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Duodenogastro-esophageal reflux in retractory gastro-esophageal reflux disease in children
ABG (n=9) PG (n=13) Controls (n=11)
Gastric pH 7* (3-8 2) 5.7* (1,9-8.2) 1.7 (1-7)
JAA (p.g/ml) 0.5* (0,1-11) 5§ (0,t-23) 17.5 (4.7-44)
PAA (pg/ml) 12.9 § (7.817.3) 14.3 § (5.9-21) 22.2 (5.7-75)
1289
JAA/PAA 0.06 § (0.007-0,64) 0.42 § (0.01-0,9) 1.1 (0.21-3.2)
The Effect of the Chinese Herbal Medicine gai-Kenchu-To on Intestinal Blood Flow Naruo ~wasaki, Kohichi Nariai, Maeatoshi Nakao, Koji Nakada, Nobuyoshi Hanyuu, Yoshiyuki Furukawa, Takamaea Iwaki, Hiroshi Yamashita, Teruaki Aoki, Jikei Univ, Tokyo Japan
*p
1287 Intravenous Proton Pump Inhibitors (IV PPI) for Peptic Ulcer Hemorrhage (PUH): Meta-Analysis ol Randomized Controlled Trials (RCTs) Allowing Endoscopic Treatment (ET) Virender K. Sharma, Univ of Arkansas for Medical Science, Little Rock, AR; Grigoris I. Leontiadis, G Papanikolaou Hosp, Thessaloniki Greece; Colin W. Howden, Northwestern Univ Medical Sch, Chicago, IL Background: Evenafter ET, PUH carries an appreciable risk of re-bleeding, surgical intervention and death. Some RCTs of IV PPI have reportd improvements in these nod-points, although results are conflicting. Aim: By meta-analysis of RCTs, to assess the evidence that IV PPI treatment improves PUH outcomes. Methods: Literature search for RCTs employing ET as necessary and comparing an adequate dose of an IV PPI with either placebo or an H2antagonist in patients with PUH. Homogeneity among RCTs was tested by the Breelow-Day method. RCTswere pooled with calculation of pooled absolute risk reduction (ARR), number needed to treat (NNT) and ManteI-Haenszelodds ratio (OR~) with their 95% confidence intervals (CI). Results: 9 RCTs gave results on re-bleeding, surgery and / or mortality. 8 used omeprazole and 1 used pantoprazole. Re-bleeding. 8 non-homoganeous (P = 0.02) RCTs included 924 patients given IV PPI and 961 controls. Pooled re-bleeding rates were 13.2% and 17.5%; ARR = 4.3% (95% CI = 1.0 to 7.5%); NNT = 23 (95% CI = 13 to 97). OR=_ H= 0.71 (95% CI = 0.55 to 0.92; P = 0.01). Surgery:.8 RCTswithout significant heterogeneity (P = 0.24) included 1019 patients given IV PPI and 1060 controls. Pooled rates of surgical intervention were 8.9% and 12.4%; ARR = 3.4% (95% CI = 0.8 to 6.1%); NNT = 29 (95% CI = 16 to 127). OR=_H= 0.69 (95% CI = 0.52 tO 0.91; P = 0.01). Mortality:. 9 nonhomogeneous RCTs (P = 0.04) included 1085 patients given IV PPI and 1127 controls. Pooled mortality rates were 5.3% and 3.9%; ARR = -1.4% (95% CI = -3.2% to 0.3%); NNT to harm = 69. ORM-H= 1.40 (95% CI = 0.93 to 2.09; P = 0.12). Conclusions: IV PPI therapy after PUll reducesthe risk of both re-bleeding and surgical intervention by around 30%. Although mortality appeared to be increased with IV PPI, this was not statistically significant. After initial endoscopic evaluation, and endoscopic therapy where indicated, patients with PUH should receive IV PPI treatment. The apparent reduction in rates of rebleeding and surgical intervention should be highly cost-effective; this aspect should be further evaluated.
