Good clinical practice recommendations for the diagnosis and treatment of gastroesophageal reflux disease. An expert review from the Asociación Mexicana de Gastroenterología

INTRODUCTION

Gastroesophageal reflux disease (GERD) is very prevalent in the general population, with a broad spectrum of clinical manifestations, requiring accurate diagnosis and treatment.

AIM

The aim of this expert review is to establish good clinical practice recommendations for the diagnosis and personalized treatment of GERD.

METHODS

The good clinical practice recommendations were produced by a group of experts in GERD, members of the Asociación Mexicana de Gastroenterología (AMG), after carrying out an extensive review of the published literature and discussing each recommendation at a face-to-face meeting. This document does not aim to be a clinical practice guideline with the methodology such a document requires.

RESULTS

Fifteen experts on GERD formulated 27 good clinical practice recommendations for recognizing the symptoms and complications of GERD, the rational use of diagnostic tests and medical treatment, the identification and management of refractory GERD, the overlap with functional disorders, endoscopic and surgical treatment, and GERD in the pregnant woman, older adult, and the obese patient.

CONCLUSIONS

An accurate diagnosis of GERD is currently possible, enabling the prescription of a personalized treatment in patients with this condition. The goal of the good clinical practice recommendations by the group of experts from the AMG presented in this document is to aid both the general practitioner and specialist in the process of accurate diagnosis and treatment, in the patient with GERD.

Prevalence of primary eosinophilic colitis in patients with chronic diarrhea and diarrhea-predominant irritable bowel syndrome

INTRODUCTION

Primary eosinophilic colitis (PEC) is an inflammatory disease caused by the infiltration of eosinophils into the mucosa of the colon, determined after having ruled out other possible causes. It is characterized by abdominal pain and diarrhea and its prevalence is unknown.

AIMS

To know the prevalence of PEC in patients with chronic diarrhea and in those with clinical criteria for diarrhea-predominant irritable bowel syndrome (IBS-D).

PATIENTS AND METHODS

All patients with chronic noninflammatory diarrhea that were consecutively seen over a decade were studied through colonoscopy, with systematic biopsy. Patients with a known or decompensated organic disease, alarm features, abnormal minimal laboratory test results, and factors associated with eosinophilia were excluded. Patients with the clinical criteria for IBS-D (Rome III) were selected from the general group. Eosinophilic colitis was defined as the presence of > 35 eosinophils/100 epithelial cells per field in any of the segments.

RESULTS

From the 683 patients seen, a total of 545 patients (361 women) were included in the study. Twenty-two cases of PEC were detected, resulting in a prevalence of 4.0%. A total of 343 patients had IBS-D criteria (223 women), with 16 cases of PEC detected, for a prevalence of 4.7%. Colonoscopy was normal, or almost normal, in all the PEC cases detected.

CONCLUSIONS

The prevalence of PEC was 4.0% in the patients with chronic diarrhea and 4.7% in the patients with IBS-D. Peripheral eosinophilia appeared to be the main distinctive clinical characteristic, but systematic biopsy was essential for making the diagnosis.

Prevalence of primary eosinophilic colitis in patients with chronic diarrhea and diarrhea-predominant irritable bowel syndrome

INTRODUCTION

Primary eosinophilic colitis (PEC) is an inflammatory disease caused by the infiltration of eosinophils into the mucosa of the colon, determined after having ruled out other possible causes. It is characterized by abdominal pain and diarrhea and its prevalence is unknown.

AIMS

To know the prevalence of PEC in patients with chronic diarrhea and in those with clinical criteria for diarrhea-predominant irritable bowel syndrome (IBS-D).

PATIENTS AND METHODS

All patients with chronic noninflammatory diarrhea that were consecutively seen over a decade were studied through colonoscopy, with systematic biopsy. Patients with a known or decompensated organic disease, alarm features, abnormal minimal laboratory test results, and factors associated with eosinophilia were excluded. Patients with the clinical criteria for IBS-D (Rome III) were selected from the general group. Eosinophilic colitis was defined as the presence of>35eosinophils/100 epithelial cells per field in any of the segments.

RESULTS

From the 683 patients seen, a total of 545 patients (361 women) were included in the study. Twenty-two cases of PEC were detected, resulting in a prevalence of 4.0%. A total of 343 patients had IBS-D criteria (223 women), with 16 cases of PEC detected, for a prevalence of 4.7%. Colonoscopy was normal, or almost normal, in all the PEC cases detected.

CONCLUSIONS

The prevalence of PEC was 4.0% in the patients with chronic diarrhea and 4.7% in the patients with IBS-D. Peripheral eosinophilia appeared to be the main distinctive clinical characteristic, but systematic biopsy was essential for making the diagnosis.

