II VR/EER = -16.730 vs control = -7.780, P =.05). In the VR only group, the phase II blood pressure decrease was greater than in control patients, but did not reach statistical significance (mean phase II VR = -9.370 vs control = -7.780, P = 0.672). CONCLUSION: Patients with VR and VR/EER have objective evidence of ANS dysfunction when compared with a group of age- and sex-matched control patients. Patients with both VR/EER demonstrate a significantly greater degree of ANS dysfunction than patients with isolated VR. The mechanism by which VR and EER interact is not entirely clear, but ANS dysfunction is objectively associated with both disorders. In addition, patients with VR/EER seem to demonstrate hypofunction of the adrenergic component of the ANS, in contrast to the generally held hypothesis that VR results from increased cholinergic activity. Further characterization of the type of ANS abnormality may allow the development of novel pharmacologic therapies for these disorders.     

Spinal manifestations of Paget's disease.

This paper reviews the syndromes which affect the spinal column as a result of Paget's disease. These are back pain, spinal canal stenosis, paraplegia or paraparesis, sarcomatous transformation, intradiscal invasion, and extramedullary haemopoesis.     

Esophagectomy for gastroesophageal reflux disease.

Failed control of pathologic gastroesophageal reflux leads to irreversible esophageal damage and progressive loss of function. Patients develop severe intractable symptoms, incapacitating dysphagia, and, with end-stage disease, stricture formation or Barrett's esophagus. When medical management and repeated antireflux operations have failed, resection of the diseased esophagus may become the only valid alternative. Careful preoperative evaluation and patient selection are essential to obtain satisfactory long-term functional results with acceptable rates of morbidity and mortality.     

Evidence-based investigation for reflux disease.

Hiatal hernia and gastroesophageal reflux disease are measurable conditions. Evidence-based evaluation techniques should be applied to quantify these conditions, to standardize investigations, to define indications, and to provide objective results.     

Medical management of gastroesophageal reflux disease.

Gastroesophageal reflux disease (GERD) is the most frequent problem seen in the esophageal clinic and laboratory Most patients who have a small hiatal hernia or an occasional reflux require only symptomatic treatment and some lifestyle modifications. However, prolonged medical treatment becomes mandatory in more severe cases, and these patients must significantly modify their lifestyle and try to correct the underlying causes of their condition.     

Opioids. Old myths,new myths and the future

Ohne Zusammenfassung Prof.Dr. Michael Zenz Universit?tsklinik für Anaesthesiologie, Intensiv- und Schmerztherapie der BG-Kliniken Bergmannsheil, Bürkle-de-la-Camp-Platz 1, 44789 Bochum, E-Mail: michael.zenz@ruhr-uni-bochum.de     

Gastroesophageal reflux and respiratory manifestations: diagnostic approach, therapeutic indications and results

The authors report a study of 140 patients presenting with a non-allergic respiratory tract disease (121 cases of asthma--19 cases of spasmodic cough). Gastro-oesophageal reflux was detected by 24-hour pHmetry in 86 of these patients. In 34 of them (i.e. 40% of cases), the gastro-oesophageal reflux appeared to be responsible for the initial respiratory tract symptoms. These 34 patients were submitted to a therapeutic trial of high dose anti-H2 therapy for at least two months. Only those patients in whom a marked improvement or even complete resolution of the respiratory tracts symptoms was observed underwent anti-reflux surgery. Out of the 13 patients undergoing surgery, there were two failures and 11 good results after a follow-up of more than 18 months.     

Vesicoureteric reflux and reflux nephropathy: from mouse models to childhood disease

Vesicoureteric reflux (VUR) is a common congenital urinary tract defect that predisposes children to recurrent kidney infections. Kidney infections can result in renal scarring or reflux nephropathy defined by the presence of chronic tubulo-interstitial inflammation and fibrosis that is a frequent cause of end-stage renal failure. The discovery of mouse models with VUR and with reflux nephropathy has provided new opportunities to understand the pathogenesis of these conditions and may provide insight on the genes and the associated phenotypes that need to be examined in human studies.     

Gastroesophageal reflux disease: symptoms versus pH monitoring results.

OBJECTIVES: The reason why some patients with gastroesophageal reflux disease (GERD) have symptoms of upper aerodigestive system irritation, while others mainly have gastroenterologic symptoms, is not well established. This retrospective case series study was designed to examine the existence of a correlation between symptoms and reflux characteristics, based on data obtained from esophageal pH monitoring. METHODS: The study population consisted of 139 patients; 97 patients presented with laryngopharyngeal symptoms of GERD, including unexplained hoarseness, throat clearing, chronic cough, laryngospasm, globus, throat pain, and 42 patients presented with gastroenterologic symptoms, including heartburn and regurgitation. The results of 24-hour, double-channel ambulatory esophageal pH monitoring were analyzed comparing 2 symptom groups. The incidence of abnormal acid reflux at the upper and lower esophageal segments and the effects of upright and supine positions on reflux parameters were evaluated. RESULTS: The incidence of laryngopharyngeal reflux was significantly higher in the laryngopharyngeal symptom group than in the other (52% versus 38%). The patients with laryngopharyngeal reflux from both groups showed no significant differences in terms of number of acid reflux episodes, percentage of times pH was 4, and esophageal acid clearance. Upright and supine parameters did not show significant differences between the patient groups. Upright acid reflux episodes were, however, common in both groups at the lower esophageal and laryngopharyngeal segments. CONCLUSION: Recent studies suggesting that otolaryngologic patients commonly show upright, daytime reflux with normal esophageal clearance and that typical GERD patients commonly have supine, nocturnal reflux with prolonged esophageal clearance are not supported by this study. This study indicates that acid reflux parameters and positional changes are not sufficient to explain why patients with GERD experience different symptoms. The regional symptoms of GERD may be attributed to the impairment of epithelial resistance, motor activity, and buffering systems for the esophageal antireflux barrier.     