BACKGROUND:Chineseherbal medicine "Dai-Kenchu-To (DKT)", which is consists of gineseng root, zaothoxylum fruit, and dried ginger rhizome, has known to enhance gastrointestinal motility. It has also been known that the patients taking this drug occasionally feel hot at the abdomen, however, the effect of DKT on intestinal blood flow is not well investigated. Aim; To examine the effect of DKT on intestinal blood flow. MATERIAL and METHOD:Ten male Japanesewh~ rabbits weighniog 3.5-4.0kg were used. After 48hours fasting, they were anesthetized with inhaled isoflurane by spontaneous ventilation. Arterial blood pressure and EKG were monitored.Through a midline incision, a silastic tube was inserted into the stomach toward the pyloms for the of DKT or saline (NS). The third branch of jejunal artery from the intestinal wall was skeletonized, and the tranjet blood flowmeter was attached. Baseline blood flow was measured three times at 5 min intervals, and then, either DKT extract 0.1 o/kg (mixed with 5 ml of saline) or 5 ml of saline was gently injected. Intestinal blood flow was measured every 5 minutes for 2 hours. In each animal, the mean of baseline blood flow was defined as 100, and each data was expressed as relative value to baseline data. Statistical analysis was performed using Wilcoxon signed-ranks test. RESULTS:Botharterial blood pressure and pulse rate had affected neither by DI(T nor NS. After giving DKT, the intestinal blood flow was significantly increased, while which had not affected by NS injection (A part of data is shown in the table. * P
gET N~
bnsdkte data
5 min.
15 mln.
35 rain.
70 rrdn.
t 15 min.
100 100
140.3 78.6
165.9. 49.6
149.8. 32.2
168.4. 54.1
66.1. 42.3
* p
'Vlgorom' Ar.halasla Is Not Simply an Eady ManifnstalJon of the Disease. Christopher G. Streets, Marizu Madu, Cedric G. Bremner, Nagammapudur S. Balaji, Faczaneh8anki, Rodney J, Mason, Peter F. Crookes, Jeffrey A. Hagen, Steven R. DeMeester, Jeffrey H. Peters, Lelan F. Sillin, Tom R. DeMeester, Univ of Southern CA, Los Angales, CA Introduction: Achaiasia is a primary motility disorder of the esophagus of uncertain etiology, characterizedby esophagealapedstalsls and the variable presenceof a pressurized esophagus and a hypertensive incompletely relaxing lower esophageal sphincter (LES). Although the esophagealcontractions are always apefistaltic, their amplitudes can vary from normal, sometimes referred to as vigorous achalasla, to zero. The aim of this study was to identify any differences between the two groups with respect to symptoms and LES manometric characteristics. Methods: The medical and motility records of 50 consecutive patients in whom the diagnosis of achalasia was made prior to any treatment between January 1997 and March 2000 were reviewed. The mean distal esophageal contraction pressures were calculated and the value of 30 mmHg used to define two groups vigorous achalasia (VA: n=20, 11 males, mean age 59 years) and typical achalasia (TA: n = 30, 14 males, mean age 50 years). Primary symptoms and LES characteristics in each group were compared. Results: The character and median duration of the primary symptom were similar in both groups VA: dysphagia 65%, regurgitation 15%, heartburn 10%, and 39 months; TA: dysphagia 67%, regurgitation 17%, heartburn 13%, and 36 months. Despite similar LES resting pressures (VA 32.8 mmHg; TA 26.1mmHg), the overall sphincter length was longer in VA than in TA patients (3.8 and 3.1 cm (p = 0.02) respectively). There was no difference between the two groups when comparing the LES relaxation characteristics of residual pressure and duration (VA 17.1 mmHg, 8.6 secs; TA 18.6 mmHg, 7.9 secs). Discussion: From these observations, patients with vigorous achalasiaand typical achalasiahave similar symptom patterns and lower esophagealsphincter profiles. Vigorous achalasia is not simply a precursor to end-stage disease.The shorter overall sphincter length in typical achalasia patients may reflect a degree of sphincter unfolding from above due to the dilated esophagus commonly identified in this group.
