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The aim of this study was to assess whether high-resolution impedance manometry (HRIM) could be used to assess bolus retention similar to the timed barium esophagram (TBE).Twenty achalasia patients (10 males, aged 21-79 years) were prospectively evaluated with HRIM and TBE to determine the correlation between barium column height and the impedance bolus height (IBH). The TBE protocol used a 200-ml barium challenge and the HRIM protocol used a 200-ml saline challenge protocol. Both protocols were performed in an upright position and the heights of the barium and impedance columns were measured at 1 and 5 min. Analysis of IBH was performed with a topographic technique and a spatial impedance variation plot.There was no significant difference between the median IBH and barium column at 1 min (IBH: 12.0 cm (interquartile range (IQR), 8.0-18.0); TBE: 12.0 cm (IQR, 7.0-19.0); P=0.90) or at 5 min (IBH: 11.0 cm (IQR, 1.0-17.0); TBE: 9.0 cm (IQR, 4.0-12.0); P=0.47). In addition, the correlation between the two measurements at 1 and 5 min was 0.60 and 0.86, respectively. Using a barium column or impedance height of5.0 as a definition of bolus retention was associated with 75% concordance at 1 min and 95% concordance at 5 min.There was excellent agreement between TBE and high-resolution impedance manometry (HRIM) for assessing bolus retention at 5 min. Thus, HRM with impedance may be used as a single test to assess bolus retention and motor function in the management of achalasia.

Several severity predictors have been tested for assessing acute pancreatitis (AP). The recently described harmless acute pancreatitis score (HAPS) could be an ideal predictor for Indian patients at the community level. We validate this system in the current study. This was a prospective pilot study conducted at a tertiary center from July 2010 to December 2011. Consecutive directly admitted patients over 18 years with a documented first episode of AP were enrolled and followed for at least 12 months after discharge/till death. HAPS was defined as absence of rebound abdominal tenderness, serum creatinine of

Radiologic investigations continue to play a pivotal role in the diagnosis of pathologic conditions of the small intestine despite enhancement of capsule endoscopy and double-balloon endoscopy. Imaging techniques continue to evolve and new techniques in MRI in particular, are being developed.Continued advances in computed tomography (CT) and MRI techniques have reinforced the importance of these imaging modalities in small bowel assessment. The more invasive enteroclysis technique yields better small bowel distension for both CT and MRI when compared with peroral enterography, but no clinically significant difference is seen in terms of diagnostic accuracy. Recent concern regarding radiation exposure means that MRI is gaining in popularity. Fluoroscopic studies such as barium follow through and small bowel enteroclysis are being replaced by the cross-sectional alternatives. Contrast-enhanced ultrasound is showing results comparable with CT and MRI, but concern remains regarding reproducibility, especially outside centres that specialize in advanced sonographic techniques.CT and MRI enterography are comparable first-line modalities for patients with suspected small bowel disease, but magnetic resonance enterography is favoured given the absence of ionizing radiation. Capsule endoscopy is a reasonable alternative investigation in exploration of chronic gastrointestinal blood loss, but is best kept as a second-line test in patients with other symptoms.

Limited evidence is available on the economic burden of ulcerative colitis (UC) in the UK, particularly relating to the impact of relapse frequency on direct medical costs. This study identifies and assesses medical resource utilization (MRU) and associated direct costs in mild and moderate UC patients in the UK.A retrospective chart review of patients with mild-to-moderate UC diagnosed at least 1 year before the study was performed. From 33 general practitioner (GP) and 34 gastroenterologist sites, charts of the last three UC patients fulfilling the inclusion criteria were reviewed. Descriptive statistics were calculated for MRU and 2011 costs (GB£) by number of relapses.The study population included 201 patients with a mean age of 39.9 years; 44% were women and the mean disease duration was 7.4 years. UC-related costs of each MRU category increased with the number of relapses. Comparing patients without relapse with those with more than two relapses, the mean annual UC-related costs were £14 versus £2556 for hospitalizations; £218 versus £988 for visits (including nurse, GP, specialist, and other visits); £21 versus £1303 for procedures; £17 versus £188 for diagnostics; and £1168 versus £6660 for all-cause total costs. Age, sex, and site of data reporting (GP vs. gastroenterologist) were not associated with MRU or costs.Patients with mild-to-moderate UC incurred considerable costs that increased markedly with the number of relapses. These findings support the importance of maintenance therapies in UC that reduce or prevent relapses. Quantifying the relationship between relapse rate and costs will inform future health economic studies.

The care of the patient with cholestasis hinges on identifying the etiology, treating reversible causes, and managing chronic cholestatic processes. PBC and PSC are important causes of chronic cholestasis, and are the most common causes of cholestatic liver disease. Effective therapy is available for patients with PBC, whereas none exists for patients with PSC. Awareness of the complications that may be associated with cholestasis and implementing the appropriate management are essential.

