Search

Acute pancreatitis has a high mortality in case of secondary infection of (peri-)pancreatic necrosis. Bacterial translocation is held responsible for the majority of these infectious complications of severe acute pancreatitis. Prophylactic strategies should therefore be directed at the three most important pathophysiological mechanisms of bacterial translocation: disturbed small-bowel motility and bacterial overgrowth, failure of the mucosal barrier function and a disturbed response of the immune system. In-vitro studies and research in experimental animals have shown that specially selected probiotics exert an effect on these mechanisms and can prevent bacterial translocation. Recently, several randomised, double-blind, placebo-controlled trials evaluating prophylactic treatment with enteral probiotics have shown good results. A Dutch multicentre trial, 'Probiotics in pancreatitis trial' (PROPATRIA), is currently underway

The role of interdigestive gallbladder emptying in gallstone formation is unknown. In fasting healthy subjects, gallbladder emptying is associated with antral phase III of the migrating motor complex (MMC) and high plasma motilin. Therefore, gallbladder volumes and motilin levels were measured during 13 MMC cycles in 10 cholesterol gallstone patients and compared with 20 MMC cycles in 10 healthy subjects. MMC cycle length was longer in gallstone patients than in healthy subjects (158.2 +/- 17.0 vs 105.5 +/- 10.4 min, respectively; P < 0.05), due to longer phase I (39.8 +/- 5.7 vs 17.2 +/- 3.7 min, respectively; P < 0.05). In contrast to healthy subjects, gallstone patients had no significant fluctuations of gallbladder volume during the MMC cycle, and motilin concentrations were not different in MMC cycles with phase III originating in antrum or duodenum. During MMC cycles with phase III originating in the duodenum, motilin levels were twice as high in gallstone patients as in healthy subjects (P < 0.002). In conclusion, cholesterol gallstone patients have an abnormal MMC and motilin release pattern. Their interdigestive gallbladder emptying is reduced and dissociated from the MMC. These disturbances may contribute to gallstone formation

Dysphagia and chest pain are the two commonest symptoms of abnormalities of oesophageal motility. Dysphagia is to be distinguished into high or oropharyngeal and low or oesophageal dysphagia. Oropharyngeal dysphagia pertains to dysfunction of the pars cricopharyngea of the M. constrictor pharyngis inferior (M. cricopharyngeus), which is frequently associated with a Zenker diverticulum. Treatment consists of endoscopical or surgical myotomy and diverticulectomy. In achalasia there is incomplete relaxation of the lower esophageal sphincter with aperistalsis. The main treatment modalities are endoscopic pneumodilation and surgical myotomy of this sphincter. In dysphagia or non-cardiac chest pain spastic or hypocontractile abnormalities of the oesophageal motility can be involved, these are often difficult to treat. Disorders of gastric motility are mainly gastroparesis and functional dyspepsia. In diabetic gastroparesis, adequate monitoring of the blood sugar level is also necessary. New insights into the pathophysiology of functional dyspepsia concern abnormal visceral sensitivity and reduced adaptive relaxation of the stomach during intake of food

Inhibitory nitrergic neurons are known to play a role in the regulation of motility patterns of the distal esophagus, the lower esophageal sphincter (LES), and the gallbladder. Our study aim was to investigate the effects of "long-term" (i.e., prolonged) oral intake of L-arginine (L-Arg), the endogenous source for nitric oxide (NO) synthesis, on postprandial LES pressure (LESP), esophageal motility, gastroesophageal reflux, and gallbladder motility. L-Arg (30 g/day) or glycine (placebo; 13 g/day; isosmolar) was given orally to 10 healthy male volunteers for 8 days, according to a randomized, crossover design. Twenty-four-hour urinary nitrite/nitrate excretion was measured to indicate NO synthesis. Basal early postprandial LESP was lower after L-Arg ingestion (2.2 kPa) than after glycine ingestion (2.7 kPa) (P < 0.05). L-Arg abolished the physiological late postprandial rise in LESP. Transient LES relaxations were longer lasting after L-Arg ingestion (P < 0.02). Esophageal motility and reflux were not affected (not significant). Fasting and residual gallbladder volumes were greater after L-Arg ingestion (P < 0.05). Urinary nitrite/nitrate excretion was higher after L-Arg intake (P < 0.05). In conclusion, long-term oral L-Arg suppresses late postprandial LESP increase, prolongs transient LES relaxations, and increases fasting and residual gallbladder volumes. These effects may be mediated by increased NO synthesis

