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PubMed1998

Intraesophageal balloon distension test in Chagas' disease patients with noncardiac chest pain.

Patients with Chagas' disease often have chest pain as a prominent symptom. The objective of this study was to compare the results of intraesophageal balloon distension in chagasic and nonchagasic patients with chest pain not caused by coronary obstruction. We studied 40 patients with chest pain and angiographically normal coronary arteries, 25 with a positive serologic test for Chagas' disease (Chagas group, 16 women, mean age 53+/-10 years), and 15 with a negative serologic test (control group, 11 women, mean age 46+/-10 years). All patients had radiologic and endoscopic examinations of esophagus, stomach, and duodenum, esophageal manometry with the acid infusion test in the distal esophagus, and intraesophageal balloon distension. None of them had esophageal dilation or any signs of cardiovascular disease. A 25-mm-long latex balloon located 10 cm above the lower esophageal sphincter was inflated and deflated over a period of 10 sec at 1-ml increments of air until the subjects reported chest pain or to a maximum volume of 20 mi. The test caused chest pain in 14 subjects in the control group (93%) and in 12 in the Chagas' disease group (48%, P < 0.05). The mean volume of air that caused chest pain was 10+/-3 ml in the control group and 15+/-4 ml in the Chagas' disease group (mean+/-SD, P < 0.05). The maximum intraesophageal pressure during the examination was higher in Chagas' disease patients with chest pain during balloon distension (60 +/- 21 mm Hg) than in patients who did not have chest pain (37 +/-18 mm Hg, P < 0.05) and did not differ from the control group (48+/-16 mm Hg, P > 0.05). With the other examinations there was no difference between groups or between patients with or without chest pain during the balloon distension test. Although esophagitis was observed in 47% of patients in the control group and in 40% of the Chagas' disease group, the acid infusion test was positive in 27% of patients in the control group and in 4% of patients in the Chagas' disease group. We conclude that, as compared to a group of patients with similar chest pain, chagasic patients are less sensitive to esophageal distension. Thus, it is unlikely that their chest pain is related to esophageal mechanisms.

Adult↗
PubMed1993

Surgical bypass for palliation of malignant oesophageal obstruction.

It is possible to achieve satisfactory palliation for most patients with malignant oesophageal obstruction by endoscopic means, surgical resection or radiotherapy. Despite these options, a small group of patients remains for whom another alternative should be considered. Fifteen patients presenting with extensive tumour, a non-dilatable stricture, or a tracheo-oesophageal fistula, not suitable for any of the standard methods of palliation, underwent palliative surgical bypass using stomach or colon. The hospital mortality was 33% and the median survival 6 months. Anastomotic leakage occurred in six patients and the median postoperative stay was 28 days (range 20-42 days). All patients who survived surgery, except one, achieved satisfactory palliation. The nature of these patients is such that whatever is done, mortality will almost inevitably be high. The authors believe that all patients in this series were better off than they would have been if left untreated, and oesophageal bypass should be considered for patients with distressing dysphagia due to disease not amenable to standard palliative methods.

Adult↗
PubMed1998

Differential symptomatic and electrogastrographic effects of distal and proximal human gastric distension.

Nausea and gastric dysrhythmias occur in conditions associated with gastric distension. The roles of distal and proximal gastric mechanoreceptors in these responses are unexplored. Because antral distension induces vomiting in animals and antral and fundic vagal afferent discharges differ, we hypothesized that distal gastric distension in humans leads to greater symptomatic and dysrhythmic responses than proximal distension. Symptoms and electrogastrograms were recorded in healthy humans during distal and proximal gastric distension with a barostat. Distal but not proximal distension induced nausea and a 747 +/- 250% increase in dysrhythmic power (P < 0.05), responses not affected by granisetron, indomethacin, or atropine, agents that block dysrhythmias in other settings. In the distal stomach, bloating and pain developed at lower pressures (P < 0.05) not modified by granisetron, and compliance was significantly lower (P < 0.05). In conclusion, gastric mechanoreceptor activation in the less-compliant distal stomach produces nausea and dysrhythmias via non-5-hydroxytryptamine3 (5-HT3), non-prostaglandin-dependent, and noncholinergic pathways. Distal mechanoreceptor activation induces greater bloating and pain than proximal mechanoreceptor activation via 5-HT3-independent pathways.

