Prevalence of upper respiratory symptoms in patients with symptomatic gastroesophageal reflux disease

This study evaluated the prevalence of upper respiratory symptoms (URS) among patients with symptomatic gastroesophageal reflux disease (GERD). Seventy-four subjects with heartburn completed a URS questionnaire before dual-probe, 24-h esophageal pH monitoring. The URS questionnaire was also completed by 74 normal volunteers without previous or current symptoms of GERD. Esophageal pH monitoring results were classified as normal, distal, or proximal and distal gastroesophageal reflux using standardized criteria. Mean URS scores (+/- SD) were 8.31 +/- 3.98 in the 52 subjects with GERD and 4.57 +/- 3.57 in the 22 subjects with negative pH probe studies, p = 0.02. Subjects with negative pH probe studies and normal volunteers scored similarly on the URS questionnaire. Reflux episodes/24 h correlated with URS scores, r = 0.47, p = 0.0001. Seventy-five percent of subjects with upper reflux, 68% of subjects with lower reflux, 36% of subjects with normal esophageal pH studies, and 9% of normal volunteers reported laryngeal symptoms for at least 5 d/mo. Sixty-nine percent of subjects with upper reflux, 50% of subjects with lower reflux, 31% of subjects with normal pH studies, and 14% of normal volunteers reported nasal symptoms for at least 5 d/mo. URS are frequent among subjects with GERD.

KEYWORDS

rhinitis; upper airway; gastroesophageal reflux

Evaluation of submucosal upper gastrointestinal tract lesions by endoscopic ultrasound

The proper diagnosis of submucosal upper gastrointestinal tract mass lesions by endoscopy or barium study is difficult. Differentiation between submucosal tumors, vascular structures, and extrinsic organs is often impossible. We performed endoscopic ultrasound examination of 91 patients with upper gastrointestinal submucosal mass lesions. Endoscopic ultrasound was accurate in determining the site of origin in 48 of 50 cases where pathology or angiography comparison was available. Leiomyoma, lipoma, varices, and carcinoma had characteristic ultrasonographic findings. Endoscopic ultrasound is a useful procedure in the evaluation of upper gastrointestinal submucosal mass lesions.

Chronic esophagitis dissecans presenting with esophageal strictures: a case report

Chronic esophagitis dissecans superficialis is a rare form of chronic esophagitis producing esophageal cast. Its clinical and histopathologic features have recently been defined. We present a 78-year-old patient with chronic esophagitis dissecans associated with esophageal strictures. The clinical and pathologic features of chronic esophagitis dissecans superficialis are reviewed. The association of chronic esophagitis dissecans superficialis with strictures has not been previously reported.

Gastroesophageal reflux and asthma: a review of pathogenesis, diagnosis, and therapy

Gastroesophageal reflux disease (GERD) occurs in up to one-third of the adult US population. Most affected individuals are either unaware of their condition or do not seek medical help, relying on nonprescription acid suppressants and antacids for relief. GERD, a common disorder of infancy, old age, and pregnancy, is particularly prevalent in patients with asthma. A causal relationship between the two diseases has been postulated by many investigators. The physiologic changes of asthma exacerbations and the actions of some of the medications used to treat asthma both aggravate GERD. The adverse effect of GERD on asthma and the pathophysiology of this relationship are still under debate. Some studies showed no objective improvement by spirometry of asthmatics treated for GERD, but recognized improvement in asthma symptoms and decreased use of asthma medication. Other studies, supporting GERD induction of asthma, have been performed to test two hypotheses: that asthma is exacerbated by endotracheal aspiration of gastric contents or by a reflex response to stimulation of esophageal receptors. Clinical experience has shown that early diagnosis and treatment of GERD often leads to better control of asthma.

Endosonographic Staging of Esophageal Cancer

BACKGROUND: Endosonography (ES) is an important tool for staging malignant esophageal cancer with the TNM staging classification. ES is a safe procedure and an accurate method of staging tumor invasion (T) and lymph node involvement (N). METHODS: The author reviewed the literature on the comparative roles of computed tomography and ES as complementary staging procedures. RESULTS: Advantages of ES in staging esophageal cancer include the ability to accurately determine the layer depth of mural infiltration and to detect metastatic involvement of regional lymph nodes. Its disadvantages include its inability to identify distant metastases, to differentiate inflammation from malignant infiltration of wall layers or in lymph nodes, and to examine beyond obstructing tumors unless esophageal dilation is performed. A recent review indicates the accuracy for T staging to be 84% and N staging to be 77%. CONCLUSIONS: ES is a valuable tool in staging esophageal cancer and should be used in combination with computed tomography for highest accuracy.