OBJECTIVES: To examine the interdigestive and postprandial antroduodenal motility patterns of patients with functional dyspepsia using prolonged ambulatory antroduodenal manometry and to compare these findings with conventional stationary manometry. METHODS: Prolonged ambulatory and short-term stationary antroduodenal manometry were performed in 10 patients with functional dyspepsia and in 10 healthy volunteers (controls). RESULTS: During stationary manometry only a few interdigestive motor complex (MMC) cycles were recorded. Using the ambulatory technique, fewer MMC cycles were observed in patients than in controls (2.2 +/- 0.63 and 4.1 +/- 0.54, respectively; P = 0.030). During phase II of the MMC, both techniques showed a higher antral motility index in patients (P = 0.017 and P = 0.049 for stationary and ambulatory manometry, respectively). The postprandial antral motility index was similar for patients and controls using stationary manometry. With the ambulatory technique, the antral motility index 1-1.5 h after breakfast was lower in patients than in controls (P = 0.020). Both techniques showed that the patients had a higher duodenal motility index after dinner and after breakfast (P < 0.05). Both techniques revealed more burst activity in patients than in controls (stationary: 10.7 versus 1.8% of the time; ambulatory: 1.7 versus 0.2% of the time; P = 0.004 and P = 0.051, respectively). Using a 10-min window period before the onset of symptoms, seven symptom episodes (33.3%) were found to be related to burst activity and retrograde or non-propagated phase III activity. CONCLUSIONS: Ambulatory manometry is superior to stationary manometry for evaluating patients with functional dyspepsia, because patients can be studied for a prolonged period (allowing adequate evaluation of interdigestive abnormalities) and under physiological conditions. Prolonged monitoring also allows assessment of the relationship between symptoms and motor abnormalities

BACKGROUND/AIMS: All methods currently used to quantify the temporal relationships between symptoms and episodes of gastroesophageal reflux, as assessed by 24-hour pH monitoring, have major shortcomings. The aim of this study was to develop and validate a simple, all-comprising statistical method to calculate the probability that gastroesophageal reflux episodes and symptoms are associated. METHODS: The 24-hour pH signal was divided into consecutive 2-minute periods. These periods and the 2-minute periods preceding the onset of symptoms were evaluated for the occurrence of reflux. Fisher's Exact Test was then applied to calculate the probability (P value) that reflux and symptom episodes were unrelated. Finally, the symptom-association probability (SAP) was calculated as (1.0 - P) x 100%. The SAP values found in 184 24-hour esophageal pH tests were compared with the symptom index and the symptom sensitivity index. RESULTS: Discordance between the SAP and the symptom index was found in 21 patients (11%) and discordance between the SAP and the symptom-sensitivity index in 28 (15%). False-positive and false-negative symptom index values occurred preferentially in patients with small and large numbers of symptom episodes during the test, respectively (P < 0.05). CONCLUSIONS: The SAP is a single, simple, quantitative measure of the strength of the association between symptoms and reflux episodes that is devoid of the disadvantages inherent to previously used methods

Recent technological developments have made it possible to measure intraluminal pH simultaneously at multiple sites using one single small-caliber catheter. The aim of this study was to investigate the dynamics of physiological gastroesophageal reflux in eight ambulatory healthy volunteers (age 21-51 yr). Esophageal pH was recorded for 24 h at 3, 6, 9, 12 and 15 cm from the lower esophageal sphincter (LES), using an 8-Fr catheter containing five ion-sensitive field effect transistor (ISFET) pH transducers and a digital data logger. Signals were sampled at a rate of 4 Hz. Automated analysis included determination of the extent of the reflux (cm above LES) and calculation of the velocity of the advance of the pH front from the LES (ascending velocity), minimum pH reached, and duration of all individual reflux episodes at different segments in the esophagus. The reflux time and the number of reflux episodes/24 h showed a gradual decrease from the distal to the proximal sensor (mean +/- SE: 4.4 +/- 0.8 to 0.9 +/- 0.2% and 46 +/- 7.6 to 11 +/- 1.9, respectively). Of all reflux episodes 23% did not reach the sensor at 6 cm above the LES, and only 25% reached the most proximal sensor. Characteristically, acid refluxed rapidly (velocity 0.4-2.4 cm/s) and was cleared in a stepwise fashion. Reflux episodes of long duration at the distal sensor reached high levels in the esophagus (P < 0.001). It was concluded that ambulatory multichannel esophageal pH monitoring using ISFET technology is a valuable tool for studies on the spatio-temporal characteristics of gastroesophageal reflux