1288 Duodenogastro-Esophageal Reflux In Refractory Gastro-Esoplmgeal Reflux Disease In Children I Hoffman, A Degreef, J Tack, V Winnepenninckx, N Ectors, M Van Den Driessche, G Veereman-Wauters, Univ Hospitals Leuven, Leuven Belgium Duodeno gastro-esophageal reflux (DGE) is involved in the pathogenesis of refractory reflux esophagitis in adults (1). The role of DGE in gastro-esophageal reflux disease (GERD) in children has not been explored. The aim of the study was to investigate acid and bile reflux in children with refractory GERD. Method~. 12 patients (7 F, 5 M) with a mean age of 11y4m (6y5m 15y2m) with GERD despite omeprazole (0.5 1 mg/kg) received an upper gastrointestinal endoscopy, 24 h pH (Synectics) - bile reflux (Bilitec) monitoring and a ~3Coctanoic acid breath test for gastric emptying (GE) (7/12) (2). Presenting symptoms (1), endoscopy (2), reflux index (HI) and hilirubine absorbance >0.14 (normal : pH >4% and bile < 4.2 % respectively) (3), # reflux episodes (4), GE (T1/2) (5) and therapeutic response (6) were analyzed. Resu/t~. 1. Patients presented with epigastric pain in 91.6 %, nausea in 74.9 %, acid regurgitation in 66.6 %, food regurgitation in 66.6 %, retrostemal pain in 49.9 % and night-time pain in 41.6 %. 2. Endoscopy revealed persistent esophegitls in 7 patients (58.3 %). In 3/7 combined DGE and GER, in 1/7 GER were demonstrated. 3. RI was 2.8 % in endoscopy negative patients and 8.8 % in patients with esophagitis (p = 0.007). The % time of bilirubine absorbance > 0.14 was 4.7 % in endoscopy negative and 2.3 % in patients with esophagitis (NS). DGE was found in 7/12 patients (58 %). Of these, 5 had combined GER and DGE (41.6 %). Two had isolated DGE and 1 isolated GER. The combination of DGE and GER resulted in esophagitis in 3/5 (60%). 4. Visual analysis of the tracings showed 38 episodes of DGE, combined with 28 acid episodes (73.6 %). 5. Combined GER and DGE was found in only 1/3 of patients with normal GE, but in 3/4 patients with delayed GE (mean T1/ 2 101.7 min (77-121)). 6. Symptoms improved by adding a prokinetic drug (cisapride 0.8 mg/ kg) to the PPI treatment in 9/12 patients. Conclusions: Epigastric pain, nausea, regurgitation, retrosternal and night-time pain are the most frequent presenting symptoms in children with refractory GERD. Bile reflux may play a role in the pathogenesis of refractory GERD and esophagitis when associated with GER in children. Most DGE reflux egsiodes are combined with GER. This suggests an underlying upper gastro-intestinal motility disorder which is supported by the finding of delayed GE. Symptoms are frequently relieved by cisapride. (1) : I Demedts et al. Gastroenterology, vol 62 : D27, 1999 (2) : M Van Den Driessche et al. Gastroenterology, vol 118 : 2057, 2000
1291 Early Complications Following Radical Two-Phase Subtotal Esophagestomy - Risk Factors and ManagemeM Samuel M Dresner, Inn Shaw, S Michael Griffin, Royal Victoria Infirmary, Newcastle upon Tyne United Kingdom Background: Esophagealresection representsa major surgical and physiological insult carrying significant morbidity and mortality. This study aimed to evaluatethe results of esophagectomy in a specialist unit with emphasis on early complications and their management. Methods: Over a 10-year period, 228 patients have undergone two-phase radical esophagectomy under the care of one surgeon in this institution. The median age was 64 (range 39-77) with a male to female ratio of 2.3:1 and a predominance of edenocarcinoma (n=146) compared to squamous cell carcinoma (n =75) and rare turnouts (n=7). Detailed prospective dam were collected on pre-operative status, operative parameters and post-operative complications. Results: Mean ICU stay was 2.9 days (1-47) and the mean post-operative stay in patients surviving surgery was 17.6 days (9-156). 