Palliation of Dysphagia of Esophageal Cancer by Endoscopic Lumen Restoration Techniques

BACKGROUND: Cure of patients with esophageal cancer has remained rare over the past four decades. The overall five-year survival rate for squamous cell and adenocarcinoma of the esophagus currently is reported as 12% in whites and 8% in blacks. The five-year survival rate for localized disease at initial staging is only 26% for whites and 13% for blacks. With regional involvement, these rates are 11% and 7%, respectively. METHODS: The author reviews the literature on optimal endoscopic lumen restoration techniques, including dilation, thermal laser and chemical ablation, photodynamic therapy, and stents. Procedures for pain relief and nutritional support are also presented. RESULTS: Lumen restoration to relieve dysphagia and provide the opportunity for sustaining reasonable peroral nutrition is an essential element in the overall management. Nonsurgical lumen restoration procedures have much to offer for dysphagia palliation and are briefly reviewed in this presentation. The major options include ablation of intraluminal tumor mass by thermal laser, photodynamic laser, chemical ablation, peroral dilation, and placement of esophageal stents. Most patients require more than one palliative method to sustain lumen patency during the course of their disease. CONCLUSIONS: Most patients with esophageal cancer will require palliation for the multiple problems that develop during their limited life span. The responsibility of the palliation therapist is to provide the patient with safe and cost-effective treatments that provide the best possible dysphagia relief.

Proton pump inhibitor-associated gastric polyps: a retrospective analysis of their frequency, and endoscopic, histologic, and ultrastructural characteristics

Since 1992 there have been reports of proton pump inhibitors being associated with fundic gland-type gastric polyps. Endoscopic and histologic characteristics and natural history of these polyps have not been clearly defined. We performed a retrospective study of patients on long-term treatment with proton pump inhibitors who developed gastric polyps. Gastric polyps developed in 17 (10 males and 7 females, 7.3%) of the 231 patients who underwent 2 or more upper endoscopies for complicated gastroesophageal reflux disease and who were receiving long-term treatment with proton pump inhibitors. The mean interval of proton pump inhibitor use after which an endoscopy revealed gastric polyps was 32.5 months. In 1 patient, discontinuation of treatment resulted in disappearance of the polyps within 3 months. The polyps recurred 4 months after the treatment was restarted. Endoscopy established that typical polyps were generally small (<1 cm), sessile, multiple, and whitish pink with a mottled partially translucent surface. The polyps were most often present in the proximal/midgastric body. Of the 15 polyps removed endoscopically, 9 were of the fundic gland type, 4 were of the hyperplastic type, and 2 were of the inflammatory type. Eight of 9 polyps with typical endoscopic appearance were of the fundic gland type. None of the polyps contained dysplasia or carcinoma. Long-term use of proton pump inhibitors may be associated with the presence of small gastric fundic gland polyps and hyperplastic polyps. A prospective study is required to establish their incidence, natural history, and clinical significance.

Chromoendoscopy--where is it useful?

Tissue staining during endoscopy (chromoendoscopy) is a technique used to study the fine details of the mucosa throughout the gastrointestinal tract. Unfortunately, its applications and results are not known by many gastrointestinal or surgical endoscopists. Each stain has a few specific clinical applications. The mechanism of action of the stains should be fully understood before their use. Ideally, the clinician should use chromoendoscopy and the variety of stains either to confirm a clinical suspicion or to provide new information that could aid management in a specific setting. Endoscopic tattooing is a different technique where a specific site in the gastrointestinal tract is labeled by an intramural injection of a carbon ink suspension solution for future surgical or endoscopic identification.

Endosonographic differentiation of benign and malignant stromal cell tumors

BACKGROUND

Endosonography (EUS) is a valuable technique for diagnosing gastrointestinal stromal cell tumors. However, EUS features that are predictive of malignancy in these tumors have not been defined.