The Mexican consensus on the detection and treatment of early gastric cancer

Gastric cancer is one of the most frequent neoplasias in the digestive tract and is the result of premalignant lesion progression in the majority of cases. Opportune detection of those lesions is relevant, given that timely treatment offers the possibility of cure. There is no consensus in Mexico on the early detection of gastric cancer, and therefore, the Asociación Mexicana de Gastroenterología brought together a group of experts and produced the "Mexican consensus on the detection and treatment of early gastric cancer" to establish useful recommendations for the medical community. The Delphi methodology was employed, and 38 recommendations related to early gastric cancer were formulated. The consensus defines early gastric cancer as that which at diagnosis is limited to the mucosa and submucosa, irrespective of lymph node metástasis. In Mexico, as in other parts of the world, factors associated with early gastric cancer include Helicobacter pylori infection, a family history of the disease, smoking, and diet. Chromoendoscopy, magnification endoscopy, and equipment-based image-enhanced endoscopy are recommended for making the diagnosis, and accurate histopathologic diagnosis is invaluable for making therapeutic decisions. The endoscopic treatment of early gastric cancer, whether dissection or resection of the mucosa, should be preferred to surgical management, when similar oncologic cure results can be obtained. Endoscopic surveillance should be individualized.

The Mexican consensus on the diagnosis and treatment of diverticular disease of the colon

Since the publication of the 2008 guidelines on the diagnosis and treatment of diverticular disease of the colon by the Asociación Mexicana de Gastroenterología, significant advances have been made in the knowledge of that disease. A systematic review of articles published in the medical literature from January 2008 to July 2018 was carried out to revise and update the 2008 guidelines and provide new evidence-based recommendations. All high-quality articles in Spanish and English published within that time frame were included. The final versions of the 43 statements accepted in the three rounds of voting, utilizing the Delphi method, were written, and the quality of evidence and strength of the recommendations were established for each statement, utilizing the GRADE system. The present consensus contains new data on the definition, classification, epidemiology, pathophysiology, and risk factors of diverticular disease of the colon. Special emphasis is given to the usefulness of computed tomography and colonoscopy, as well as to the endoscopic methods for controlling bleeding. Outpatient treatment of uncomplicated diverticulitis is discussed, as well as the role of rifaximin and mesalazine in the management of complicated acute diverticulitis. Both its minimally invasive alternatives and surgical options are described, stressing their indications, limitations, and contraindications. The new statements provide guidelines based on updated scientific evidence. Each statement is discussed, and its quality of evidence and the strength of the recommendation are presented.

The Mexican consensus on nonalcoholic fatty liver disease

Nonalcoholic fatty liver disease (NAFLD) affects nearly one third of the population worldwide. Mexico is one of the countries whose population has several risk factors for the disease and its prevalence could surpass 50%. If immediate action is not taken to counteract what is now considered a national health problem, the medium-term panorama will be very bleak. This serious situation prompted the Asociación Mexicana de Gastroenterología and the Asociación Mexicana de Hepatología to produce the Mexican Consensus on Fatty Liver Disease. It is an up-to-date and detailed review of the epidemiology, pathophysiology, clinical forms, diagnosis, and treatment of the disease, whose aim is to provide the Mexican physician with a useful tool for the prevention and management of nonalcoholic fatty liver disease.

Mexican consensus on dyspepsia

Since the publication of the 2007 dyspepsia guidelines of the Asociación Mexicana de Gastroenterología, there have been significant advances in the knowledge of this disease. A systematic search of the literature in PubMed (01/2007 to 06/2016) was carried out to review and update the 2007 guidelines and to provide new evidence-based recommendations. All high-quality articles in Spanish and English were included. Statements were formulated and voted upon using the Delphi method. The level of evidence and strength of recommendation of each statement were established according to the GRADE system. Thirty-one statements were formulated, voted upon, and graded. New definition, classification, epidemiology, and pathophysiology data were provided and include the following information: Endoscopy should be carried out in cases of uninvestigated dyspepsia when there are alarm symptoms or no response to treatment. Gastric and duodenal biopsies can confirm Helicobacter pylori infection and rule out celiac disease, respectively. Establishing a strong doctor-patient relationship, as well as dietary and lifestyle changes, are useful initial measures. H2-blockers, proton-pump inhibitors, prokinetics, and antidepressants are effective pharmacologic therapies. H.pylori eradication may be effective in a subgroup of patients. There is no evidence that complementary and alternative therapies are beneficial, with the exception of Iberogast and rikkunshito, nor is there evidence on the usefulness of prebiotics, probiotics, or psychologic therapies. The new consensus statements on dyspepsia provide guidelines based on up-to-date evidence. A discussion, level of evidence, and strength of recommendation are presented for each statement.

The Mexican consensus on probiotics in gastroenterology

INTRODUCTION

Probiotics are frequently prescribed in clinical practice. Their efficacy in treating gastrointestinal disorders is supported by a significant number of clinical trials. However, the correct prescription of these agents is hampered due to a lack of knowledge of the scientific evidence and to the different presentations and microbial compositions of the probiotics that are currently available.

