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Omeprazole's efficacy in patients with intractable erosive esophagitis
ESOPHAGUS 177
~/79
H2-RECEPTOR ANTAGONISTS' EFFECTIVENESS IN PATIENTS WITH REFLUX RELATED EROSIVE ESOPHAG1TIS (A LONG TERM CLINICAL STUDY). MOHAMMAD FARIVAIL NORWOOD HOSPITAL, ONE LENOX STREET, NORWOOD MA 02062
BOTLrLINZ~M TOXIN FOR A C ~ I A : RESULTS OF A CONTROLLED TRIAL WITH A FOLLOW-UP OF TWELVE MONTHS. Fiorini AB, Corti R, Valero JL, Bai JC, Boerr L. Endoscopy Service. Esophageal Section. Medicine Departament. G a s t r o e n t e r o l o g y Hospital "Dr. C.B.Udaondo" . A R G E N T I N A
This study was undertaken in order to evaluate the effectiveness of continuous long-term H2 receptor blockade in healing esophageal mucosal disruption in patients with reflux esophagitis. Materials & Methods: The office records of 70 consecutive patients seen with erosive esophagitis were retrospectively reviewed. In addition to bland diet, elevation of head of bed, and use of antacid as necessary, treatment was begun with the usual dose of H2 receptor antagonists (ranitidine 150 nag p.o. bid or its equivalent). All patients were seen every 3-4 months and endoscoped periodically. During each follow up visit, medications were adjusted up to a maximum dose of ranitidine 300 mg tid, plus prokinetics, metoclopranude or cisapride ( 10 nag qid) and sucralfate ( 1 g qid), in order to make patients asymptomatie, nad/or to heal mucosal disruption. Results: There were 34 female patients (28-82 yr. old, average 57) and 36 males (31-75 yr old, average 54), 14 smoked, 11 used ethanol. 269 EGD's were done (2-12/patient, average 3.9). Combined follow up time was 386 patient years or 4,632 months (10-166 months per patient, average 67 months. In 7 patients (10%) with mild grade 1 esophagitis (Savary-Miller Classification), erosions healed with the usual dose of H2 receptor antagonists. In 4 more patients (6%) mucosal lesions healed with increasing dose of H2 receptor antagonists (equivalent of 300 mg ranitidine tid). The addition of prokinetie alone had no effect, but when combined with sucralfate healed erosions in 2 more patients (3%). 54 patients (77%) continue to have erosive esophagitis in spite of continuous long term treatment with H2 receptor antagonists and prokinetics and sucralfate. On subsequent follow up, four patients on the usual dose of H2 receptor antagonists for hearthum developed erosive esophagitis, 2 patients developed Sehatzki's Ring and one developed adenoearcinoma of the esophagns. Conclusion: In this group of patients with erosive reflux esophagitis, long term use of H2 receptor antagonists healed mucosal disruption in only 16% of the patients.
178
OMEPRAZOLE'S EFFICACY IN PATIENTS WITH INTRACTABLE EROSIVE ESOPHAGITIS. MOHAMMAD FARIVAR NORWOOD HOSPITAL, 1 LENOX ST, NORWOOD, MA 02062 This is a retrospective review designed to deternune omeprazole's effectiveness in healing esophageal mucosal lesions in patients with severe erosive esophagitis who did not respond to other forms of medical treatment. Materials and Methods: Of seventy consecutive patients with erosive esophagitis that were seen in the office, there were twenty-four patients who were switched to omeprazole due to persistent, severe mucosal lesions (ten with grade-IV, and fourteen with grade-Ill Savary-Miller classification) in spite of maximal medical treatment. There were fifteen females (thirty-three to seventynine years old, averaging fifty-eight years of age) and nine males (thirty-one to seventy-three, averaging forty-nine years of age). They were followed for a total of one hundred forty-three patient years (1,715 months), had eighty-six endoscopies, and were treated as follows (prior to switching to omeprazole): three patients received usual dose of H2 receptor antagonists (ranitidine 150 nag p.o. bid or its equivalent plus antacids), ten patients received maximal dose of H2 receptor antagonists (ranitidine 150 mg p.o. qid or its equivalent), and eleven patients received maxmml dose H2 receptor antagonists plus metoclopramide (10 mg p.o. qid) and four of eleven received additional sucralfate (1 g qid). Omeprazole was started at 20 mg p.o. daily and adjusted to forty nag daily or twenty nag every other day to make patients asymptomatic, or to heal persistent mucosal lesions. In patients with regurgitation, nausea, or post-prandial bloating, cisapride (ten to twenty mg p.o. at bedtime) was added. The patients were followed for a total of 199 months on omeprazole (one to twenty-two months) and had thirty-six follow-up endoscopies. Results: Mucosal lesions healed in seventeen patients (71%). Of the seven remaining patients, there was improvement of mucosal injury, three from grade-IV to grade-ll, and four patients from grade-Ill to grade-ll or I SavaryMiller classification. In five patients with complete healing of mueosal lesions, when omeprazole was reduced to 20 mg p.o. qod erosions reocenrred. Conclusions: In this group of patients with intractable severe esophagitis who had failed other medical forms of reflux treatment, omeprazole healed mucosal injury in 71% and reduced the severity of mucosal lesions in the remaining patients.
