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Cisapride compared with ranitidine in the treatment of functional dyspepsia.
OBJECTIVE: To compare the efficacy of the prokinetic drug cisapride and the antisecretory agent ranitidine in relieving symptoms of functional dyspepsia, as well as their effect on the recurrence of symptoms after the discontinuation of treatment. DESIGN: A randomized double-blind parallel-group trial of cisapride 30 mg daily and ranitidine 300 mg daily given for 2, 4 or 8 weeks, followed by a 4-week drug-free follow-up of the patients with a good or excellent response. Rescue antacid tablets were allowed only if pain was unbearable. PATIENTS: A total of 203 patients (99 cisapride, 104 ranitidine) with symptoms of functional dyspepsia for more than 4 weeks, after the exclusion of organic disease by endoscopy and sonography or radiology. RESULTS: Cisapride and ranitidine improved the symptoms of diffuse epigastric pain, postprandial epigastric fullness, epigastric distension, belching, heartburn, regurgitation, and nausea when compared with baseline. Pain at night and gastric discomfort also greatly improved. Cisapride produced a greater reduction in epigastric pain (P = 0.07) and epigastric distension (P = 0.03) scores than ranitidine. Both drugs were equally effective in reducing the concomitant reflux-like symptoms of heartburn and regurgitation. At week 8, 87% of cisapride patients versus 61% of ranitidine patients had an excellent or good result. The deterioration of symptoms during the follow-up phase was limited in both groups. However, after the withdrawal of medication there was a greater reduction in scores in the cisapride group than in the ranitidine group for diffuse epigastric pain (P = 0.05), epigastric distension (P = 0.002), the cluster of six symptoms of epigastric discomfort (P = 0.05), and the cluster of all nine upper gastrointestinal symptoms (P = 0.06). Adverse events occurred in 15 cisapride patients and 18 ranitidine patients, and two of the ranitidine patients were withdrawn from treatment. CONCLUSIONS: Although cisapride and ranitidine both improved the symptoms of functional dyspepsia, cisapride was superior to ranitidine, particularly on the combined evaluation of the response to treatment and the recurrence of symptoms.
The nature and control of gastric motility in ruminants.
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Delayed gastric emptying and its relationship to symptoms of "gas float" after antireflux surgery.
OBJECTIVE: To analyse the association between gastric motor function before and after operation and the development of symptoms of bloating after antireflux operations. DESIGN: Open study. SETTING: University department of surgery. SUBJECTS: 81 patients with long-standing severe gastro-oesophageal reflux before antireflux operations. INTERVENTIONS: Gastric emptying of liquids and solids before (n = 81) and after (n = 47) antireflux operations. MAIN OUTCOME MEASURES: Pre- and postoperative gastric emptying times, and in reported symptoms of bloating and other postfundoplication complaints. RESULTS: 31 patients had fundoplication alone, 38 had highly selective vagotomy and fundoplication, and 12 had an Angelchik prosthesis inserted. Delayed gastric emptying of solids before operation was associated with symptoms of bloating (particularly postprandial pain and feeling sated) after operation. Delayed emptying of liquids correlated with transient symptoms only. Inability to belch and relieve bloating by belching were associated with postoperative delayed gastric emptying as well. There was no relationship between solid gastric emptying parameters and the final outcome of the operation as judged by the patients. CONCLUSION: Abnormalities of gastric motor function before operation are associated with symptoms of bloating after antireflux operations, and may therefore play a part in causing the symptoms.
Effect of fundoplication on transient lower oesophageal sphincter relaxation and gas reflux.
BACKGROUND: Fundoplication is used widely to treat severe gastro-oesophageal reflux disease. Difficulty in belching and increased flatulence are common side-effects. Transient lower oesophageal sphincter (LOS) relaxation is important to help vent gas from the stomach. The effect of fundoplication on LOS function and gas reflux was therefore investigated. METHODS: Oesophageal manometry was performed before operation and 3-15 months after fundoplication in 14 patients with reflux disease who had a total (360 degrees) fundoplication. Five patients also had highly selective vagotomy. Gastric distension was induced by 750 ml carbon dioxide. RESULTS: Fundoplication reduced the median number of episodes of gas reflux during 10 min of gastric distension from 5 (interquartile range (i.q.r.) 3-7) to 0 (i.q.r. 0), and the median number of transient LOS relaxations from 4 (i.q.r. 2-6) to 0 (i.q.r. 0-1). Fundoplication did not affect basal LOS pressure but significantly increased nadir pressure during swallow-induced relaxation. CONCLUSION: Fundoplication controls reflux by inhibiting the triggering of transient LOS relaxation and by preventing the complete ablation of pressure at the gastro-oesophageal junction during LOS relaxation. These effects may also contribute to the side-effects of the operation.
Coated expandable esophageal stents in the treatment of digestive-respiratory fistulas.
BACKGROUND: Malignant digestive-respiratory fistula (DRF) is associated with significant morbidity and mortality. In addition to the other recognized advantages of expandable stents, coated expandable stents can seal off DRF. METHODS: Eight men and five women, mean age 52 yr, with endoscopically and radiographically proven DRF were treated with the coated Wallstent (Schneider). Eleven had dysphagia, 11 postprandial cough, and two required mechanical ventilation. The DRF was proximal in four, mid-esophageal in seven, and distal in two. Two had a normal esophagus and 11 had stricture. RESULTS: Stent placement and DRF obliteration were successful in all. During a median follow-up of 157 days (range 30-423), no recurrent DRF were noted. The median dysphagia score improved from 3.4 to 1.3. Respiratory symptoms were corrected in all. A gastrostomy tube was required in three. The only complications were transient chest pain and foreign body sensation in three patients and constant sensation of belching in one. There was no procedure-related mortality. CONCLUSION: In this small group of patients, the coated Wallstent demonstrated excellent palliation of DRF with minimal morbidity and no mortality.