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R E Sampliner

Publications and source records attributed to R E Sampliner.

At least 37 records · Page 2Linked to original sources
PubMed2001

Mucosal ablation therapy of barrett esophagus.

Barrett esophagus is defined by the metaplasia of existing squamous mucosa into a specialized intestinal-type mucosa. The importance of this metaplasia is the association of this condition with the development of adenocarcinoma of the esophagus. Elimination of the metaplastic mucosa may decrease the cancer risk. Currently, several forms of therapy have evolved with the goal of replacing the specialized mucosa with normal squamous mucosa. These proposed treatments include photodynamic therapy and thermal techniques. The effectiveness of photodynamic therapy varies depending on the pharmaceutical photosensitizer used and the wavelength of light applied to activate the drug. Thermal techniques include multipolar coagulation, argon plasma coagulation, KTP:YAG laser therapy, Nd:YAG laser therapy, and argon laser therapy. Finally, mucosal resection has been attempted through the endoscope to remove large areas of the Barrett mucosa. All of these ablative strategies attempt to destroy the metaplastic mucosa and promote the regrowth of squamous epithelium. These therapies have demonstrated the ability to "reverse" the metaplasia to varying degrees, but a decrease in cancer risk has not been demonstrated conclusively with any of these treatment methods.

Antacids↗
PubMed2001

How far to go? Screening and surveillance in Barrett's esophagus.

There is no dispute that Barrett's esophagus (BE) is associated with an increased risk of esophageal adenocarcinoma. Detecting these cancers early can improve patient survival. But should screening be used to detect BE, or should a surveillance program monitor those already diagnosed with BE for neoplastic changes? Endoscopy and endoscopic biopsy are the only tools available for such screening and surveillance, and the cost effectiveness of either approach must be considered. Two possible solutions are discussed. First, screening could be limited to patients considered at high risk for BE and associated adenocarcinoma. With this approach, more precise risk stratification would be required. The second possible approach is to combine screening for high-risk patients and surveillance for those already diagnosed with BE. Additional outcomes data are needed to determine how often and for what length of time endoscopic surveillance should continue in a patient after several examinations are negative for adenocarcinoma.

Adenocarcinoma↗
PubMed2000

Lack of effect of a high-fiber cereal supplement on the recurrence of colorectal adenomas. Phoenix Colon Cancer Prevention Physicians' Network.

BACKGROUND: The risks of colorectal cancer and adenoma, the precursor lesion, are believed to be influenced by dietary factors. Epidemiologic evidence that cereal fiber protects against colorectal cancer is equivocal. We conducted a randomized trial to determine whether dietary supplementation with wheat-bran fiber reduces the rate of recurrence of colorectal adenomas. METHODS: We randomly assigned 1429 men and women who were 40 to 80 years of age and who had had one or more histologically confirmed colorectal adenomas removed within three months before recruitment began to a supervised program of dietary supplementation with either high amounts (13.5 g per day) or low amounts (2 g per day) of wheat-bran fiber. The primary end point was the presence or absence of new adenomas at the time of follow-up colonoscopy. Subjects and physicians, including colonoscopists, were unaware of the group assignments. RESULTS: Of the 1303 subjects who completed the study, 719 had been randomly assigned to the high-fiber group and 584 to the low-fiber group. The median times from randomization to the last follow-up colonoscopy were 34 months in the high-fiber group and 36 months in the low-fiber group. By the time of the last follow-up colonoscopy, at least one adenoma had been identified in 338 subjects in the high-fiber group (47.0 percent) and in 299 subjects in the low-fiber group (51.2 percent). The multivariate adjusted odds ratio for recurrent adenoma in tile high-fiber group, as compared with the low-fiber group, was 0.88 (95 percent confidence interval, 0.70 to 1.11; P=0.28), and the relative risk of recurrence according to the number of adenomas, in the high-fiber group as compared with the low-fiber group, was 0.99 (95 percent confidence interval, 0.71 to 1.36; P=0.93). CONCLUSIONS: As used in this study, a dietary supplement of wheat-bran fiber does not protect against recurrent colorectal adenomas.

Adenoma↗
PubMed2000

Clinical and fiscal impact of lansoprazole intolerance in veterans with gastro-oesophageal reflux disease.

