Efficacy of small-volume simethicone given at least 30 min before gastroscopy

AIM

To evaluate the efficacy of 5 mL simethicone solution in decreasing gastric foam if given at least 30 min before gastroscopy.

METHODS

This was a randomized, placebo controlled, endoscopist blinded study performed at Changi General Hospital. Patients were at least 21 years old, had no prior surgical resection of the upper gastrointestinal tract, and scheduled for elective diagnostic gastroscopies. The primary outcome was the total mucosal visibility score (TMVS) which was evaluated using McNally score. The sample size was calculated to be 24 per group (SD 2.4, 80% power, P < 0.05, 2-sample t test).

RESULTS

Fifty-four patients were randomised to receive either simethicone [1 mL liquid simethicone (100 mg) in 5 mL of water] or placebo (5 mL of water) at least 30 min before their gastroscopy. Six accredited consultants conducted the gastroscopy, and the interobserver agreement of scoring TMVS was good with a Kappa statistic of 0.73. The simethicone group had significantly better mean TMVS compared to placebo (5.78 ± SD 1.65 vs 8.89 ± SD 1.97, P < 0.001). The improvement was statistically significant for the duodenum and the gastric antrum, angularis, body, and fundus. Percent 51.9 of patients in the simethicone group had a TMVS of 4 (no bubbles at all) to 5 (only 1 area with minimal bubbles), while in the placebo group 3.7% of patients had TMVS of 4 or 5. The number needed to treat was 2.1 to avoid a TMVS of 6 and more. The simethicone group also had a significantly shorter procedure time with less volume of additional flushes required during gastroscopy to clear away obscuring gastric foam.

CONCLUSION

With a premedication time of at least 30 min, 5 mL simethicone can significantly decrease gastric foam, decrease the volume of additional flushes, and shorten gastroscopy time.

Pheochromocytoma in pregnancy: a case report and review of literature

Hypertension is a common problem in pregnancy that can result in significant maternal and fetal morbidity and mortality. The common causes include pre-eclampsia, gestational hypertension and essential hypertension. Although phaeochromocytoma is a rare cause of hypertension in pregnancy, it can lead to potentially life-threatening cardiovascular complications for the mother and increased fetal mortality if left undiagnosed and untreated. The diagnosis can be confirmed by measurement of plasma and urinary catecholamines and their metabolities followed by radiological localization of the tumour. Surgical resection of the tumour after adequate pre-operative control of hypertension using sequential alpha- followed by beta-blockers is the definitive treatment. In pregnancy, depending on the gestation at which diagnosis is made, the optimal timing for surgery is during the late first or early second trimester. When the pregnancy is more advanced, medical management followed by combined caesarean section and tumour resection closer to term is preferred.

The utility of narrow band imaging in improving the endoscopic diagnosis of gastroesophageal reflux disease

BACKGROUND & AIMS

Narrow band imaging (NBI) facilitates mucosal surface evaluation and may improve the endoscopic diagnosis of gastroesophageal reflux disease (GERD). We investigated the utility of NBI in improving the endoscopic diagnosis of GERD when compared with conventional endoscopy.

METHODS

A total of 107 subjects (nonerosive reflux disease [NERD], 36; erosive reflux disease [ERD], 41; controls, 30) were recruited prospectively. The mucosal morphology at the squamocolumnar junction (SCJ) in GERD and controls was visualized using conventional endoscopy and NBI. The main outcome measurements were as follows: (1) The differences in mucosal morphology at the SCJ between conventional endoscopy and NBI; and (2) the differences in mucosal morphology at the SCJ between GERD and controls with NBI.

RESULTS

Micro-erosions, increased vascularity, and pit patterns at the SCJ not seen on conventional endoscopy were well seen with NBI. Compared with controls, ERD and NERD had a significantly higher prevalence of micro-erosions (ERD, 100%; NERD, 52.8%; controls, 23.3%), and increased vascularity (ERD, 95.1%; NERD, 91.7%; controls, 36.7%), but a lower prevalence of round pit pattern (ERD, 4.9%; NERD, 5.6%; controls, 70%). ERD and NERD were similar in terms of increased vascularity and pit patterns. Increased vascularity with absence of round pit pattern was useful to distinguish NERD from controls (sensitivity, 86.1%; specificity, 83.3%). Interobserver agreement was good for increased vascularity (kappa = 0.95) and micro-erosions (kappa = 0.89), but lower for pit pattern (kappa = 0.59).

CONCLUSIONS

NBI enhanced mucosal morphology at the SCJ and appeared useful for improving the endoscopic diagnosis of GERD.