Acute gastroenteritis (AGE) remains a major cause of childhood morbidity and mortality in the United States. The routine use of vaccines targeting rotavirus, the most common cause of pediatric AGE, has decreased all-cause AGE emergency department (ED) visits and hospitalizations.1 However, the burden of pediatric AGE remains substantial. With annual hospitalization rates of 3 to 5 per 1000 US children $350 million in costs annually.3 Care for uncomplicated AGE is largely supportive, and guidelines from the American Academy of Pediatrics and other international organizations emphasize conservative management and discourage routine diagnostic testing for AGE, with or without dehydration.4–6 Yet there continues to be wide variation in AGE management among individual providers and hospitals in the United States and abroad.7,8 Studies in children with acute respiratory illness show similar variation in care that is associated with important outcome differences, with higher resource utilization linked to higher rates of hospitalization and longer hospital length of stay (LOS), irrespective of the severity of illness.9,10 Whether similar associations exist between resource utilization and outcomes in children with AGE is largely unexplored. With the use of data from 34 US children’s hospitals, we sought …

BACKGROUND Achalasia diagnosis requires elevated integrated relaxation pressure (IRP; manometric marker of lower esophageal sphincter [LES] relaxation). Yet, some patients exhibit clinical features of achalasia despite normal IRP and have LES dysfunction demonstrable by other means. We hypothesized these patients to exhibit equivalent therapeutic response compared to standard achalasia patients. METHODS Symptomatic achalasia-like cases, despite normal IRP, displayed evidence of impaired LES relaxation using rapid drink challenge (RDC), solid swallows during high-resolution manometry, and/or barium esophagogram; were treated with achalasia therapies and compared to standard achalasia patients with raised IRP. Outcomes included equivalence for short- and long-term symptom response and stasis on barium esophagogram. KEY RESULTS Twenty-nine normal IRP achalasia cases (14 males, median age 50 year, median Eckardt 6, barium stasis 12 ± 7 cm) and 29 consecutive standard achalasia controls underwent therapy. Among cases, LES dysfunction was most often identified by RDC and/or barium esophagogram. Short-term symptomatic success was equivalent in cases vs controls (90% vs 93%; 95% CI for difference: -19% to 13%). Median short-term (1 vs 1; 95% CI for difference: 0-1) and long-term Eckardt scores (2 vs 1; 95% CI for difference: 0-2) were similar in cases and controls, respectively. Adequate clearance was observed in 67% of cases vs 81% of controls on post-therapy esophagogram. CONCLUSIONS AND INFERENCES We described a subset of achalasia patients with normal IRP, but impaired LES relaxation identifiable only on additional provocative tests. These patients benefited from treatment, suggesting that such tests should be performed to increase the number of clinically relevant diagnoses.

Gastric emptying has been known to correlate the pyloric sphincter contractile function and distention-induced gastric relaxation (gastric accommodation). In the present study, the effects of l -tryptophan on the gastric emptying and accommodation were evaluated by breath test using [1- 13 C]acetic acid and Barostat study, respectively, in rats. l -Tryptophan significantly decreased Cmax and AUC120min and delayed Tmax, indicating the inhibition of gastric emptying. l -Tryptophan significantly enhanced the gastric accommodation. These findings show that l -tryptophan may inhibit the gastric emptying through the enhanced gastric accommodation. Therefore, l -tryptophan may be useful for the therapy of postprandial dyspepsia, especially for early satiety.

Aim The present study was carried out to clarify tube feeding utilization and the prevalence of swallowing difficulty among residents in geriatric long-term settings, and to elucidate the implementation of swallowing assessment at four different types of facilities in Japan. Methods We mailed a questionnaire to a total of 4334 facilities. Results We received responses from 1137 (26.2%) facilities, including 440 (29.0%) from 1517 nursing homes, 275 (29.2%) from 941 long-term care facilities, 205 (18.1%) from 1134 sanatorium medical facilities and 217 (29.2%) from 742 rehabilitation hospitals. The number of tube-fed residents per 100 beds in each facility was 11.6 at the nursing homes, 7.4 at the long-term care facilities, 36.3 at the sanatorium medical facilities and 7.9 at the rehabilitation facilities. The number of residents per 100 beds with swallowing difficulty was 23.7 in the nursing homes, 15.6 in the long-term care facilities, 19.2 in the sanatorium medical facilities and 15.4 in the rehabilitation hospitals. The percentages of facilities that assessed swallowing difficulty were 31.8% of the nursing homes, 63.0% of the long-term care facilities, 77.9% of the sanatorium medical facilities and 91.7% of the rehabilitation hospitals. Conclusion A large number of residents using a feeding tube and with difficult swallowing were observed in geriatric long-term settings without adequate evaluation of swallowing function. Geriatr Gerontol Int 2014; 14: 577–581.