AIM

To provide the clinician with a consensus review of probiotics and recommendations for their use in gastroenterology.

MATERIALS AND METHODS

Controlled clinical trials, meta-analyses, and systematic reviews published up to 2015 were selected, using the MESH terms: probiotics, gastrointestinal diseases, humans, adults, AND children. The Delphi method was employed. Eighteen gastroenterologists treating adult patients and 14 pediatric gastroenterologists formulated statements that were voted on until agreement>70% was reached. The level of evidence based on the GRADE system was evaluated for each statement.

RESULTS AND CONCLUSIONS

Eleven statements on the general concepts of probiotics and 27 statements on the use of probiotics in gastrointestinal diseases in both adults and children were formulated. The consensus group recommends the use of probiotics under the following clinical conditions: the prevention of diarrhea associated with antibiotics, the treatment of acute infectious diarrhea, the prevention of Clostridium difficile infection and necrotizing enterocolitis, the reduction of adverse events from Helicobacter pylori eradication therapy, relief from irritable bowel syndrome symptoms, the treatment of functional constipation in the adult, and the induction and maintenance of remission in patients with ulcerative colitis and pouchitis, and the treatment of covert and overt hepatic encephalopathy.

Functional dyspepsia and dyspepsia associated with Helicobacter pylori infection: Do they have different clinical characteristics?

BACKGROUND

Helicobacter pylori causes motor, secretory, and inflammatory gastrointestinal disorders and therefore the term "functional" has been questioned when referring to dyspepsia associated with this bacterium. Patients with dyspepsia and Helicobacter pylori infection could have clinical characteristics that differentiate them a priori from those with true functional dyspepsia.

AIMS

To determine whether there are clinical differences between patients with functional dyspepsia and Helicobacter pylori-associated dyspepsia that enable their a priori identification and to know the prevalence of Helicobacter pylori infection in patients with functional dyspepsia.

PATIENTS AND METHODS

A total of 578 patients with dyspepsia with no significant lesions detectable through endoscopy were divided into 2 groups according to the presence of Helicobacter pylori. The clinical characteristics, medical history, comorbidities, and use of health resources were compared between the two groups. A sub-analysis pairing the groups by age and sex in a 1:1 ratio was carried out to reduce bias.

RESULTS

A total of 336 patients infected with Helicobacter pylori were compared with 242 non-infected patients. The prevalence of infection in the patients with dyspeptic symptoms and no endoscopically detectable lesions was 58%. The initial analysis showed that the cases with dyspepsia and Helicobacter pylori infection were more frequently associated with overweight, obesity, high blood pressure, diabetes mellitus, and metabolic syndrome, but the paired analysis nullified all these differences.

CONCLUSIONS

The patients with dyspepsia infected with Helicobacter pylori had similar clinical characteristics to the non-infected patients and could not be differentiated a priori. The prevalence of Helicobacter pylori infection in patients with functional dyspepsia was 58% and increased with age.

Usefulness of oil lubrication during colonoscopy: A comparative study with the conventional technique

BACKGROUND

The different forms of lubrication are among the most simple, accessible, and economic techniques that have been implemented for improving the diagnostic performance of colonoscopy.

AIM

To determine whether the use of oil improved the number of complete colonoscopies, facilitated the procedure, reduced pain, or improved the study's diagnostic performance, compared with the conventional lubrication technique.

PATIENTS AND METHODS

One hundred and seventy-five patients referred for colonoscopy were alternately allocated to receive treatment with the standard lubrication method with chlorhexidine gel (group 1) or lubrication with corn oil administered through the working channel (group II). The number of complete colonoscopies, the length of time needed to reach the cecum, the degree of difficulty estimated by the endoscopist and the assistant, the level of pain at the end of the study estimated by the patient, and the endoscopic findings were all determined.

RESULTS

Eighty-eight patients made up group I and 87 made up group II. No statistically significant differences were found between the two groups in relation to general characteristics, the number of complete colonoscopies (93 vs. 97%, respectively), the time needed to reach the cecum (8:00 vs. 8:41min, respectively), the level of pain at the end of the study, or the detection of polyps. The degree of difficulty was slightly lower in group II, but with no statistical significance.

CONCLUSIONS

Lubrication with oil during colonoscopy did not improve the number of complete colonoscopies, did not facilitate the study, nor did it reduce pain or increase the diagnostic performance of the study, when compared with the conventional technique.

Microbiota, gastrointestinal infections, low-grade inflammation, and antibiotic therapy in irritable bowel syndrome: an evidence-based review

BACKGROUND

Post-infectious irritable bowel syndrome (PI-IBS) prevalence, small intestinal bacterial overgrowth (SIBO), altered microbiota, low-grade inflammation, and antibiotic therapy in IBS are all controversial issues.

