'Free' surfactant in gastric aspirates and bronchoalveolar lavage in children with and without reflux oesophagitis

Aim: Dipalmitoylphosphatidycholine (DPPC) is the characteristic and main constituent of surfactant. Adsorption of surfactant to epithelial surfaces may be important in the masking of receptors. The aims of the study were to (i) compare the quantity of free DPPC in the airways and gastric aspirates of children with gastroesophageal reflux disease (GORD) to those without and (ii) describe the association between free DPPC levels with airway cellular profile and capsaicin cough sensitivity. Methods: Children aged < 14 years were defined as 'coughers' if a history of cough in association with their GORD symptoms was elicited before gastric aspirates and nonbronchoscopic bronchoalveolar lavage (BAL) were obtained during elective flexible upper gastrointestinal endoscopy. GORD was defined as histological presence of reflux oesophagitis. Spirometry and capsaicin cough-sensitivity test was carried out in children aged > 6 years before the endoscopy. Results: Median age of the 68 children was 9 years (interquartile range (IQR) 7.2). Median DPPC level in BAL of children with cough (72.7 mu g/mL) was similar to noncoughers (88.5). There was also no significant difference in DPPC levels in both BAL and gastric aspirates of children classified according to presence of GORD. There was no correlation between DPPC levels and cellular counts or capsaicin cough-sensitivity outcome measures. Conclusion: We conclude that free DPPC levels in the airways and gastric aspirate is not influenced by presence of cough or GORD defined by histological presence of reflux oesophagitis. Whether quantification of adsorbed surfactant differs in these groups remain unknown. Free DPPC is unlikely to have a role in masking of airway receptors.

Oesophageal afferent pathway sensitivity in non-erosive reflux disease

Patients with non-erosive reflux disease (NERD) report symptoms which commonly fail to improve on conventional antireflux therapies. Oesophageal visceral hyperalgaesia may contribute to symptom generation in NERD and we explore this hypothesis using oesophageal evoked potentials. Fifteen endoscopically confirmed NERD patients (four female, 29–56 years) plus 15 matched healthy volunteers (four female, 23–56 years) were studied. All patients had oesophageal manometry/24-h pH monitoring and all subjects underwent evoked potential and sensory testing, using electrical stimulation of the distal oesophagus. Cumulatively, NERD patients had higher sensory thresholds and increased evoked potential latencies when compared to controls (P = 0.01). In NERD patients, there was a correlation between pain threshold and acid exposure as determined by DeMeester score (r = 0.63, P = 0.02), with increased oesophageal sensitivity being associated with lower DeMeester score. Reflux negative patients had lower pain thresholds when compared to both reflux positive patients and controls. Evoked potentials were normal in reflux negative patients but significantly delayed in the reflux positive group (P = 0.01). We demonstrate that NERD patients form a continuum of oesophageal afferent sensitivity with a correlation between the degree of acid exposure and oesophageal pain thresholds. We provide objective evidence that increased oesophageal pain sensitivity in reflux negative NERD is associated with heightened afferent sensitivity as normal latency evoked potential responses could be elicited with reduced afferent input. Increased oesophageal afferent pain sensitivity may play an important role in a subset of NERD and could offer an alternate therapeutic target.

Development of esophageal hypersensitivity following experimental duodenal acidification

OBJECTIVES: As visceral afferents from different regions of the gastrointestinal tract converge at the level of the spinal cord, we hypothesized that sensitization of one gut organ would induce visceral hypersensitivity in another gut organ, remote to the sensitizing stimulus. METHODS: Protocol 1: Eight healthy male volunteers, age 30 +/- 8.2 yr, underwent three studies on different days. Esophageal pain thresholds (PT) were recorded at 10-min intervals prior to and for 2 h following a 30-min duodenal infusion of either 0.15 M hydrochloric acid (HCl), saline, or no infusion. Five subjects repeated the study to demonstrate reproducibility. Protocol 2: Esophageal evoked potentials (EEP) were studied in six subjects on two occasions prior to and 1 h after a 30-min duodenal infusion of 0.15 M HCl or saline. RESULTS: Protocol 1: After acid infusion, there were reproducible reductions in esophageal PT (ICC = 0.88), which were maximal at 110 min (15.05 +/- 2.25 mA) (p < 0.002). Following saline infusion there was an increase in esophageal PT (ICC = 0.71), which was similar to the no-infusion condition (6.21 +/- 1.54 mA vs 8.5 + 7.6 mA; p > 0.05). Protocol 2: Esophageal sensation scores increased (p= 0.02) after acid, but not after saline infusion (p= 0.1). A comparison of the latencies of EEP components prior to and following acid and saline infusion revealed a reduction in the N1 (p= 0.02) and P2 components (p= 0.04). CONCLUSION: This study provides the first objective evidence that duodenal acidification can induce esophageal hypersensitivity associated with changes in sensitivity of the central visceral pain pathway. As the esophagus was remote from the sensitizing stimulus, central sensitization of spinal dorsal horn neurons is likely to have contributed to these changes.