Patterns of gastroesophageal reflux in health and disease.

Twenty-four pH monitoring the distal esophagus quantitates gastroesophageal reflux in a near physiologic setting by measuring the frequency and duration of acid exposure to the esophageal mucosa. Fifteen asymptomatic volunteers were studies with 24-hour pH and esophageal manometry. The normal cardia was more competent supine than in the upright position. Physiologic reflux was unaffected by age, rarely occurred during slumber, and was the rule after alimentation. One hundred symptomatic pateitns with an abnormal 24-hour pH record (2 S.D. above the mean of controls) could be divided into three patterns of pathological reflux: those who refluxed only in the upright position (9), only in the supine position (37), and in both positions (54). Upright differed from supine refluxers by excessive aerophagia causing reflux episodes by repetitive belching. Compared to controls, they had excessive post-prandial reflux, lower DES pressure, and less DES exposed to the positive pressure of the abdomen. Supine differed from upright refluxers by having a higher incidence of esophagitis and an inability to clear the esophagus of acid after a supine reflux episode. Compared to controls, they had only a lower DES pressure. Combined refluxers had a higher incidence of esophagitis than supine refluxers. Stricture (15%) was seen only in this group. They were similar to supine refluxers in their inability to clear a supine reflux episode. Compared to controls, they had a lower DES pressure and less DES exposed to the positive pressure of the abdomen. Forty of the 100 patients had an antireflux procedure (4 upright, 8 supine, 28 combined). The most severe postoperative flatus and abdominal distention was seen in the upright refluxers. It is concluded that minimal reflux is physiological. Patients with pathological reflux all have lower DES pressure. Patients with upright reflux have less of their DES exposed to the positive pressure environment of the abdomen. Patients with supine reflux have an inability to clear the esophagus of reflux acid and are prone to develop esophagitis. Patients with both upright and supine reflux have the most severe disease and are at risk in developing strictures. In patients with only upright reflux, aerophagia and delayed gastric emptying may be an important etiological factor.     

Calcium stone disease: a multiform reality

In calcium renal stones, calcium oxalate and calcium phosphate in various crystal forms and states of hydration can be identified. Calcium oxalate monohydrate (COM) or whewellite and calcium oxalate dihydrate (COD) or weddellite are the commonest constituents of calcium stones. Calcium oxalate stones may be pure or mixed, usually with calcium phosphate or sometimes with uric acid or ammonium urate. The aim of this study was to compare the clinical and urinary patterns of patients forming calcium stones of different composition according to infrared spectroscopic analysis in order to obtain an insight into their etiology. The stones of 84 consecutive calcium renal stone formers were examined by infrared spectroscopy. In each patient, a blood sample was drawn and analysed for serum biochemistry and a 24-h urine sample was collected and analysed for calcium, phosphate, oxalate, citrate and other electrolytes. We classified 49 patients as calcium oxalate monohydrate (COM) stone formers, 32 as calcium oxalate dihydrate (COD) stone formers and three as apatite stone formers according to the main component of their stones. Patients with COM stones were significantly older than patients with COD stones (P<0.002). Mean daily urinary calcium and urinary saturation with respect to calcium oxalate were significantly lower in patients with COM than in those with COD stones (P<0.000). Patients with calcium oxalate stones containing a urate component (10%) presented with higher saturation (P<0.012) with respect to uric acid in their urine (and lower with respect to calcium oxalate and calcium phosphate, respectively P<0.024 and P<0.003) in comparison with patients without a urate component in the stone. Patients with calcium oxalate stones with a calcium phosphate component (15%) showed higher (P<0.0016) urinary saturation levels with respect to calcium phosphate (and lower with respect to uric acid (P<0.009), compared with patients forming stones without calcium phosphate or with a low calcium phosphate component. Patients with calcium stones mixed with urate had a significantly lower urinary pH (P<0.002) and urinary calcium (P<0.000), and patients with calcium phosphate >15%, higher urinary pH (P<0.004) and urinary calcium (P<0.000). In conclusion, in the evaluation of the individual stone patient, an accurate analysis of the stone showing its exact composition and the eventual presence of minor components of the stone is mandatory in order to plan the correct prophylactic treatment. Patients with calcium stones could require various approaches dependent on the form and hydration of the calcium crystals in their stones, and on the presence of minor crystalline components that could have acted as epitaxial factors.     

Ultrashort Hirschsprung's disease: myth or reality

The term ultrashort Hirschsprung's disease has been used to define a spectrum of conditions with clinical presentation similar to Hirschsprung's disease but with presence of ganglion cells on rectal biopsy. In contrast to Hirschsprung's disease, there is no transition zone on barium enema. However, as in classical Hirschsprung's disease, there is no reflex internal sphincter relaxation on rectal manometry. We reviewed the presentation of five patients with chronic constipation who fulfilled the criteria for ultrashort Hirschsprung's disease. After positive anorectal manometry, despite the presence of ganglion cells on suction rectal biopsy, internal sphincter myomectomy was performed in four patients. Resolution of symptoms was noted in all operated patients. Normal ganglion cells were present throughout the entire length of all myomectomy specimens. There is controversy in the literature concerning the diagnosis of ultrashort Hirschsprung's disease. Most of the confusion concerns whether a short segment of aganglionosis proximal to the dentate line is permissible for the diagnosis of ultrashort Hirschsprung's disease and to what extent such aganglionosis is physiological. Perhaps it would be more accurate to define this entity by the presence of ganglion cells on rectal biopsy as well as the failure of the internal sphincter to relax on rectal manometry and to describe it as anorectal achalasia in severely constipated patients.