Esophageal and gastric biopsies in symptomatic children and adolescents. Should both be performed?

This study investigated the relationship among the histological diagnosis of esophagitis and gastritis in children and adolescents with gastroesophageal reflux disease (GERD) and/or dyspepsia. Records of 366 patients submitted to endoscopic biopsies were reviewed. Two groups were analyzed: G1 n=258 with esophageal and gastric biopsies, G2 n=108 with gastric biopsies only. For total subjects median age (range) was 8.5y (2mo-19.9y). Helicobacter pylori infection was detected in 30.6 %, median age 12.5y for H pylori-infected and 5.5y for uninfected children. Histological esophagitis was found in 216/258 (83.7 %) and gastritis in 95/258 (36.8 %) of G1. Both biopsies were normal for 13.6 % cases. Normal gastric biopsies were associated with esophagitis in 128/ 163 (78.5 %) of G1, but gastritis was associated with normal esophageal biopsies in only 7/95 (7.4 %) (0<.001). Histological gastritis was found in 80/108 (74.1 %) of G2 patients. Therefore, for symptomatic children both biopsies are indicated.

Avaliação dos danos do DNA na mucosa esofágica e sangue periférico de portadores da doença do refluxo gastroesofágico

RACIONAL: A doença do refluxo gastroesofágico é a afecção digestiva de maior prevalência. Os portadores podem apresentar na evolução algumas complicações, sendo o esôfago de Barrett a de maior importância, tendo em vista seu potencial de malignidade. Todavia os processos inflamatórios do trato gastrointestinal podem apresentar degeneração maligna. OBJETIVOS: Avaliar os possíveis danos do DNA em portadores de esofagite de refluxo gastroesofágico de vários graus e verificar a aplicação do ensaio Cometa na detecção dos mesmos. MÉTODOS: Foram estudados 25 pacientes distribuídos em quatro grupos: controle (n=5), esofagite leve (n=8), esofagite severa (n=5) e câncer (n=7). O ensaio Cometa foi realizado no sangue periférico (linfócitos) e biópsia do terço distal do esôfago. RESULTADOS: O ensaio Cometa detectou danos no DNA nos pacientes com esofagite leve e severa (sangue periférico e biópsia), sendo que na esofagite severa a intensidade dos danos foi maior (p<0,05). Os danos do DNA dos pacientes com esofagite severa e câncer não mostraram diferença significativa e a intensidade dos mesmos corresponde ao ensaio Cometa classe 4 (maior que 95% de danos). CONCLUSÕES: 1) As frequências de quebras do DNA da mucosa esofágica e linfócitos estão diretamente relacionadas ao grau de inflamação; 2) a esofagite severa apresenta praticamente a mesma frequência de danos no DNA do câncer esofágico; 3) o ensaio Cometa mostrou-se muito sensível para a detecção dos danos do DNA.

Esofagopatia chagásica complicada com esôfago de Barrett

Gastroesophageal reflux disease (GERD) is an uncommon condition in chagasic esophagopathy not previously treated. In this report, a case of chagasic esophagopathy associated to GERD and complicated with Barrett's esophagus is described. Potential pathophysiologic mechanisms underlying the condition are presented and commented.

Estudo das alterações funcionais respiratórias em pacientes dubmetidos à cirurgia videolaparoscópica de válvula anti-refluxo

Pós-graduação em Bases Gerais da Cirurgia - FMB

Influência da exposição à fumaça do cigarro e ao etanol sobre as alterações da mucosa do esôfago induzidas por dieta modificada em camundongos C57BL/6

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Avaliação dos parâmetros salivares de pacientes portadores da doença do refluxo gastroesofágico antes e após tratamento cirúrgico

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Severe distal cytomegalovirus esophagitis with aerodigestive symptoms in an immunocompetent infant