METHODS

Videotapes and photographs of EUS examinations performed prior to surgical resection of 35 stromal cell tumors (9 malignant) were blindly reviewed by a single examiner. EUS features associated with malignancy were determined. Interobserver agreement in interpreting these features was then measured among a panel of five expert endosonographers who judged EUS videotapes of 35 resected stromal cell tumors (10 malignant).

RESULTS

Stepwise logistic regression analysis demonstrated that tumor size (diameter > 4 cm), irregular extraluminal border, echogenic foci, and cystic spaces were independently associated with malignancy in stromal cell tumors (p < 0.05). Interobserver agreement for irregular extraluminal border, echogenic foci, and cystic spaces, as measured by mean kappa statistic, was 0.43, 0.39, and 0.28, respectively. For the five experts, the sensitivity for detecting malignancy ranged between 80% to 100% when at least two of the three features were judged to be present. The likelihood of finding malignancy ranged between 0% to 11% for the experts when all three features were judged absent.

CONCLUSIONS

Tumor size and certain EUS features are useful for predicting malignancy in stromal cell tumors. Absence of these features indicates benign disease. Agreement among experts in interpreting these EUS features is fair to moderate.

Therapeutic approaches to healing esophagitis

Medical therapy for reflux esophagitis is designed to provide symptom relief and esophageal healing, and to prevent complications. Life-style modifications serve as an adjunct to drug therapy. Sucralfate, prokinetic agents, and H2-receptor antagonists promote symptom relief and esophageal healing in mild esophagitis, but are less effective in the treatment of moderate to severe esophagitis. For patients with mild to severe (erosive) esophagitis, rapid symptom relief and esophageal healing have been achieved with proton pump inhibitors such as omeprazole and lansoprazole.

Prospective multicenter trial of esophageal Z-stent placement for malignant dysphagia and tracheoesophageal fistula

BACKGROUND

Conventional esophageal prosthesis placement has been associated with a 6% to 8% perforation rate and numerous postplacement complications. Expandable esophageal stents have been developed to preclude the above but there are few studies that have prospectively defined clinical results and subsequent stent-related complications.

METHODS

All patients who underwent esophageal Z-stent placement at nine university or referral hospitals were prospectively assessed. Data collected included patient demographics, acute and subacute placement problems, the ability to occlude airway fistulas, prestent and poststent dysphagia scores, and patient survival.

RESULTS

Fifty-four of 56 patients (96%) with refractory dysphagia or malignant esophagoairway fistulae had 73 Z-stents successfully inserted. Initial distal deployment occurred in 13% of the patients and an additional 17% required balloon dilation to achieve maximal diameter. Acute placement complications occurred in 11% of patients and included severe pain (3), bleeding from necrotic tumor (2), and hiatal hernia intussusception (1). No perforations occurred. Eight of 11 patients (73%) had complete tracheoesophageal fistula occlusion and mean dysphagia score (+/- SD) improved from 2.6 (0.7) to 1.1 (1.2) (p < 0.01). Fifteen stents (27%) had delayed migration at a mean of 1 month and 3 required surgery for retrieval. Three patients had ultimate stent erosion resulting in bleeding in 2 (exsanguination 1) or fistula (treated with a conventional stent).

CONCLUSIONS

The authors conclude that esophageal Z-stents can be placed safely and successfully in the majority of patients. The tendency of distal deployment during placement and subsequent migration problems at a time distant from placement in a patient subset deserve attention and are currently being addressed.

Clinical implications of endoscopic ultrasound: the American Endosonography Club Study

BACKGROUND

Despite increased clinical use of endoscopic ultrasound (EUS), there are little data regarding complications of EUS or its impact on patient management.

METHODS

A prospective multicenter study was completed to evaluate clinical outcomes of EUS. Before each EUS examination the endosonographer recorded further theoretical patient management plans as if EUS was unavailable. After the EUS, endosonographers recorded actual management plans based on EUS results. The actual management plan after EUS was compared to the theoretical management before EUS. Complications were assessed in short-term follow-up.

