Lymphocytic Esophagitis: Assessing Risk Factors and Clinical Outcomes

Digestive Diseases and Sciences - Lymphocytic esophagitis is a rare esophageal condition. Our knowledge of potential risk factors and treatment outcomes of lymphocytic esophagitis is limited. To...     

Opportunistic infections with Strongyloides stercoralis in renal transplantation

Opportunistic infections with the nematode Strongyloides stercoralis occur most often in patients with impaired T lymphocyte function, including recipients of renal allografts. Occult intestinal infection can remain quiescent for more than 30 years, becoming apparent only after the initiation of immunosuppression. Pulmonary and gastrointestinal symptoms predominant as initial clinical manifestations in patients with strongyloides hyperinfection or dissemination. Although thiabendazole remains the treatment of choice for all forms of strongyloidiasis, the duration of therapy must be individualized on the basis of frequent examinations of both stool and sputum. Transplantation centers drawing patients from areas with endemic Strongyloides should evaluate potential recipients closely for occult strongyloides infection prior to initiating immunosuppressive therapy. Empiric therapy with thiabendazole should be considered for renal allograft recipients with unexplained eosinophilia and a history of travel or residence in an area with endemic Strongyloides. Prophylactic monthly administration of thiabendazole in immunocompromised patients who have survived strongyloides hyperinfection or dissemination can prevent reinfection.     

Extended stent usage for persistent esophageal leak: should there be limits?

A patient with a spontaneous esophageal perforation was unsuccessfully managed elsewhere by repeated stent placement. Because of inability to remove the stents and persistent empyema, staged procedures of esophagectomy and later restoration of gastrointestinal continuity were necessary.     

Medical management of gastroesophageal reflux disease

Gastroesophageal reflux disease is a common worldwide disorder. Most patients have typical symptoms of heartburn, regurgitation and exacerbation of symptoms with large meal volumes, fatty meals, recumbency or bending forward. Patients who show typical symptoms for under 10 years may be treated empirically with lifestyle and dietary modifications plus acid-suppressing medications. The recent decrease in cost, established safety and wide availability of proton pump inhibitors make them the best choice for monotherapy. Other medical therapies include antacids, H(2) receptor antagonists and prokinetic agents. Patients who have alarm symptoms or long-standing symptoms should have an esophagoscopy to evaluate for complications of reflux. Patients who do not respond to therapy should have a test to confirm the diagnosis of gastroesophageal reflux disease.     

Use of Acid Suppressive Medications After Laparoscopic Antireflux Surgery: Prevalence and Clinical Indications

Laparoscopic antireflux surgery (LARS) provides effective control of gastroesophageal reflux (GER) in more than 90% of patients. Despite this high success rate, some patients continue to consume acid suppressive medications after surgical intervention. In this study we evaluate the prevalence, clinical indications, and cause of use of acid reducing drugs in patients after LARS. Consecutive patients undergoing LARS for GERD were surveyed 2–3 years after surgery regarding use of acid suppressive medications, surgical outcome, and GERD specific symptoms. During the study period, 119 patients underwent LARS at our center. Ninety-eight (82%) were available for interview. Two patients died of unrelated causes and two declined to be interviewed. The remaining 94 individuals are the subject of this report. Ninety-four percent were satisfied with the outcome of surgery. Despite this high satisfaction rate, 37 of 94 (39%) were on antireflux medication (ARM; 62% proton pump inhibitors, 22% H2-receptor antagonists, and 16% others), with 70% using continuous medication. Of these patients, 54% took ARM after surgery for GERD-related symptoms, 95% of these patients responded to medical therapy, and yet again, 85% remained satisfied with the surgical outcome. Forty-six percent of patients on ARM after surgery had no GERD symptoms and took ARM for nonappropriate indications such as bloating. Only 47% of these responded to ARM; 82% of this group was satisfied with the surgical outcome. In conclusion, the use of ARM after LARS is a common occurrence despite a high satisfaction rate with this operation. Nearly half of patients consuming ARS after LARS are taking these medications for symptoms not necessarily related to GER. These findings underscore the importance of patient education in the use of these agents. The first two authors contributed equally to this article.     

Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease

Guidelines for the diagnosis and treatment of gastroesophageal reflux disease (GERD) were published in 1995 and updated in 1999. These and other guidelines undergo periodic review. Advances continue to be made in the area of GERD, leading us to review and revise previous guideline statements. GERD is defined as symptoms or mucosal damage produced by the abnormal reflux of gastric contents into the esophagus. These guidelines were developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee, and approved by the Board of Trustees. Diagnostic guidelines address empiric therapy and the use of endoscopy, ambulatory reflux monitoring, and esophageal manometry in GERD. Treatment guidelines address the role of lifestyle changes, patient directed (OTC) therapy, acid suppression, promotility therapy, maintenance therapy, antireflux surgery, and endoscopic therapy in GERD. Finally, there is a discussion of the rare patient with refractory GERD and a list of areas in need of additional study.     

Bowel dysfunction after laparoscopic antireflux surgery: incidence,severity, and clinical course

PURPOSE: To evaluate the incidence, severity, and clinical course of postoperative bowel dysfunction, primarily diarrhea, after laparoscopic antireflux surgery. METHODS: Patients who underwent laparoscopic antireflux surgery during January to December 1998 responded to a questionnaire about pre-existing and postoperative bowel symptoms, which included questions about the type of bowel dysfunction (diarrhea, abdominal pain, bloating, constipation), onset in relation to surgery, frequency, severity, duration, use of medical resources or diagnostic evaluations, and treatment outcome. RESULTS: Of the 109 patients who underwent laparoscopic antireflux surgery at our center during the study, 84 (77%) completed the survey. Thirty-six (43%) had no bowel dysfunction before or after surgery, whereas 29 (35%) had pre-existing bowel dysfunction. New bowel symptoms developed postoperatively in 30 patients (36%), including bloating in 16 (19%) and diarrhea in 15 (18%). Two thirds of the patients with new diarrhea developed it within 6 weeks after surgery. The severity of the diarrhea ranged from mild to debilitating; 4 had fecal incontinence. Most patients (13/15) with diarrhea had symptoms for > or =2 years following surgery. No patient was hospitalized, and only 2 patients reported temporary work loss. CONCLUSION: Postoperative bowel dysfunction, namely diarrhea, is an important adverse effect of antireflux surgery. Awareness of this complication should lead to prompt recognition, effective management, and reduction in anxiety.