Unsedated transnasal small-caliber esophagogastroduoden oscopy in elderly and bedridden patients

AIM:To evaluate the safety of unsedated transnasal small-caliber esophagogastroduodenoscopy(EGD)for elderly and critically ill bedridden patients. METHODS:One prospective randomized comparative study and one crossover comparative study between transnasal small-caliber EGD and transoral conventional EGD was done(Study 1).For the comparative study, we enrolled 240 elderly patients aged>65 years old. For the crossover analysis,we enrolled 30 bedridden patients with percutaneous endoscopic gastrostomy (PEG)(Study 2).We evaluated cardiopulmonary effects by measuring arterial oxygen saturation(SpO2)and calculating the rate-pressure product(RPP)(pulse rate×systolic blood pressure/100)at baseline,2 and 5 min after endoscopic intubation in Study 1.To assess the risk for endoscopy-related aspiration pneumoniaduring EGD,we also measured blood leukocyte counts and serum C-reactive protein(CRP)levels before and 3 d after EGD in Study 2. RESULTS:In Study 1,we observed significant decreases in SpO2 during conventional transoral EGD, but not during transnasal small-caliber EGD(0.24%vs -0.24%after 2 min,and 0.18%vs-0.29%after 5 min, P=0.034,P=0.044).Significant differences of the RPP were not found between conventional transoral and transnasal small-caliber EGD.In Study 2,crossover analysis showed statistically significant increases of the RPP at 2 min after intubation and the end of endoscopy (26.8 and 34.6 vs 3.1 and 15.2,P=0.044,P=0.046), and decreases of SpO2(-0.8%vs-0.1%,P=0.042) during EGD with transoral conventional in comparison with transnasal small-caliber endoscopy.Thus,for bedridden patients with PEG feeding,who were examined in the supine position,transoral conventional EGD more severely suppressed cardiopulmonary function than transnasal small-caliber EGD.There were also significant increases in the markers of inflammation, blood leukocyte counts and serum CRP values,in bedridden patients after transoral conventional EGD,but not after transnasal small-caliber EGD performed with the patient in the supine position.Leukocyte count increased from 6053±1975/L to 6900±3392/L(P=0.0008)and CRP values increased from 0.93±0.24 to 2.49±0.91 mg/dL(P=0.0005)at 3 d after transoral conventional EGD.Aspiration pneumonia,possibly caused by the endoscopic examination,was found subsequently in two of 30 patients after transoral conventional EGD. CONCLUSION:Transnasal small-caliber EGD is a safer method than transoral conventional EGD in critically ill, bedridden patients who are undergoing PEG feeding.

Effects of anti-hypertensive drugs on esophageal body contraction

AIM:To clarify the effects of anti-hypertensive drugs on esophageal contraction and determine their possi-ble relationship with gastro-esophageal reflux disease.METHODS:Thirteen healthy male volunteers were enrolled. Esophageal body peristaltic contractions and lower esophageal sphincter (LES) pressure were measured using high resolution manometry. All subjects were randomly examined on four separate occasions following administrations of nifedipine,losartan,and atenolol,as well as without any drug administration.RESULTS:Peristaltic contractions by the esophageal body were separated into three segments by two troughs. The peak peristaltic pressures in the mid and lower segments of the esophageal body under atenolol administration were signifi cantly higher than those without medication in a supine position. On the other hand,peristaltic pressures under nifedipine administration were lower than those observed without drug ad-ministration. Losartan did not change esophageal body peristalsis. Atenolol elevated LES pressure and slowed peristaltic wave transition,while the effects of nifedip-ine were the opposite. CONCLUSION:Among the anti-hypertensive drugs tested,atenolol enhanced esophageal motor activity,which was in contrast to nifedipine.

