1/77. Gastrojejunal interposition for esophageal replacement.The main considerations in replacing the esophagus are to avoid postoperative necrosis of all or part of the graft, leakage or stenosis of the anastomoses, and complications related to acid-peptic or alkaline reflux. A 5-year-old boy, after two unsuccessful thoracic operations for atresia and then stenosis of the esophagus, underwent resection of the esophagus because of duodeno-gastroesophageal reflux. The continuity of the alimentary tract was restored by gastrojejunal interposition. We recommend this method of reconstruction when the esophago-gastrostoma is created in the chest, and the possibility of alkaline reflux must be considered.- - - - - - - - - - ranking = 1keywords = chest (Clic here for more details about this article) |
2/77. Importance of duodeno-gastro-esophageal reflux in the medical outpatient practice.BACKGROUND/AIMS: The role of acid and duodeno-gastro-esophageal reflux (DGER), also termed bile reflux, in esophageal mucosal injury is controversial. Several recent developments, especially availability of the recent bilirubin monitoring device (Bilitec), have resulted in clarifications in this area. In order to better understand the role of acid and DGER in esophageal mucosal injury, we summarized the recent publications in this area. METHODOLOGY: review of published medical literature (medline) on the clinical consequence of esophageal exposure to gastric acid or DGER. RESULTS: Recent data suggest that esophageal ph monitoring and pH > 7 is a poor marker for reflux of duodenal contents into the esophagus. DGER in non-acidic environments (i.e., partial gastrectomy patients) may cause symptoms but does not cause esophageal mucosal injury. Acid and duodenal contents usually reflux into the esophagus simultaneously, and may be contributing to the development of Barrett's metaplasia and possibly adenocarcinoma. proton pump inhibitors decrease acid and DGER by reducing intragastric volume available for reflux and raising intragastric pH. The promotility agent cisapride decreases DGER by increasing LES pressure and improving gastric emptying. CONCLUSIONS: 1) The term "alkaline reflux" is a misnormer and should no longer be used in referring to reflux of duodenal contents. 2) Bilitec is the method of choice in detecting DGER and should always be used simultaneously with esophageal pH-monitoring for acid reflux. 3) DGER alone is not injurious to esophageal mucosa, but can result in significant esophageal mucosal injury when combined with acid reflux. 4) Therefore, controlling esophageal exposure to acid reflux by using proton pump inhibitors also eliminates the potentially damaging effect of DGER.- - - - - - - - - - ranking = 0.013650164735503keywords = area (Clic here for more details about this article) |
3/77. Fixed drug eruption in hands caused by omeprazole.OBJECTIVE: omeprazole is one of the most widely prescribed gastric antisecretory drugs. It is generally well tolerated and significant adverse reactions occur rarely. The objective of this report is to describe a case of fixed drug eruption that occurred during omeprazole treatment. CASE REPORT: A 37-year-old white female patient admitted with epigastric pain and heartburn symptoms. An upper gastrointestinal endoscopy revealed reflux esophagitis and the patient was given 20 mg b.i.d. omeprazole. She developed dark-red coloration on her hands, at the fourth day of treatment, which has been defined as fixed drug eruption. These lesions were attributed to treatment and recurred soon after a rechallenge with omeprazole. CONCLUSION: Fixed drug eruption is associated with many drugs but this is the first such report with omeprazole. We suggest being aware of such reactions during omeprazole usage.- - - - - - - - - - ranking = 0.4458155509707keywords = pain (Clic here for more details about this article) |
4/77. Acute postoperative dermatosis at the site of the electrocautery pad: sweet diagnosis of a burning issue.Acute febrile neutrophilic dermatosis or Sweet's syndrome is a well-described acute condition with possible paraneoplastic and inflammatory associations. A case of a 49-year-old man with a prior history of Hodgkin's disease is described, who underwent a laparotomy for operative treatment of a small intestinal stricture and therapy-refractory gastroesophageal reflux. Incidentally, mild mesenteric lymphadenopathy was encountered, and a biopsy confirmed the presence of a new, unrelated low-grade follicular lymphoma. Two weeks postoperatively, the patient developed a tender erythematous plaque at the site of the Bovie electrocautery pad on the proximal thigh. Over the following week, the affected area extended in size, and became markedly edematous and infiltrated, with hemorrhagic surface studding. Multiple small plaques, some with annular arrays of pustules, were found on the opposite lower extremity, the lower back, and the arms. A skin biopsy suggested the presence of Sweet's syndrome, and corticosteroid treatment was initiated. All cutaneous manifestations disappeared within 48 h except for the presence of postinflammatory erythema. Acute neutrophilic dermatoses have not been previously described in this postoperative presentation. The differential diagnostic importance of this emergent entity and the potential for it being caused by surgical trauma are discussed.- - - - - - - - - - ranking = 0.0068250823677517keywords = area (Clic here for more details about this article) |