VOLUME 43, NO. 4, 1996
Recently, intrasphincteric injection of hotulinum toxin (BoTox) was demonstrated to be effective in the short term treatment of achalasia. AIM: TO evaluate in a prospective and controlled study the response to a single intrasphincteric injection of BoTox in patients with achalasia after 12 months. MATERIALS: Thirteen symptomatic patients 7 males, mean age 48.9 y (r 29-84) diagnosed of grade II of achalasia (Siewert classification) were included. All patients received a single dose of BoTox: 80U in four quadrants of cardia=20U/ml each one. METHODS: BoTox was injected directly into the lower esophageal sphincter (LES) located by manometry and endoscopy, via a sclerotherapy injector. Response to treatment was assessed by changes in Bown dysphagia score, weight, LES pressure, b a r i u m esophagogram and endoscopy. All determinations were p e r f o r m e d before and after l-3-and 12 months from treatment. Response was c o n s i d e r e d positive if at twelve months 3 of 4 parameters were improved. RESULTS: 13 patients fulfilled initial control. Two of them were lost in the long terra follow-up. Treatment was unsuccessful in 3 patients after 3 months of BoTox therapy. Eight patients completed the long term follow-up and remain well. Data are as follows(~• Basal 3 months 12 months N=II
N=8
Dysphagia Score 3.2• 1.3• 1.7• * LES pressure 23.6• 17.8• 19.1• Weight ( K g g a i n ) 53.1 b+3.4 b+3.3 % esophageal diameter reduction 50 % p<0.0001 (Wilcoxon test) CONCLUSION:BoTox transendoscopic injection is safe and effective in the long term treatment of achalasia.
['180 ENDOSCOPIC THERAPY FOR EARLY ESOPHAGEALCANCER (EEC) AND DYSPLASIA (D). DE Fleischer, GQ Wang, SH Dawsey, TL Tio, JA Kidwel]. Georgetown Univ Hed Ctr, Washington, I)C; National Cancer I n s t i t u t e , Bethesda, 1413; CHCAHS, Beijing, China. As part of an ongoing project to i d e n t i f y and t r e a t pts with EEC and D in Linxian, a rural county in north, central China, pts were screened with balloon cytology and endoscoped i f cytology was abnormal. At endoscopy, the mucosa was sprayed with Lugol's iodine which stains normal (glycogen-containing) squamous epithelium brown but leaves areas of cancer and dysplasla unstained. Pts with localized abnorm a l i t i e s were considered for endoscopic therapy. RESULTS: Balloon cytology was performed on 2043 asymptomatic pts >50 yrs of age. 225 pts (llSH;IIOF) underwent endoscopy. 23 pts were selected for endoscopic therapy i f they had localized findings on endoscopy. The intent had been to use endoscopic ultrasonography (EUS) to assist with the selection of pts but technical problems did not allow for the use of EUS in this phase of the study. 23 pts underwent endoscopic therapy by the following methods: 1) coagulation-15; 2) mucosectomy5; and 3) l i f t and cut followed by coagulation-3. The h i s t ology in the treated pts was as follows: moderate or severe dysplasia-15; carcinoma i n - s i t u - 6 ; squamous carcinoma-l; und e f i n e d - l . Hucosectomywas performed by i n j e c t i n g the lesion with saline to raise a bleb. Then a variceal l i g a t o r was adapted to the endoscope and a band applied to form a polypold lesion which was l a t e r snared and sent for pathological evaluation. Successful mucosectomy was carried out in a l l 5 pts. In pt #], 2 ligatton/polypectomies were required. In pt #5, the tissue specimen was not retrieved because of post polypectomy bleeding which required endo rx. Tissue depth was submucosa i~ 3 and musc mucosa in 1. No other complications occurred in these 5 pts or in the other 18 treated pts. Endoscopic follow-up, which is ongoing, was carried out in a l l pts to assess adequacy of Rx. CONCLUSIONS:l) Screening in a high risk population i d e n t i f i e s asymptomatic pts with EEC and D. 2) Endoscopy with mucosal spraying i d e n t i fies a group of pts with localized pathology. 3) Endoscopic therapy should be beneficial in t h i s group of pts. 4) Screening programs which are planned in high r i s k pts in the United States should consider these methods.