BACKGROUND: Omeprazole was replaced by lansoprazole as the only proton pump inhibitor on the Veterans Affairs (VA) formulary in February 1997. We aimed to assess the clinical and fiscal impact of this conversion at two VA hospitals. METHODS: We identified lansoprazole intolerant patients using pharmacy databases. We reviewed medical records to obtain data regarding reasons for lansoprazole intolerance. The costs of the formulary change and the savings to the VA were calculated. RESULTS: A total of 3833 patients required long-term proton pump inhibitor therapy; 2224 (58%) were started on lansoprazole and 1479 (39%) were converted from omeprazole to lansoprazole. The remaining 130 (3.4%) patients were never converted from omeprazole to lansoprazole. Of the 3833 patients, 325 (8.5%) currently receive omeprazole therapy; of these, 195 out of 3703 (5.3%) patients are true lansoprazole failures; 172 of these 195 patients completed the study. Most (87%) of the lansoprazole intolerant patients received prior omeprazole. Discontinuation of lansoprazole was due to poor symptom control in 69% and/or side-effects (22%) including diarrhoea (10%), abdominal pain (5%), or hives (1%). The 1-year cost of managing lansoprazole failure in 195 patients was $61 690. However, the savings to the VA during the same time period, which totalled $321 360, more than offset the costs associated with the conversion. CONCLUSIONS: Lansoprazole intolerance requiring omeprazole conversion occurred in 5% of veterans on proton pump inhibitor therapy for chronic gastro-oesophageal reflux disease (GERD) symptoms and in 10% of patients with prior omeprazole success. The VA realized substantial cost savings in association with the formulary change.

2-Pyridinylmethylsulfinylbenzimidazoles↗
PubMed2000

The omeprazole test is as sensitive as 24-h oesophageal pH monitoring in diagnosing gastro-oesophageal reflux disease in symptomatic patients with erosive oesophagitis.

BACKGROUND: Ambulatory 24-h oesophageal pH monitoring and a short course of high dose omeprazole can be used as diagnostic modalities for GERD. However, comparative studies of the diagnostic accuracy and reliability of both strategies have not been performed. AIM: To compare the omeprazole test to ambulatory 24-h oesophageal pH monitoring in diagnosing GERD in symptomatic patients using endoscopically proven erosive oesophagitis as a gold standard. METHODS: Patients with heartburn underwent an upper endoscopy. Only those with erosive oesophagitis were included in the study. Subsequently, patients underwent ambulatory 24-h oesophageal pH monitoring and an 'omeprazole test.' Daily symptoms were recorded during the first week (baseline) and repeated during the second week on therapy (omeprazole 40 mg in the morning and 20 mg in the evening). RESULTS: Thirty-five patients were included in the study. The omeprazole test was significantly more sensitive in diagnosing GERD than total acid contact time on 24-h oesophageal pH monitoring (83% vs. 60%; P < 0.03). However, the sensitivity of the pH test increased to 80% after adding patients with a positive symptom index, and patients with abnormal acid exposure in the supine or erect positions despite normal total acid contact time. Patients with a normal pH test were significantly younger (49 +/- 2.6 years) than those with abnormal test (59 +/- 1.8; P=0.002). CONCLUSIONS: In this study an omeprazole test was at least as sensitive as ambulatory 24-h oesophageal pH monitoring in diagnosing GERD in patients with erosive oesophagitis.

Adult↗
PubMed2000

Failure of oesophageal acid control in candidates for Barrett's oesophagus reversal on a very high dose of proton pump inhibitor.

