Biomedical subjects

R C Heading

Publications and source records attributed to R C Heading.

At least 37 records · Page 2Linked to original sources

PubMed1997

Topical glyceryl trinitrate relaxes the sphincter of Oddi.

BACKGROUND/AIM: Nitric oxide (NO) may be involved in non-adrenergic non-cholinergic (NANC) inhibitory innervation of the sphincter of Oddi (SO). The effects of topical application of glyceryl trinitrate (GTN), a NO donor, upon SO motility were examined. METHODS: Nineteen patients undergoing routine SO manometry for investigation of abdominal pain were studied. After routine recording of SO motility, they were randomised into three groups to receive 10 ml of normal saline, 5 mg GTN (0.5 mg/ml) or 10 mg (1 mg/ml) GTN. Drug solutions were infused topically onto papilla via the manometry catheter and recordings were continued for a further 5 minutes. RESULTS: There was no significant change in SO motor variables following application of normal saline. GTN reduced SO tonic and phasic contractions. In four patients, there was complete abolition of all phasic contraction. CONCLUSIONS: Local application of GTN inhibits SO motility. This may have application for diagnostic and therapeutic biliary endoscopy.

Administration, Topical↗

PubMed1997

Influence of cholecystectomy on sphincter of Oddi motility.

BACKGROUND: Gall bladder and sphincter of Oddi (SO) function are coordinated by hormonal and neuronal mechanisms. Nerve fibres pass between the gall bladder and the SO via the cystic duct. It is therefore possible that cholecystectomy may alter SO motility. AIM: To investigate the effect of cholecystectomy on SO function. METHODS: SO manometry was performed in five women (median age 52 years), a few days before and six months after laparoscopic cholecystectomy which was undertaken for uncomplicated cholelithiasis. Basal and post-cholecystokinin (CCK) SO motility were measured. RESULTS: All patients were symptom free after laparoscopic cholecystectomy. Prior to surgery common bile duct pressure, and tonic and phasic SO motility were normal and phasic contractions were inhibited by intravenous CCK (1 Ivy Dog Unit/kg). Six months later, common bile duct pressure and baseline tonic and phasic activity were unchanged but CCK failed to suppress phasic activity. CONCLUSION: Cholecystectomy, at least in the short term, suppresses the normal inhibitory effect of pharmacological doses of CCK on the SO. The mechanism of this effect is unknown but it could be due to SO denervation.

Adult↗

PubMed1995

Clinical characteristics and natural history of symptomatic but not excess gastroesophageal reflux.

Esophageal pH monitoring in patients with gastroesophageal reflux symptoms identifies some who have normal esophageal acid exposure but nevertheless a convincing correlation between symptoms and those reflux events that do occur. These patients may exhibit enhanced sensory perception of physiological reflux. Little is known about the natural history of reflux symptoms in this group, which in our experience comprises up to 6% of those referred for diagnostic pH monitoring. We have therefore followed up by postal questionnaire 70 patients whose initial pH study had demonstrated normal acid exposure but a symptom index > or = 50% and 58 patients found to have excess reflux, for a median of 4.4 and 6.5 years, respectively. The presenting character and frequency of symptoms and endoscopic and manometric findings were similar in the two groups. At review overall symptom frequency had improved (P < 0.01) for both groups similarly. However, 87% of those with normal acid exposure and 79% of those with excess reflux remained symptomatic, 53% and 47%, respectively, recording their symptoms to be the same or worse than at original presentation, despite over 60% in each group continuing to take regular medication. Only six patients in each group were asymptomatic and receiving no therapy at the time of review. The results demonstrate that patients with symptomatic but not excess gastroesophageal reflux constitute a significant clinical problem. Both the persistence of their symptoms and their requirement for therapy are similar to that observed in "genuine" refluxers.

Case-Control Studies↗

PubMed1995

Heightened visceral sensation in functional gastrointestinal disease is not site-specific. Evidence for a generalized disorder of gut sensitivity.