RESULTS

Four hundred twenty-eight subjects were enrolled. Of subjects able to be evaluated, EUS changed the treatment plan in 74%. Management changes of major importance occurred in 120 patients (31% of subjects able to be evaluated) and included decisions regarding surgery (62 patients), decisions regarding nonsurgical invasive management (36 patients), and decisions regarding further follow-up (22 patients). When there was a change in management, the change was to less costly, risky, or invasive management in 55%, to more costly/risky/invasive in 37%, and to equally costly/risky/invasive in 8%. Short-term follow-up was completed in 81% of subjects, with six complications identified (1.7%). Three complications were mild, two were moderate, one severe, and none fatal.

CONCLUSIONS

(1) Changes in management plan may occur in the majority of patients based on EUS results. (2) The management changes are often of major importance with regard to health care costs and safety, and are more often in the direction of less costly, risky, and invasive management. (3) EUS is safe in experienced hands.

Plasma and erythrocyte thiamin concentrations in geriatric outpatients

OBJECTIVE

The objective of this study was a) to determine the plasma and red cell thiamin levels in geriatric outpatients and b) to evaluate, using the rat model, the sensitivity of plasma thiamin concentration as an indicator of nutritional status for this vitamin.

SUBJECTS

Thirty geriatric outpatients were evaluated for their plasma and erythrocyte thiamin levels.

METHODS

Plasma and red cell thiamin levels were determined by a microbiologic assay using kloeckera apiculata. Sprague-Dawley rats were fed a thiamin deficient diet. Blood samples were obtained on specified days and the plasma and erythrocyte thiamin levels determined.

RESULTS

Forty-three percent of the subjects studied had plasma thiamin levels below 2 SD of the mean of the younger-age group (20-60 yr) while 57% had a plasma thiamin below 10 ng/ml (the lower reference range of the younger age group). Twenty-seven percent were found to have red cell thiamin levels below 2 SD of the mean of the younger-age group, while 33% had red cell thiamin levels below 138 ng/ml (the lower reference range of the younger-age group). The rat study indicated that plasma thiamin concentration is a sensitive indicator of the nutritional status for this vitamin.

CONCLUSION

About 50% of geriatric outpatients in this study had low plasma thiamin levels. The long-term effect of a low plasma thiamin level on cognitive functions remains to be investigated.

Prognosis of esophageal cancers preoperatively staged to be locally invasive (T4) by endoscopic ultrasound (EUS): a multicenter retrospective cohort study

BACKGROUND

Endosonography is a significant advance in the preoperative staging (TNM classification) of esophageal cancer. Its accuracy for evaluating depth of tumor invasion is over 80%.

METHODS

A multicenter retrospective cohort study of patients with esophageal carcinomas defined to be invasive (T4) by endosonography was performed to compare the survival of surgically and nonsurgically treated patients. Median survival time, overall mortality, and Kaplan-Meier survival curves were compared by treatment group. Univariate and Cox regression analysis were used to evaluate the effects of various prognostic factors and treatment on the risk of death.

RESULTS

A total of 79 patients were studied. The surgical group (Group I, n = 42) was significantly younger and had more distal tumors (adenocarcinomas) than the nonsurgical group (Group II, n = 37). Endosonography was significantly more accurate than CT scanning in identifying tumor invasion (87.5% versus 43.8%, respectively, p = .0002). Overall mortality rate was not significantly different between treatment groups; 59.5% of the surgical group and 64.9% of the nonsurgical group were dead at follow-up (p = 0.65). Similarly, the median survival times of Group I and Group II patients were similar (5.2 and 7.0 months, respectively, p = 0.50). Survival curves for the two groups were almost overlapping (log rank test, p = 0.84). Even after adjusting for age, histologic diagnosis, tumor location, and regional lymph node status, surgical treatment did not significantly influence survival (p = 0.24).

CONCLUSIONS

Endosonography accurately identifies patients with invasive T4 tumors who have a poor prognosis. This prognosis is independent of mode of therapy.

Evaluation of submucosal upper gastrointestinal tract lesions by endoscopic ultrasound

The proper diagnosis of submucosal upper gastrointestinal tract mass lesions by endoscopy or barium study is difficult. Differentiation between submucosal tumors, vascular structures, and extrinsic organs is often impossible. We performed endoscopic ultrasound examination of 91 patients with upper gastrointestinal submucosal mass lesions. Endoscopic ultrasound was accurate in determining the site of origin in 48 of 50 cases where pathology or angiography comparison was available. Leiomyoma, lipoma, varices, and carcinoma had characteristic ultrasonographic findings. Endoscopic ultrasound is a useful procedure in the evaluation of upper gastrointestinal submucosal mass lesions.

