Sleep-related gastro-oesophageal reflux: provocation with a late evening meal and treatment with acid suppression

BACKGROUND: Two studies were carried out in order to investigate the issue of meal-provoked nocturnal gastrooesophageal reflux. METHODS: In Experiment 1, 20 symptomatic reflux patients underwent both pH and polysomnographic monitoring on two nights. On one night, patients ate a non-provocative meal prior to 19.00 hours, while on the other night patients consumed a late evening meal (21.00 hours). In Experiment 2.17 symptomatic reflux patients were studied using pH and polysomnographic monitoring on two nights subsequent to a late evening provocative meal. On one night, patients received 75 mg of the H2-antagonist ranitidine, while on another night they received a placebo. The data from 12 of the 17 patients studied were used in the analysis. RESULTS: For Experiment 1, no significant differences in the number or duration of reflux events, acid exposure (total %), or polysomnographic measures of per cent of sleep stages between the two nights were observed. The results of the second experiment demonstrated that when given ranitidine, patients experienced significant decrease in acid contact time (total %), and mean duration of reflux events. Subjective reports of discomfort and sleep disturbance were also significantly improved on the drug night. However, significant differences in polysomnographic measures were not observed. CONCLUSIONS: Based on these results, we conclude that in some symptomatic reflux patients a late-night non-provocative meal may not increase the incidence of gastro-oesophageal reflux, and that a low dose of an H2-antagonist is effective in decreasing oesophageal acid contact time following a late evening provocative meal.     

One-year prophylactic efficacy and safety of pantoprazole in controlling gastro-oesophageal reflux symptoms in patients with healed reflux oesophagitis

BACKGROUND: Pantoprazole is a benzimidazole derivative which selectively inhibits the proton pump H+. K+-ATPase necessary for the final step in gastric acid secretion. AIM: To investigate the tolerability and the prophylactic effect of pantoprazole 40 mg once daily on relapse in patients whose reflux oesophagitis had been healed. METHODS: The safety of pantoprazole 40 mg once daily was assessed in an open 1-year trial on 222 patients whose reflux oesophagitis had been healed with omeprazole or pantoprazole. Relapse was defined as endoscopically-confirmed reflux oesophagitis (at least Grade I), with endoscopies being performed for patients experiencing 3 consecutive days of disease-specific symptoms. RESULTS: Kaplan-Meier survival analysis at 6 and 12 months gave estimated treatment failure rates of 2% and 6% from confirmed relapses (per-protocol), and of 9% and 30% for a worst-case group (all withdrawals counted as failures). The only population shift in laboratory variables was a doubling of the median serum gastrin level over the first 6 months; thereafter it stabilized. Fifty-four (24%) patients experienced adverse events; 15 of these withdrew. Serious adverse events were reported for 12 patients. CONCLUSIONS: Pantoprazole appears to be highly effective and to have a good safety profile for long-term prophylaxis of reflux oesophagitis.     

Motor function of the proximal stomach and visceral perception in gastro-oesophageal reflux disease

Oxytocin (OT) is present in the mammalian testis and has been shown to play a role in the modulation of seminiferous tubule contractility and steroidogenesis. However, stage-specific effects of the peptide have not been previously investigated. In this study, computer-assisted analysis and time-lapse videomicrography were used to investigate basal contractility and the response to OT of seminiferous tubules at specific stages of the spermatogenic cycle. Adult rat testes were placed in fresh oxygenated DMEM F12 medium, decapsulated, and the tubules gently teased apart. Stages were identified by transillumination and a 10 mm section of tubule at each of stages IV-V, VII-VIII and XIII-I was placed in a microslide chamber and perifused with medium. After a control period of 3 h, OT (2 nM) was given for 1 h, followed by another control period of 1 h. The experiment was repeated using tubules from different rats and data were analysed to give arbitrary units of tubule contractility. Contractility was observed in all the tubules studied and the contractile activity was shown to vary depending on the stage of the spermatogenic cycle. Mean basal contractility at stages VII-VIII, the time when sperm are shed from the epithelium, was significantly lower than that at stages IV-V and XIII-I. The response of the tubules to OT was also stage-dependent, with the peptide producing the largest increases in contractile activity at stages VII-VIII and having no effect at stages IV-V. We postulate that these stage-specific differences in basal and OT-stimulated contractility may be important in co-ordinating the movement of developing germ cells towards the lumen of the seminiferous epithelium and in the process of spermiation.     