Defense against environmental ammonia toxicity in the African lungfish, Protopterus aethiopicus: Bimodal breathing, skin ammonia permeability and urea synthesis

This study aimed to determine how the African lungfish Protopterus aethiopicus defended against ammonia toxicity when confronted with high concentrations (30 or 100 mmoll(-1)) of environmental ammonia. Exposure to 100 mmoll(-1) of NH(4)Cl for 1 or 6 days had no significant effect on the rate of O(2) uptake from water or from air, and the rate of total O(2) consumption. Using an Ussing-like apparatus, we report for the first time that the skin of P. aethiopicus had low permeability (1.26 x 10(-4) micromol min(-1)cm(-1)) to NH(3)in vitro. Indeed, the influx of exogenous ammonia into fish exposed to 30 mmoll(-1) NH(4)Cl was low (0.117 micromol min(-1) 100g(-1) fish). As a result, P. aethiopicus could afford to maintain relatively low ammonia contents in plasma, muscle, liver and brain even after 6 days of exposure to 100 mmoll(-1) NH(4)Cl. Surprisingly, fish exposed to 30 or 100 mmoll(-1) NH(4)Cl had comparable ammonia contents in the muscle and the brain in spite of the big difference (70 mmoll(-1)) in environmental ammonia concentrations. Significant increases in urea contents occurred in various tissues of fish exposed to 30 mmoll(-1) NH(4)Cl for 6 days, but there were no significant differences in tissue urea contents between fish exposed to 30 mmoll(-1) and 100 mmoll(-1) NH(4)Cl. Between days 3 and 6, the rate of urea excretion in fish exposed to 30 mmoll(-1) NH(4)Cl was significantly greater than that of the control. By contrast, there was no significant difference in urea excretion rates between fish exposed to 100 mmoll(-1) NH(4)Cl and control fish throughout the 6-day period, and such a phenomenon has not been reported before for other lungfish species. Thus, our results suggest that P. aethiopicus was capable of decreasing the NH(3) permeability of its body surface when exposed to high concentrations of environmental ammonia. Indeed, after 6 days of exposure to 100 mmoll(-1) NH(4)Cl, the NH(3) permeability constant of the skin (0.55 x 10(-4) micromol min(-1)cm(-1)) decreased to half of that of the control. A decrease in the already low cutaneous NH(3) permeability and an increased urea synthesis, working in combination, allowed P. aethiopicus to effectively defend against environmental ammonia toxicity without elevating the plasma ammonia level. Therefore, unlike other fishes, glutamine and alanine contents did not increase in the muscle and liver, and there was no accumulation of glutamine in the brain, even when the fish was immersed in water containing 100 mmoll(-1) NH(4)Cl.

Helicobacter pylori eradication versus prokinetics in the treatment of functional dyspepsia: a randomized, double-blind study

BACKGROUND

This randomized, double-blind study compared the efficacy of Helicobacter pylori eradication against prokinetics in H. pylori-infected functional dyspepsia patients.

METHODS

Patients with moderately severe or severe dyspepsia fulfilling the Rome II criteria were randomized to either H. pylori eradication for 1 week and 6 weeks of placebo prokinetics or 6 weeks of prokinetics and placebo H. pylori eradication in the first week. Symptoms were assessed at baseline and at 6 and 12 months using the Glasgow Dyspepsia Severity Score (GDSS). Global response to treatment was assessed at 12 months.

RESULTS

Altogether 130 patients were enrolled (H. pylori eradication, 71; prokinetics, 59). The mean baseline GDSS was 9.3 for the H. pylori eradication group and 8.9 for the prokinetic group. At 6 months, the score was 3.6 and 4.1, respectively, and it remained at 3.5 and 3.8, respectively, at 12 months. With H. pylori eradication, 31.0% had complete symptom resolution (GDSS 0 or 1) at 12 months compared with 23.7% with prokinetics (a nonsignificant difference). At 12 months, global symptomatic improvement was seen in 62.0% of the H. pylori eradication group compared with 67.8% of the prokinetics group.

CONCLUSIONS

Both H. pylori eradication and prokinetic therapy resulted in symptom improvement in two-thirds of dyspeptic patients at 1 year. More patients tended to achieve complete symptom relief with H. pylori eradication.

Abnormal liver function tests in the symptomatic pregnant patient: the local experience in Singapore

INTRODUCTION

The causes of abnormal liver function tests in pregnancy are varied and may or may not be pregnancy-related. Often, the diagnosis can be difficult. This study looked at the causes of deranged liver function tests in obstetric patients with significant symptoms and signs.

MATERIALS AND METHODS

Data from 50 cases of abnormal liver function tests in pregnant patients, who presented from 1998 to 2001, were analysed. Their presenting symptoms included persistent vomiting (48%), pruritus (14%), jaundice (26%), upper abdominal discomfort (24%) and hypertension (46%).