GASTROINTESTINAL ENDOSCOPY
335
~/79
H2-RECEPTOR ANTAGONISTS' EFFECTIVENESS IN PATIENTS WITH REFLUX RELATED EROSIVE ESOPHAG1TIS (A LONG TERM CLINICAL STUDY). MOHAMMAD FARIVAIL NORWOOD HOSPITAL, ONE LENOX STREET, NORWOOD MA 02062
BOTLrLINZ~M TOXIN FOR A C ~ I A : RESULTS OF A CONTROLLED TRIAL WITH A FOLLOW-UP OF TWELVE MONTHS. Fiorini AB, Corti R, Valero JL, Bai JC, Boerr L. Endoscopy Service. Esophageal Section. Medicine Departament. G a s t r o e n t e r o l o g y Hospital "Dr. C.B.Udaondo" . A R G E N T I N A
This study was undertaken in order to evaluate the effectiveness of continuous long-term H2 receptor blockade in healing esophageal mucosal disruption in patients with reflux esophagitis. Materials & Methods: The office records of 70 consecutive patients seen with erosive esophagitis were retrospectively reviewed. In addition to bland diet, elevation of head of bed, and use of antacid as necessary, treatment was begun with the usual dose of H2 receptor antagonists (ranitidine 150 nag p.o. bid or its equivalent). All patients were seen every 3-4 months and endoscoped periodically. During each follow up visit, medications were adjusted up to a maximum dose of ranitidine 300 mg tid, plus prokinetics, metoclopranude or cisapride ( 10 nag qid) and sucralfate ( 1 g qid), in order to make patients asymptomatie, nad/or to heal mucosal disruption. Results: There were 34 female patients (28-82 yr. old, average 57) and 36 males (31-75 yr old, average 54), 14 smoked, 11 used ethanol. 269 EGD's were done (2-12/patient, average 3.9). Combined follow up time was 386 patient years or 4,632 months (10-166 months per patient, average 67 months. In 7 patients (10%) with mild grade 1 esophagitis (Savary-Miller Classification), erosions healed with the usual dose of H2 receptor antagonists. In 4 more patients (6%) mucosal lesions healed with increasing dose of H2 receptor antagonists (equivalent of 300 mg ranitidine tid). The addition of prokinetie alone had no effect, but when combined with sucralfate healed erosions in 2 more patients (3%). 54 patients (77%) continue to have erosive esophagitis in spite of continuous long term treatment with H2 receptor antagonists and prokinetics and sucralfate. On subsequent follow up, four patients on the usual dose of H2 receptor antagonists for hearthum developed erosive esophagitis, 2 patients developed Sehatzki's Ring and one developed adenoearcinoma of the esophagns. Conclusion: In this group of patients with erosive reflux esophagitis, long term use of H2 receptor antagonists healed mucosal disruption in only 16% of the patients.
178
OMEPRAZOLE'S EFFICACY IN PATIENTS WITH INTRACTABLE EROSIVE ESOPHAGITIS. MOHAMMAD FARIVAR NORWOOD HOSPITAL, 1 LENOX ST, NORWOOD, MA 02062 This is a retrospective review designed to deternune omeprazole's effectiveness in healing esophageal mucosal lesions in patients with severe erosive esophagitis who did not respond to other forms of medical treatment. Materials and Methods: Of seventy consecutive patients with erosive esophagitis that were seen in the office, there were twenty-four patients who were switched to omeprazole due to persistent, severe mucosal lesions (ten with grade-IV, and fourteen with grade-Ill Savary-Miller classification) in spite of maximal medical treatment. There were fifteen females (thirty-three to seventynine years old, averaging fifty-eight years of age) and nine males (thirty-one to seventy-three, averaging forty-nine years of age). They were followed for a total of one hundred forty-three patient years (1,715 months), had eighty-six endoscopies, and were treated as follows (prior to switching to omeprazole): three patients received usual dose of H2 receptor antagonists (ranitidine 150 nag p.o. bid or its equivalent plus antacids), ten patients received maximal dose of H2 receptor antagonists (ranitidine 150 mg p.o. qid or its equivalent), and eleven patients received maxmml dose H2 receptor antagonists plus metoclopramide (10 mg p.o. qid) and four of eleven received additional sucralfate (1 g qid). Omeprazole was started at 20 mg p.o. daily and adjusted to forty nag daily or twenty nag every other day to make patients asymptomatic, or to heal persistent mucosal lesions. In patients with regurgitation, nausea, or post-prandial bloating, cisapride (ten to twenty mg p.o. at bedtime) was added. The patients were followed for a total of 199 months on omeprazole (one to twenty-two months) and had thirty-six follow-up endoscopies. Results: Mucosal lesions healed in seventeen patients (71%). Of the seven remaining patients, there was improvement of mucosal injury, three from grade-IV to grade-ll, and four patients from grade-Ill to grade-ll or I SavaryMiller classification. In five patients with complete healing of mueosal lesions, when omeprazole was reduced to 20 mg p.o. qod erosions reocenrred. Conclusions: In this group of patients with intractable severe esophagitis who had failed other medical forms of reflux treatment, omeprazole healed mucosal injury in 71% and reduced the severity of mucosal lesions in the remaining patients.