We report a case of an immunocompetent infant, with no evidence of neurological disorders, which developed clinical manifestation of recurrent crisis of choking, dysphagia, laryngeal stridor and sub costal retractions since the first day of life. Direct laryngoscopy was unremarkable. Upper gastrointestinal series showed a dilated tortuous esophagus with severe peristalsis impairment and reflux episodes till the proximal third of the esophagus. An upper gastrointestinal endoscopy showed a moderately dilated esophagus with erosive lesions in the distal esophagus. Esophageal biopsy specimens revealed CMV inclusion bodies associated to moderate inflammation and immunohistochemistry was positive for CMV early antigen. Prolonged 24 h esophageal pH metry was within normal limits. Antiviral therapy with intravenous ganciclovir was introduced and was associated with rapid improvement of the symptoms. Child gradually increased oral intake and weight gain, and there were no side effects related to therapy. Thus, the respiratory symptoms could have been a supra esophageal manifestation of a non-acid reflux disease related to the CMV esophagitis.

Respiratory physiotherapy can increase lower esophageal sphincter pressure in GERD patients

Background: Inspiratory muscle training (IMT) has been shown to increase diaphragm thickness. We evaluated the effect of IMT on mid-respiratory pressure (MRP) in patients with gastroesophageal reflux disease (GERD) and hypotensive lower esophageal sphincter (LES), and compared the results with a sham group. Methods: Twenty consecutive patients (progressive loading group) and 9 controls (sham group) were included. All patients had end expiratory pressure (EEP) between 5 and 10 mmHg, underwent esophageal manometry and pulmonary function tests before and after 8 weeks of training, and used a threshold IMT twice daily. The threshold IMT was set at 30% of the maximal inspiratory pressure for the progressive loading group; while, the threshold for sham-treated patients was set at 7 cmH(2)O for the whole period. Results: There was an increase in MRP in 15 (75%) patients in the progressive loading group, with an average gain of 46.6% (p<0.01), and in six (66%) patients in the sham group with a mean increase of 26.2% (p<0.01). However, there was no significant difference between the groups (p = 0.507). The EEP also increased compared with measurements before training (p<0.01), but it did not differ between groups (p = 0.727). Conclusion: IMT increased LES pressure in patients with GERD, in both the treatment and sham groups, after an eight-week program. Although there was no statistically significant difference between groups, suggesting the pressure increase in LES occurs regardless of the resistance load of the threshold IMT. These findings need to be confirmed in further studies with a larger sample. Registration number: 0922/09. (C) 2012 Elsevier Ltd. All rights reserved.

Analisi proteomica dei meccanismi sottesi alla malatia da reflusso gastroesofageo

La malattia da reflusso gastroesofageo (GERD) si divide in due categorie: malattia non erosiva (NERD) ed erosiva (ERD). Questi due fenotipi di GERD mostrano caratteristiche patofisiologiche e cliniche differenti. NERD è la forma più comune. Anche se ERD e NERD sono difficili da distinguere a livello clinico, la forma NERD possiede caratteristiche fisiologiche, patofisiologiche, anatomiche, e istologiche uniche. La replicazione cellulare dello strato basale si pensa sia una delle cause implicate nella resistenza della mucosa e nella difesa strutturale dell’epitelio. Diversi studi hanno dimostrato che la proliferazione cellulare è ridotta nella mucosa esofagea esposta ad insulti acidi e peptici cronici, in pazienti GERD, in più uno studio recente ha dimostrato che il recettore per i cannabinoidi CB1 era implicato nella riparazione delle ferite nella mucosa del colon. Sulla base di questi dati abbiamo valutato la presenza del recettore CB1 in biopsie della mucosa esofagea, di pazienti ERD, NERD e di controlli sani, tramite analisi Western Blot, Immunoistochimica e Real-Time PCR, dimostrando per la prima volta la presenza di questo recettore nell’epitelio dell’esofago e una riduzione dei suoi livelli di espressione nei pazienti ERD, camparati con i NERD e con i controlli sani. Successivamente, per chiarire meglio i meccanismi molecolari che caratterizzano ERD e NERD, abbiamo effettuato un analisi proteomica con la tecnica shotgun, la quale ha evidenziato un patter proteico di 33 proteine differenzialmente espresse in pazienti NERD vs ERD, sette delle quali confermate in wester Blot, e quattro in immunoistochimica. Concludendo i nostri risultati hanno confermato che ERD e NERD sono due entità distinte a livello proteico, e hanno proposto dei candidati biomarker per la diagnosi differenziale di ERD e NERD.