5/77. Superior mesenteric and portal vein thrombosis following laparoscopic nissen fundoplication.This case report describes superior mesenteric and portal vein thrombosis after laparoscopic Nissen fundoplication. As a thromboembolic prophylaxis, 2,500 IU of dalteparin was given preoperatively. After postoperative day 19, the patient experienced gradually increasing abdominal pain, mostly related to meals. physical examination and laboratory tests were normal. CT scan revealed a portal and superior mesenteric vein thrombosis. dalteparin and warfarin treatment was started, and symptoms relieved rapidly. In a control Doppler ultrasound 1 month after the onset of the treatment, a good flow in the portal and superior mesenteric vein was seen. Possible mechanisms are discussed.- - - - - - - - - - ranking = 0.4458155509707keywords = pain (Clic here for more details about this article) |
6/77. liver hematoma after laparoscopic nissen fundoplication: a case report and review of retraction injuries.Laparoscopic fundoplication is a safe and effective alternative to long-term medical therapy in select patients with gastroesophageal reflux disease. Among the technical challenges of laparoscopic fundoplication, retraction of the left lobe of liver can cause significant morbidity. intraoperative complications from retraction injuries have been reported in the literature, but postoperative complications arising from liver retraction have not been published. The authors present a case of a symptomatic liver hematoma requiring hospital readmission for diagnosis and pain control and a review of retraction injuries.- - - - - - - - - - ranking = 0.4458155509707keywords = pain (Clic here for more details about this article) |
7/77. The spectrum of pediatric eosinophilic esophagitis beyond infancy: a clinical series of 30 children.OBJECTIVES: eosinophilic esophagitis, previously confused with esophageal inflammation due to gastroesophageal reflux, has recently begun to be distinguished from it. We undertook this analysis of our large series of children with the condition to clarify its spectrum: its presenting symptoms; its relation to allergy, respiratory disease, and reflux; its endoscopic and histological findings; and its diagnosis and therapy. methods: We analyzed the details of our clinical series of 30 children with eosinophilic esophagitis, defining it as > or =5 eosinophils per high power field in the distal esophageal epithelium. Retrospective chart review was supplemented by prospective, blinded, duplicate quantitative evaluation of histology specimens, and by telephone contact with some families to clarify subsequent course. Presentation and analysis of the series as a whole is preceded by a case illustrating a typical presentation with dysphagia and recurrent esophageal food impactions. RESULTS: Presenting symptoms encompass vomiting, pain, and dysphagia (some with impactions or strictures). Allergy, particularly food allergy, is an associated finding in most patients, and many have concomitant asthma or other chronic respiratory disease. A subtle granularity with furrows or rings is newly identified as the endoscopic herald of histological eosinophilic esophagitis. Histological characteristics include peripapillary or juxtaluminal eosinophil clustering in certain cases. association with eosinophilic gastroenteritis occurs, but is not common. Differentiation from gastroesophageal reflux disease is approached by analyzing eosinophil density and response to therapeutic trials. Therapy encompasses dietary elimination and anti-inflammatory pharmacotherapy. CONCLUSION: awareness of the spectrum of eosinophilic esophagitis should promote optimal diagnosis and treatment of this elusive entity, both in children and in adults.- - - - - - - - - - ranking = 0.4458155509707keywords = pain (Clic here for more details about this article) |
8/77. zollinger-ellison syndrome. Clinical presentation in 261 patients.We prospectively evaluated the initial presenting symptoms in 261 patients with zollinger-ellison syndrome (ZES) over a 25-year period. Twenty-two percent of the patients had multiple endocrine neoplasia-type 1 (men-1) with ZES. Mean age at onset was 41.1 /- 0.7 years, with men-1 patients presenting at a younger age than those with sporadic ZES (p < 0.0001). Three percent of the patients had onset of the disease < age 20 years, and 7% > 60 years. A mean delay to diagnosis of 5.2 /- 0.4 years occurred in all patients. A shorter duration of symptoms was noted in female patients and in patients with liver metastases. abdominal pain and diarrhea were the most common symptoms, present in 75% and 73% of patients, respectively. heartburn and weight loss, which were uncommonly reported in early series, were present in 44% and 17% of patients, respectively. Gastrointestinal bleeding was the initial presentation in a quarter of the patients. patients rarely presented with only 1 symptom (11%); pain and diarrhea was the most frequent combination, occurring in 55% of patients. An important presenting sign that should suggest ZES is prominent gastric body folds, which were noted on endoscopy in 94% of patients; however, esophageal stricture and duodenal or pyloric scarring, reported in numerous case reports, were noted in only 4%-10%. patients with men-1 presented less frequently with pain and bleeding and more frequently with nephrolithiasis. Comparing the clinical presentation before the introduction of histamine H2-receptor antagonists (pre-1980, n = 36), after the introduction of histamine H2-receptor