Effect of alginate and alginate-cimetidine combination therapy on stimulated postprandial gastro-oesophageal reflux

This randomized, single-blind cross-over study compared the effectiveness of a conventional alginate reflux barrier formulation (20 mL single dose of Liquid Gaviscon; sodium alginate, sodium bicarbonate, calcium carbonate) with a 20 mL single dose of an alginate-cimetidine combination formulation (Algitec Suspension; sodium alginate, cimetidine) in the suppression of food and acid reflux into the oesophagus after a test meal in 12 healthy volunteers. Subjects were fasted overnight before the study. A pH electrode and gamma detector were accurately positioned 5 cm above the cardia. The volunteers received a 99mTc-labelled meal designed to provoke reflux and then either remained untreated, or 30 min later were given either Algitec Suspension or Liquid Gaviscon. Reflux of both food and acid into the oesophagus was measured for 3 h. There was a seven day wash-out period between each treatment. Food reflux in the control group was 22,878 +/- 14,385 counts x 10(3) and this was significantly suppressed by both Liquid Gaviscon (174 +/- 128 (s.e.) counts x 10(3); P = 0.003); however, although the reduction of food reflux to 3812 +/- 2322 counts x 10(3) observed after Algitec treatment was considerable, this did not reach statistical significance (P > 0.05) due to the large intersubject variation. Liquid Gaviscon was significantly better at reducing food reflux than Algitec (P = 0.001). Gaviscon also significantly reduced acid reflux when compared with the control group (1.08 +/- 0.73 vs 5.87 +/- 3.27% recording time oesophageal pH < 4, respectively) (P = 0.03). The slight reduction in acid reflux after Algitec treatment (3.25 +/- 1.82% recording time oesophageal pH < 4) also did not reach statistical significance. The difference between Algitec and Gaviscon treatment was also not significant.     

Ranitidine effervescent and famotidine wafer in the relief of episodic symptoms of gastro-oesophageal reflux disease

Radioligands that specifically target dopamine uptake sites can provide a means of determining dopamine fiber loss at intrastriatal mesencephalic grafts in Parkinsonian patients, using Positron Emission Tomography (PET). The BTCP derivative, 1-[1-(2-benzo(b)thiophenyl)cyclohexyl]-4-(2-hydroxyethyl)-piperazine, shows in vitro high affinity and selectivity for the dopamine transporter. To evaluate the potential of such a compound as a potential dopaminergic PET tracer the positron-emitting analogues, 1-[1-(2-benzo(b)thiophenyl)cyclohexyl]-4-(2-[18F]fluoroethyl)-piperazine and 1-[1-(2-benzo(b)thiophenyl)cyclohexyl]-4-[11C]methylpiperazine, were synthesized. Radiofluorination was carried out by the reaction of 1-[1-(2-benzo(b)thiophenyl)cyclohexyl]-4-(2-chloroethyl)-piperazine with cyclotron-produced n.c.a. 18F-(half life 109.9 min) obtained by the (p,n) reaction on 18O-enriched water. Labelling with carbon-11 (half life 20.4 min) was achieved by 11C methylation of 1-[1-(2-benzo(b)thiophenyl)cyclohexyl]-piperazine with [11C]methyl iodide. After intravenous administration to rats these two compounds enter the brain, but despite their high in vitro affinity they display a high non specific binding in vivo which greatly limits their use as PET radioligands.     

Incidence of abdominal wall hernia in aortic surgery

In chronic tophaceous gout, tophi may occur in various tissues of the body. The joints are one of the main tissues of the tophaceous deposits. The articular surface may be coated by heavy deposits. We present a case of a patient with chronic tophaceous gout where the tophaceous deposits formed an intra-articular mass causing symptoms of a loose body.     

Effects of oral rabeprazole on oesophageal and gastric pH in patients with gastro-oesophageal reflux disease

BACKGROUND: This study examined the dose-response effects of the new proton-pump inhibitor rabeprazole on oesophageal and gastric pH in patients with gastro-oesophageal reflux disease. METHODS: This study had a single-centre, double-blind, randomized, two-way crossover design. Twenty patients were treated for two 7-day periods separated by a 7-10-day washout period. Patients were randomly assigned to receive either 20 mg of rabeprazole once daily during the first treatment period and 40 mg once daily during the second treatment period, or 40 mg during the first treatment period and 20 mg during the second treatment period. The primary efficacy variable was oesophageal acid exposure determined by 24-hour ambulatory pH monitoring. Acid-reflux time was defined as the percentage of time over 24 h that oesophageal pH was < 4. A dosage was considered effective if reflux time was reduced to < 6%, a number which has been our internal laboratory reference. RESULTS: Both rabeprazole 20 mg and 40 mg, given once daily, normalized reflux time, with decreases of 79% and 92% in acid exposure by day 7. Both dosages also decreased the mean total number of reflux episodes and the number of episodes lasting > 5 min, with no significant differences between dosages for any reflux parameter. Mean gastric pH increased with 20 mg from 1.86 at baseline to 3.71 on day 1 and 4.17 on day 7. Rabeprazole 40 mg once daily increased gastric pH from 2.01 to 4.37 on day 1, and to 4.65 on day 7. Safety analyses revealed no significant acute side-effects for either dosage. CONCLUSIONS: Pathological oesophageal acid exposure was normalized with both 20 mg and 40 mg dosages of rabeprazole, and the effects of these two doses did not differ. Rabeprazole was well-tolerated in this short-term study.     