Effect of 5-fluorouracil on methotrexate transport and cytotoxicity in HT29 colon adenocarcinoma cells

Exposure of the human colon adenocarcinoma HT29 cells to different concentrations of 5-fluorouracil (5FU) for 24 h resulted in a dose-dependent increase in the cellular glutathione (GSH) level which remained elevated up to 72 h following 5FU treatment. Pretreatment of HT29 cells with 5FU was found to enhance the uptake of methotrexate (MTX) as compared to control cells. Administration of MTX 24 h after 5FU was found to be synergistic, whereas administration of MTX 24 h before 5FU or together with 5FU was not found to be synergistic. The results of this study suggest that the increase in cellular GSH level as a result of 5FU pretreatment may play a role in the enhancement of MTX uptake and the cytotoxicity of both drugs in HT29 cells.

Cruciferous vegetables and glutathione: their effects on colon mucosal glutathione level and colon tumor development in rats induced by DMH

The effect of a diet containing 10-40% lyophilized cabbage or broccoli as cruciferous vegetable or 10-40% lyophilized potato as noncruciferous vegetable fed for 14 days on the colon mucosal glutathione (GSH) level was studied in male rats. The GSH levels of the duodenum mucosa and the liver were also measured. Cabbage and broccoli enhanced the colon and duodenum mucosal GSH levels in a dose-related manner; potato had no effect. All three vegetables had no effect on the liver GSH level. The effect of GSH on colon tumorigenesis induced by 1,2-dimethylhydrazine (DMH) was also examined in rats. Male Sprague-Dawley rats were injected with DMH (20 mg/kg body wt) weekly for 20 weeks. DMH lowered the colon mucosal GSH level. GSH (100 mg/day/rat) dissolved in the drinking water and given to rats during and after DMH injections had little or no effect on tumor incidence and total number of colon tumors. Tumors were larger in rats that received GSH than in those that received water. This study shows that the colon mucosal GSH level can be enhanced by feeding rats a diet high in cabbage or broccoli and that GSH added to the drinking water did not affect DMH-induced colon tumorigenesis under the experimental conditions used.

5-Fluorouracil cytotoxicity in human colon HT-29 cells with moderately increased or decreased cellular glutathione level

Little is known whether diet or certain components in the diet can modulate the efficacy of 5-fluorouracil (5FU) in patients with colon carcinoma. Glutathione (GSH), an important antioxidant and anticarcinogen, is present in many foods in varying amounts. This study examined whether a moderately increased or decreased cellular GSH level had any effect on the growth of human colon adenocarcinoma cells HT-29 and on the cytotoxic activity of 5FU in these cells. GSH and buthionine sulfoximine were used to enhance or reduce the GSH level respectively in these cells. A 34% increase in cellular GSH level had no effect on the growth of HT-29 cells, nor on the cytotoxic activity of 5FU as determined by the MTT colorimetric assay and cell counts. A 50% reduction in the cellular GSH level was found to enhance 5FU cytotoxicity by 20% to 31% as determined by the MTT colorimetric assay, depending on the 5FU concentration. This study shows that a moderate change in the GSH level in HT-29 cells had little or no effect on the cells' growth, but a decrease in cellular GSH level slightly enhanced the cytotoxic activity of 5FU in these cells.

Effect of ascorbic acid on plasma alcohol clearance

The effects of short-term and long-term ascorbic acid supplements on plasma alcohol clearance were studied in 13 clinically healthy male subjects. Two dose levels of alcohol, 0.5 and 0.8 g/kg body weight, were used. Blood samples were taken at zero time, 0.5 hours, then hourly up to 6 hours after alcohol consumption for the measurement of plasma alcohol and ascorbic acid levels, red-cell reduced glutathione level, and plasma alanine aminotransferase activity. At both dosages of alcohol, short-term as well as long-term pretreatment with ascorbic acid significantly enhanced the clearance of plasma alcohol. Although long-term ascorbic acid pretreatment resulted in better alcohol clearance, no significant difference in alcohol clearance was found between short-term and long-term ascorbic acid pretreatment. The two dose levels of alcohol had no significant effect on the red-cell reduced glutathione concentration or plasma alanine aminotransferase activity.