Alteration in visceral sensation locally at the site of presumed symptom origin in the gastrointestinal tract has been proposed as an important etiopathological mechanism in the so-called functional bowel disorders. Patients presenting with one functional gastrointestinal syndrome, however, frequently have additional symptoms referable to other parts of the gut, suggesting that enhanced visceral nociception may be a panintestinal phenomenon. We measured the sensory thresholds for initial perception (IP), desire to defecate (DD), and urgency (U) in response to rectal balloon distension, and the thresholds for initial perception and for discomfort in response to esophageal balloon distension in 12 patients with irritable bowel syndrome (IBS) and 10 patients with functional dyspepsia (FD), in comparison with healthy controls. As expected, IBS patients exhibited lower rectal sensory thresholds than controls (P < 0.0001), but in addition had significantly lower sensory thresholds for both perception and discomfort evoked by balloon distension of the esophagus (mean +/- SEM: 8.8 +/- 1.3 ml vs 12.1 +/- 1.5 ml (P < 0.05) and 12.2 +/- 1.4 ml vs 16.4 +/- 1.4 ml (P < 0.02) respectively. Patients with FD showed similarly enhanced esophageal sensitivity, with thresholds for perception and discomfort of 8.1 +/- 0.9 ml (P < 0.02), and 10.1 +/- 1.0 ml (p < 0.001), respectively, but were also found to have sensory thresholds for rectal distension similar to those observed in the IBS group, significantly lower than in controls: IP 45.0 +/- 17.6 vs 59.3 +/- 1.5 ml (P < 0.001), DD 98.0 +/- 17.9 vs 298.7 +/- 9.0 ml (P < 0.0001), U 177.2 +/- 25.4 vs 415.1 +/- 12.6 ml (p < 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed1995

Lowered oesophageal sensory thresholds in patients with symptomatic but not excess gastro-oesophageal reflux: evidence for a spectrum of visceral sensitivity in GORD.

Some patients undergoing ambulatory oesophageal pH monitoring to investigate symptoms suggestive of gastro-oesophageal reflux disease (GORD) are found to have oesophageal acid exposure within the physiological range but show a close correlation between their symptoms and individual reflux episodes. It is suggested that these patients might exhibit enhanced oesophageal sensation, akin to the heightened perception of both physiological and provocative stimuli in the gut that has been described in patients with functional gastrointestinal disorders. This study tested the hypothesis by measuring the sensory thresholds for oesophageal balloon distension and discomfort in 20 patients with symptoms of GORD, in whom ambulatory pH monitoring had shown normal acid exposure times, but in whom the symptom index for reflux events was 50% or greater, and compared these with 15 healthy volunteer controls, and with control groups with confirmed excess reflux. The study group showed lower thresholds both for initial perception of oesophageal distension, and for discomfort, compared with healthy controls (median ml (range)); 7.5 (2-19) v 12 (6-30) (p = 0.002) and 10 (5-20) v 16 (8-30) (p < 0.0001), respectively. Sensory thresholds in the study group were also significantly lower than in patients with excess reflux, and than patients with Barrett's oesophagus, who also exhibited significantly higher sensory thresholds than healthy controls. No differences in sensory thresholds for somatic nerve stimulation were found between the study group and health controls. The results show a spectrum of visceral sensitivity in GORD, with enhanced oesophageal sensation in patients with symptomatic but not excess gastro-oesophageal reflux, suggesting that their symptoms result from a heightened perception of normal reflux events.

Adolescent↗

PubMed1995

Diagnosis and treatment of dyspepsia in the elderly.

Although dyspeptic symptoms are very common, the vast majority of patients have modest symptoms and rarely seek medical advice. The major organic causes of dyspepsia are chronic peptic ulcer disease, gastro-oesophageal reflux disease and malignancy. Functional dyspepsia is very common. In the fit elderly patient, prompt investigation may be more appropriate than empirical treatment in view of the higher proportion of patients with organic disease and the likelihood of malignancy. The symptoms of peptic ulceration and gastro-oesophageal reflux disease are often atypical in the elderly population. Frail patients, especially those with multiple pathology, should be treated empirically in the first instance. Empirical treatment should be with histamine H2-receptor antagonists or prokinetic agents. Drug treatment is not always required in dyspepsia and should be avoided where possible, especially given the increased risk of drug interactions and poor compliance in the elderly. For those patients with documented non-malignant organic disease, the advent of the H2-receptor antagonists, proton pump inhibitors, prokinetic drugs and regimens which eradicate Helicobacter pylori means that treatment is almost always successful.

Aged↗

PubMed1995

Twenty-four hour esophageal pH monitoring: technique and application.