AIMS

To conduct an evidence-based review of these factors.

METHODS

A review of the literature was carried out up to July 2012, with the inclusion of additional articles as far as August 2013, all of which were analyzed through the Oxford Centre for Evidence-Based Medicine (OCEBM) system.

RESULTS

1.There is greater SIBO probability in IBS when breath tests are performed, but prevalence varies widely (2-84%). 2.The gut microbiota in individuals with IBS is different from that in healthy subjects, but a common characteristic present in all the patients has not been established. 3.The incidence and prevalence of PI-IBS varies from 9-10% and 3-17%, respectively, and the latter decreases over time. Bacterial etiology is the most frequent but post-viral and parasitic cases have been reported. 4.A sub-group of patients has increased enterochromaffin cells, intraepithelial lymphocytes, and mast cells in the intestinal mucosa, but no differences between PI-IBS and non-PI-IBS have been determined. 5.Methanogenic microbiota has been associated with IBS with constipation. 6.Rifaximin at doses of 400mg TID/10days or 550mg TID/14days is effective treatment for the majority of overall symptoms and abdominal bloating in IBS. Retreatment effectiveness appears to be similar to that of the first cycle.

CONCLUSIONS

Further studies are required to determine the nature of the gut microbiota in IBS and the differences in low-grade inflammation between PI-IBS and non-PI-IBS. Rifaximin has shown itself to be effective treatment for IBS, regardless of prior factors.

[Prevalence of microscopic colitis in patients with irritable bowel syndrome with diarrhea predominance]

BACKGROUND

Microscopic colitis (MC) and irritable bowel syndrome with diarrhea (IBSD) have a similar clinical and endoscopic presentation. The prevalence of MC in Mexican patients with IBS-D is unknown.

OBJECTIVES

To find out the prevalence of MC in patients with IBS-D and compare it with the one observed in patients with IBS with constipation (IBS-C).

METHODS

All patients with IBS (Rome III) seen consecutively from January 2008 to August 2010 were included. Those with organic disease, alarm signs, mixed IBS or unsubtyped- IBS (Rome III) were excluded. Colonoscopy with biopsies was performed in all patients that were examined by two pathologists who did not know the clinical characteristics of the subjects. MC was defined according with the universally accepted histological criteria.

RESULTS

155 patients with IBS-D and 145 with IBS-C were studied. Both groups were matched from the standpoint of age, gender ratio and time course of disease. MC was detected in 28 patients with IBS-D and in one with IBS-C (18% vs. 0.7%, p <0.0001). Fifteen patients with lymphocytic colitis and 14 with collagenous colitis were detected. The endoscopic appearance of the colon mucosa was normal in 20 of the 29 patients with MC (69%).

CONCLUSIONS

The prevalence of MC in patients with IBS-D was 18%, significantly higher than the one observed in patients with IBS-C. Colonic mucosa had a normal appearance in most of the patients with MC. Systematic biopsies are recommended in patients with IBS-D.

[Pharmacological treatment of the irritable bowel syndrome: a technical review]

INTRODUCTION

The goal of a comprehensive treatment in irritable bowel syndrome (IBS) patients should be the improvement of symptoms and improve the quality of life.

AIM

To review the drugs recommended in IBS, their mechanisms of action, side effects, risks and benefits, contraindications, availability in our country and the evidence supporting their use.

MATERIAL AND METHODS

A technical and narrative review which evaluated the articles published in national and world literature regarding the pharmacological treatment of IBS was performed. PubMed and IMBIOMED electronic databases were searched (until September 2009) using all descriptors regarding IBS and drug therapy.

RESULTS

There is enough clinical evidence to recommend the use of antispasmodics (alone orin combination) and tricyclic antidepressants for pain treatment in IBS. Laxatives are useful in the management of chronic constipation, but there is little evidence in the management of IBS. Although, antiflatulents and antidiarrheals are widely used there is little information supporting its use. The use of a nonabsorbable antibiotic (rifaximin) is effective in a subgroup of IBS patients. Serotoninergics drugs have proven effective in relieving symptoms of IBS; however, these drugs require caution in their use. There are studies have shown that probiotics improve some symptoms of IBS.

CONCLUSIONS

There are many effective treatment options in the symptomatic management of IBS. The choice of treatment should be based on the predominant symptoms of each patient.

[What people mean by constipation? A general population based-study.]

INTRODUCTION

The word "constipation" is used by people to refer multiple symptoms such as infrequent stools, hard stools, excessive straining and feeling of incomplete evacuation. This variability is a confounding factor and may induce discrepancies between doctors and patients.

AIM

to evaluate among the general population of 6 different cities of Mexico, what is meant by constipation.