The effect of endotoxin on 1,2-dimethylhydrazine-induced colonic tumors in rats

The effect of endotoxin on colon tumors was studied in male Sprague-Dawley rats. Colon tumors were induced in weanling rats by the administration of 20 weekly subcutaneous injections of 1,2-dimethylhydrazine (DMH). When colon tumors were detected by colonoscopy in 80% of the rats around week 24 after DMH injection, the animals were divided randomly into two groups. One group served as the control. The other group received six endotoxin (Escherichia coli) treatments every fifth day. The first dose was 50 micrograms/100 g (intraperitoneally); the remaining doses were 100 micrograms/100 g (subcutaneously). Rats were killed 2 weeks after the last endotoxin injection. Endotoxin treatments resulted in larger colon tumors. The median tumor size was 71 mm2 for endotoxin-treated and 31 mm2 for untreated rats (P less than 0.02). Endotoxin treatments also resulted in a significantly higher incidence (P less than 0.05) of ulcer development in the small intestine, that is 47% in the endotoxin-treated versus 23% in the untreated rats. After a single subcutaneous injection of endotoxin (100 micrograms/100 g), the colon mucosal reduced glutathione (GSH) level was raised by 21% at 16 hours, reached a peak on day 2, then decreased to baseline by day 4. The increased GSH level in the colon mucosa was maintained up to the third endotoxin injection. By the fifth injection, no increase in the GSH level was observed. These results suggest that the growth of colon tumors in rats induced by DMH could be enhanced by endotoxin treatments. The enhanced tumor growth may be due to an increase in the colon GSH level and/or other mediators released by macrophages as a result of endotoxin treatments.

Effect of DL-buthionine-S,R-sulfoximine on 1,2-dimethyl-hydrazine-induced colonic tumors in rats

The effect of DL-buthionine-S,R-sulfoximine (BSO), a specific inhibitor of glutathione biosynthesis, on colon tumor development was studied in rats. Weanling male Sprague-Dawley rats were randomly assigned to one of three groups following a week of adaptation. Group 1 rats received BSO (4.5 mM) daily in the drinking water one week before 1,2-dimethylhydrazine (DMH) injections and continued to receive BSO daily until sacrificed; group 2 rats received BSO (4.5 mM) after the last DMH injection, and continued to receive BSO daily until sacrificed; group 3 rats did not receive BSO. All experimental rats received 20 weekly subcutaneous injections of DMH (20 mg/kg body wt.) for colon tumor induction. The tumor incidence was lower in group 1 (54%) than in group 2 (97%) or group 3 (96%). The median tumor size is significantly smaller in group 1 (11 mm2) than group 3 (46 mm2). The group 2 had the largest median tumor size (65 mm2).

Incomplete intestinal metaplasia in the diagnosis of columnar lined esophagus (Barrett's esophagus)

To investigate the distribution and specificity of intestinal metaplasia (IM) in columnar lined esophagus (CLE), the authors reviewed biopsies of the hiatal hernia pouch (HHP) and esophagus from 17 patients with CLE (84 biopsies) and 10 controls (25 biopsies). The proximal margin of the gastric folds was used as an endoscopic landmark, corresponding to the gastroesophageal muscular junction (GEMJ). No biopsies obtained above the GEMJ in control patients showed columnar mucosa. No goblet cell metaplasia was seen in 21 biopsies of the HHP from patients with CLE or in 13 corresponding biopsies from controls. In contrast, alcian blue (AB) stains showed diffuse acid mucins in 3 of 21 biopsies of the HHP from patients with CLE and in 10 of 13 corresponding biopsies from controls, demonstrating that goblet cell metaplasia clearly distinguishes biopsies of CLE from the HHP (P less than 0.01), whereas small amounts of diffuse acid mucin on AB stains do not. IM evidenced by goblet cell metaplasia was frequently seen in biopsies only 2-3 cm above the GEMJ, and CLE was limited to that area in three patients, suggesting that the distal esophagus cannot be dismissed as a site for metaplastic and possibly premalignant mucosa. Adenocarcinoma was diagnosed during the course of the study in one patient with only 5 cm of columnar mucosa above the GEMJ.