In the last three decades, esophageal pH monitoring has progressed from an exclusively laboratory-based physiological research tool to a routine outpatient clinical investigation in patients with one of the most common gastrointestinal disorders. Technological advancement has considerably simplified both the procedure and the interpretation of data obtained, and there is currently reasonable consensus as to the parameters that best discriminate between physiological and pathological gastroesophageal reflux. There remains a need for internationally agreed definitions and standards, particularly with regard to calculation of these parameters, which would improve comparability of future research studies from different centers. Clinical applications of the technique have increased with our enhanced knowledge of the protean clinical manifestations of reflux disease. The advent of potent pharmacotherapy and the recognition of a need for ongoing treatment in many patients will ensure that the most sensitive test for the diagnosis of gastroesophageal reflux disease will remain an essential part of the investigation of upper gastrointestinal symptoms.

Esophagus↗

PubMed1995

Long-term management of gastroesophageal reflux disease.

Gastroesophageal reflux disease is a common disorder for which a range of treatment options is now available. Most information relates to short-term treatment, but in many respects it is questions concerning long-term management that cause physicians and patients most difficulty. Review of older evidence and some more modern studies shows that reflux disease is not invariably a chronic, unremitting condition and that in a significant number of patients, acceptable long-term management requires only intermittent symptomatic therapy or no medication at all. For those patients requiring continuous maintenance medication, current evidence implies that proton pump inhibitors, prokinetic agents such as cisapride and surgical treatment are the main options to be considered. The selection of therapeutic strategies for long-term management of reflux disease should involve consideration of patient preferences and opinions. In many cases this reveals the acceptability of a p.r.n. approach to symptom control, where medication is given only when required. Clinical trials and proposed management algorithms which presume complete symptom abolition and complete resolution of esophagitis to be the desirable therapeutic goals need to justify these assumptions in the face of evidence which seems to suggest that patients may think differently.

Gastroesophageal Reflux↗

PubMed1995

The function of free jejunal autografts in the pharyngo-oesophageal segment.

Eight patients were studied 6 weeks to 16 months following pharyngo-oesophageal reconstruction using a free jejunal interposition graft. Ambulatory manometry was carried out using an intraluminal strain gauge assembly linked to a portable microprocessor. In one patient, the assembly could not be passed because of a redundant jejunal loop. In four subjects, the jejunal interposition appeared to function as a passive conduit with very little manometric activity. In the remaining three patients, however, there was evidence of both propagated peristaltic waves within the graft and regular contractile activity, characteristic of Phase III of the intestinal Migrating Motor Complex (MMC). The presence of MMC activity at only 7 weeks following surgery confirms its independence of extrinsic intestinal innervation. Spontaneous contractile activity, however, was not interrupted by propagated water swallows and may contribute to post-operative dysphagia in some individuals.

Aged↗

PubMed1994

Achalasia of the oesophagus in elderly patients responds poorly to conservative therapy.

In a retrospective study the symptoms and results of pneumatic dilatation in achalasia of the oesophagus were analysed in 11 patients (six women) aged 65 years and above (group 1) and compared with 19 younger patients (two women, group 2) over a 48-month period. Weight loss occurred in 91% of group 1 patients and 53% of group 2 patients. Pulmonary complications were commoner in group 1 than in group 2. All patients in group 1 and 84% of patients in group 2 complained of regurgitation. Lower oesophageal sphincter pressures were similar in the groups but the median diameter of the oesophageal body was greater in group 1 patients. The duration of dysphagia before presentation was longer in group 1 (median 5 years; range 1-9 years) compared with group 2 (median 2 years; range 0.5-4 years). None of the six elderly patients receiving pharmacological treatment with nifedipine or nitrates improved while five of the six younger patients treated with medications reported transient improvement. In group 1 only 50% of the pneumatic dilatations resulted in improvement and the median duration of improvement was 12 weeks. These results were significantly worse than those in group 2 where 90% of the dilatations resulted in improvement which lasted for a median duration of 52 weeks. Long-term results were satisfactory in six of the 11 elderly patients and 16 of the 19 younger patients.

Aged↗

PubMed1994

Intestinal spirochaetosis.

Two cases of intestinal spirochaetosis are described. The first case improved with treatment while the second case improved spontaneously without any intervention. Controversy over treatment and pathogenicity of intestinal spirochaetosis is discussed with review of previous publications.

