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Pre-operative evaluation of biliary strictures remains challenging. The dilemma that exists is how to balance the risk of failing to detect malignancy and the potential morbidity caused by unnecessary surgery in patients with benign etiologies. With emerging novel diagnostic modalities, this study aims to assess the efficacy of diagnostic techniques and facilitate a clinical approach to indeterminate biliary strictures. Areas covered: Conventional imaging modalities are crucial in identifying the location of a stricture and are helpful for choosing further diagnostic modalities. Utilization of endoscopic techniques, including endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS), is key in establishing a diagnosis. The emergence of novel diagnostic modalities, such as fluorescence in-situ hybridization (FISH), peroral cholangioscopy (POC), intraductal endoscopic ultrasound (IDUS) and confocal laser endomicroscopy (CLE), enhance the diagnostic yield in the evaluation of indeterminate biliary strictures. Expert commentary: More reliable and validated visual criteria for differentiating malignancy from benign biliary conditions, utilizing advanced imaging modalities such as POC and CLE, need to be established. It is of significance to further evaluate these novel diagnostic modalities through ongoing trials and to develop a diagnostic algorithm that reconciles cost-effectiveness with diagnostic accuracy.

Prevalence of chronic gastritis has markedly declined in developed populations during the past decades. However, chronic gastritis is still one of the most common serious pandemic infections with such severe killing sequelae as peptic ulcer or gastric cancer. Globally, on average, even more than half of people may have a chronic gastritis at present. Helicobacter pylori infection in childhood is the main cause of chronic gastritis, which microbial origin is the key for the understanding of the bizarre epidemiology and course of the disease. A life-long and aggressive inflammation in gastritis results in destruction (atrophic gastritis) of stomach mucosa with time (years and decades). The progressive worsening of atrophic gastritis results subsequently in dysfunctions of stomach mucosa. Atrophic gastritis will finally end up in a permanently acid-free stomach in the most extreme cases. Severe atrophic gastritis and acid-free stomach are the highest independent risk conditions for gastric cancer known so far. In addition to the risks of malignancy and peptic ulcer, acid-free stomach and severe forms of atrophic gastritis may associate with failures in absorption of essential vitamins, like vitamin B12, micronutrients (like iron, calcium, magnesium and zinc), diet and medicines.

Dysphagia is a common, serious health problem with a wide variety of etiologies and manifestations. This review gives a general overview of diagnostic and therapeutic options for oropharyngeal as well as esophageal swallowing disorders respecting the considerable progress made over recent years. Diagnosis can be challenging and requires expertise in interpretation of symptoms and patient history. Endoscopy, barium radiography and manometry are still the diagnostic mainstays. Classification of esophageal motor-disorders has been revolutionized with the introduction of high-resolution esophageal pressure topography and a new standardized classification algorithm. Automated integrated impedance manometry is a promising upcoming tool for objective evaluation of oropharyngeal dysphagia, in non-obstructive esophageal dysphagia and prediction of post fundoplication dysphagia risk. Impedance planimetry provides new diagnostic information on esophageal and LES-distensibility and allows controlled therapeutic dilatation without the need for radiation. Peroral endoscopic myotomy is a promising therapeutic approach for achalasia and spastic motility disorders.

There continues to be significant controversy related to diagnostic testing for gastroesophageal reflux disease (GERD). Symptoms of GERD may be associated with physiologic esophageal acid exposure measured by intraesophageal pH monitoring or pH-impedance monitoring, and a significant percentage of patients with abnormal esophageal acid (or weak acid) exposure have no or minimal clinical symptoms of reflux. On the other hand, endoscopic lesions are only present in a minority of GERD patients. In clinical practice, presumptive diagnosis of GERD is reasonably assumed by the substantial reduction or elimination of suspected reflux symptoms during the therapeutic trial of acid reduction therapy, the so-called proton pump inhibitor (PPI) test. We aimed to assess the optimal cutoff value and duration of this test in GERD patients with and without esophagitis. We conducted a prospective study of 544 patients, endoscopically investigated and treated for 2 weeks with PPIs at double dose, and for an additional 3 months at standard dose. The status of the patient at the end of the study was used as an independent diagnostic standard. We found esophagitis present in 55.8% and absent in 44.2% of patients (corresponding to a diagnosis of nonerosive reflux disease [NERD]). The test was positive in 89.7-97.8% of the patients according to the cutoff or duration of the test used. The sensitivity of the PPI test was excellent, ranging from 95.5 to 98.8%, whereas the specificity was poor, not exceeding 36.3%. Erosive esophagitis patients responded more favorably to the PPI test and subsequent PPI therapy compared with NERD patients. In conclusion, the PPI test is a sensitive but less specific test. Its optimal duration is 1 week, and the optimal cutoff value is a decrease of heartburn score of more than 75%. NERD patients respond less satisfactorily to PPIs, even when functional heartburn patients are excluded and only 'true' NERD patients are considered.

In order to measure the important physiological parameters such as temperature, pressure and pH value, we developed a miniature, high precision, non-invasive and multi-sensor radiotelemetry system. The system comprises multi-sensor radiotelemetry capsule, data logger, location device and workstation. The radiotelemetry capsule can monitor the pH, pressure and temperature of the entire intestinal tract and send the data to the data logger outside the body through a wireless communication link. After the capsule is egested from the anus, further analysis of the physiological parameter data saved in the data logger can be performed via the special software installed at the workstation. Clinical experiments prove that the radiotelemetry system is non-invasive and reliable. Moreover it is found that the radiotelemetry system is an effective method to study intestine motility characteristics.