Systematic review:Eosinophilic esophagitis in Asian countries

AIM: to investigate the prevalence and the clinical characteristics of Asian patients with eosinophilic esophagitis.METHODS: We conducted a systematic search of the Pub Med and Web of Science databases for original studies, case series, and individual case reports of eosinophilic esophagitis in Asian countries published from January 1980 to January 2015. We found 66 and 80 articles in the Pub Med and Web of Science databases, respectively; 24 duplicate articles were removed. After excluding animal studies, articles not written in English, and meeting abstracts, 25 articles containing 217 patients were selected for analysis.RESULTS: Sample size-weighted mean values were determined for all pooled prevalence data and clinical characteristics. The mean age of the adult patients with eosinophilic esophagitis was approximately 50 years, and 73% of these patients were male. They frequently presented with allergic diseases including bronchial asthma, allergic rhinitis, food allergy, and atopic dermatitis. Bronchial asthma was the most frequent comorbid allergic disease, occurring in 24% of patients with eosinophilic esophagitis. Dysphagia was the primary symptom reported; 44% of the patients complained of dysphagia. Although laboratory blood tests are not adequately sensitive for an accurate diagnosis of eosinophilic esophagitis, endoscopic examinations revealed abnormal findings typical of this disease, including longitudinal furrows and concentric rings, in 82% of the cases. One-third of the cases responded to proton pump inhibitor administration.CONCLUSION: The characteristics of eosinophilicesophagitis in Asian patients were similar to those reported in Western patients, indicating that this disease displays a similar pathogenesis between Western and Asian patients.

Randomized study of lafutidine vs lansoprazole in patients with mild gastroesophageal reflux disease

AIM: To compare the clinical efficacy of the secondgeneration H2 RA lafutidine with that of lansoprazole in Japanese patients with mild gastroesophageal reflux disease(GERD). METHODS: Patients with symptoms of GERD and a diagnosis of grade A reflux esophagitis(according to the Los Angeles classification) were randomized to receive lafutidine(10 mg, twice daily) or lansoprazole(30 mg, once daily) for an initial 8 wk, followed by maintenance treatment comprising half-doses of the assigned drug for 24 wk. The primary endpoint was the frequency and severity of heartburn during initial and maintenance treatment. The secondary endpoints were the sum score of questions 2 and 3 in the Gastrointestinal Symptom Rating Scale(GSRS), and the satisfaction score.RESULTS: Between April 2012 and March 2013, a total of 53 patients were enrolled, of whom 24 and 29 received lafutidine and lansoprazole, respectively. After 8 wk, the frequency and severity of heartburn was significantly reduced in both groups. However, lafutidine was significantly inferior to lansoprazole with regard to the severity of heartburn during initial and maintenance treatment(P = 0.016). The sum score of questions 2 and 3 in the GSRS, and satisfaction scores were also significantly worse in the lafutidine group than the lansoprazole group(P = 0.0068 and P = 0.0048, respectively).CONCLUSION: The clinical efficacy of lafutidine was inferior to that of lansoprazole, even in Japanese patients with mild GERD.

Esophageal epithelial surface in patients with gastroesophageal reflux disease:An electron microscopic study

AIM: To investigate the intercellular spaces between the most superficially located esophageal epithelial cells in patients with gastroesophageal reflux disease (GERD). METHODS: Eighteen patients with erosive esophagitis, 10 patients with non-erosive reflux disease (NERD), and 18 normal asymptomatic volunteers were enrolled. Biopsy specimens were obtained from the lower esophageal mucosa without ulcer or erosion. Scanning electron microscopy was employed to investigate the tightness of the superficial cellular attachment. RESULTS: The intercellular space between the most superficially located epithelial cells in patients with erosive esophagitis or NERD was not different from that in asymptomatic healthy individuals. CONCLUSION: Widened luminal intercellular spaces of esophageal superficial epithelium are not responsible for the induction of reflux symptoms in patients with GERD.

A dose-up of ursodeoxycholic acid decreases transaminases in hepatitis C patients

AIM:To examine whether a dose-up to 900 mg of ursodeoxycholic acid(UDCA) decreases transaminases in hepatitis C patients.METHODS:From January to December 2007,patients with chronic hepatitis C or compensated liver cirrhosis with hepatitis C virus(HCV)(43-80 years old) showing positive serum HCV-RNA who had already taken 600 mg/d of UDCA were recruited into this study.Blood parameters were examined at 4,8 and 24 wk after increasing the dose of oral UDCA from 600 to 900 mg/d.RESULTS:Serum alanine aminotransferase(ALT),aspartate aminotransferase(AST),and gamma-glutamyl transpeptidase(GGT) levels were signifi cantly decreased following the administration of 900 mg/d as compared to 600 mg/d.The decrease in ALT from immediately before the dose-up of UDCA to 8 wk after the dose-up was 14.3 IU/L,while that for AST was 10.5 IU/L and for GGT was 9.8 IU/L.Platelet count tended to increase after the dose-up of UDCA,although it did not show a statistically signifi cant level(P=0.05).Minor adverse events were observed in 3 cases,although no drop-outs from the study occurred.CONCLUSION:Oral administration of 900 mg/d of UDCA was more effective than 600 mg/d for reducing ALT,AST,and GGT levels in patients with HCV-related chronic liver disease.