Adolescent↗

PubMed1993

Nature and standards of gastrointestinal and liver services in the United Kingdom.

1. Purpose of the working party: 1.1 To describe the scope of major digestive and liver disorders and identify changes in patterns of disease. 1.2 To identify diagnostic and therapeutic services required to manage these disorders in the United Kingdom. 1.3 To describe the facilities and staffing required to provide these services. 1.4 To examine the training requirements for medical, nursing, and other support staff. 1.5 To define the part that audit and research should play in the provision and maintenance of high quality gastrointestinal and liver services.

Education, Medical, Graduate↗

PubMed1992

Site and mechanism of pain perception with oesophageal balloon distension and intravenous edrophonium in patients with oesophageal chest pain.

Ten healthy volunteers and 13 patients with oesophageal motility disorders whose primary presenting complaint was chest pain were studied by distending an intraoesophageal balloon in 1 ml steps to the point of a sensation of discomfort. The net balloon pressure (intra-balloon pressure when inflated within the oesophagus minus the pressure recorded at the same volume outside the patient) was measured at each volume increment and the distension volume at the perception of discomfort was noted. The measurements were repeated after intravenous injection of edrophonium (80 micrograms/kg) and again after 1.2 mg intravenous atropine. Oesophageal wall compliance was similar in patients and controls, and the two groups showed a similar effect of decreased compliance with edrophonium and increased compliance after atropine. There were no significant differences between patients and controls of distending volume at perception of discomfort. Edrophonium, however, resulted in a significant reduction in distension threshold for pain (p less than 0.03) in patients. A similar though non-significant trend was seen in controls. In both controls and patients, distension volume for pain production after atropine was significantly (p less than 0.01) higher than after edrophonium. From these results and other published data, we suggest that the pain receptor for noxious stretch and after edrophonium challenge is likely to be an 'in series' mechanoreceptor located in oesophageal longitudinal muscle.

Adult↗

PubMed1992

Five year prospective study of the incidence, clinical features, and diagnosis of achalasia in Edinburgh.

With the increasing availability of manometry, patients with achalasia are often referred at an early stage when they lack the classic features of established disease. A prospective five year study of the presenting features of untreated achalasia referred to our department was undertaken. Twenty men and 18 women presented throughout adult life, with a mean age at the time of diagnosis of 44 years (range 17 to 76 years). The presenting symptoms were dysphagia: for solids (100%) and for liquids (97%), chest pain (74%), and weight loss (60%). Endoscopy was reported as normal in 15 patients and achalasia was suggested in only 21 of 33 barium examinations. Fourteen had been treated for gastrooesophageal reflux but none had been misdiagnosed as having cardiac or psychiatric disease. The annual incidence of achalasia in the Lothian region is 0.8/100,000 of population. Persistent dysphagia is the cardinal symptom of achalasia which presents throughout adult life. Nevertheless, recent onset achalasia is often misdiagnosed as gastrooesophageal reflux disease. Because endoscopy is frequently normal and the diagnosis is often not made by radiology, manometric investigation is necessary if the condition is to be recognised and treated at an early stage.

Adolescent↗

PubMed1991

Systematic comparison of conventional oesophageal manometry with oesophageal motility while eating bread.

Conventional oesophageal manometry is seldom accompanied by symptoms and may indeed be normal in patients with a history of dysphagia. We have recently shown that oesophageal manometry during eating may be helpful in the evaluation of patients with dysphagia but there has been little systematic comparison of fed oesophageal motor patterns with conventional clinical manometry. Oesophageal manometry in response to water swallows and during eating was therefore examined in 58 consecutive patients who had been referred for clinical oesophageal function studies. The patients were divided into three groups according to the percentage of peristaltic activity during conventional manometry: group 1 (n = 21) had 100% peristalsis; group 2 (n = 29) had 1-99% peristalsis and group 3 (n = 8) were aperistaltic. All the patients in group 3 had achalasia and remained aperistaltic during eating, however, was less than with water swallows in both group 1 (53% compared with 100%) and group 2 (49% compared with 82.3%) patients. Synchronous contractions and non-conducted swallows were correspondingly increased during eating. Although there was a significant correlation between the amplitude of peristaltic contractions with water and bread in groups 1 and 2, mean peristaltic amplitudes were less with bread than with water swallows. The data show that there are substantial differences in the distal oesophageal motility patterns produced by water swallows and by eating. Conventional manometry with water swallows does not allow prediction of the fed oesophageal motility pattern, except in patients with achalasia.