A new objective measurement of esophageal lumen patency

This study was performed to develop a system to measure dysphagia in an objective fashion, test its correlation with subjective estimates of dysphagia, and encourage the use of a standardized measure of esophageal stenosis. Thirty-five patients with mechanical dysphagia underwent subjective estimates of dysphagia using a dysphagia scale graded from 0 to 5, as well as a diet scale. Lumen diameter was measured endoscopically, using the open or closed biopsy forceps as a measuring guide. Patients were then given barium capsules or tablets of increasing diameter under fluoroscopy, in the upright position. Pills were given sequentially until a pill failed to traverse the esophagus in less than 20 s. The diameter of the pill failing to traverse the esophagus within 20 s correlated strongly with the endoscopically measured diameter by Spearmans rank correlation (Rs = 0.85). The weakest correlation was between endoscopically measured diameter and the dysphagia scale (Rs = 0.48). The diameter of the pill failing to traverse the esophagus within 20 s is an excellent estimate of esophageal lumen diameter. Pill size correlates much better with esophageal lumen diameter than dysphagia or diet scales. This new dysphagia assessment system should simplify standardization of the grading of dysphagia.

Comparative evaluation of gastrointestinal intolerance produced by plain and tri-buffered aspirin tablets

Two multi-investigator, double-blind, randomized, placebo-controlled, crossover trials were conducted to determine whether tri-buffered formulations of both regular strength aspirin and extra strength aspirin would be less likely than plain aspirin to provoke subjective gastrointestinal (GI) intolerance. Each trial was divided into two phases, a qualification phase and a test phase. During the qualification phase, subjects with a history of gastrointestinal intolerance to aspirin were randomized to a double-blind crossover treatment with aspirin and placebo (325 mg aspirin per tablet in study 1 and 500 mg aspirin per tablet in study 2), two tablets four times a day for 3 days or until the occurrence of stomach upset. Subjects who reported gastrointestinal symptoms with aspirin and not with placebo qualified to participate in the test phase of the study. They were rerandomized to participate in a three-way crossover study of plain aspirin, tri-buffered aspirin, and placebo in the test phase. Tri-buffered aspirin was associated with an appreciable reduction in the incidence of gastrointestinal upset relative to plain aspirin, 34 percentage points in study 1 (p less than 0.001) and 33 percentage points in study 2 (p less than 0.001). Similar results were obtained in the evaluation of the reduction of the severity of gastrointestinal symptoms.

Treatment of pharyngoesophageal stenosis by polyvinyl prosthesis

Many authors have objected to the use of esophageal stents in the palliative management of lesions obstructing the cervical esophagus, especially when the prosthesis must lie within 2 cm of the cricopharyngeus muscle (CPM). Ten patients with stenosis of the cervical esophagus by lesions within 2 cm of or involving the CPM were considered for prosthesis placement. The prosthesis was successfully placed in eight patients, five of whom had a tracheoesophageal fistula (TEF). A prosthesis could not be placed in two patients, and two patients complained of a minimal but tolerable foreign body sensation. Six prostheses were custom-made. The necessity to place a prosthesis within 2 cm of or even immediately proximal to the CPM should not be considered an absolute contraindication to esophageal prosthesis placement in selected patients. Foreign body sensation may be absent or minimal, and stent migration is common.

Effect of endotoxin on the rat colon glutathione level

The effect of endotoxin on the colon glutathione level was studied in male rats. Endotoxin (Escherichia coli) from 25 ug to 100 ug/100g body weight was administered intravenously. The Glutathione level was measured 16 hours after endotoxin was given. Results showed that endotoxin significantly enhanced the colon glutathione concentration as measured by 5,5'-dithiobis (2-nitrobenzoic acid). The increase which ranged from 11% to 50% was dose dependent. At an endotoxin dose of 1000 ug/100g body weight, colon glutathione level was found to be enhanced from 2 hours up to 48 hours. In contrast, the duodenum and jejunum glutathione levels were found to be significantly reduced. The increase in the colon glutathione level may have a protective effect against oxidative damage to the colon.