Lifetime costs of surgical versus medical treatment of severe gastro-oesophageal reflux disease in Finland

BACKGROUND: Gastro-oesophageal reflux disease (GERD) can be effectively treated pharmacologically or surgically. As GERD is often a chronic condition, we compared the long-term costs of medical and surgical management. METHODS: The medical regimens were ranitidine (150 or 300 mg/day), omeprazole (20 or 40 mg/day), and lansoprazole (30 mg/day), with costs calculated for total life expectancy after diagnosis and for one-third of that time. Costs for open or laparoscopic surgery (Nissen fundoplication) included pre- and post-operative investigations, sick leave, and calculated financial loss due to fatal outcome. RESULTS: Costs were lowest with ranitidine, 150 mg/day, for one-third of the patient's lifetime and highest with lifelong omeprazole, 40 mg/daily. The cost of open or laparoscopic operation was less than that of lifelong daily treatment with proton pump inhibitors or ranitidine, 300 mg daily. CONCLUSION: In Finland, antireflux surgery for GERD is cheaper than lifetime treatment with proton pump inhibitors.     

Fundoplication for the treatment of gastroesophageal reflux in hiatal hernia

Blood pressure (BP) levels were recorded in 2223 male and 2205 female children and adolescents ranging in age from 7 to 18 years. In addition, 521 male adults (soldiers) ranging in age from 21 to 25 years were included in the study. Children and adolescents who participated in the survey were selected at random the Elementary and High Schools. The results of the study showed that a gradual increase occurred in the systolic, as well as in the diastolic component of blood pressure from 7 to 18 years of age. By contrast, there was no increase with age in the systolic and diastolic blood pressure in the young male adult subjects, who had BP measurements comparable to those observed in children. A child was characterized as hypertensive according to the criteria outlined by Master et al. Children with BP between the 90th and the 95th percentile were considered as suspect hypertensive, whereas those with BP exceeding the 95th percentile were considered definitely hypertensive. The overall incidence of hypertension in children in this survey was 3.1%.     

Treating the symptoms of gastro-oesophageal reflux disease: a double-blind comparison of omeprazole and cisapride

BACKGROUND: Few studies have specifically addressed the management of the symptoms of gastro-oesophageal reflux disease, and there are no comparative data in this respect for acid pump inhibitors and prokinetic agents. METHODS: Following endoscopy 424 patients presenting with heartburn as the predominant symptom of gastro-oesophageal reflux disease were randomized to treatment with omeprazole 20 or 10 mg once daily, or cisapride 10 mg four times daily, in a double-blind, double-dummy, parallel group, multicentre study. Symptoms and quality of life were assessed at 4 weeks. Patients still experiencing heartburn continued therapy for a further 4 weeks and the assessments were repeated. RESULTS: At 4 weeks, heartburn was resolved in 65% (95% CI: 57-73%), 56% (48-64%) and 41% (32%-49%) of patients treated, respectively, with omeprazole 20 mg and 10 mg once daily, and cisapride. Both omeprazole doses were significantly more effective than cisapride (P < 0.01). The same order of efficacy was observed regardless of the presence of erosive oesophagitis. Regurgitation and epigastric pain also improved to a greater degree with omeprazole than with cisapride. Quality of life was improved in all treatment groups, and the improvement in the reflux dimension of the Gastrointestinal Symptom Rating Scale (GSRS) score was significantly different between groups (P = 0.002). CONCLUSIONS: Omeprazole 20 or 10 mg once daily is significantly more effective than cisapride in the resolution of heartburn, regardless of the presence of erosive oesophagitis, and this is accompanied by an improvement in patient quality of life.     