VOLUME 43, NO. 4, 1996
Recently, intrasphincteric injection of hotulinum toxin (BoTox) was demonstrated to be effective in the short term treatment of achalasia. AIM: TO evaluate in a prospective and controlled study the response to a single intrasphincteric injection of BoTox in patients with achalasia after 12 months. MATERIALS: Thirteen symptomatic patients 7 males, mean age 48.9 y (r 29-84) diagnosed of grade II of achalasia (Siewert classification) were included. All patients received a single dose of BoTox: 80U in four quadrants of cardia=20U/ml each one. METHODS: BoTox was injected directly into the lower esophageal sphincter (LES) located by manometry and endoscopy, via a sclerotherapy injector. Response to treatment was assessed by changes in Bown dysphagia score, weight, LES pressure, b a r i u m esophagogram and endoscopy. All determinations were p e r f o r m e d before and after l-3-and 12 months from treatment. Response was c o n s i d e r e d positive if at twelve months 3 of 4 parameters were improved. RESULTS: 13 patients fulfilled initial control. Two of them were lost in the long terra follow-up. Treatment was unsuccessful in 3 patients after 3 months of BoTox therapy. Eight patients completed the long term follow-up and remain well. Data are as follows(~• Basal 3 months 12 months N=II
N=8
Dysphagia Score 3.2• 1.3• 1.7• * LES pressure 23.6• 17.8• 19.1• Weight ( K g g a i n ) 53.1 b+3.4 b+3.3 % esophageal diameter reduction 50 % p<0.0001 (Wilcoxon test) CONCLUSION:BoTox transendoscopic injection is safe and effective in the long term treatment of achalasia.
['180 ENDOSCOPIC THERAPY FOR EARLY ESOPHAGEALCANCER (EEC) AND DYSPLASIA (D). DE Fleischer, GQ Wang, SH Dawsey, TL Tio, JA Kidwel]. Georgetown Univ Hed Ctr, Washington, I)C; National Cancer I n s t i t u t e , Bethesda, 1413; CHCAHS, Beijing, China. As part of an ongoing project to i d e n t i f y and t r e a t pts with EEC and D in Linxian, a rural county in north, central China, pts were screened with balloon cytology and endoscoped i f cytology was abnormal. At endoscopy, the mucosa was sprayed with Lugol's iodine which stains normal (glycogen-containing) squamous epithelium brown but leaves areas of cancer and dysplasla unstained. Pts with localized abnorm a l i t i e s were considered for endoscopic therapy. RESULTS: Balloon cytology was performed on 2043 asymptomatic pts >50 yrs of age. 225 pts (llSH;IIOF) underwent endoscopy. 23 pts were selected for endoscopic therapy i f they had localized findings on endoscopy. The intent had been to use endoscopic ultrasonography (EUS) to assist with the selection of pts but technical problems did not allow for the use of EUS in this phase of the study. 23 pts underwent endoscopic therapy by the following methods: 1) coagulation-15; 2) mucosectomy5; and 3) l i f t and cut followed by coagulation-3. The h i s t ology in the treated pts was as follows: moderate or severe dysplasia-15; carcinoma i n - s i t u - 6 ; squamous carcinoma-l; und e f i n e d - l . Hucosectomywas performed by i n j e c t i n g the lesion with saline to raise a bleb. Then a variceal l i g a t o r was adapted to the endoscope and a band applied to form a polypold lesion which was l a t e r snared and sent for pathological evaluation. Successful mucosectomy was carried out in a l l 5 pts. In pt #], 2 ligatton/polypectomies were required. In pt #5, the tissue specimen was not retrieved because of post polypectomy bleeding which required endo rx. Tissue depth was submucosa i~ 3 and musc mucosa in 1. No other complications occurred in these 5 pts or in the other 18 treated pts. Endoscopic follow-up, which is ongoing, was carried out in a l l pts to assess adequacy of Rx. CONCLUSIONS:l) Screening in a high risk population i d e n t i f i e s asymptomatic pts with EEC and D. 2) Endoscopy with mucosal spraying i d e n t i fies a group of pts with localized pathology. 3) Endoscopic therapy should be beneficial in t h i s group of pts. 4) Screening programs which are planned in high r i s k pts in the United States should consider these methods.
GASTROINTESTINAL ENDOSCOPY
335