MATERIAL AND METHODS

A cross-sectional study was performed in the cities of Veracruz, Tampico, Tuxtepec, Colima, Puebla and San Luis Potosi (representing 4 geographical areas of Mexico). All subjects answer a questionnaire that assesses self-perception of constipation with the question: Do you consider yourself constipated? Frequency and stool form (Bristol), symptoms and associated factors to constipation were also evaluated. Rome III criteria for functional constipation (FC) and irritable bowel syndrome with constipation (IBS-C) were applied.

RESULTS

One thousand and forty one subjects were evaluated (mean age 35 +/- 15 years), 657 (63%) women. In our study, 87% (n = 907) had a bowel movement at least every 48 hours and most of them (67%) have stools type 3-4. Thirty four percent (n = 356) of subjects considered to have constipation, of whom 73 (21%) met criteria for FC, 65 (18%) for IBS-C and 218 subjects (61%) did not meet diagnostic criteria. The symptom that best defines constipation was straining (47%). Correlation and concordance between self-perception and the Rome criteria was 0.14 (p = 0.61).

CONCLUSIONS

In our population, 61% of subjects who perceived symptoms of constipation are not really constipated according to the criteria of Rome.

[Self-perception, colonic transit and characteristics of subjects seeking medical care for constipation in Mexico.]

OBJECTIVES

Subjects seeking medical care for constipation were evaluated to find out: a) how they describe their complaint, b) their symptoms and colonic transit (CT) time, and c) determine what factors may allow to detect colonic inertia (CI) or obstructive defecation (OD). MATERIAL AND METHODS Patients demographics and medical history were collected and the modular Rome III questionnaire was applied. A screening CT with radioopaque markers was performed in all subjects. Those with an abnormal result underwent a multiple-pellet CT . Factors associated with CI and OD were analyzed.

RESULTS

105 patients were enrolled (92 females, mean age 36.7 years). Seventy patients described constipation as a bowel movement involving straining or being less frequently than expected (67%). The screening CT was normal in 79 patients (75%). Multiple-pellet CT was performed in 23 patients (9 normal, CI in 6, OD in 8). Irritable bowel syndrome (IBS) criteria were met by 79 subjects (75%) and functional constipation by 26 (25%). A greater proportion of patients with CI or OD had attended the Emergency Room, used suppositories or enemas and interfered their activities due to constipation, during the previous year to the survey (p<0.05).

CONCLUSIONS

Most patients described constipation as straining or lower frequency (67%) than expected. CT was normal in 84% of the patients, but it detected 6 cases of CI and 8 of OD. Patients that attended the Emergency Room, used suppositories or enemas and those whom activities were interfered turned out with CI or OD more frequently.

[Idiopathic spontaneous hemoperitoneum.]

Intraperitoneal bleeding is common in patients with abdominal trauma or in those with benign gynecologic diseases, but it is very rare to occur spontaneously. The purpose of this communication is to report a female patient with idiopathic spontaneous hemoperitoneum (ISH).

CASE PRESENTATION

A 28-year-old patient was admitted with 12-hour acute abdominal pain. Laboratory tests upon admission showed: Hb 9.0 g/dL, WBC 8.9 x 109/dL and negative immunologic pregnancy test. The ultrasound showed free intraperitoneal fluid. She underwent exploratory laparoscopy with findings of massive hemoperitoneum, which was resolved and, after a thorough exploration of the abdominal cavity, no evidence of the bleeding site was found. She was closely followed-up for 2 years without any recurrence or complications related to the ISH. An extensive review of the literature was performed. We conclude that ISH is a rare entity that usually presents as a surgical emergency and whose diagnosis is made in the absence of predisposing factors and excluding lesions in the abdominal blood vessels and organs. It warrants immediate intervention, which is crucial for patient survival.

[Hypertensive inferior esophageal sphincter. Prevalence and clinico-manometric features]

BACKGROUND

The hypertensive lower esophageal sphincter (HLES) is an unusual primary motor disorder of the esophagus. The lack of a precise definition has made it difficult to establish its prevalence and its clinical and manometric characteristics.

OBJECTIVES

1) To determine the prevalence of HLES using precise diagnostic criteria, 2) To identify the clinical manifestations of this disease, and 2) To compare manometric findings in patients with HLES against normal subjects.

METHODS

A total of 705 consecutive esophageal manometries were performed over 52 months. HLES was defined as basal pressure 45 > or = mmHg, normal relaxation in response to swallowing, and normal peristalsis of the esophageal body. Clinical records were reviewed to identify the main symptoms that prompted the manometry. The manometric data of patients with HLES was compared to that of 16 healthy control subjects.

RESULTS

Seven HLES patients were identified establishing a prevalence of 1%. Four HLES cases were referred due to dysphagia, two due to symptoms of gastroesophageal reflux disease, and one due to thoracic pain. Upon comparing manometric data of patients with HLES and healthy control subjects the motor function of the esophageal body, the total length of the lower esophageal sphincter, and its position in respect to the diaphragm were similar in both groups.