BACKGROUND: Normalization of oesophageal acid exposure using high dose proton pump inhibitors in patients who are candidates for ablation therapy has been suggested to be essential for successful Barrett's reversal. However, the success rate for achieving pH normalization has not been determined. METHODS: Patients with Barrett's oesophagus (2-6 cm in length) who were found to be eligible for ablation therapy using multipolar electrocoagulation were included in this prospective study. Patients underwent an upper endoscopy to determine Barrett's length and other anatomic characteristics. Biopsies were obtained to rule out dysplasia. Subsequently, patients were treated with omeprazole 40 mg b.d. Twenty-four hour oesophageal pH monitoring was performed after a mean period of 8.4 +/- 0.6 days of therapy. RESULTS: Twenty-five patients were enrolled into the study. The pH test was abnormal in four (16%) of the study subjects. An additional two (8%) patients had abnormal supine percentage time with pH less than 4. There was no significant difference in oesophageal acid control between patients with long vs. short segment Barrett's oesophagus. Elderly (> 60 years) patients tended to have less acid control than younger (</= 60 years) patients. CONCLUSIONS: Failure of oesophageal acid control in candidates for Barrett's oesophagus reversal on very high dose of proton pump inhibitor is not uncommon. Our study suggests that ambulatory 24-h oesophageal pH monitoring should be considered in all candidates for Barrett's reversal who are treated with high dose proton pump inhibitor to ensure normalization of oesophageal acid exposure.

Adult↗
PubMed2000

Extension of squamous epithelium into the proximal stomach: a newly recognized mucosal abnormality.

BACKGROUND AND STUDY AIMS: The presence of squamous epithelium in the stomach has been rarely noted in the past with only sporadic case reports of squamous cell carcinoma of the stomach and a variety of other pathological processes. We report the documentation, over a period of 9 months, of squamous epithelium extending beyond the esophagogastric junction and into the proximal stomach in 16 patients who underwent upper endoscopy. PATIENTS AND METHODS: This newly recognized mucosal abnormality was systematically identified by both antegrade and retrograde views of the esophagogastric junction during routine upper endoscopy. Other associated mucosal abnormalities were also evaluated (Barrett's esophagus, erosive esophagitis, etc.). Biopsies were obtained from the distal esophagus, cardia, antrum and the squamous extension. Additionally, all patients underwent a detailed interview. RESULTS: Of the patients, 14 were Caucasian and two Hispanic; all were males, with a mean age 61.2+/-4.2. Indications for upper endoscopy included dysphagia, Barrett's esophagus surveillance, failure of antireflux treatment and anemia. Heartburn was reported by 12 patients (75%). None of the patients reported a history of corrosive injury, foreign body ingestion or surgery. A total of 12 patients had a solitary tongue of squamous cell extension, three had two tongues and in addition, two had squamous islands. Hiatal hernia was present in all patients, Barrett's esophagus in six (37.5 %), and esophageal stricture in four. CONCLUSION: Squamous cell extension into the proximal stomach is a newly recognized mucosal abnormality with presently unknown clinical significance. This mucosal abnormality may represent an esophageal mucosal response to proximal gastric injury.

Aged↗
PubMed2000

Symptom severity and oesophageal chemosensitivity to acid in older and young patients with gastro-oesophageal reflux.

INTRODUCTION: elderly patients appear to have a more aggressive form of gastro-oesophageal reflux disease than younger patients. Reduced pain perception with age is a possible underlying mechanism. AIMS: to compare the extent of oesophageal mucosal injury, acid exposure, symptom severity and perception thresholds for acid infusion in older (aged 60 or older) and younger patients with gastro-oesophageal reflux. METHODS: twenty-five younger and 23 older patients completed the study. We determined acid exposure and oesophageal mucosal injury by ambulatory 24-h oesophageal pH monitoring and upper endoscopy, respectively. We determined chemosensitivity by infusing 0.1 N hydrochloric acid into the mid-oesophagus for 10 min at 10 ml/min after a 2-min infusion of normal saline at a similar rate. We quantified acid perception thresholds by the lag time to initial typical symptom perception, intensity rating at the end of acid infusion and an acid perfusion sensitivity score, calculated from the fractional duration of symptom perception and intensity rating. RESULTS: mean percentage of total time with pH <4 was higher in the older (15.8+/-2.4) than in the younger patients (11.9+/-1.8; P = 0.18). Of the older group, 74% had erosive oesophagitis versus 64% in the younger group. Frequency of symptoms (heartburn, acid regurgitation and dysphagia) was lower in the elderly group. Older patients perceived heartburn and acid regurgitation as much less severe than younger patients (P < 0.05).Younger patients had a significantly shorter lag time to initial symptom perception (P < 0.05) and a higher sensory intensity rating (P < 0.08). The acid perfusion sensitivity score was significantly lower in the older group (P < 0.05). CONCLUSIONS: older patients with gastro-oesophageal reflux disease have reduced symptom severity for heartburn despite a tendency towards increased severity of oesophageal mucosal injury and acid exposure. Age-related reduction in chemosensitivity to acid is a possible underlying mechanism.