119 separate post-operative complications occurred in 45% (102/228) of patients comprising predominantly pulmonary morbidity. Major respiratory complications (17%) were significantly associated with poor preoperative spimmetry
A-248
Gastric pH 7* (3-8 2) 5.7* (1,9-8.2) 1.7 (1-7)
JAA (p.g/ml) 0.5* (0,1-11) 5§ (0,t-23) 17.5 (4.7-44)
PAA (pg/ml) 12.9 § (7.817.3) 14.3 § (5.9-21) 22.2 (5.7-75)
1289
JAA/PAA 0.06 § (0.007-0,64) 0.42 § (0.01-0,9) 1.1 (0.21-3.2)
The Effect of the Chinese Herbal Medicine gai-Kenchu-To on Intestinal Blood Flow Naruo ~wasaki, Kohichi Nariai, Maeatoshi Nakao, Koji Nakada, Nobuyoshi Hanyuu, Yoshiyuki Furukawa, Takamaea Iwaki, Hiroshi Yamashita, Teruaki Aoki, Jikei Univ, Tokyo Japan
*p
1287 Intravenous Proton Pump Inhibitors (IV PPI) for Peptic Ulcer Hemorrhage (PUH): Meta-Analysis ol Randomized Controlled Trials (RCTs) Allowing Endoscopic Treatment (ET) Virender K. Sharma, Univ of Arkansas for Medical Science, Little Rock, AR; Grigoris I. Leontiadis, G Papanikolaou Hosp, Thessaloniki Greece; Colin W. Howden, Northwestern Univ Medical Sch, Chicago, IL Background: Evenafter ET, PUH carries an appreciable risk of re-bleeding, surgical intervention and death. Some RCTs of IV PPI have reportd improvements in these nod-points, although results are conflicting. Aim: By meta-analysis of RCTs, to assess the evidence that IV PPI treatment improves PUH outcomes. Methods: Literature search for RCTs employing ET as necessary and comparing an adequate dose of an IV PPI with either placebo or an H2antagonist in patients with PUH. Homogeneity among RCTs was tested by the Breelow-Day method. RCTswere pooled with calculation of pooled absolute risk reduction (ARR), number needed to treat (NNT) and ManteI-Haenszelodds ratio (OR~) with their 95% confidence intervals (CI). Results: 9 RCTs gave results on re-bleeding, surgery and / or mortality. 8 used omeprazole and 1 used pantoprazole. Re-bleeding. 8 non-homoganeous (P = 0.02) RCTs included 924 patients given IV PPI and 961 controls. Pooled re-bleeding rates were 13.2% and 17.5%; ARR = 4.3% (95% CI = 1.0 to 7.5%); NNT = 23 (95% CI = 13 to 97). OR=_ H= 0.71 (95% CI = 0.55 to 0.92; P = 0.01). Surgery:.8 RCTswithout significant heterogeneity (P = 0.24) included 1019 patients given IV PPI and 1060 controls. Pooled rates of surgical intervention were 8.9% and 12.4%; ARR = 3.4% (95% CI = 0.8 to 6.1%); NNT = 29 (95% CI = 16 to 127). OR=_H= 0.69 (95% CI = 0.52 tO 0.91; P = 0.01). Mortality:. 9 nonhomogeneous RCTs (P = 0.04) included 1085 patients given IV PPI and 1127 controls. Pooled mortality rates were 5.3% and 3.9%; ARR = -1.4% (95% CI = -3.2% to 0.3%); NNT to harm = 69. ORM-H= 1.40 (95% CI = 0.93 to 2.09; P = 0.12). Conclusions: IV PPI therapy after PUll reducesthe risk of both re-bleeding and surgical intervention by around 30%. Although mortality appeared to be increased with IV PPI, this was not statistically significant. After initial endoscopic evaluation, and endoscopic therapy where indicated, patients with PUH should receive IV PPI treatment. The apparent reduction in rates of rebleeding and surgical intervention should be highly cost-effective; this aspect should be further evaluated.