Adult↗
PubMed2005

"Watermelon stomach" in patients on chronic hemodialysis.

"Watermelon stomach" is a common name for gastric antral vascular ectasia (GAVE syndrome). This endoscopic finding is characterized by the appearance of parallel longitudinal red columns along mucosal folds, along with capillars dilatation and hemorrhagy. Finding reliable method for its recognition is of paramount importance. Patient B.D., a 54-year-old woman, developed renal failure, which led to hemodialysis treatment, on the basis of pyelonephritis chronica. As a consequence of the gastrointestinal bleeding, the patient had black stools and developed severe anemia. The endoscopic finding showed the existence of visible columns of vessels transversing the antrum in longitudinal folds and converging in the pylorus, with clear red spots and surrounding hyperemy covered by drops of fresh blood. The diagnosis of "watermelon stomach" was confirmed after the pathohistological examination of the tissue taken at the biopsy, followed by total gastrectomy. Postoperative status was normal, without gastrointestinal hemorrhagia, and she went on with hemodialysis. Before the surgery she received 105 blood transfusions, and after surgical treatment she has received only 18 so far. At the moment she is in good health condition, and on hemodialysis. The reason we have reported this case of "watermelon stomach" syndrome in patient with chronic renal failure is to indicate that this rare anomaly of gastric blood vessels can lead to gastrointestinal blood loss in these patients. Since it is often the reason for many wrong diagnoses, it should be also taken into consideration in cases like these.

Biopsy, Needle↗
PubMed1999

Bochdalek diaphragmatic hernia presenting with acute gastric dilatation.

Congenital diaphragmatic hernia through the foramen of Bochdalek may present after infancy. A 21/2-year-old Malay girl presented with acute respiratory distress. Chest examination showed reduced chest expansion and decreased breath sounds on the left side. Chest radiograph showed a large "cyst" in the left chest, which was thought to be a lung cyst under tension. Tube thoracostomy resulted in clinical improvement. Results of a barium study showed that the cyst perforated by the thoracostomy tube was the stomach, which had herniated through a Bochdalek diaphragmatic defect. Surgical repair of the diaphragmatic defect and closure of the perforated stomach was performed successfully. Congenital diaphragmatic hernia should be included in the differential diagnosis of respiratory distress in young children. Nasogastric tube placement must be considered as an early diagnostic or therapeutic intervention when the diagnosis is suspected.

Child, Preschool↗
PubMed1985

Transhiatal esophagectomy for benign disease.

Transhiatal esophagectomy without thoracotomy has been performed in 65 adult patients with dysphagia from benign esophageal disease: strictures (30), neuromotor dysfunction (24), acute iatrogenic perforation (five), acute caustic injury (four), and recurrent gastroesophageal reflux (two). Nearly 70% (45) had undergone at least one prior esophageal operation, and 26% (17) had a history of between two and four esophageal operations. The esophagus was replaced with stomach in 53 patients (82%), colon being used only when there was a history of either prior gastric resection or caustic injury to the stomach (10 patients). Intraoperative blood loss averaged 1,050 ml. Intraoperative complications included pneumothorax in 38 patients (58%) and a tracheal laceration in one patient. Postoperative complications included transient recurrent laryngeal nerve paresis (11 patients, 17%), chylothorax (four patients, 6%), anastomotic leak (four patients, 6%), and small bowel obstruction (two patients). There were five hospital deaths (8% mortality), none related to the technique of esophagectomy. Follow-up ranges from 1 to 84 months (average 28 months). Of 46 patients with a cervical esophagogastric anastomosis in the original esophageal bed, 42 have had an excellent functional result although 17 have required at least one postoperative esophageal dilation. Two have developed true anastomotic strictures. Clinically significant gastroesophageal reflux has not occurred. Transhiatal esophagectomy for benign disease is feasible and safe, even after multiple previous esophageal operations. The stomach appears to be a better visceral esophageal substitute than colon, because it allows an initially easier technical operation and superior long-term functional results.