Obesity and GERD: pathophysiology and effect of bariatric surgery

Epidemiologic, endoscopic, and pathophysiologic studies document the relationship between obesity and gastroesophageal reflux disease (GERD). Increased body mass index and accumulation of visceral fat are associated with a two- to threefold increased risk of developing reflux symptoms and esophageal lesions. Given this association, many studies were designed to evaluate the outcome of reflux symptoms following conventional and surgical treatment of obesity. Among bariatric procedures, gastric sleeve and banded gastroplasty were shown to have no effect or even worsen reflux symptoms in the postoperative setting. Gastric banding improves reflux symptoms and findings (endoscopic and pH-measured distal esophageal acid exposure) in many patients, but is associated with de novo reflux symptoms or lesions in a considerable proportion of patients. To date, Roux-en-Y gastric bypass is the most effective bariatric procedure that consistently leads to weight reduction and improvement of GERD symptoms in patients undergoing direct gastric bypass and among those converted from restrictive bariatric procedures to gastric bypass.

Is dental erosion really a problem?

Dental erosion is the non-carious dental substance loss induced by direct impact of exogenous or endogenous acids. It results in a loss of dental hard tissue, which can be serious in some groups, such as those with eating disorders, in patients with gastroesophageal reflux disease, and also in persons consuming high amounts of acidic drinks and foodstuffs. For these persons, erosion can impair their well-being, due to changes in appearance and/or loss of function of the teeth, e.g., the occurrence of hypersensitivity of teeth if the dentin is exposed. If erosion reaches an advanced stage, time- and money-consuming therapies may be necessary. The therapy, in turn, poses a challenge for the dentist, particularly if the defects are diagnosed at an advanced stage. While initial and moderate defects can mostly be treated non- or minimally invasively, severe defects often require complex therapeutic strategies, which often entail extensive loss of dental hard tissue due to preparatory measures. A major goal should therefore be to diagnose dental erosion at an early stage, to avoid functional and esthetic impairments as well as pain sensations and to ensure longevity of the dentition.

Pediatric and adult eosinophilic esophagitis: similarities and differences

Early in the 1990s, several case series described adults suffering from dysphagia and children with refractory reflux symptoms, both accompanied by an eosinophil-predominant infiltration, thereby conclusively distinguishing it from gastroesophageal reflux disease. Eosinophilic esophagitis (EoE) was recognized as its own entity in the adult and in the pediatric literature. In the last decade, evidence has accumulated that EoE represents a T-helper (Th)2-type inflammatory disease. Remodeling of the esophagus is a hallmark of EoE, leading to esophageal dysfunction and bolus impaction. Familial occurrence and disease association with single-nucleotide polymorphisms underscore the influence of genetics in this disease. Eosinophilic esophagitis may affect individuals at any age, although the clinical presentation is highly age dependent. There is a significant allergic bias in the EoE population, with the majority of patients having concurrent allergic rhinitis, asthma, eczema, and/or a history of atopy. One noteworthy difference is that in children, EoE seems to be primarily a food antigen-driven disease, whereas in adults, mainly aeroallergen sensitization has been observed. Treatment modalities for EoE include the 3Ds: drugs, diet, and dilation. The crucial question of whether adult and pediatric EoE are different phenotypes of one single entity or whether we are confronted with two different diseases is still open. Here, we review similarities and differences between EoE in adults and children.