antagonists (1981-1989, n = 118), and after the introduction of proton pump inhibitors (PPIs) (> 1990, n = 106) demonstrates no change in age of onset; delay in diagnosis; frequency of pain, diarrhea, weight loss; or frequency of complications of severe peptic disease (bleeding, perforations, esophageal strictures, pyloric scarring). Since the introduction of histamine H2-receptor antagonists, fewer patients had a previous history of gastric acid-reducing surgery or total gastrectomy. Only 1 patient evaluated after 1980 had a total gastrectomy, and this was done in 1977. The location of the primary tumor in general had a minimal effect on the clinical presentation, causing no effect on the age at presentation, delay in diagnosis, frequency of nephrolithiasis, or severity of disease (strictures, perforations, peptic ulcers, pyloric scarring). Disease extent had a minimal effect on symptoms, with only bleeding being more frequent in patients with localized disease. patients with advanced disease presented at a later age and with a shorter disease history (p = 0.001), were less likely to have men-1 (p = 0.0087), and tended to have diarrhea more frequently (p = 0.079). A correct diagnosis of ZES was made by the referring physician initially in only 3% of the patients. The most common misdiagnosis made were idiopathic peptic ulcer disease (71%), idiopathic gastroesophageal reflux disease (GERD) (7%), and chronic idiopathic diarrhea (7%). Other less common misdiagnosis were crohn disease (2%) and various diarrhea diseases (celiac sprue [3%], irritable bowel syndrome [3%], infectious diarrhea [2%], and lactose intolerance [1%]). Other medical disorders were present in 55% of all patients; patients with sporadic disease had fewer other medical disorders than patients with men-1 (45% versus 90%, p < 0.00001). hyperparathyroidism and a previous history of kidney stones were significantly more frequent in patients with men-1 than in those with sporadic ZES. Pulmonary disorders and other malignancies were also more common in patients with men-1. These results demonstrate that abdominal pain, diarrhea, and heartburn are the most common presenting symptoms in ZES and that heartburn and diarrhea are more common than previously reported. The presence of weight loss especially with abdominal pain, diarrhea, or heartburn is an important clue suggesting the presence of gastrinoma. The presence of prominent gastric body folds, a clinical sign that has not been appreciated, is another important clue to the diagnosis of ZES. patients with men-1 presented at an earlier age; however, in general, the initial symptoms were similar to patients without men-1. gastrinoma extent and location have minimal effects on the clinical presentation. overall, neither the introduction of successful antisecretory therapy nor widespread publication about ZES, attempting to increase awareness, has shortened the delay in diagnosis or reduced the incidence of patients presenting with peptic complications. The introduction of successful antisecretory therapy, however, has dramatically decreased the rate of surgery in controlling the acid secretion and likely led to patients presenting with less severe symptoms and fewer complications. (ABSTRACT TRUNCATED)- - - - - - - - - - ranking = 2.6748933058242keywords = pain (Clic here for more details about this article) |
9/77. Approach to the patient with unexplained chest pain.patients with unexplained or noncardiac chest pain continue to present a difficult challenge to the gastroenterologist. Cardiac disease must be ruled out first as the history will not distinguish between coronary artery disease and other causes of substernal chest pain. A systematic approach to evaluation should include reassurance that the heart is normal and attempts to confirm an esophageal etiology. gastroesophageal reflux disease is the most common esophageal abnormality associated with unexplained chest pain and may be identified by an aggressive trial of anti-reflux therapy or an abnormal prolonged ambulatory pH monitoring study. endoscopy is almost always normal and of less use in this population than in those with heartburn as the presenting symptom. Judicious use of manometry with provocative testing to evaluate for esophageal motility abnormalities or esophageal sensitivity allows for optimal evaluation of those who do not have gastroesophageal reflux disease. This article reviews the clinical presentation, differential diagnosis, and approach to evaluation and therapy of this complex group of patients.- - - - - - - - - - ranking = 253.74997073227keywords = chest pain, chest, pain (Clic here for more details about this article) |
10/77. Treatment of post-stent gastroesophageal reflux by anti-reflux Z-stent.Severe symptoms of heartburn and retrosternal pain consistent with gastro-esophageal reflux (GER) developed in a patient following placement of a conventional self-expanding 16-24-mm-diameter x 12-cm-long esophageal stent across the gastroesophageal junction to treat an obstructing esophageal carcinoma. A second 18-mm-diameter x 10-cm-long esophageal stent with anti-reflux valve was deployed coaxially and reduced symptomatic GER immediately. Improvement was sustained at 4-month follow-up. An anti-reflux stent can be successfully used to treat significant symptomatic GER after conventional stenting.- - - - - - - - - - ranking = 0.4458155509707keywords = pain (Clic here for more details about this article) |
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