Adolescent↗
PubMed1979

Vagovagal stimulation of pancreatic-polypeptide secretion by graded distention of the gastric fundus and antrum in man.

Previous studies have shown that pancreatic polypeptide (PP) secretion is regulated by efferent, vagal stimulation. In the present study the afferent part of a vagovagal pathway has been investigated in two different ways: (I) Graded fundic distention: in 8 patients with duodenal ulcer ballon distention with 150 ml of the fundus and the body of the stomach increased PP concentrations in plasma from 19 (17--26) to 41 (35--48) pmol/l, median and interquartile range. Distention by 300 and 600 ml did not further increase PP concentrations. After denervation of the fundus by proximal gastric vagotomy, no increase in PP levels was observed during distention with 50 and 300 ml whereas distention by 600 ml was followed by a small increase. (II) Graded antral distention: balloon distention with 50, 100 and 150 ml of the antrum increased plasma PP concentrations in 7 healthy subjects and 14 duodenal ulcer patients. Maximal PP response was achieved by distention with 100 ml, healthy subjects: from 14 (12--23) to 40 (26--44) pmol/l, and duodenal ulcer patients: from 25 (13--38) to 47 (22--63) pmol/l, median and interquartile range. It is concluded that a gastropancreatic reflex stimulating PP secretion through a long vagovagal pathway is present in man, and that this mechanism probably is involved in the initial PP response during a meal.

Adult↗
PubMed1982

[Treatment results in cardiospasm using cardiodilatation as dependent on stomach function].

On the basis of investigations of the acid-formation and motor activity of the stomach in 95 patients with cardiospasm and results of the treatment of 50 of them the author has shown that most of the patients with cardiospasm had an increased acid-formation and a delayed gastric evacuation. Correction of these disorders in addition to routine methods of treatment of cardiospasm gives better early and late results.

Cardia↗
PubMed1994

[Choice of the method of forming an isoperistaltic graft from the stomach for total esophagoplasty].

An anatomical experiment was conducted on 50 cadavers of human adults and an acute experiment on 50 unbred dogs to choose the most rational method for forming an isoperistaltic graft from the stomach for total esophagoplasty. The anatomo-experimental study was concerned with the peculiarities of angioarchitectonics and the merits and shortcomings of some methods for lengthening gastric grafts. The macro- and microcirculation in the modelled isoperistaltic gastric grafts of various width and configuration was studied in the animal experiments. It was shown that the best gastric graft was an isoperistaltic tube measuring 2.5 cm at the base, formed by the authors' suggested method of angular division of the gastric walls above the pylorus, and with a dilatation in the proximal part (beginning 4 cm below the level of division of the main vascular arcade) up to 3.5 cm in size. When the length of the greater curvature of the stomach from the lower pole of the spleen to the pylorus, measured in mild stretching of the tissues (before mobilization of the stomach) is less than 20 cm it is advisable that the vascular connections in the hilus of the spleen are included in the nutrient-supplying pedicle of the graft to improve the supply of blood to its proximal segment. The method for formation of the gastric graft along a broken line was used in the clinic in 300 operations for extirpation of the esophagus with one-stage esophagoplasty. Necrosis of the graft was not encountered. Total postoperative mortality was 3%. It is concluded that wider introduction of this operation into clinical practice is expedient.

Animals↗
PubMed1984

Surgical management of reflux-induced oesophageal stenoses: results in 101 patients.

One hundred and one patients with benign, reflux-induced oesophageal stenosis were surgically treated at the Mayo Clinic during a recent 6 year period by the author. In 71 patients, the stenosis was readily dilated and treated by a variety of antireflux procedures, depending on presence or absence of oesophageal peristalsis or acquired shortening of the oesophagus. Thirteen additional patients were managed by gastric secretion suppression with duodenal diversion using the Roux-Y principle. Seventeen patients with undilatable stenoses were managed by resection and a variety of reconstructions. The modified Ivor-Lewis procedure with or without thoracotomy was the procedure employed in 12 of the 17 with the remainder managed with either substernal colon or upper digestive secretion suppression-diversion. These 101 operations were accomplished without mortality and all but one patient have resumed an oral diet and returned to their usual occupation. While 91 per cent of the 101 patients are free of reflux symptoms or demonstrable stenosis and are considered improved, only 83 per cent of all patients have "excellent' to "good' late results in terms of both oesophageal and gastrointestinal symptoms.