BACKGROUND:Chineseherbal medicine "Dai-Kenchu-To (DKT)", which is consists of gineseng root, zaothoxylum fruit, and dried ginger rhizome, has known to enhance gastrointestinal motility. It has also been known that the patients taking this drug occasionally feel hot at the abdomen, however, the effect of DKT on intestinal blood flow is not well investigated. Aim; To examine the effect of DKT on intestinal blood flow. MATERIAL and METHOD:Ten male Japanesewh~ rabbits weighniog 3.5-4.0kg were used. After 48hours fasting, they were anesthetized with inhaled isoflurane by spontaneous ventilation. Arterial blood pressure and EKG were monitored.Through a midline incision, a silastic tube was inserted into the stomach toward the pyloms for the of DKT or saline (NS). The third branch of jejunal artery from the intestinal wall was skeletonized, and the tranjet blood flowmeter was attached. Baseline blood flow was measured three times at 5 min intervals, and then, either DKT extract 0.1 o/kg (mixed with 5 ml of saline) or 5 ml of saline was gently injected. Intestinal blood flow was measured every 5 minutes for 2 hours. In each animal, the mean of baseline blood flow was defined as 100, and each data was expressed as relative value to baseline data. Statistical analysis was performed using Wilcoxon signed-ranks test. RESULTS:Botharterial blood pressure and pulse rate had affected neither by DI(T nor NS. After giving DKT, the intestinal blood flow was significantly increased, while which had not affected by NS injection (A part of data is shown in the table. * P
gET N~
bnsdkte data
5 min.
15 mln.
35 rain.
70 rrdn.
t 15 min.
100 100
140.3 78.6
165.9. 49.6
149.8. 32.2
168.4. 54.1
66.1. 42.3
* p
'Vlgorom' Ar.halasla Is Not Simply an Eady ManifnstalJon of the Disease. Christopher G. Streets, Marizu Madu, Cedric G. Bremner, Nagammapudur S. Balaji, Faczaneh8anki, Rodney J, Mason, Peter F. Crookes, Jeffrey A. Hagen, Steven R. DeMeester, Jeffrey H. Peters, Lelan F. Sillin, Tom R. DeMeester, Univ of Southern CA, Los Angales, CA Introduction: Achaiasia is a primary motility disorder of the esophagus of uncertain etiology, characterizedby esophagealapedstalsls and the variable presenceof a pressurized esophagus and a hypertensive incompletely relaxing lower esophageal sphincter (LES). Although the esophagealcontractions are always apefistaltic, their amplitudes can vary from normal, sometimes referred to as vigorous achalasla, to zero. The aim of this study was to identify any differences between the two groups with respect to symptoms and LES manometric characteristics. Methods: The medical and motility records of 50 consecutive patients in whom the diagnosis of achalasia was made prior to any treatment between January 1997 and March 2000 were reviewed. The mean distal esophageal contraction pressures were calculated and the value of 30 mmHg used to define two groups vigorous achalasia (VA: n=20, 11 males, mean age 59 years) and typical achalasia (TA: n = 30, 14 males, mean age 50 years). Primary symptoms and LES characteristics in each group were compared. Results: The character and median duration of the primary symptom were similar in both groups VA: dysphagia 65%, regurgitation 15%, heartburn 10%, and 39 months; TA: dysphagia 67%, regurgitation 17%, heartburn 13%, and 36 months. Despite similar LES resting pressures (VA 32.8 mmHg; TA 26.1mmHg), the overall sphincter length was longer in VA than in TA patients (3.8 and 3.1 cm (p = 0.02) respectively). There was no difference between the two groups when comparing the LES relaxation characteristics of residual pressure and duration (VA 17.1 mmHg, 8.6 secs; TA 18.6 mmHg, 7.9 secs). Discussion: From these observations, patients with vigorous achalasiaand typical achalasiahave similar symptom patterns and lower esophagealsphincter profiles. Vigorous achalasia is not simply a precursor to end-stage disease.The shorter overall sphincter length in typical achalasia patients may reflect a degree of sphincter unfolding from above due to the dilated esophagus commonly identified in this group.