The clinical functional evaluation is the usual method for dysphagia screening in patients with acute stroke. This study compared two methods of evaluation--with liquid and semisolid viscosities.Twenty-six patients with stroke onset within 7 days--with a mean age of 63.5 +/- 12.4 years--were prospectively evaluated for deficit severity, swallowing mechanisms, chest X-ray studies, and late (30 days after discharge) assessment of disability with the modified Rankin Scale.Tests using water and pudding correlated poorly (p.001). The water test exhibited higher sensitivity for detection of problems in laryngeal protection, and the test with pudding was more sensitive for the functional analysis of dysphagia itself. Abnormalities in the water test were associated with weak spontaneous cough, while a normal pudding test correlated well with oral feeding 30 days after hospital discharge. The initial neurological severity correlated with results from both tests. No patient had pulmonary infiltrates 72 hours after testing or pneumonia up to 30 days after hospital discharge.The two evaluation methods should be used to both decrease the risk of aspiration and increase the likelihood of a safe and early reintroduction of oral feeding.

In a prospective study to outline the aetiology of bleeding per rectum (BPR) in Egyptian infants and children, a subsidiary aim was to define some of the clinical characteristics of the different aetiologies.194 children with BPR are described. The diagnostic work-up included laboratory investigations, radiological and endoscopic assessment, radio-isotope scanning, angiography and histopathological examination of mucosal biopsies, as appropriate.Ages ranged from 3 to 192 months with a mean (SD) of 49.8 (43.5). Infectious enterocolitis was the most common cause (37.1%). Others included colorectal polyps (21.1%), chronic colitis (16%) including inflammatory bowel diseases (5.2%), allergic colitis (2.6%), solitary rectal ulcer syndrome (1.5%) and non-specific colitis (6.7%). Intussusception and Meckel's diverticulae were the cause in 7.3% and 2.6%, respectively, while other aetiologies included vascular (6.2%), systemic (3.6%), local anal (3.1%) and upper gastro-intestinal causes (1.5%). In 1.5% of cases, the cause remained 'obscure'.In Egyptian children, infectious enterocolitis followed by colorectal polyps and chronic colitis are major causes of BPR.

Owing to lack of objective measures, the diagnosis of food hypersensitivity may be difficult. The aim of this study was to investigate whether the intestinal response to direct provocation in patients with food hypersensitivity could be recognized by ultrasound.Thirty-two patients with chronic abdominal complaints, self-attributed to food hypersensitivity/allergy were included in the study. Via a nasoduodenal tube, the duodenal mucosa was challenged with the suspected food item dissolved in 10 ml water or saline. Using external ultrasound, the sonographic features (wall thickness and diameter of the duodenal bulb and jejunum, peristalsis activity and luminal fluid) were recorded before and during one hour after challenge.Sonographic changes were observed after challenge in 14 (44%) of the 32 patients. A positive sonographic response (increased wall thickness, diameter, peristalsis and/or luminal fluid) was significantly related to a positive skin prick test (p = 0.008) and a positive double-blind placebo-controlled food challenge (p = 0.03). A significant correlation was found between provocation-induced symptoms and wall thickness of the duodenal bulb (r = 0.50, p = 0.004) or the jejunum (r = 0.42, p = 0.02). Intra- and interobserver variation of the tracing procedure showed low values.Responses of the proximal small intestines to direct provocation (swelling of the wall and exudation of fluid into the lumen) could be visualized by transabdominal ultrasound. This new provocation test could be helpful in the evaluation of patients with food hypersensitivity.

Faecal incontinence is a complex problem, often of multifactorial origin. Although the condition is widely accepted as a problem in the elderly, it is now becoming apparent that much younger age groups are frequently affected. Its exact incidence is about 2% of the general population, while in other individuals, the prevalence has been reported to approach 60%. Despite the considerable advances that have been made the past decades in the evaluation of anorectal incontinence, our understanding of it remains limited. A thorough history, good physical examination, and detailed anorectal physiological investigations can help the therapeutic decision-making algorithm. Complete functional and anatomical assessments of the anorectum, anal sphincters, and pelvic floor are mandatory in all patients with faecal incontinence to correctly identify the cause and type of incontinence and allow correct treatment. Anorectal manometry is used to establish the presence and extent of the weakness degree of the pelvic floor sphincter muscles, allowing an objective measure of resting and squeeze pressure. Anal endosonography is a very valuable tool in planning restorative surgery or in assessing results after sphincter repair. Because electromyography may detect functional abnormalities, the two techniques are complementary and not mutually exclusive. Determining the most appropriate tests will largely depend on the patient's history and symptoms and can vary for each patient.

It is unknown whether short-term regular or high-dose omeprazole has any influence on the colonization of Helicobacter pylori in the stomach. We therefore studied the effect of 3-day treatment of 2 different doses of omeprazole.H. pylori-positive patients with peptic ulcer bleeding (n = 101) were randomized to receive either a regular dose (20 mg/day for 3 days) (n = 51) or a high dose of omeprazole (80 mg bolus + 8 mg/h infusion/day for 3 days) (n = 50). H. pylori status was assessed by histology and urease testing of gastric biopsies pre-entry and after 3-day therapy.With the high dose of omeprazole, tests for the diagnosis of H. pylori became negative significantly more often than with the regular dose (60% versus 27.5%, P=0.001 (any test), 67.6% versus 31.7%, P=0.003 (histology) and 82.2% versus 43.6%, P=0.001 (urease test)).Conversion of the H. pylori tests negative after 3-day treatment of omeprazole is dose-dependent. The diagnosis of H. pylori infection depends on the timing of biopsies in relation to the beginning of proton-pump inhibitor treatment. If samples to find H. pylori are not taken before the treatment, the presence of the bacteria may be overlooked.