Background Defecatory disorders can be diagnosed by rectal balloon expulsion (BE) and anorectal manometry, which are traditionally evaluated in the seated and left lateral (LL) positions, respectively. The aims of this study were to compare BE in the LL and seated positions and to compare anorectal manometric parameters to BE performed in the seated and LL positions. Methods 220 women [healthy (62), chronic constipation (158)] had anorectal high-resolution manometry and BE, summarized by time required (seated position, normal ≤60 s) or external traction to facilitate expulsion (LL position, normal ≤100 g). Key Results Balloon expulsion results in both positions were either concordant [normal (141) or abnormal (32)] or discordant [only LL abnormal (30), only seated abnormal (17)]. There was modest agreement [κ = 0.44 (95% CI 0.30–0.57)] between seated and LL BE. Compared with subjects with normal BE in both positions, anal pressure during simulated evacuation (SE) was higher, and the rectoanal gradient (rectal-anal pressure) during SE was more negative in the other 3 categories (i.e., abnormal LL only, abnormal seated only, and both abnormal). High anal pressure during SE (OR = 1.02, 95% CI 1.00–1.04) and high rectal sensory threshold for desire to defecate (OR = 1.01, 95% CI 1.00–1.02) were associated with increased risk of abnormal BE in both positions, whereas high rectal pressure during SE (OR = 0.96, 95% CI 0.93–0.98) was associated with lower risk. Conclusions & Inferences There is modest agreement between rectal BE in LL and seated positions. In addition to abnormal seated BE, which is considered indicative of pelvic floor dysfunction, high resolution manometry findings suggest that even some patients with abnormal BE in the LL position have pelvic floor dysfunction.

Primary and acquired abdominal pathology accounts for a significant proportion of sepsis and SIRS in the ICU population. Abdominal processes often present a difficult diagnostic dilemma in the truly critically ill patient who, due to hemodynamic instability or severe acute respiratory distress syndrome (ARDS) requiring high-level ventilatory support, is at significant risk during transport to radiology department. Furthermore, the accuracy of radiologic studies in the ICU setting is often limited. Laparoscopy provides a “minimally invasive” definitive modality to diagnose intra-abdominal problems. It may quickly provide the necessary information to define further management. In selective circumstances, it may actually allow appropriate intervention. However, the overall mortality of patients who undergo diagnostic laparoscopy in the ICU is high regardless of diagnostic findingsduring this procedure. Although not a technically difficult procedure, diagnostic laparoscopy does require a certain skill level, especially when limited time and unfavorable patient physiology are taken into account. The use of diagnostic laparoscopy should be limited to patients in whom a therapeutic intervention is feasible.

This narrative review summarizes published studies on diagnostic examinations and therapeutic interventions for phagophobia. The electronic databases Embase, PubMed, PsycINFO(A (R)), and The Cochrane Library were used. The literature search was limited to publications in the English, German, French, Spanish, or Dutch language. The original articles are summarized in the present narrative review. The body of literature on phagophobia and swallowing fear remains very limited; only 12 studies were found. The present narrative review discovered heterogeneity in the definitions of phagophobia or similar syndromes. A systematic review, including a qualitative analysis, was planned but not carried out as studies were not of sufficient quality to warrant doing so. All the studies had severe methodological shortcomings. In general, the conclusions could not be compared across the studies because of the different study designs, small populations, different ways of evaluating and treating phagophobia, and complex combinations of treatments. A general conclusion is provided.

Electrogastrography (EGG) is a non-invasive diagnostic motility for recording gastric myoelectrical activity. Gastric myoelectrical activity was first recorded in 1922. Advances in recording equipment enabled widespread use of cutaneous EGG after 1985. Later, introduction of multichannel EGG (M-EGG) enabled measurement of electrical activity transmission. At present, M-EGG findings are used as objective indicators of gastric motility disorders caused by various diseases. EGG measures two categories of gastric electrical activity: electrical response activity, or spike potentials; and electrical control activity, or slow waves. The appearance of abnormal rhythmic electrical activity is indicative of abnormalities in gastric motility. The normal frequency range of gastric electrical activity (normogastria) is around 3 cycles per min. Multiple EGG parameters assist in the assessment of gastric myoelectrical activity, and significant correlations between EGG and other gastric motility tests have been demonstrated in many studies. In Japan, however, EGG remains in the exploratory stage, and its clinical use is limited. There are large variations in procedures and systems used in previous studies, thus there is a need for standardization of EGG procedures and technical terminology. Here, we outline the current status of EGG and report the M-EGG procedures used in our department in addition to our M-EGG findings. The abstract of this manuscript was presented during an educational seminar titled "Current status of gastrointestinal motility tests and keys for immediate implementation" at the 54th Annual Meeting of the Japan Society of Smooth Muscle Research