Colon↗
PubMed1994

Amniotic fluid digestive enzymes: diagnostic value in fetal gastrointestinal obstructions.

The diagnostic value of amniotic fluid gamma-glutamyl-transpeptidase (GGTP) and intestinal alkaline phosphatase (iALP) was evaluated in 55 patients who underwent amniocentesis for karyotyping because fetal gastric or small bowel dilatation had been detected by ultrasound. Gastrointestinal malformation was confirmed in 46 cases and there was no gastrointestinal anomaly in nine cases. Prenatal ultrasound was suggestive of gastroduodenal dilatation in 34 cases (group I) and small bowel dilatation in 21 cases (group II). In group I, amniotic fluid GGTP above the 99th percentile was 71 per cent sensitive and 100 per cent specific for a true anatomical defect of the digestive tract (mainly duodenal atresia). In group II, high levels of GGTP and/or iALP were 69 per cent sensitive and 83 per cent specific for a fetal digestive tract anomaly. In other words, when digestive tract dilatations were diagnosed by prenatal sonography, abnormal amniotic fluid enzyme activities were strongly suggestive of such an anomaly, the possibility of which was not precluded by normal amniotic fluid iALP and GGTP activities. But amniotic fluid digestive enzyme activities do not help in defining the prognosis.

Alkaline Phosphatase↗
PubMed2004

Esophageal replacement in children by an isoperistaltic gastric tube: a 12-year experience.

The colonic segment is the most frequently used material for replacing the esophagus in children; however, the use of a gastric tube has become a reliable alternative operation. Since 1987, we have used an isoperistaltic gastric tube to replace the esophagus in children, and we present a series of 21 patients. Indications for operation included caustic injury (nine), esophageal atresia (eight), peptic stricture (two), congenital stricture (one), and esophageal duplication (one). There was no death or necrosis of the graft during the early postoperative period. The esophagogastric anastomosis leaked in two cases, but both of them closed spontaneously. A temporary dumping syndrome was encountered in two children. Two patients had strictures of their upper anastomosis responding to dilatations. The two patients who had a pharyngogastric anastomosis developed either intractable stricture or nonfunctioning anastomosis. One of them died 9 months later from aspiration pneumonitis. At follow-up, 16 of 21 patients could accept a normal diet (13 were entirely asymptomatic, and three suffered occasional mild dysphagia). Two patients suffered significant dysphagia (one had a durable dilation of his gastric tube), and three needed a feeding jejunostomy. Acid secretion of the gastric tube was proved in nine cases. Two patients were shown to have cervical Barrett's esophagus above the anastomosis. These findings indicate the need for lifelong endoscopic follow-up for these patients.

Child↗
PubMed1998

Myoepithelial hamartoma of the duodenal wall.

A rare case of myoepithelial hamartoma of the duodenal wall is presented, and previous case reports found in the literature are reviewed. Myoepithelial hamartomas are thought to arise from displaced pancreatic anlage present along the gastrointestinal tract during embryogenesis, which can differentiate into various pancreatic elements; the most highly differentiated form is heterotopic pancreas. An alternative theory is pancreatic metaplasia of endodermal tissues. We describe a 41-year-old man who presented with abdominal pain and vomiting. CT scanning revealed a mass at the head of the pancreas. A pancreaticoduodenectomy was performed for presumed cystadenoma. Histology of the mass revealed a disorderly arrangement of smooth muscle, dilated and nondilated ducts, pancreatic acinar tissue and mucus glands. The relationship of myoepithelial hamartomas involving the small bowel to similar lesions in the stomach, bile ducts and gallbladder is discussed.

Adult↗
PubMed1983

What is the role of prosthesis insertion in esophageal carcinoma?