Adult↗
PubMed2000

Barrett esophagus.

Barrett esophagus continues to intrigue investigators and clinicians alike as the new millennium begins. A large number of publications in the past year have discussed issues of epidemiology, prevalence, detection, and treatment of Barrett esophagus. Chronic symptoms of gastroesophageal reflux were identified as a strong risk for esophageal adenocarcinoma. The relative frequency of short and long Barrett and cardia intestinal metaplasia in patients who undergo upper endoscopy have been better defined. Biomarkers in patients with Barrett may eventually be helpful in identifying those at high risk for the development of neoplasia. High-dose proton pump inhibition to the point of near elimination of esophageal acid exposure remains disappointing in its impact on the surface area of Barrett. Finally, the developments in endoscopic therapy for patients with Barrett esophagus continue to be promising.

Journal Article↗
PubMed2000

Screening for high-grade dysplasia in gastroesophageal reflux disease: is it cost-effective?

OBJECTIVE: The present study aimed to assess the cost-effectiveness of endoscopic screening in patients with gastroesophageal reflux disease (GERD) to rule out high-grade dysplasia of Barrett's esophagus. METHODS: Using an incremental cost-effectiveness ratio as outcome measure, the cost-effectiveness of endoscopic screening was compared to not screening in a decision tree. It was assumed that GERD patients at age 60 yr undergo a one-time endoscopy with esophageal biopsies, targeting abnormal-appearing epithelium. Positive biopsies with respect to high-grade dysplasia or early esophageal adenocarcinoma result in esophagectomy. Transition rates were estimated from U.S. cancer statistics, as well as published data of endoscopic sensitivity, specificity, and surgical outcome. Costs of screening and cancer care were estimated from Medicare reimbursement data from the perspective of a third-party-payor. RESULTS: Compared with no screening, screening endoscopy cost $24,700 per life-year saved. The cost-effectiveness of screening is quite sensitive to the prevalence of Barrett's esophagus, high-grade dysplasia, and adenocarcinoma, as well as the sensitivity, specificity, and cost of screening endoscopy. A small drop in the health-related quality of life associated with postsurgical states markedly reduced the effectiveness of screening. Simultaneous variations of the prevalence, specificity, and health-related quality of life can easily change screening endoscopy from a life-saving into a life-losing strategy. CONCLUSIONS: Under favorable conditions, general screening by endoscopy of all patients with reflux symptoms to prevent death from esophageal adenocarcinoma may represent a cost-effective strategy; however, such conditions may be difficult to meet.

Cost-Benefit Analysis↗
PubMed2000

Long-term follow-up of intestinal metaplasia of the gastric cardia.

OBJECTIVE: Recent studies have found a relatively high prevalence of gastric cardia intestinal metaplasia in individuals presenting for elective upper endoscopy. It has been hypothesized that this lesion may be a precursor of gastric cardia cancer. Our objective was to identify the incidence of dysplasia in patients with gastric cardia intestinal metaplasia. METHODS: Twenty-eight patients who had previously been identified with cardia intestinal metaplasia had follow-up examinations performed. None of the patients had dysplasia at the time of diagnosis. All had an examination at 1 yr, and 20 patients had an examination at 3 yr after diagnosis. During follow-up examinations all patients underwent vital staining with methylene blue to help identify areas of intestinal metaplasia in the cardia. Two to four biopsies were taken from blue-stained mucosa. Histological specimens were stained using a combination of hematoxylin and eosin with Alcian blue at pH 2.5. RESULTS: There were 27 men and one woman with a mean age of 69.8 yr (range, 48-83 yr). The mean length of follow-up was 2.5 yr (range, 12-46 months). Only one patient was diagnosed with dysplasia (low-grade) during the study, for an incidence of 1.4% per yr. CONCLUSIONS: The prevalence (0%) and incidence (1.4%/yr) of dysplasia in cardia intestinal metaplasia are low. Although further studies are needed, screening and surveillance for gastric cardia intestinal metaplasia is unlikely to be clinically useful for the prevention of gastric cardia cancer.