BACKGROUND: Autoimmune pancreatitis and autoimmune cholangitis are new clinical entities that are now recognized as the pancreaticobiliary manifestations of immunoglobulin (Ig) G4-related disease.OBJECTIVE: To summarize important clinical aspects of IgG4-related pancreatic and biliary diseases, and to review the role of IgG4 in the diagnosis of autoimmune pancreatitis (AIP) and autoimmune cholangitis (AIC).METHODS: A narrative review was performed using the PubMed database and the following keywords: “IgG4”, “IgG4 related disease”, “autoimmune pancreatitis”, “sclerosing cholangitis” and “autoimmune cholangitis”. A total of 955 articles were retrieved; of these, 381 contained relevant data regarding the IgG4 molecule, pathogenesis of IgG-related diseases, and diagnosis, management and long-term follow-up for patients with AIP and AIC. Of these 381 articles, 66 of the most pertinent were selected.RESULTS: The selected studies demonstrated the increasing clinical importance of both AIP and AIC, which can mimic pancreatic cancer and cholangiocarcinoma, respectively. IgG4 titration in tissue or blood cannot be used alone to diagnose all IgG4-related diseases; however, it is often a useful adjunct to clinical, radiological and histological features. AIP and AIC respond to steroids; however, relapse is common and long-term maintenance treatment often required.CONCLUSIONS: A review of the diagnosis and management of both AIC and AIP is timely and pertinent to clinical practice because the amount of information regarding these conditions has increased substantially in the past few years, resulting in significant impact on the clinical management of affected patients.

OBJECTIVES: Tube feedings are commonly prescribed to infants with swallowing abnormalities detected by videofluoroscopic swallow study (VFSS), but there are no studies demonstrating efficacy of these interventions to reduce risk of acute respiratory illness (ARI). We sought to measure the association between swallowing interventions and future ARI, among VFSS-tested infants. METHODS: Retrospective cohort of all infants ( RESULTS: 576 infants were tested with a VFSS in their first year of life, receiving a total of 1051 VFSSs in their first 3 years of life. More than 60% of infants received a measured feeding intervention. With the exception of infants with silent OPA who received thickened feedings, neither thickening nor nasal tube feedings, compared with no intervention, were associated with a decreased risk of subsequent ARI. CONCLUSIONS: Swallowing interventions and repeated testing are common among VFSS-tested infants. However, the importance of diagnosing and intervening on VFSS-detected swallowing abnormalities for the majority of tested infants remains unclear.