No effects of high-dose omeprazole in patients with severe airway hyperresponsiveness and (a)symptomatic gastro-oesophageal reflux

Uptake of inhaled anesthetics may be measured as the amount of anesthetic infused to maintain a constant alveolar concentration of anesthetic. This method assumes that the patient absorbs all of the infused anesthetic, and that none is lost to circuit components. Using a standard anesthetic circuit with a 3-L rebreathing bag simulating the lungs, and simulating metabolism by input of carbon dioxide, we tested this assumption for halothane, isoflurane, and sevoflurane. Our results suggest that after washin of anesthetic sufficient to eliminate a material difference between inspired and end-tidal anesthetic, washin to other parts of the circuit (probably the ventilator) and absorbent (soda lime) continued to remove anesthetic for up to 15 min. From 30 min to 180 min of anesthetic administration, circuit components absorbed trivial amounts of isoflurane (12 +/- 13 mL vapor at 1.5 minimum alveolar anesthetic concentration, slightly more sevoflurane (39 +/- 15 mL), and still more halothane (64 +/- 9 mL). During this time, absorbent degraded sevoflurane (321 +/- 31 mL absorbed by circuit components and degraded by soda lime). The amount degraded increased with increasing input of carbon dioxide (e.g., the 321 +/- 31 mL increased to 508 +/- 48 mL when carbon dioxide input increased from 250 mL/min to 500 mL/min). Measurement of anesthetic uptake as a function of the amount of anesthetic infused must account for these findings. Implications: Systems that deliver inhaled anesthetics may also remove the anesthetic. Initially, anesthetics may diffuse into delivery components and the interstices of material used to absorb carbon dioxide. Later, absorbents may degrade some anesthetics (e.g., sevoflurane). Such losses may compromise measurements of anesthetic uptake.     

Comparison of the barium test meal and the gamma camera scanning technic in measuring gastric emptying

In 21 patients with nonresected stomachs and symptoms of delayed gastric emptying, obstruction was excluded by upper gastrointestinal series and upper endoscopy; all had abnormal results of barium test meal (BTM) study. Each had repeat BTM after the administration of 10 mg of metoclopramide. Each patient also had two gamma camera studies after a technetium Tc 99m sulfur colloid labeled meal; normal saline or metoclopramide was administered before each test in a blinded and random manner. Half-time (T1/2) and percentage of isotope remaining at six hours (GC6) were recorded. Ten asymptomatic controls had a gamma camera scanning study, and seven of these had a BTM. Nine of 19 patients had a T1/2 in the normal range, and in 12 of 19 patients the GC6 was in the normal range. The magnitude of retention of barium at six hours on the BTM did not correlate with the T1/2 (r = 0.076) or the GC6 (r= 0.296). Thus, these tests were not comparable in this study. By regression analysis, a significant reduction was shown in the amount of retained food and barium (P less than .01), the T1/2 (P less than .01), and the GC6 (P less than .01) after intramuscular administration of metoclopramide, indicating that both tests were able to evaluate the effects of this drug.     

Radiation dose and diagnosticity of barium enema examinations by radiographers and radiologists: a comparative study

With the current emphasis on the extension of the role of the radiographer, radiographers in some hospitals now undertake some of the procedures traditionally performed by radiologists. In the present study, dose-area product (DAP) measurements for over 1000 barium enema examinations performed by radiologists and radiographers were analysed and compared to ascertain whether there were significant differences in the radiation dose to the patient, depending on the category of staff performing the examination. All examinations were reported by a radiologist. The radiologist's reports were analysed against the known outcomes to compare the diagnosticity of the examination when carried out by the two categories of staff. The study shows that although radiographers are able to produce consistent diagnostic results, there is an increase in patient dose due to extra films taken for reporting, which may be difficult to justify. Measures for reducing the dose from this component of the examination were explored.     

Serum ferritin and other iron indices in adult Nigerians with chronic renal failure--review of management of anaemia

Iron studies were carried out in twenty five adult male and female patients with chronic renal failure and thirty one "healthy" individuals as control. Results showed moderately severe anaemia in all the patients with a mean haemoglobin concentration of 7.4 mg/dl (range 6-9.8 gm/dl). Transferin saturation of 28.8% in the patients was similar to the value of 29.2% in the control group. However, the mean serum ferritin value of 610 micrograms/L in the patients was significantly higher than the corresponding values of 165 micrograms/L and 58 micrograms/L in the control groups respectively. In patients with chronic renal failure, three out of ten bone marrow aspiration showed no stainable iron, and in five patients, iron was grossly increased with corresponding increases in serum ferritin values. In addition, four of the five patients had severe megaloblastic changes in the marrow.