Aged↗
PubMed2000

Helicobacter pylori eradication dramatically improves inflammation in the gastric cardia.

OBJECTIVES: Inflammation of the gastric cardia, i.e., "carditis," has been associated with Helicobacter pylori (H. pylori) infection; however, some investigators believe carditis to be a histological marker for gastroesophageal reflux disease. The aim of this study was to investigate the role of H. pylori eradication on the grade of carditis scored according to the updated Sydney classification. METHODS: Consecutive patients presenting for upper endoscopy underwent systematic gastric biopsies (eight antral, 12 corpus, and four cardia). Patients with H. pylori infection and carditis were identified and followed prospectively before and after H. pylori treatment. At pretreatment and, on average, 2 yr after eradication of H. pylori, the degree of inflammation in the gastric cardia and H. pylori status were blindly assessed by a single pathologist. RESULTS: A total of 31 patients with H. pylori infection and carditis were identified. The mean age was 70 yr (range: 37-81 yr); all were male. Four were African-American and 27 were Caucasian. All patients were treated with standard anti-H. pylori therapy, including a proton pump inhibitor in combination with two antibiotics for 2 wk. Eradication of H. pylori was successful in 23 patients (group I), whereas eight patients had persistent infection (group II). Patients were followed after eradication therapy for a mean of 23.2 months (range: 6-48 months). After eradication therapy, there was a significant decrease (p < 0.0001) in the carditis scores (activity and inflammation scores) in group I, whereas the scores remained unchanged in group II patients. In both groups, there were no significant changes in the degree of intestinal metaplasia or atrophy. There were four patients with intestinal metaplasia, and one with atrophy. CONCLUSIONS: There is a dramatic improvement in the degree of inflammation and activity scores in the gastric cardia of patients with successful H. pylori eradication compared to those with persistent infection. By fulfilling one of Koch's postulates (i.e., improvement in the disease after cure of the possible etiological organism), these data support H. pylori as being the etiological agent for carditis in this group of patients.

Aged↗
PubMed2000

Relative risk of dysplasia for patients with intestinal metaplasia in the distal oesophagus and in the gastric cardia.

BACKGROUND: Biopsy specimens obtained from the gastro-oesophageal junction can reveal intestinal metaplasia in patients presenting for routine upper endoscopy. The site of biopsy may play a critical role in determining the dysplasia risk of a patient. AIMS: To evaluate prospectively the dysplasia risk in patients with intestinal metaplasia of the distal oesophagus or within the gastric cardia. METHODS: Patients with short segment Barrett's oesophagus (SSBO) and cardia intestinal metaplasia (CIM) were followed prospectively. RESULTS: 177 patients with SSBO were identified (mean age 62 years, range 38-82; 91% whites). Twenty prevalence cases of dysplasia in SSBO were detected: 17 low grade dysplasia (LGD), three high grade dysplasia (HGD). Seventy six patients with CIM were identified (mean age 67 years, range 37-81; 81% whites). A single prevalence case of LGD in CIM was detected. During follow up of 78 SSBO and 34 CIM patients, dysplasia developed in nine (seven LGD, two HGD) with SSBO and in one (LGD) with CIM. There were significant differences between the two groups with respect to age, ethnicity, dysplasia prevalence, and incidence. Time to dysplasia progression was significantly longer in CIM compared with SSBO patients. Of the five patients with SSBO and HGD, one developed adenocarcinoma of the oesophagus on follow up. No HGD or cancers have been detected over this time period in CIM patients. CONCLUSIONS: The dysplasia risk is significantly greater in SSBO than in CIM patients, indicating two potentially different clinical processes. Future studies should separate SSBO from CIM in order to enhance the understanding of the pathophysiology and malignant potential of each entity.

Adenocarcinoma↗
PubMed2000

Diagnosing and managing Barrett's esophagus.

Although significant advances have been made in our understanding of Barrett's esophagus (BE), several questions remain. The answers will affect the way BE is defined, identified, monitored, and treated. This paper reviews the current definition of BE, the rationale for surveillance and risk stratification, the possible role of p53 mutations in adenocarcinoma, and the relationships among metaplasia, dysplasia, and adenocarcinoma.