RESULTS

Pregnancy-related causes accounted for 84% of the abnormal liver function tests. Abnormal liver function tests occurred more frequently in the first (34%) and third (58%) trimesters than in the second trimester (8%). Hyperemesis gravidarum (94%) and partial haemolysis, elevated liver enzymes and low platelets (HELLP) syndrome (31%) were the commonest causes in the first and third trimesters respectively. Hepatitis B flare resulted in 2 maternal deaths. Seven patients with pre-eclampsia toxaemia, acute fatty liver of pregnancy or partial/complete HELLP syndrome had their liver function tests measured sequentially before and after delivery. All of them showed rapid improvement postpartum with their alanine aminotransferase (ALT) dropping 50% within 3 days.

CONCLUSIONS

The majority of patients with abnormal liver function tests had a cause related to pregnancy, and pregnancy-related causes in the third trimester improved rapidly postpartum. Hepatitis B flare was a significant non-obstetric cause leading to maternal mortality. This diagnosis must therefore be considered in ethnic groups where the incidence of chronic hepatitis B infection is high, especially in chronic hepatitis B carriers with suspected pregnancy-related disease who deteriorate postpartum.

Clinical profile of primary sclerosing cholangitis in Singapore

BACKGROUND AND AIM

Primary sclerosing cholangitis (PSC) is a rare chronic disease in Singapore and its epidemiological profile has not been described previously. The present study aimed to define the demographic and clinical profile of patients with PSC in Singapore.

METHODS

The case records of patients with PSC seen at Changi General Hospital were analyzed in terms of demographic profile, clinical presentation, clinical course, treatment and complications.

RESULTS

Ten cases of PSC were diagnosed over a 10-year period. The male:female ratio was 9:1. The median age of diagnosis was 49.5 years (mean: 50.9 years; range: 35-63 years). With regards to clinical presentation, seven patients had hepatobiliary sepsis, two patients had asymptomatic liver biochemistry abnormalities while one patient had cholestatic jaundice. Prevalence rate of perinuclear antineutrophil cytoplasmic antibody (pANCA) was 20%. Symptomatic inflammatory bowel disease (IBD) was diagnosed in 20% of PSC cases. Eight patients (80%) had intrahepatic ductal involvement while two patients (20%) had combined intrahepatic and extrahepatic ductal involvement on endoscopic retrograde cholangiopancreatography (ERCP). The prevalence rate of recurrent cholangitis was 30% while that of recurrent liver abscess, cirrhosis and common bile duct stricture were all 10%. The mean duration of follow up was 6.6 years with one death from liver failure.

CONCLUSION

The clinical profile of patients with PSC in Singapore appears to differ with other published data, with a greater number presenting with hepatobiliary sepsis and less frequent association with IBD and pANCA. It is hypothesized that this may be related to differences in environmental triggers and genetic susceptibility.

Thrombophilia in pregnancy

INTRODUCTION

Thrombophilia refers to disorders which are associated with a persistent hypercoagulable state and a tendency towards thrombosis. They may be inherited, acquired or complex, when genetic factors interact with environmental influences. The objective was to review the various inherited thrombophilias and the antiphospholipid syndrome in relation to pregnancy-related venous thromboembolism and other obstetric complications.

METHODS

A Medline search for articles highlighting thrombophilia and pregnancy-related venous thromboembolism and obstetric complications (pre-eclampsia, recurrent miscarriage, intrauterine growth restriction and placental abruption) was performed.

RESULTS

The incidence of venous thromboembolism in pregnant Chinese women is similar to that which is reported for Caucasian women. Venous thromboembolism remains a major cause of maternal mortality worldwide as well as locally, where it ranks as the second commonest cause of maternal deaths (rate of maternal deaths from thromboembolism, 0.12 per 10,000 live births and stillbirths). The major risk factors for thrombosis during pregnancy include thrombophilia, operative delivery, advanced maternal age, obesity and pre-eclampsia; these can be identified in about 70% of women who develop the complication during pregnancy and the puerperium. Due to the higher prevalence of factor V Leiden and prothrombin gene G20210A mutation in the Caucasian population, up to 50% of Caucasian women who develop thrombosis during pregnancy or the puerperium test positive for thrombophilia. Recent studies have also shown an association between thrombophilia and adverse obstetric outcomes such as recurrent miscarriage, intrauterine growth restriction, pre-eclampsia and placental abruption.

CONCLUSION

Venous thromboembolism is now recognised as a multicausal and multigenic condition. This is particularly evident in pregnancy where multiple risk factors interact and are often identified in women who develop venous thrombosis. With the discovery of factor V Leiden and the prothrombin gene G20210A mutation, inherited thrombophilia can now be detected in a significant proportion of Caucasians who develop venous thromboembolism; however, both these mutations are rarely found in Asians. Identifying women at risk for venous thromboembolism and instituting thromboprophylaxis appropriate to the level of risk remains the key to reducing morbidity and mortality from the condition. Additional research into the intensity, type and duration of thromboprophylaxis for different levels of risk are required. The role of inherited thrombophilia in the pathogenesis of obstetric complications needs to be further defined before screening can be recommended for indications other than venous thromboembolism.