Early diagnosis of columnar-lined esophagus: a new endoscopic diagnostic criterion

The relationship between the proximal margins of the gastric mucosal folds and the squamocolumnar mucosal junction (SCMJ) in normal subjects and in patients with columnar-lined esophagus (CLE) was studied. Results indicate that in the normal esophagus, the SCMJ is located within 2 cm of the proximal margin of the gastric folds. The proximal margin of the gastric folds in a hiatal hernia pouch provide a fixed, reproducible, anatomic landmark at endoscopy, which designates the junction of the muscular wall of the esophagus and stomach and permits one to predict the expected normal location of the SCMJ. The diagnosis of CLE should be considered at endoscopy when either the SCMJ is located or columnar epithelium is obtained by biopsy at a site greater than 2 cm above the proximal margin of the gastric folds located within a hiatal hernia pouch. This study provides an endoscopic criterion to permit a more accurate diagnosis of CLE in its earliest stages and may permit a better assessment of its prevalence.

Longitudinal follow-up of chronic hemodialysis patients without vitamin supplementation

Vitamin supplementation for dialysis patients is still controversial. In our study, we followed longitudinally over a period of a year, 15 patients on chronic hemodialysis who were deprived of vitamin supplementation. Microbiological assays were used to determine the levels of five vitamins of the B group (folate, niacin, B12, B6, and thiamine). Vitamin C was measured chemically. During the observation period when vitamins were not supplemented, a marked drop of many of these vitamins in blood levels were encountered. For vitamins B12 and C, the plasma levels remained within the normal range in all the subjects studied. For the other vitamins, the blood levels were found to be low in a few patients. Our data suggest that vitamin supplementation is probably not needed in most stable hemodialysis patients as it is recommended now, and that perhaps, if supplementation is indicated, less should be given than is presently prescribed. Further research is needed in this area.

The plasma and red cell vitamin B levels of chronic hemodialysis patients: a longitudinal study

Plasma B12, folate, B6 and thiamine, and red blood cell folate, thiamine and niacin levels were monitored for a period of 6 months in 15 clinically stable, chronic hemodialysis patients who were not supplemented with the water-soluble vitamins. Microbiological assays were used to determine the blood levels of the water-soluble vitamins. Over the period of 6 months, none of the patients had plasma or red cell vitamin levels below the normal range. No appreciable changes were observed in the plasma and red blood cell vitamin levels before and after dialysis in 5 patients. This study showed that chronic hemodialysis patients are able to maintain normal plasma and red cell levels of some water-soluble vitamins without daily supplementation.

Stability of the B vitamins in mixed parenteral nutrition solution

The effects of various light conditions such as fluorescent light, and indirect and direct sunlight on the stability of the water-soluble B vitamins in parenteral mixtures were studied. The levels of the B vitamins were determined by microbiologic assays and spectrophotometrically. Most of the B vitamins were found to be stable. However, indirect and direct sunlight destroyed 47 and 100%, respectively, of riboflavin-5-phosphate in eight hours. Direct sunlight destroyed 86% of pyridoxine HCl. There was no loss of folic acid in parenteral nutrition mixtures after storage for 7 wk. The microbiologic assays were found to be reliable to measure the levels of the B vitamins in parenteral nutrition solution.

Medical management of esophageal obstruction and esophageal-pulmonary fistula

In patients with advanced esophageal stenosis, the quality of life is significantly effected. Nutrition and hydration are impaired, meals cause agony not pleasure, oral secretions cannot be swallowed properly, and pulmonary aspiration is common. Restoration of an adequate lumen will relieve the symptoms of esophageal stenosis. The goal of initial therapy is to establish and maintain a patent esophagus at the lowest risk and cost to the patient. Malignant esophageal stenosis safely may be dilated by the peroral route even in patients undergoing radiotherapy or with esophagopulmonary fistula. In those patients who fail to respond to esophageal dilation, surgery, or irradiation therapy for malignant esophageal stenosis, a peroral esophageal prosthesis may be placed under local anesthesia after proper esophageal dilation. The prosthesis is prepared for each patient based on the length of the esophageal stenosis. The procedure requires less than one minute to perform. The patient has no foreign body sensation and is able to swallow a soft-to-regular diet for the remainder of his life. This method may also be used to occlude esophagopulmonary fistulae caused by malignancy. The quality and duration of life both are significantly improved by use of the peroral prosthesis in patients with malignant esophageal obstruction. Nutrition support by nasoenteric or jejunostomy tube should be used when needed to restore nitrogen balance and immune competence.