UVOD: Hronične inflamatorne bolesti se ispoljavaju kao Kronova bolest i ulcerozni kolitis. Njihova značajnost ogleda se u hronicitetu kao i u stepenu u kom ograničavaju rast i razvoj dece i omladine. Brojne su posledice ovih oboljenja: dugotrajno izostajanje sa nastave, ograničavanje životnih aktivnosti i pojava komplikacija koje neretko zahvataju i druge organske sisteme. Etiologija je i dalje nerazjašnjenja navodeći kao značajan hronični inflamatorni proces u genetski uslovljenih pojedinaca a provociranih nekim infektivnim agensom. Početkom 21. veka genetska istraživanja su otkrila osnovu nasleđivanja hroničnih inflamatornih oboljenja povezanih sa NOD2 genom. Kako je u pitanju organskim sistem koji je ograničeno pristupačan kliničkom pregledu, osnovu dijagnostike čine radiološke metode. Kako je potrebno sprečiti kontinuirano izlaganje štetnom dejstvu rendgenskog zračenja istraživanja se usmeravaju ka UZ i magnetnoj rezonanca. Naše istraživanje se baziralo na mogućnostima ovih dveju metoda u svakodnevnom radu za dijagnostiku i dalje praćenje hroničnih inflamatornih bolesti creva. CILJEVI: Utvrditi senzitivnost i specifičnost ultrazvučne dijagnostike i magnetne resonance kod upalnih oboljenja creva u dečjem i adolescentnom uzrastu. Definisati i uporediti prednosti i ograničenja ultrazvučne dijagnostike sa dijagnostikom magnetne rezonace kod upalnih obolenja creva u dečjem i adolescentnom uzrastu. MATERIJAL I METODE: U istraživanje je uključeno 62. dece i adolescenata u toku prvog ataka bolesti ili ponovljenim fazama bolesti ili tokom redovnog praćenja u remisiji. Obuhvaćeni uzrast je od 4. do 18. godina. Potom su razvrstani u grupe na osnovu vrste pregleda i prisustva zadebljanja crevnog zida na A i B (pregled UZ), gde je A grupa imala zabeleženo zadebljanje crevnog zida preko 3 mm, a kod dece u grupi B debljina crevnog zida je bila između 2,5-3 mm. Sa druge strane na osnovu pregleda magnetnom rezonancom podeljeni su u A1 i B1 grupe, takođe po kriterijumu zadebljanja crevnog zida većeg od 3 mm (A1), odnosno između 2,5-3 mm (B1). Istraživanje je sprovedeno na Institutu za zdravstvenu zaštitutu dece i omladine Vojvodine i Institutu za radiologiju Kliničkog centra Vojvodine. Prvi pregled načinjen je UZ a potom je načinjen pregled magnetnom rezonanacom. Podaci su obrađivani retrospektivno i prospektivno. Kriterijumi za uključivanje u studiju pored uzrasta bili su radiološki: zadebljanje crevnog zida >3mm, postojanje narušene arhitektonike crevnog zida, zadebljanje pojedinih crevnih segmenata-dužina segmenta, znaci fibroze, odsustvo peristaltike, izražena hiperemija na kolor Doppleru, transmuralni znaci upale, uvećani mezenterijalni limfni nodusi kao i kontrolni pregledi kod dece sa ranije ustanovljenom dijagnozom. Načinjena je endoskopija sa biopsijom radi postavljanja definitivne dijagnoze, potom se pristupilo statističkoj obradi dobijenih podataka. Izračunate su prosečne i standardne devijacije i frekvencije kao i pripadajući procenti. Određivane su maksimalne i minimalne vrednosti, medijane i interkvartalni raspon. Dobijeni podaci prikazani su u grafikonima i tabelama. Za parametrijske varijable upotrebljavan je Man – Vitni U test. Za kategoričke vrednosti upotrebljeni su χ2 i Fišerov test. Nadalje su određivane senzitivnost, specifičnost kao i pozitivne i negativne prediktivne vrednosti. Veze između dva parametra uspostavljene su pomoću Pirsonove korelacione analize i linearnim regresionim modelom. Upotrebljen je program za obradu podataka SPSS 21 Statistics,a kao statistički značajne vrednosti uzete su vrednosti p, INTRODUCTION: Chronic inflammatory diseases are manifested through two clinical entities: Crohn's disease and ulcerative colitis. Their significance lies in the chronicity and the degree to which they restrict the growth and development of children and youth. There are many consenquences that come with the very nature of the disease, in addition to long-term absence from school, limiting life activities and the occurrence of complications that often affect other organ systems. The etiology of the disease has long been in favor of the theory that a chronic inflammatory process in genetically conditioned individual is provoking an inflammation due to a certain infectious agent. However, a step closer was made regarding the etiology of the disease - when the genetic basis of inheritance studies have revealed chronic inflammatory bowel diseases were associated with NOD2 gene. It is particularly important to prevent continuous exposure to the harmful effects of X-rays. Therefore, numerous studies have been made towards the validation of complementarity, accuracy and diagnostic capabilities of ultrasound and magnetic resonance imaging as noninvasive techniques. Our research was based on the capabilities of these two methods in their daily work for diagnosis and follow-up of chronic inflammatory bowel disease. OBJECTIVES: The objectives were to determine the sensitivity and specificity of ultrasound and magnetic resonance imaging in inflammatory bowel disease in children and adolescents. Furthermore, the aim was to define and compare the advantages and limitations between ultrasound diagnosis and magnetic resonance in inflammatory bowel disease in children and adolescents. MATERIAL AND METHODS: The study included 62 children and adolescents during the first attack of disease or recurrent stages of the disease, or during regular monitoring in remission. Patients included children of both sexes, aged 4-18. Then they were sorted into groups based on the type of the examination and the presence of a thickening of the intestinal wall into groups A and B - in these groups children were examined by ultrasound, A group had observed thickening of the intestinal wall > 3 mm whereas children in group B had had thickening of the intestinal wall between 2,5-3 mm. Based on the review of MRI children were divided into groups A1 and B1, also according to the criterion of bowel wall thickening greater than 3mm (A1) and between 2,5-3mm (B1). The research was conducted at the Institute for Health Protection of Children and Youth and the Institute of Radiology, Clinical Center of Vojvodina. The first review was made by ultrasound, followed by the review of magnetic resonance. Data were analyzed retrospectively and prospectively. Criteria for inclusion in the study were: thickening of the intestinal wall greater than 3 mm, the existence of disturbed intestinal wall architectural structure, no clear distinction of layers, abnormal thickening of certain intestinal segments, signs of fibrosis, the absence of peristalsis, expressed hyperemia on color Doppler, transmural inflammation, increased mesenterial lymph nodes as well as check-ups for children with previously established diagnosis. Endosccopy with biopsy has made for the definitive diagnosis and then we approached statistical analysis of the data obtained. The data are presented in graphs and tables. For parametric variables we used Man - Whitney U test. For categorical values χ2 and Fisher's test were used. Further the sensitivity, specificity and positive and negative predictive values were determined. Relationship between these two parameters were established using Pearson correlation analysis and linear regression model. For data processing we used the program SPSS Statistics 21, statistically significant values were taken p values