Investigation of liquid sodium alginates as mucoadhesive bandages coating the oesophageal mucosa and protecting it from gastric reflux

Gastro-oesophageal Reflux Disease (GORD), is generally caused by excess gastric reflux back to the oesophagus where damage to the mucosa results in injury. GORD is a very common disease in western countries, more than a quarter of western people are suffering from this disease and there is a trend that the percentage population in eastern countries who are diagnosed as GORD is increasing. GORD and its complications damage the quality of life and can lead to serious oesophageal diseases including Barrett’s disease and oesophageal carcinoma. Sodium alginate dissolved in water forms a viscous liquid and can coat on oesophageal mucosa for a period of time. In this study the ability of the liquid alginate to adhere to the oesophageal mucosa was investigated and the factors that affect this retention were examined. The potential of this liquid alginate as a drug delivery vehicle to extend the duration of contact with the oesophageal mucosa was confirmed by this study. The capacity of an alginate coating to retard acid and pepsin diffusion, the two main aggressive factors in gastric reflux, was investigated. A significant reduction in acid and pepsin diffusion by alginate gel layer was demonstrated in this project, indicating that alginate has great potential to protect against damage caused by acidic reflux. A novel method was introduced using an independent score system to assess the protection of oesophageal tissue by a coating of liquid alginate using microscopy as a technique. This technique demonstrated that alginate can protect the oesophageal epithelial tissue from the damage caused by gastric acid and pepsin. Many techniques were used in this study. The experimental results suggested that liquid sodium alginate is a very promising candidate in treating local oesophageal diseases through forming a coating on the oesophageal mucosal surface, retarding the diffusion of components of gastric refluxate and thus reducing the contact of these noxious factors with the epithelium and minimising injury.

Vesicoureteral reflux and the extracellular matrix connection.

Primary vesicoureteral reflux (VUR) is a common pediatric condition due to a developmental defect in the ureterovesical junction. The prevalence of VUR among individuals with connective tissue disorders, as well as the importance of the ureter and bladder wall musculature for the anti-reflux mechanism, suggest that defects in the extracellular matrix (ECM) within the ureterovesical junction may result in VUR. This review will discuss the function of the smooth muscle and its supporting ECM microenvironment with respect to VUR, and explore the association of VUR with mutations in ECM-related genes.

Biodistribution of the Radiopharmaceutical Sodium Pertechnetate after Biliopancreatic Bypass with a Duodenal Switch

Study with the purpose to examine the effects of duodenal switch (DS), regularly performed in morbidly obese patients, on biodistribution of sodium pertechnetate in several organs of rats. There was no early or late mortality in either rats groups. The values of percent radioactivity per gram of tissue (%ATI/g), showed no significant difference in liver, stomach, small bowel, duodenum, kidney, heart, bladder, bone and brain, when compared the DS rats with sham and controls rats. A postoperative significant increase (p<0.05) in mean %ATI/g levels was observed in spleen, pancreas and muscle in group DS rats, as compared to group S and C rats. In the lung there was an increase and in thyroid a decrease in mean %ATI/g of DS rats, when compared to sham rats (p<0.05). In conclusion, the biliopancreatic diversion with duodenal switch in rats modified the biodistribution of sodium pertechnetate in thyroid, lung, pancreas, spleen and muscle

Duodenal carcinoma at ligament of Treitz. Case report and review of the literature

We report a case of adenocarcinoma of the duodenojejunal angle and remark the rarity of this pathology, the difficulty of diagnosis and treatment peculiar to tumours of the duodenum. Thise rare tumour ischaracterized by polymorphic and non specific symptomatology. The possible therapy is surgery. Radio and chemotherapy don't significantly improve survival

Duodenal tumors: four case reports

We report 4 cases of neuroendocrine tumors of the duodenum. Signs and symptoms were non-specific. The choice of surgery depended on the site and stage of the tumor and any concomitant diseases.