CONCLUSIONS

Prevalence of HLES was 1%. Dysphagia was the main symptom. Total length of the sphincter, as well as length of the thoracic and abdominal segments do not appear to contribute to high basal pressure.

[Usefulness of gel lidocaine in esophageal manometry]

BACKGROUND

Esophageal manometry (EM) is a functional study performed without sedation. The insertion of a catheter through nasal passages provokes the greatest discomfort as it is being performed.

OBJECTIVE

To evaluate the usefulness of lidocaine jelly to diminish discomfort patient during EM and to ease the procedure.

MATERIAL AND METHODS

Ninety patients sent to EM were randomly assigned to receive lidocaine jelly at 2% (n = 45) or chlorexidine gluconate (n = 45) as a lubricant for the catheter. A solid-state catheter was employed via the pull-through technique under topic anesthesia of the hypopharynx in all cases. Patients quantified nasal pain and nausea produced by analog visual scale (AVS, 0-10 cm). The physician quantified difficulty of insertion using the same method. An independent observer kept time records from the moment of insertion of the probe through the nasal passages until the location of all sensors in the stomach (time of insertion).

RESULTS

No significant differences were found between the two groups in their evaluation of nasal pain (2.8 cm lidocaine group vs. 2.6 cm chlorhexidine group), and there was no difference found in the intensity of nausea (3.3 cm vs. 3.1, respectively). Ease of the procedure was similar (2.2 cm lidocaine group vs. 1.8 cm chlorhexidine group), as well as insertion time (120 vs. 111 sec, respectively).

CONCLUSIONS

Lidocaine jelly at 2% neither diminishes the discomfort provoked by the insertion of an EM catheter, nor does it make the procedure any easier.

Potential harmful effect of iodinated intravenous contrast medium on the clinical course of mild acute pancreatitis

HYPOTHESIS

A worse clinical outcome might be expected in patients with acute pancreatitis (AP) who receive intravenous contrast medium for a nondynamic contrast-enhanced computed tomographic (CECT) study early during hospital admission.

DESIGN

Cohort analytic study.

SETTING

Tertiary care center.

PATIENTS

Of 126 patients with mild AP, 52 patients underwent CECT to establish AP diagnosis (group 1), and the remaining 74 did not (group 2).

MAIN OUTCOME MEASURES

Survival and development of local or systemic complications during the hospital stay. Potential confounders were demographic, clinical, and biochemical data, as well as therapeutic measures. The Atlanta classification was used to define local and systemic complications.

RESULTS

Mean age, etiology of AP, prognostic score on admission, and pharmacologic treatment were similar between groups. Local and systemic complications were more frequently observed in patients who underwent CECT (odds ratio, 11.4; 95% confidence interval, 2.0-64.8; P =.008). Six patients, all in group 1, developed a pancreatic abscess (odds ratio, 20.8; P =.004). In 5 of them, a second CECT showed more severe AP changes. The association between CECT and abscess development was more apparent in patients with a body mass index of 25 or more and/or nasogastric suction. Six patients in group 1 and 1 in group 2 had systemic complications (odds ratio, 9. 5; P =.01). There were no deaths.

CONCLUSIONS

The observed increased incidence of local and systemic complications in patients with mild AP who undergo CECT, particularly in those with a body mass index of 25 or more, suggests a potentially harmful effect of intravenous contrast medium. Until this issue is clarified, it seems reasonable to restrict the use of dynamic CECT to patients with severe AP, protracted clinical course, or suspected local septic complication.

[Utility of botulinum toxin in stasis esophagitis secondary to achalasia. Report of a case]

Upper gastrointestinal bleeding is an infrequent complication of achalasia. Stasis esophagitis is a rare cause of esophageal bleeding in which conventional forms of treatment may be associated with a high risk of complications. Botulinum toxin has emerged as a therapeutic alternative with few secondary effects. We present a case report of achalasia complicated by upper gastrointestinal bleeding secondary to stasis esophagitis which was successfully treated with botulinum toxin. Interesting aspects related to stasis esophagitis and the potential role of botulinum toxin in achalasia are discussed.

[Prospective evaluation of gastroesophageal reflux in patients with achalasia treated with pneumatic dilatation, thoracic or abdominal myotomy]

INTRODUCTION

Symptomatic gastroesophageal reflux (GER) occurs in 0-20% of patients treated with pneumatic dilation and in 5-30% with cardiomyotomy. However, the prevalence of GER evaluated with esophageal pH-monitoring is unknown.

AIM

To investigate the frequency of GER in achalasia patients treated with pneumatic dilation or myotomy.