Diagnosis of oesophageal motility disorders has been well established for many years now, although circadian gastrointestinal motility is still purely understood. So far, high-resolution manometry (HRM) is only available for short-term measurement in clinical practice to evaluate simultaneous pressure conditions throughout the esophagus. Thus, only a very limited period of time can be investigated. There is evidence that disorders in esophageal motility can cause severe discomfort and symptoms even though they only tend to occur spontaneously. When performing short-term-measurements, these often cannot be detected. Therefore, one can assume that long-term analysis of the esophageal function will provide valuable new insights, which will contribute to more effective medicamenteous and operative treatment in esophageal motility disorders. At our gastrointestinal functional diagnostic laboratory, it has been possible to perform high-resolution manometry over the period of 24 hours since June 2014. We used a manometric probe consisting of 36 pressure sensors which are connected to a mobile recording device for ambulatory measurement. This article describes our experiences in clinical use when performing long-term high-resolution manometry and discusses usability and relevance of the results in the context of the underlying esophageal motility disorder.

There has been a rapid increase in the incidence of oesophageal adenocarcinoma in most Western countries over the past thirty years. Barrett's oesophagus (BE) is a common premalignant lesion of oesophageal adenocarcinoma, although the risk of developing cancer in BE remains low. Therefore, screening is not recommended in the general population. Surveillance of BE is recommended to detect high grade dysplasia or carcinoma in an early stage, although there is no clear evidence that surveillance leads to a reduced mortality. This review discusses the several screening and surveillance techniques, including chromoendoscopy, narrow band imaging, autofluorescence imaging and confocal laser endomicroscopy, pointing out the areas that are well established as well as the new techniques that require more research.

This meta-analysis assessed the value of interferon-γ release assays (IGRAs) in the differential diagnosis of intestinal tuberculosis (ITB) from Crohn's disease (CD).Systematic search without language restriction was conducted in the main computerized databases until June 2015. Studies that have evaluated the performance of IGRAs (QuantiFERON-TB Gold or T-SPOT.TB) in distinguishing ITB from CD were eligible. Main outcome measures included sensitivity and specificity. Area under the curve (AUC) of the summary receiver operating characteristic (sROC) curve was used to evaluate the accuracy of IGRAs.Twelve studies (all from Asia) were finally included. The pooled sensitivity and specificity of IGRAs for the differential diagnosis of ITB from CD were 82.8% (95%CI 78.4%-86.6%) and 86.7% (95%CI 83.2%-89.6%) respectively. The positive likelihood ratio (PLR) and negative likelihood ratio (NLR) were 6.870 (95%CI 5.345-8.830) and 0.171 (95%CI 0.105-0.279). The diagnostic odds ratio was 44.030 (95%CI 27.964-69.325). And the AUC of sROC was 0.939.IGRAs have a high sensitivity and specificity for the diagnosis of ITB, and specificity is consistent from study to study. IGRAs may be considered as a supplementary method in the differential diagnosis of ITB from CD.

Hepatitis E, although commonly recognized in the Eastern Hemisphere, is less well recognized in the West. Particularly owing to this disease's grave impact on outcomes after liver transplantation, greater consideration of hepatitis E is necessary in the context of abnormal liver tests. Here, we review the most recent data on detecting and managing hepatitis E, both pre- and post-liver transplantation, discuss major detection assay limitations, consider future directions, and propose an algorithm for the diagnosis and management of pre-and post-transplantation hepatitis E.

The laryngeal adductor reflex and the pharyngoglottal closure reflex protect the trachea and lower respiratory tract against the entrance of foreign material. The laryngeal expiration reflex and the cough reflex serve to propel foreign material, which has penetrated in the cranial direction. The inspiration reflex, the sniff reflex, and the swallowing reflex are further larynx-associated reflexes. In patients with dysphagia the laryngeal adductor reflex can be clinically tested with air pulses. The water swallow test serves to show the integrity of the cough reflex. The sniff reflex is useful to test the abduction function of the vocal folds. Future studies should address laryngeal reflexes more specifically, both for a better understanding of these life-supporting mechanisms and to improve diagnostic procedures in patients with impaired laryngeal function.