1288 Duodenogastro-Esophageal Reflux In Refractory Gastro-Esoplmgeal Reflux Disease In Children I Hoffman, A Degreef, J Tack, V Winnepenninckx, N Ectors, M Van Den Driessche, G Veereman-Wauters, Univ Hospitals Leuven, Leuven Belgium Duodeno gastro-esophageal reflux (DGE) is involved in the pathogenesis of refractory reflux esophagitis in adults (1). The role of DGE in gastro-esophageal reflux disease (GERD) in children has not been explored. The aim of the study was to investigate acid and bile reflux in children with refractory GERD. Method~. 12 patients (7 F, 5 M) with a mean age of 11y4m (6y5m 15y2m) with GERD despite omeprazole (0.5 1 mg/kg) received an upper gastrointestinal endoscopy, 24 h pH (Synectics) - bile reflux (Bilitec) monitoring and a ~3Coctanoic acid breath test for gastric emptying (GE) (7/12) (2). Presenting symptoms (1), endoscopy (2), reflux index (HI) and hilirubine absorbance >0.14 (normal : pH >4% and bile < 4.2 % respectively) (3), # reflux episodes (4), GE (T1/2) (5) and therapeutic response (6) were analyzed. Resu/t~. 1. Patients presented with epigastric pain in 91.6 %, nausea in 74.9 %, acid regurgitation in 66.6 %, food regurgitation in 66.6 %, retrostemal pain in 49.9 % and night-time pain in 41.6 %. 2. Endoscopy revealed persistent esophegitls in 7 patients (58.3 %). In 3/7 combined DGE and GER, in 1/7 GER were demonstrated. 3. RI was 2.8 % in endoscopy negative patients and 8.8 % in patients with esophagitis (p = 0.007). The % time of bilirubine absorbance > 0.14 was 4.7 % in endoscopy negative and 2.3 % in patients with esophagitis (NS). DGE was found in 7/12 patients (58 %). Of these, 5 had combined GER and DGE (41.6 %). Two had isolated DGE and 1 isolated GER. The combination of DGE and GER resulted in esophagitis in 3/5 (60%). 4. Visual analysis of the tracings showed 38 episodes of DGE, combined with 28 acid episodes (73.6 %). 5. Combined GER and DGE was found in only 1/3 of patients with normal GE, but in 3/4 patients with delayed GE (mean T1/ 2 101.7 min (77-121)). 6. Symptoms improved by adding a prokinetic drug (cisapride 0.8 mg/ kg) to the PPI treatment in 9/12 patients. Conclusions: Epigastric pain, nausea, regurgitation, retrosternal and night-time pain are the most frequent presenting symptoms in children with refractory GERD. Bile reflux may play a role in the pathogenesis of refractory GERD and esophagitis when associated with GER in children. Most DGE reflux egsiodes are combined with GER. This suggests an underlying upper gastro-intestinal motility disorder which is supported by the finding of delayed GE. Symptoms are frequently relieved by cisapride. (1) : I Demedts et al. Gastroenterology, vol 62 : D27, 1999 (2) : M Van Den Driessche et al. Gastroenterology, vol 118 : 2057, 2000
1291 Early Complications Following Radical Two-Phase Subtotal Esophagestomy - Risk Factors and ManagemeM Samuel M Dresner, Inn Shaw, S Michael Griffin, Royal Victoria Infirmary, Newcastle upon Tyne United Kingdom Background: Esophagealresection representsa major surgical and physiological insult carrying significant morbidity and mortality. This study aimed to evaluatethe results of esophagectomy in a specialist unit with emphasis on early complications and their management. Methods: Over a 10-year period, 228 patients have undergone two-phase radical esophagectomy under the care of one surgeon in this institution. The median age was 64 (range 39-77) with a male to female ratio of 2.3:1 and a predominance of edenocarcinoma (n=146) compared to squamous cell carcinoma (n =75) and rare turnouts (n=7). Detailed prospective dam were collected on pre-operative status, operative parameters and post-operative complications. Results: Mean ICU stay was 2.9 days (1-47) and the mean post-operative stay in patients surviving surgery was 17.6 days (9-156). 119 separate post-operative complications occurred in 45% (102/228) of patients comprising predominantly pulmonary morbidity. Major respiratory complications (17%) were significantly associated with poor preoperative spimmetry
A-248