MATERIAL AND METHODS

Patients with achalasia were evaluated prospectively and classified in 4 groups: group A = treated with pneumatic dilation; group B = treated with open abdominal myotomy; group C = transthoracic myotomy; and group D = submitted to laparoscopic abdominal myotomy with antireflux procedure. Esophageal manometry and 24 h pH-monitoring were performed in all patients. GER was defined as a pH < 4 in more than 4% of the total time.

RESULTS

Thirty-one patients, 22 women and 9 men, with a mean age of 44.7 years were evaluated. Nine patients had GER symptoms and 22 were asymptomatic. GER was detected with pH-metry in 42% of the total group: 33% for group A, 75% for group B, 44% for group C and none for group D.

CONCLUSIONS

Prevalence of GER in achalasia patients treated with pneumatic dilation and surgical myotomy was high. We suggest the inclusion of 24 hr esophageal pH-metry in the follow-up due to the significant prevalence of asymptomatic GER. Minimal hiatus dissection and antireflux procedure were surgical factors related with a lower frequency of GER after achalasia myotomy.

[Gastroesophageal reflux in asthmatic patients: an incidence study and clinical correlation]

The prevalence of gastroesophageal reflux (GER) in asthmatic patients is elevated, but the exact frequency remains unknown. The relationship between GER and asthma has not been investigated in Mexico. The objective of this study is to know the frequency of GER in Mexican asthmatic patients and the possible relationship with the severity of asthma. Fifty patients with adult-onset asthma were studied. AII of them fulfill the diagnostic criteria of the National Institutes of Health, U.S. The evaluation included a symptoms questionnaire, spirometry, esophageal manometry, 24-h esophageal pH-recording, and an upper gastrointestinal endoscopy. Twenty-three patients had mild asthma (46%), 16 moderate (32%) and 11 had severe asthma (22%). Twenty-seven (54%) reported heartburn and regurgitation at least twice a week. The esophageal pH-recording showed pathologic GER in 37 subjects (74%) and endoscopic esophagitis was found in 7 cases (14%). The pH-recording showed pathologic GER in 13 patients with mild asthma (57%), in 13 with moderate asthma (81%) and in all patients with severe asthma (100%). The frequency of GER in Mexican asthmatic patients is high and increases proportionately with the severity of asthma. This factor must be considered in the integral evaluation of these patients.

[Hiatal hernia in asthmatic patients: prevalence and its association with gastroesophageal reflux]

INTRODUCTION

Evidence of a high prevalence of hiatal hernia (HH) and gastroesophageal reflux (GER) in asthmatic patients has been found. However, the relationship between these entities has not been studied in our country.

OBJECTIVES

1) To inform the prevalence of hiatal hernia in asthmatic patients, 2) To compare the prevalence of hiatal hernia in asthmatic vs. non-asthmatic patients, 3) To establish a possible association between hiatal hernia and GER in asthmatic patients.

MATERIALS AND METHODS

In order to detect and to compare the prevalence of hiatal hernia in asthmatic and non-asthmatic patients, upper gastrointestinal endoscopy was performed. To establish the association between asthma and GER, data obtained from a gastrointestinal symptoms questionnaire, an esophageal manometry and an ambulatory pH recording in asthmatics with or without hiatal hernia were compared.

RESULTS

Hiatal hernia was more frequently observed in asthmatics than in non-asthmatics (62% vs. 34%, p = 0.02). The frequency of typical symptoms of GER was similar in both asthmatics with or without hiatal hernia (54 vs. 43%, p = 0.3). Lower esophageal sphincter incompetence was similar in asthmatics with hiatal hernia (35%) vs. asthmatics without hiatal hernia (22%), as detected by manometry. Pathological GER was diagnosed by pH recording in 81% of the asthmatics with hiatal hernia and in 65% of asthmatics without hiatal hernia (p = 0.1).

CONCLUSIONS

There is a high prevalence of hiatal hernia in asthmatics, which in turn results to be greater than in non-asthmatic patients. The presence of hiatal hernia does not correlate with the detection of pathological GER as determined by pH recording in this group of patients.

[Duodenal pseudomelanosis]

Pseudomelanosis duodeni is a rare entity characterized by dark pigmentation of duodenal mucosa of uncertain etiology and clinical significance. We report a case with endoscopic and pathologic correlation. Some aspects about etiology, clinical and histopathologic characteristics are discussed.

Obesity: a risk factor for severe acute biliary and alcoholic pancreatitis

OBJECTIVE

In this study we evaluate the association between obesity and complication development in patients with a first-attack acute pancreatitis (AP), and investigate the influence of comorbid factors on this association.

METHODS

Medical records of 150 patients with AP were reviewed. General data, AP etiology, admission AP prognostic criteria, and occurrence of complications were recorded. Patients were classified according to body mass index (BMI) as obese (BMI > 25 kg/m2) and nonobese (BMI < or = 25 kg/m2).