Adenocarcinoma↗
PubMed1999

Clinical and economic assessment of the omeprazole test in patients with symptoms suggestive of gastroesophageal reflux disease.

OBJECTIVE: To evaluate the diagnostic accuracy of a trial of a high-dose proton pump inhibitor (the omeprazole test) in detecting gastroesophageal reflux disease (GERD) in patients with heartburn symptoms. DESIGN: A randomized, double-blind, placebo-controlled, crossover trial. PATIENTS AND SETTING: Forty-three consecutive patients with symptoms suggestive of GERD were enrolled at a Veterans Affairs medical center. MAIN OUTCOME MEASURES: Symptom response to the omeprazole test vs placebo in GERD-positive and GERD-negative patients; sensitivity, specificity, and positive and negative predictive values of the omeprazole test; and cost per correct diagnosis achieved with the omeprazole test compared with traditional diagnostic strategies. RESULTS: Of 42 patients (98%) who completed the study, 35 (83%) were classified as GERD positive and 7 (17%) as GERD negative. Twenty-eight GERD-positive and 3 GERD-negative patients responded to the omeprazole test, providing a sensitivity of 80.0% (95% confidence interval, 66.7%-93.3%) and a specificity of 57.1% (95% confidence interval, 20.5%-93.8%). Economic analysis revealed that the omeprazole test saves $348 per average patient evaluated, and results in a 64% reduction in the number of upper endoscopies performed and a 53% reduction in the use of pH testing. CONCLUSIONS: The omeprazole test is sensitive and fairly specific for diagnosing GERD in patients with typical GERD symptoms. This strategy could result in significant cost savings and decreased use of invasive diagnostic tests.

Adult↗
PubMed1999

Barrett's esophagus: update on screening, surveillance, and treatment.

The last 2 decades have seen dramatic advances in Barrett's esophagus. The definition has evolved; the rising incidence of adenocarcinoma has been recognized; and effective therapy to control gastroesophageal reflux disease has been developed. Both proton pump inhibitor therapy and laparoscopic fundoplication represent major developments. Studies of patients with dysplasia have helped to clarify appropriate surveillance intervals and treatment strategies for these patients, although controversy still exists. The possibility of reversing Barrett's esophagus in selected high-risk patients offers major hope for the future prevention of adenocarcinoma of the esophagus.

Adenocarcinoma↗
PubMed1999

A bile acid-induced apoptosis assay for colon cancer risk and associated quality control studies.

Bile acids are important in the etiology of colorectal cancer. Bile acids induce apoptosis in colonic goblet cells at concentrations comparable to those found in fecal water after high-fat meals. Preliminary evidence indicated that cells of the normal-appearing (nontumorous) portion of the colon epithelium of colon cancer patients are more resistant to bile salt-induced apoptosis than are cells from normal individuals. In the present study, 68 patients were examined, and biopsies were taken at 20 cm from the anal verge, cecum, and descending colon. The patients included 17 individuals with a history of colorectal cancer, 37 individuals with adenomas, and 14 individuals who were neoplasia free. The mean bile salt-induced apoptotic index among normal individuals was 57.6 +/- 3.47 (SE), which differed significantly (P < 0.05) from the mean value of 36.41 +/- 3.12 in individuals with a history of colon cancer. The correlation between independent observers was 0.89 (P < 0.001), indicating good interobserver reliability. Components of variance comparing interindividual versus intraindividual sources of variation suggested that site-to-site variability, both between regions of the colon and for adjacent biopsies, was larger than the interpatient variability for individuals with a history of neoplasia. Therefore, there was "patchiness" of the susceptibility of regions of the colon to bile acid-induced apoptosis in individuals with a history of neoplasia (a patchy field effect). There was no obvious correlation of low-apoptotic index regions with regions in which previous neoplasias had been found and removed. On the other hand, for normal, i.e., neoplasia-free, individuals, there was relatively less intraindividual variation compared to interindividual variation. Our assay shows an association between resistance to bile acid-induced apoptosis, measured at 20 cm from the anal verge, and colon cancer risk. Thus, this assay may prove useful as a biomarker of colon cancer risk.

Adenoma↗