The author presents definition of pancreatic cancer (PC), epidemiological data on its prevalence, risk factors (chronic pancreatitis, viral hepatitis B, smoking, etc.), and clinical symptoms. Modern laboratory and instrumental differential diagnostic methods are discussed. Morphological classification and stages of the neoplastic process are considered with special reference to the methods of its surgical treatment and adjuvant therapy.

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.

Background. Rome III criteria add physiological criteria to symptom-based criteria of chronic constipation (CC) for the diagnosis of defecatory disorders (DD). However, a gold-standard test is still lacking and physiological examination is expensive and timeconsuming. Aim. Evaluate the usefulness of two low-cost tests-digital rectal examination (DRE) and balloon expulsion test (BET)-as screening or excluding tests ofDD. Methods. Weperformeda systematic search inPUBMEDandMEDLINE. We selected studies where constipated patients were evaluated by DRE or BET. Heterogeneity was assessed and random effect models were used to calculate the sensitivity, specificity, and negative predictive value (NPV) of the DRE and the BET. Results. Thirteen studies evaluating BET and four studies evaluating DRE (2329 patients) were selected. High heterogeneity (.. 2 > 80%) among studies was demonstrated. The studies evaluating the BET showed a sensitivity and specificity of 67% and 80%, respectively. Regarding the DRE, a sensitivity of 80% and specificity of 84% were calculated. NPV of 72% for the BET and NPV of 64% for the DRE were estimated. The sensitivity and specificity were similar when we restrict the analysis to studies using Rome criteria to define CC. The BET seems to performbetter when a cut-off time of 2minutes is used and when it is compared with a combination of physiological tests. Considering the DRE, strict criteria seem to improve the sensitivity but not the specificity of the test. Conclusion. Neither of the low-cost tests seems suitable for screening or excluding DD., info:eu-repo/semantics/publishedVersion

Objective: To estimate the cost-effectiveness of a new strategy that uses an amino acid formula in the elimination diet of infants with suspected cow’s milk allergy (CMA). Methods: This pharmacoeconomic study was developed from the perspective of the Brazilian Public Healthcare System. The new strategy proposes using an amino acid formula in the diagnostic elimination diet of infants (≤ 24 months) with suspected CMA. Our rationale is that infants who do not respond to the amino acid formula do not suffer from CMA. Patients with a positive oral challenge test receive a therapeutic elimination diet based on Brazilian Food Allergy Guidelines. This approach was compared to the current recommendations of the Brazilian Food Allergy Guidelines. A decision model was constructed using TreeAge Pro 2012 software. Model inputs were based on a literature review and the opinions of a panel of experts. A univariate sensitivity analysis of incremental cost-effectiveness ratios was performed. Results: The mean cost per patient of the new amino acid formula strategy was R$3,341.57, while the cost of the current Brazilian guidelines strategy was R$3,641.08. The mean number of symptom-free days per patient, which was used as an indicator of effectiveness, was 900.6 and 875.7 days, respectively. The new strategy is therefore dominant. In the sensitivity analysis, the dominance was maintained with parameter variation. Limitations: This analysis did not evaluate the impact of the new strategy on quality of life or whether it improved the general well-being of infants with CMA or their parents. Conclusions: The new strategy, which uses an amino acid formula in the elimination diagnostic diet followed by an oral food challenge, is a dominant pharmacoeconomic approach that has a lower cost and results in an increased number of symptom-free days.

BACKGROUND/AIMS Pathogenesis of functional dyspepsia (FD) is unclear and not well documented. Some gastric motility abnormalities have been reported to be important factors. Transcutaneous electrogastrography (EGG) is an experimental method that is used to assess FD. We aimed to compare FD patients with control subjects in terms of motility abnormalities according to the EGG results. MATERIALS AND METHODS Thirty patients with FD and thirty control subjects were included. EGG was preprandially and postprandially performed. The recordings were analyzed and compared between the two groups. RESULTS Mean ages of the cases and controls were 31.4±9.3 and 32.58±7.6 years, respectively. Female subjects constituted 80% of the FD group and 76.67% of the control group. In terms of the preprandial dominant frequency (DF), the FD group demonstrated lower incidence of normal subjects than the control group [13 (43.3%) and 22 (73.3%), respectively] and a higher incidence of bradygastria than the control group [17 (56.7%) and 8 (26.6%), respectively]. In the FD group, the rate of cases with normal postprandial DF was lower than that in the control group [10 (33.3%) and 23 (76.7%), respectively], whereas the rates of bradygastria [18 (60%) and 7 (23.3%), respectively] and tachygastria [2 (6.7%) and 0 (0%), respectively] were higher in the FD group (p