RESULTS

Prevalence of obesity was 57%. Thirty-eight percent of the obese patients developed complications as compared with 21% of the nonobese (RR=1.74; 95% CI, 1-2.9). The risk for severe AP increased according to the degree of obesity. Pancreatic and peripancreatic necrosis was more common in obese patients (17.6% vs 6%), as was the incidence of infectious complications. The risk for severe AP was highest in obese patients with either alcoholic (RR=5.3; 95% CI, 1.2-23) or biliary etiology (RR=5.2, 95% CI, 1-26).

CONCLUSION

Obesity may predispose to a complicated course of AP, especially if it is secondary to alcohol or gallstones. Further studies are needed to establish the precise prognostic value of obesity in AP, as well as the pathogenic mechanisms involved in the process.

[New concepts on the physiopathology, diagnosis, and treatment of achalasia]

OBJECTIVES

To review the most relevant publications on the pathophysiology, clinical manifestations, diagnosis and treatment of esophageal achalasia, and the clinical experience achieved at our institution in order to propose a practical strategy to facilitate the management of these patients.

DATA SOURCES

Manual and MEDLINE search of key articles published between January 1986 and July 1997 in addition to publications of our institute of thirty years.

STUDY SELECTION

All kinds of publications with substantial clinical experience, new information or research protocols.

DATA SYNTHESIS

Achalasia is an uncommon disorder of the myenteric plexus of the esophagus. Main symptoms are dysphagia, regurgitations and chest pain. The diagnosis is established by manometric criteria. Esophagogram, endoscopy and radionuclide esophageal emptying test help to differentiate other conditions and evaluate the response to treatment. Pharmacotherapy may provide relief to patients with mild symptoms and is useful for patients with high risk of complications. Dilations and myotomy are safe, effective and long lasting procedures. Botulinum toxin may be effective in selected cases. Predictive factors of response have been described for each therapy.

CONCLUSION

A systematic approach to the management of patients with achalasia is necessary. Introduction of new therapies as botulinum toxin and minimal invasion surgery are changing the therapeutic decisions in this field. Drugs and BoTox are considered the first line of treatment for high risk patients and dilation and surgery for patients with no risk.

[Why is the esophageal pH-metry required? Comparison with the recommendations of the American Association of Gastroenterology for its correct use]

INTRODUCTION

The esophageal pH monitoring is the most sensitive method to diagnose gastroesophageal reflux disease (GERD). However, there is a significant number of patients who do not require this test. Recently, guidelines for the appropriate use of pH monitoring have been published.

AIM

To study the indications for the use of esophageal pH monitoring and to compare these indications with the guidelines published by the American Gastroenterological Association (AGA).

METHODS

Seventy-five files of patients submitted to esophageal pH monitoring from February 1997 to July 1997 were reviewed. The clinical indications of this test were defined by history and endoscopic findings. These indications were compared with the AGA guidelines.

RESULTS

In 50 cases (67%) the indications for esophageal pH monitoring were performed according to AGA's guidelines, in 15 (20%) the indications of pH monitoring did not follow these guidelines and in ten cases (13%), the indication could not be determined. The most frequent indications were: 1) diagnosis of GERD in patients with a negative endoscopy; 2) detection of GERD in patients with extraesophageal manifestations; 3) refractory symptoms of GERD to proton pump inhibitors; 4) evaluation of GERD after antireflux surgery; and 5) assessment of non-cardiac chest pain. In 11 cases (15%), the indications for the use of pH monitoring was erroneous.

CONCLUSIONS

In our motility laboratory, the majority of indications for esophageal pH monitoring were consistent with the AGA's guidelines. However, in 15% of the cases the pH monitoring was erroneously indicated.

[Use and abuse histamine H2 receptor blockers in hospitalized patients]

OBJECTIVE

To evaluate if the histamine H2 blockers (H2B) are adequately prescribed in hospitalized patients outside intensive care units.

BACKGROUND

H2B are frequently prescribed. However their good tolerance and easy access have contributed to misuse them.

METHODS

Six hundred and seventy eighth hospitalized patients from three different Mexican institutions were included in a prospective study, 100 patients from each hospital who were taking H2B were selected. We investigated the indication for prescribing them as well as the type, dose and adverse effects, international recommendations were taken into account to assess if the treatment was correctly prescribed.

RESULTS

Two hundred twenty seven patients (76%) received H2B for prophylactic reasons, however a clear justification for their use was found in only 79 of the cases (35%). H2B were prescribed to treat peptic ulcer disease or upper gastrointestinal bleeding in 17 patients (6%). Two out of three patients received more than 10 doses of H2B, being ranitidine the most frequently prescribed.

CONCLUSIONS

Although H2B have a low rate of adverse reactions, their use in hospitalized patients should be rigorously controlled. In fact, the majority of our patients did not need them. Thus, their routine use should be proscribed to avoid unnecessary costs.