Delayed presentation of blunt duodenal injuries in children. Case report and review of literature

Background. Duodenal injuries are rare in children and classically present following a fall over the handle bar. Retroperitoneal location of the duodenum may lead to delay in diagnosis, and missed injuries are associated with increased morbidity and mortality. Case report. A 5-year-old child was admitted to the National Trauma Center, in Tirana (Albania), 28 hours after a Motor Vehicle Crash (MVC), complaining of mild abdominal pain. He was febrile (39°C) and had a white blood cells count of 18,000 mm3. On physical exam he had mild tenderness. Plain abdominal X-rays and Focused Abdominal Sonography for Trauma (FAST) were negative for free air or free fluid. The CT scan of the abdomen demonstrated free air and fluid in the retroperitoneal space. At laparatomy, a perforation of the second portion of the duodenum was found. A single layer suture repair of the duodenum with wide drainage was performed. The patient was discharged from the hospital tolerating oral feeding 8 days later. Conclusion. Duodenal injuries in children are rare. Most duodenal hematomas are managed non-operatively. This is a case of MCV with delayed presentation that was treated surgically for perforation successfully.

Biodistribution of the Radiopharmaceutical Sodium Pertechnetate after Biliopancreatic Bypass with a Duodenal Switch

Study with the purpose to examine the effects of duodenal switch (DS), regularly performed in morbidly obese patients, on biodistribution of sodium pertechnetate in several organs of rats. There was no early or late mortality in either rats groups. The values of percent radioactivity per gram of tissue (%ATI/g), showed no significant difference in liver, stomach, small bowel, duodenum, kidney, heart, bladder, bone and brain, when compared the DS rats with sham and controls rats. A postoperative significant increase (p<0.05) in mean %ATI/g levels was observed in spleen, pancreas and muscle in group DS rats, as compared to group S and C rats. In the lung there was an increase and in thyroid a decrease in mean %ATI/g of DS rats, when compared to sham rats (p<0.05). In conclusion, the biliopancreatic diversion with duodenal switch in rats modified the biodistribution of sodium pertechnetate in thyroid, lung, pancreas, spleen and muscle

Sensitivity and specificity of the Gastrointestinal Short Form Questionnaire in diagnosis of gastroesophageal reflux disease

Introduction: Gastrointestinal Short Form Questionnaire (GSFQ) is a questionnaire for gastroesophageal reflux disease (GERD) diagnosis, with a version in Spanish language, not yet compared to an objective test. Aims: To establish GSFQ diagnostic performance against 24-hour pH monitoring carried out in two tertiary care hospitals. Methods: Consecutive adult patients with typical GERD symptoms (heartburn, regurgitation) referred for pH monitoring fulfilled the GSFQ (score range 0-30, proportional to probability of GERD). Diagnosis of GERD was established when acid exposure time in distal esophagus was superior to 4.5% or symptom association probability was greater than 95%. Receiver-operator characteristic (ROC) curves were calculated and best cut-off score determined, with corresponding sensitivity, specificity and likelihood ratios (LR) (95% confidence interval for each). Results: One hundred and fifty-two patients were included (59.9% women, age 47.9 ± 13.9; 97.4% heartburn; 71.3% regurgitation). pH monitoring was abnormal in 65.8%. Mean GSFQ score was 11.2 ± 6. Area under ROC was 56.5% (47.0-65.9%). Optimal cut-off score was 13 or greater: sensitivity 40% (30.3-50.3%), specificity 71.2% (56.9-82.9%), positive LR 1.39 (0.85-2.26) and negative LR 0.84 (0.67-1.07). Exclusion of questions 1 and 3 of the original GSFQ, easily interpreted as referred to dyspepsia and not GERD, improved only marginally the diagnostic performance: AUROC 59.1%. Conclusion: The GSFQ does not predict results of pH monitoring in patients with typical symptoms in a tertiary care setting.