BackgroundGastrointestinal (GI) complications are common after renal transplantation, mainly owing to immunosuppressive therapy. Assessment of GI transit time can facilitate rational management of these disorders.ObjectiveWe evaluate the GI transit parameters in renal transplant recipients taking tacrolimus, azathioprine, and prednisone with the use of the alternate current biosusceptometry (ACB) technique and compared them with healthy volunteers.MethodsTen renal transplant recipients and 10 healthy volunteers were enrolled in this study. After an overnight fast, patients and volunteers ingested a standard meal containing magnetic markers. The biomagnetic monitoring was performed at 10-minute intervals for at least 8 hours to obtain gastric emptying as well as the colonic arrival time–intensity curves. Mean gastric emptying time (MGET), mean colon arrival time (MCAT), and mean small intestinal transit time (MSITT) were quantified and compared between control and patient groups with results expressed as mean ± SD.ResultsThe MGET measured by the ACB technique was 48 ± 31 minutes and 197 ± 50 minutes for patients and healthy subjects, respectively. MSITT and MCAT values calculated for patients versus volunteers were 171 ± 71 minutes versus 197 ± 71 minutes and 219 ± 83 minutes versus 373 ± 52 minutes, respectively. Renal transplant recipients showed significantly faster; gastric emptying and colon arrival times (P < .001) compared with normal volunteers; however, small intestinal transit time was not significantly different (P = .44).ConclusionsIn stable renal transplant recipients, the GI transit parameters were significantly faster than in normal healthy volunteers. ACB sensors are versatile technologies that can be used for clinical research, because they offer an excellent opportunity to evaluate GI transit in a noninvasive manner without the use of ionizing radiation.

Constipation is one of the most common gastrointestinal complaints in the United States and can seriously affect quality of life. It is an acute or chronic condition in which bowel movements are infrequent and difficult to eliminate. In severe cases, constipation may cause bowel obstruction. Constipation is a symptom, rather than a disease, resulting from a number of causes and disorders, including dietary factors, neurologic disorders, psychiatric disorders, colon disease, metabolic abnormalities, and medication side effects. This may explain the high prevalence rates and associated excessive costs. This article assists the provider in identifying the correct diagnoses associated with constipation and guiding the practitioner through obtaining a pertinent medical history, performing a comprehensive physical examination, and prescribing the appropriate diagnostics tests. A diagnostic algorithm that considers an extensive list of differential diagnoses including medications contributing to constipation is provided to assist the practitioner in evaluating and diagnosing the cause(s) of the constipation.

Our article discusses the current understanding of screening and surveillance options for Barrett's esophagus and emerging concepts that have the potential to improve the effectiveness and cost-effectiveness of surveillance.Although endoscopic surveillance of patients with Barrett's esophagus is commonly practiced in order to detect high-grade dysplasia and early esophageal adenocarcinoma (EAC), the reported incidence of EAC in Barrett's esophagus patients varies widely. Recent studies found the risk of progression from Barrett's esophagus to EAC to be significantly lower than previously reported, raising concerns regarding the limitations of current surveillance strategies. Advances in imaging techniques and their enhanced diagnostic accuracy may improve the value of endoscopic surveillance. Additionally, various efforts are ongoing to identify biomarkers that identify individuals at higher risk of cancer, possibly allowing for individual risk stratification.These new data highlight some of the opportunities to revise and improve surveillance in patients with Barrett's esophagus. The incorporation of new advances such as imaging techniques and biomarkers has the potential to improve the effectiveness and cost-effectiveness of new surveillance regimens.

Graphical abstractDisplay Omitted Highlights? Documentation requires provider effort and cooperation before, during, and after procedures. ? Double-checks, regulation requirements, and cross-checks cause data overlap among documents. ? Documents required are paper copies of electronic data and consent, process, and facilitation forms. ? Current paper documentation processes raise the bar for future electronic documentation systems. Documentation processes are an indispensible part of patient care. Timely access to complete and accurate documentation is crucial to patient safety. However, there is no sufficient tool to help health care professionals effectively manage documentation processes. In this study, we developed an evaluation methodology, including a documentation matrix, a documentation process flow diagram, and a document value tool, to analyze the necessity and redundancy of the documentation processes. We applied this methodology in a gastrointestinal lab and improved the transparency of the documentation processes among providers.

OBJECTIVE Bile-acid diarrhoea (BAD) is a recognized cause of chronic diarrhoea; however, its detection remains suboptimal. Currently, there is a paucity of follow-up studies evaluating BAD. This work evaluates the natural history of BAD by examining individuals diagnosed with BAD [7 days of Se-homocholic acid taurine (SeHCAT) retention