Bread↗

PubMed1991

Symptomatic gastro-oesophageal reflux, abnormal oesophageal acid exposure, and mucosal acid sensitivity are three separate, though related, aspects of gastro-oesophageal reflux disease.

The Bernstein test has been used as a test of oesophageal acid sensitivity for over 30 years but its clinical value has been challenged by the advent of ambulatory pH monitoring. Furthermore, the relation between mucosal acid sensitivity, symptomatic reflux, and abnormal oesophageal acid exposure time is unclear. This study examined the relation between these three parameters in patients referred for pH monitoring with unexplained chest pain or heartburn. Fifty consecutive patients were studied - nine with non-cardiac chest pain and 41 with a history of heartburn. Symptomatic reflux was defined as a greater than or equal to 50% temporal association between pain episodes and reflux events (pH less than 4) during pH monitoring. A positive acid perfusion test (in which the patient's usual symptoms were evoked by acid, though not saline) had a 100% sensitivity, 73% specificity, and 81% accuracy for the detection of symptomatic reflux. All 10 patients with symptomatic reflux during pH monitoring had evidence of mucosal acid sensitivity. A negative acid perfusion test made symptomatic reflux unlikely. However, symptomatic reflux or a positive acid perfusion test, or both, were found in some patients with a normal oesophageal acid exposure time during pH monitoring. Mucosal acid sensitivity, abnormal oesophageal acid exposure time, and symptomatic reflux should be regarded as separate, though related aspects of reflux disease. The Bernstein test is simple, safe, and easily performed. A positive test helps to identify an oesophageal cause of symptoms, particularly in patients in whom other aspects of 'gastro-oesophageal reflux disease' are absent, or who do not have symptoms during pH monitoring.

Adult↗

PubMed1991

Definitions of dyspepsia.

The definition of the term dyspepsia and of derived terms such as organic dyspepsia, functional dyspepsia, reflux-like dyspepsia, and non-ulcer dyspepsia continues to provoke controversy. In recent literature, however, it is apparent that a measure of agreement is now emerging with regard to 'dyspepsia', which is considered simply to denote episodic or persistent symptoms that include abdominal pain or discomfort and which are referable to the upper gastrointestinal tract. Particular symptom patterns may justify the use of descriptions such as reflux-like dyspepsia, ulcer-like dyspepsia, or dysmotility-like dyspepsia, but these terms should not carry any implication that the symptom patterns can be attributed to particular pathogenetic processes. In many patients with dyspepsia, clinical assessment and investigation fail to identify any abnormality to which the symptoms can reasonably be attributed. The label of 'functional dyspepsia' is well-established medical parlance in these circumstances and is generally accepted as the converse of 'organic dyspepsia', which denotes dyspepsia for which a responsible disease process has been identified.

Dyspepsia↗

PubMed1990

Hours, volume, and type of work of preregistration house officers.

OBJECTIVE: To determine the hours, volume, and type of work undertaken by preregistration house officers. DESIGN: Continuous observation of 472 hours of work performed by 12 preregistration house officers based in medical wards, using standard procedures for studying work patterns. SETTING: A teaching hospital with 340 beds assigned to general medicine and coronary care. SUBJECTS: 12 Of the 16 preregistration house officers in medicine at the hospital. MAIN OUTCOME MEASURES: The hours, volume, and type of work undertaken by preregistration house officers in February 1989, as recorded by trained observers on a one to one basis. RESULTS: The hours of duty ranged from 83 to 101 hours each week, the longest period of continuous duty being 58 hours. Each shift, house officers spent up to 25 minutes travelling between wards and an average of 85 minutes treating patients in wards that were cross covered. Between 50% and 71% of house officers' time was spent on patient oriented duties during the day; this fell to between 21% and 53% at night. Each doctor spent an average of 40 minutes filing when off duty after 6 pm. CONCLUSIONS: Established procedures for studying workload were effective in monitoring doctors' hours, providing accurate information on the volume and type of work, which is essential to resolve the problems of medical staffing. The study showed that more house officers were needed and that the cross cover system should be stopped. As a result three extra preregistration house officers were appointed.

Hospital Bed Capacity, 100 to 299↗