We review our experience with 13 patients in whom esophageal dilation was used for palliation of malignant esophageal obstruction and with five patients treated with esophageal prostheses for malignant esophagorespiratory fistula. Twelve of the 13 patients with dilation alone received satisfactory palliation and were able to eat a soft or regular diet. Four of five patients with esophagorespiratory fistulas had esophageal dilation followed by insertion of a esophageal prosthesis and received good palliation. Endoscopic insertion of esophageal prosthetic devices has become increasingly popular as a palliative procedure, despite lack of controlled trials either proving efficacy of this therapy or comparing it to radiation therapy with or without dilation of the esophagus. The reported mortality and morbidity rates for esophageal prosthesis insertion are higher than those reported for radiotherapy. There is little to suggest that prostheses are better than or even equal to radiotherapy alone or radiotherapy and bougienage. We review the reported series (greater than 2300 cases) of push-through prostheses insertions in esophageal cancer and compare prosthesis insertion to other therapy. The need for a carefully controlled trial of the different forms of therapy is emphasized, and guidelines for such a study are suggested.

Adenocarcinoma↗
PubMed2002

Effect of the low-affinity, noncompetitive N-methyl-d-aspartate receptor antagonist dextromethorphan on visceral perception in healthy volunteers.

BACKGROUND: The use of N-methyl-d-aspartate (NMDA) receptor antagonists may hold promise for the treatment of pain of visceral origin, in particular in conditions characterized by visceral hypersensitivity. AIM: To study the effect of dextromethorphan, a low affinity, non-competitive NMDA receptor antagonist, on visceral perception in healthy volunteers. METHODS: Nine healthy volunteers (5 female, median age 22 years) underwent a gastric barostat study after oral administration of placebo, dextromethorphan 10 mg or dextromethorphan 30 mg, on three separate days in a double-blind, randomised order. Sensations induced by step-wise isobaric gastric distension (2 mmHg/2 min) were studied during fasting and 30 min after a meal. In addition, proximal gastric tone was measured during fasting and postprandially. RESULTS: Compared to placebo, dextromethorphan 30 mg significantly increased the distension-evoked sensation scores for nausea (P=0.004) and satiation (P=0.004) during fasting; and for bloating (P= 0.001), nausea (P=0.000) and satiation (P=0.01) 30 min postprandially. Dextromethorphan did not alter pain scores, proximal gastric tone or gastric compliance. CONCLUSIONS: Dextromethorphan increases the perception of non-painful sensations during gastric distension, without altering the perception of pain. Therefore, application of dextromethorphan as a visceral analgesic is questionable. Future studies with more specific NMDA receptor antagonist are warranted.

Adult↗
PubMed1983

[Clinical significance of the dilated common bile duct in the sonogram].

The data of 34 patients with a sonographically established dilated common bile duct were analysed as to the clinical significance of these findings. Whereas it was possible to diagnose dilated proximal common bile ducts in all of the cases under examination, presentation of the distal section succeeded in only 56% of the patients involved. Thus distal concretions escaped diagnosis in seven out of 24 cases. There is no established relation between the extent of dilatation of the common bile duct and hyperbilirubinemia; quite to the contrary, in three cases without any signs of arrest of bile excretion under chemical analysis, it was not until ultrasonography was performed that some initial indications of an impeded bile outflow due to concretions were discovered. It was possible to obtain a confirmed diagnosis in the case of two pancreas carcinomas, three bile duct carcinomas, a local recurrent carcinoma of the gall bladder and lymph node metastases of a gastric carcinoma in the hepaticoduodenal ligament. In another gall bladder carcinoma nothing but dilated bile ducts presented itself. What was thought to be a hepatoma, turned out to be a carcinoma of the bile duct during autopsy. A cirrhotic carcinoma of the common bile duct was considered to be a case of calculi in the common bile duct without shadow when examined with ultrasound. During their stay in the hospital, four patients passed gallstones, thus relieving distention of the duct. Additional tests were carried out in 16 patients (47%) in order to confirm the diagnosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1981

[Sonography for the demonstration of investigation of dilatation of the main pancreatic duct (author's transl)].

Amongst 284 sonographic examinations of the pancreas, dilatation of the main duct was found in nine instances. Six cases were due to chronic pancreatitis and three to tumour. In all the six cases due to chronic inflammation, the cause of the dilated duct could be demonstrated sonographically. Only one of the tumours was recognised. Simultaneous dilatation of the biliary tree was found in inflammatory and malignant lesions.

Adult↗