Dental erosion in children

Erosive tooth wear in children is a common condition. The overlapping of erosion with mechanical forces like attrition or abrasion is probably in deciduous teeth more pronounced than in permanent teeth. Early erosive damage to the permanent teeth may compromise the dentition for the entire lifetime and require extensive restorative procedures. Therefore, early diagnosis of the condition and adequate preventive measures are of importance. Knowledge of the etiological factors for erosive tooth wear is a prerequisite for such measures. In children and adolescents (like in adults) extrinsic and intrinsic factors or a combination of them are possible reasons for the condition. Such factors are frequent and extensive consumption of erosive foodstuffs and drinks, the intake of medicaments (asthma), gastro-esophageal reflux (a case history is discussed) or vomiting. But also behavioral factors like unusual eating and drinking habits, the consumption of designer drugs and socio-economic aspects are of importance.

Quantification of dental erosions in patients with GERD using optical coherence tomography before and after double-blind, randomized treatment with esomeprazole or placebo

OBJECTIVES: Dental erosion, the chemical dissolution of enamel without bacterial involvement, is a rarely reported manifestation of gastroesophageal reflux disease (GERD), as well as of recurrent vomiting and dietary habits. It leads to loss of tooth substance, hypersensitivity, functional impairment, and even tooth fracture. To date, dental erosions have been assessed using only very basic visual methods, and no evidence-based guidelines or studies exist regarding the prevention or treatment of GERD-related dental erosions. METHODS: In this randomized, double-blind study, we used optical coherence tomography (OCT) to quantify dental tissue demineralization and enamel loss before and after 3 weeks of acid-suppressive treatment with esomeprazole 20 mg b.i.d. or placebo in 30 patients presenting to the Berne University Dental Clinic with advanced dental erosions and abnormal acid exposure by 24-h esophageal pH manometry (defined as >4% of the 24-h period with pH<4). Enamel thickness, reflectivity, and absorbance as measures of demineralization were quantified by OCT before and after therapy at identical localizations on teeth with most severe visible erosions as well as several other predefined changes in teeth. RESULTS: The mean+/-s.e.m. decrease of enamel thickness of all teeth before and after treatment at the site of maximum exposure was 7.2+/-0.16 black trianglem with esomeprazole and 15.25+/-0.17black trianglem with placebo (P=0.013), representing a loss of 0.3% and 0.8% of the total enamel thickness, respectively. The change in optical reflectivity to a depth of 25 black trianglem after treatment was-1.122 +/-0.769 dB with esomeprazole and +2.059+/-0.534 dB with placebo (P 0.012), with increased reflectivity signifying demineralization. CONCLUSIONS: OCT non-invasively detected and quantified significantly diminished progression of dental tissue demineralization and enamel loss after only 3 weeks of treatment with esomeprazole 20 mg b.i.d. vs. placebo. This suggests that esomeprazole may be useful in counteracting progression of GERD-related dental erosions. Further validation of preventative treatment regimens using this sensitive detection method is required, including longer follow-up and correlation with quantitative reflux measures.

Case-control analysis on metformin and cancer of the esophagus

PURPOSE Metformin use has been associated with decreased cancer risks, though data on esophageal cancer are scarce. We explored the relation between use of metformin or other anti-diabetic drugs and the risk of esophageal cancer. METHODS We conducted a case-control analysis in the UK-based general practice research database (GPRD, now clinical practice research datalink, CPRD). Cases were individuals with an incident diagnosis of esophageal cancer between 1994 and 2010 at age 40-89 years. Ten controls per case were matched on age, sex, calendar time, general practice, and number of years of active history in the GPRD prior to the index date. Various potential confounders including diabetes mellitus, gastro-esophageal reflux, and use of proton-pump inhibitors were evaluated in univariate models, and the final results were adjusted for BMI and smoking. Results are presented as odds ratios (ORs) with 95 % confidence intervals (CI). RESULTS Long-term use (≥30 prescriptions) of metformin was not associated with a materially altered risk of esophageal cancer (adj. OR 1.23, 95 % CI 0.92-1.65), nor was long-term use of sulfonylureas (adj. OR 0.93, 95 % CI 0.70-1.23), insulin (adj. OR 0.87, 95 % CI 0.60-1.25), or of thiazolidinediones (adj. OR 0.71, 95 % CI 0.37-1.36). CONCLUSION In our population-based study, use of metformin was not associated with an altered risk of esophageal cancer.