We examined the relationship of interdigestive gallbladder emptying with the different phases of the migrating motor complex (MMC) and with plasma levels of cholecystokinin (CCK) and motilin. In 10 volunteers 20 cycles of the MMC were recorded. In 11 cycles phase III occurred in antrum and duodenum (group 1). In nine cycles phase III was observed only in duodenum (group 2). In group 1 gallbladder emptying started at 30% of total cycle length and continued until the end of the cycle. Maximal gallbladder emptying was 33.3 +/- 3.3% (SE). In group 2 gallbladder emptying also started at 30% of total cycle length but ended at 60%. Maximal gallbladder emptying in this group was 24.3 +/- 3.1% (P < 0.05). Motilin levels were higher in group 1 than in group 2 during phase IIB (240.1 +/- 28.5 and 142.1 +/- 30.9 pg/ml, respectively, P < 0.05) and during phase III (210.8 +/- 24.3 and 93.5 +/- 12.5 pg/ml, respectively, P < 0.05). We conclude that: 1) phase III activities starting in the antrum are preceded by greater and prolonged gallbladder emptying, higher motilin levels, and higher intraduodenal bile acid concentrations than phase III activities starting in the duodenum and 2) no relationship between interdigestive gallbladder motility and CCK levels could be demonstrated

Fourty-four unselected patients with noncardiac chest pain were studied using conventional manometry with additional edrophonium provocation and 24-hour ambulatory esophageal pH and pressure recording with a system developed by our group. New, fully automated techniques of statistical analysis of the complete set of esophageal pressure and pH signals were used to examine the temporal relation between pain, esophageal motility disturbances, and gastroesophageal reflux. The analysis used the 97.5th percentile of amplitude and duration of all esophageal contractions in each patient as well as a chi 2 test of the distribution of contraction types to determine whether a pain episode was related to abnormal motility or not. The edrophonium test results were positive in 2 patients. Only 25 patients (56.8%) had at least one pain episode (total, 111 episodes) during 24-hour recording. Thirty-three percent of the pain episodes were related to reflux and 23.4% to abnormal motility, and 43.2% were not related to an esophageal function disturbance. In the patient-oriented analysis in this study, it was required for a positive correlation that the symptom index (percentage of related pain episodes) was higher than 75%. It was found that the pain was related to reflux in 2 patients (4.6%), to reflux and motor abnormalities in 4 (9.2%), and to motor abnormalities in 2 patients (4.6%). In 36 patients (81.8%), no relation with an esophageal abnormality could be established, either because the patients had no pain during the 24-hour study, or because the pain seemed unrelated to reflux or abnormal motility

In 27 patients with uncontrollable gastroesophageal reflux, a modified Nissen fundoplication was performed. To investigate the long term effects of this procedure, 24-hour ambulatory esophageal pH monitoring was performed on three occasions: preoperatively, four weeks and two years postoperatively. Preoperative and postoperative symptoms were assessed. In 13 patients, fundoplication reduced reflux to zero (percentage of time pH less than 4, zero per cent), and in another 11 patients, reflux was reduced to a very low level (percentage of time pH less than 4, 0.75 +/- 0.21 per cent). The procedure failed in three patients, in whom both reflux symptoms and a pathologic pH profile persisted. No significant differences could be demonstrated between reflux variables in the early and late postoperative pH studies. Postoperatively, ten patients complained of heartburn or regurgitation, but pathologic reflux could only be demonstrated in three of these, and in two, there was macroscopic evidence of esophagitis. It is concluded that Nissen fundoplication abolishes or nearly abolishes gastroesophageal reflux in the majority of patients. Also, as in patients not operated upon, symptoms are unreliable indicators of the severity of gastroesophageal reflux after an antireflux procedure