1/34. 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 = 1keywords = pressure (Clic here for more details about this article) |
2/34. Symptom priority ranking in the care of gastroesophageal reflux: a review of 1,850 cases.BACKGROUND: Clinical history remains an important part of the medical evaluation of patients with gastroesophageal reflux disease (GERD). heartburn, regurgitation, and dysphagia are considered typical symptoms of GERD. Priority rankings of these symptoms can be determined with a standardized questionnaire. OBJECTIVE: To determine whether symptom priority ranking and symptom severity grading can provide useful information in the evaluation of patients with GERD. methods: From 1,850 patients that were analyzed retrospectively, patients with dysphagia unrelated to GERD were excluded. A standardized questionnaire was applied before each patient underwent any esophageal diagnostic study. Priority of symptoms was determined to be primary, secondary, tertiary, or none based on the patient response to the questionnaire. Presence of a stricture was determined either by endoscopy, esophagraphy, or both studies. Stationary esophageal manometry and 24-hour pH monitoring were performed on all patients. Through bivariate and multivariate analysis, the relationships among typical GERD symptoms, esophageal reflux-related stenosis, lower esophageal sphincter pressure, and composite score were established. RESULTS: High priority ranking of the symptom dysphagia is predictive of the presence of an esophageal stricture, but has a negative association with abnormal manometric and pH studies. In contrast, high priority ranking of the symptom heartburn and regurgitation are positively associated with abnormal manometric and pH results. CONCLUSIONS: Priority ranking can be a valuable adjunct to objective testing in the evaluation of GERD. In certain clinical situations it can obviate the need for 24-hour pH monitoring.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
3/34. Hyperbaric oxygen therapy for cerebral palsy: two complications of treatment.There is growing interest in the use of hyperbaric oxygen therapy (HBO(2)) for children with cerebral palsy. Although there is no rigorous evidence to support this management, private hyperbaric centers have been established throughout the united states and canada. There is likely to be increasing pressure on pediatricians and other health professionals to prescribe HBO(2). We describe 2 children with cerebral palsy who suffered significant morbidity immediately after treatment with hyperbaric oxygen. Both the temporal association and pathologic findings suggest that the hyperbaric treatment is likely to have been responsible for the resulting complications. As with any new therapy, we suggest waiting for the results of a randomized, controlled trial before recommending this treatment.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
4/34. Airway difficulties caused by improperly applied cricoid pressure.Cricoid pressure, when properly applied, may prevent gastric regurgitation and may improve the view of laryngoscopy. When improperly applied, however, it can impede laryngoscopy and mask-ventilation. When faced with a "cannot intubate" or "cannot mask-ventilate" situation, clinicians should reevaluate the manner with which the assistant is applying cricoid pressure and must be prepared to adjust or even to release it.- - - - - - - - - - ranking = 6keywords = pressure (Clic here for more details about this article) |
5/34. The possible role of helicobacter pylori in GERD.A variety of abnormalities contribute to the development of gastroesophageal reflux disease (GERD) including transient lower esophageal sphincter relaxation, low esophageal sphincter pressure, presence of a hiatal hernia, diminished esophageal clearance of refluxed gastric contents, and alterations in esophageal mucosal resistance. helicobacter pylori infection clearly plays a role in the pathogenesis of peptic ulcer disease and mucosa associated lymphoma of the stomach and is a definite risk factor for distal gastric cancer. The role of H. pylori infection in GERD remains controversial and incompletely understood. Although H. pylori infection does not cause reflux disease, circumstantial evidence suggests that it may protect against the development of GERD and its complications in some patients. The most likely mechanism whereby H. pylori infection protects against GERD is by decreasing the potency of the gastric refluxate in patients with corpus predominant gastritis. A variety of implications of H. pylori infection on GERD treatment have also arisen in recent years. These focus on the risk of gastric atrophy while on proton pump inhibitor therapy and the efficacy of proton pump inhibitors before and after eradication of H. pylori. This article puts into perspective our current understanding of the complex, incompletely understood relationship between H. pylori infection and GERD.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
6/34. Surgical correction of reflux. An effective therapy for esophageal strictures.An effective antireflux operation, posterior gastropexy with cardiac calibration, was performed on 24 patients with well established peptic strictures of the esophagus. Without intraoperative or postoperative dilation, the diameter of the strictures went from a mean of 6.3 mm to a postoperative mean diameter of 13.0 mm. Significant increases in sphincter pressure were recorded and endoscopic evaluation showed a return to normal. Preoperative dysphagia was relieved. It is concluded that an adequate antireflux operation will obviate the need for postoperative dilations or more formidable operations such as interposition.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
7/34. Totally endoscopic Nissen fundoplication with a robotic system in a child.The Da Vinci robot device represents the latest advance in laparoendoscopic surgery. We report the case of an endoscopic Nissen fundoplication performed with the aid of a telemanipulation robot system in a 10-year-old girl. To our knowledge, this is the first such case to be reported. In addition to standard monitoring, we used invasive blood pressure monitoring during the 282-min period of general anesthesia. Arterial blood gas samples were analyzed at short intervals. During surgery, which included a 172-min period of intraperitoneal insufflation of carbon dioxide (CO2), no significant changes were observed in PH, arterial oxygen pressure (PaO2), arterial carbon dioxide pressure (PaCO2), heart rate, or mean arterial pressure. body temperature was maintained with an external warming blanket. Total intravenous anesthesia with continously administered propofol, remifentanil, and mivacurium for continous muscle relaxation allowed extubation immediately after skin closure. The girl was discharged from hospital on postoperative day 6. Robot-assisted techniques have the potential to significantly improve the performance of laparoendoscopic surgery. However, despite our encouraging first results, the potential risks of robot-assisted surgery have not yet been definitively established. Therefore, patients submitted to this type of procedure require intensive and even invasive monitoring.- - - - - - - - - - ranking = 4keywords = pressure (Clic here for more details about this article) |
8/34. Outpatient laparoscopic Nissen fundoplication.gastroesophageal reflux disease affects more than 40% of Americans, causing heartburn and reflux of gastric contents into the esophagus when bending or lying down. Lifestyle modification, such as weight loss and a diet rich in protein and low in fat and glucose, should increase the patient's resting lower esophageal sphincter pressure. Avoiding exacerbating substances, such as mint, chocolate, alcohol, and tobacco, also may reduce symptoms. Medications may be prescribed to reduce persistent symptoms, although no medication currently available cures the disease process. patients who need antireflux medication regularly for four to six weeks or more may be candidates for laparoscopic Nissen fundoplication. patients who do not want to take antireflux medication for the rest of their lives, cannot afford the medication for an extended period of time, or suffer significant side effects from the medication also are candidates. This article describes performing Nissen fundoplication laparoscopically on an outpatient basis. The average length of hospital stay has been decreased to two to three hours when performed laparoscopically on an outpatient basis from 10 days for the open procedure and two to three days when performed laparoscopically on an inpatient basis. The incidence of recurrent heartburn is less than 2% when the procedure is performed laparoscopically and does not appear to be clinically significant.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
9/34. Effective treatment of rumination with Nissen fundoplication.Rumination is a syndrome characterized by the effortless regurgitation of recently ingested food. It has been linked to severe medical and psychosocial conditions including malnutrition, aspiration pneumonia, and complete social withdrawal. psychotherapy, the current treatment modality for rumination, may improve symptoms but requires significant motivation and is rarely curative. We hypothesized that a complete fundoplication would eliminate, or at least impair, the ability to regurgitate gastric contents through the esophagogastric junction. We performed a Nissen fundoplication in five patients with a classic history of rumination. In all cases, symptoms had been resistant to medical and psychiatric intervention prior to fundoplication. Formal preoperative testing included esophageal manometry, 24-hour pH monitoring, endoscopy, and upper gastrointestinal barium swallow studies. All patients reported their primary symptom to be effortless recurrent postprandial regurgitation for 1 to 2 hours after meals consistent with rumination. Four (80%) of the five patients had low resting lower esophageal sphincter pressures with evidence of gastroesophageal reflux disease on 24-hour pH monitoring. All patients reported complete cessation of ruminating behavior after Nissen fundoplication. We report, for the first time, complete elimination of rumination symptoms after a Nissen fundoplication. Although further trials are needed to confirm our results, we recommend considering a Nissen fundoplication for treatment of rumination refractory to behavioral and medical interventions.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
10/34. Worsening of gastroesophageal reflux symptoms in professional singers during performances.Professional singers perform singing tasks requiring rapid changes of subglottal pressure with consistent use of the diaphragm. They regularly activate the diaphragm when there is a need for a rapid decrease in subglottal pressure, with an abrupt and prolonged increase in intraabdominal pressure. We describe the occurrence of stress-induced gastroesophageal reflux disease (GERD) in four professional singers. The reflux symptoms, which occurred in these patients during vocal performances, were an important obstacle to the movement of the respiratory muscles. To our knowledge, these are the first case reports of worsening of GERD symptoms in professional singers during performances.- - - - - - - - - - ranking = 3keywords = pressure (Clic here for more details about this article) |
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