Search

Alteration in visceral sensation locally at the site of presumed symptom origin in the gastrointestinal tract has been proposed as an important etiopathological mechanism in the so-called functional bowel disorders. Patients presenting with one functional gastrointestinal syndrome, however, frequently have additional symptoms referable to other parts of the gut, suggesting that enhanced visceral nociception may be a panintestinal phenomenon. We measured the sensory thresholds for initial perception (IP), desire to defecate (DD), and urgency (U) in response to rectal balloon distension, and the thresholds for initial perception and for discomfort in response to esophageal balloon distension in 12 patients with irritable bowel syndrome (IBS) and 10 patients with functional dyspepsia (FD), in comparison with healthy controls. As expected, IBS patients exhibited lower rectal sensory thresholds than controls (P

Some patients undergoing ambulatory oesophageal pH monitoring to investigate symptoms suggestive of gastro-oesophageal reflux disease (GORD) are found to have oesophageal acid exposure within the physiological range but show a close correlation between their symptoms and individual reflux episodes. It is suggested that these patients might exhibit enhanced oesophageal sensation, akin to the heightened perception of both physiological and provocative stimuli in the gut that has been described in patients with functional gastrointestinal disorders. This study tested the hypothesis by measuring the sensory thresholds for oesophageal balloon distension and discomfort in 20 patients with symptoms of GORD, in whom ambulatory pH monitoring had shown normal acid exposure times, but in whom the symptom index for reflux events was 50% or greater, and compared these with 15 healthy volunteer controls, and with control groups with confirmed excess reflux. The study group showed lower thresholds both for initial perception of oesophageal distension, and for discomfort, compared with healthy controls (median ml (range)); 7.5 (2-19) v 12 (6-30) (p = 0.002) and 10 (5-20) v 16 (8-30) (p < 0.0001), respectively. Sensory thresholds in the study group were also significantly lower than in patients with excess reflux, and than patients with Barrett's oesophagus, who also exhibited significantly higher sensory thresholds than healthy controls. No differences in sensory thresholds for somatic nerve stimulation were found between the study group and health controls. The results show a spectrum of visceral sensitivity in GORD, with enhanced oesophageal sensation in patients with symptomatic but not excess gastro-oesophageal reflux, suggesting that their symptoms result from a heightened perception of normal reflux events.

Esophageal pH monitoring in patients with gastroesophageal reflux symptoms identifies some who have normal esophageal acid exposure but nevertheless a convincing correlation between symptoms and those reflux events that do occur. These patients may exhibit enhanced sensory perception of physiological reflux. Little is known about the natural history of reflux symptoms in this group, which in our experience comprises up to 6% of those referred for diagnostic pH monitoring. We have therefore followed up by postal questionnaire 70 patients whose initial pH study had demonstrated normal acid exposure but a symptom index > or = 50% and 58 patients found to have excess reflux, for a median of 4.4 and 6.5 years, respectively. The presenting character and frequency of symptoms and endoscopic and manometric findings were similar in the two groups. At review overall symptom frequency had improved (P < 0.01) for both groups similarly. However, 87% of those with normal acid exposure and 79% of those with excess reflux remained symptomatic, 53% and 47%, respectively, recording their symptoms to be the same or worse than at original presentation, despite over 60% in each group continuing to take regular medication. Only six patients in each group were asymptomatic and receiving no therapy at the time of review. The results demonstrate that patients with symptomatic but not excess gastroesophageal reflux constitute a significant clinical problem. Both the persistence of their symptoms and their requirement for therapy are similar to that observed in "genuine" refluxers.

Abnormalities of the thyroid gland are said to be common in patients with dermatitis herpetiformis (DH), treated with dapsone (Thyroid abnormalities in dermatitis herpetiformis. Cunningham andZone, Annals Int.Med. 1985: 102, 194-196). Thepossibility that the goitrogenic effects of dapsone may play a role in this has not been evaluated. We therefore studied thyroid abnormalities in 40 patients with DH, 25 of whom were taking dapsone and 15 of whom were on a gluten free diet alone. All patients were examined clinically for evidence of thyroid dysfunction and blood was drawn for total thyroxine, thyrotrophin levels and thyroid microsomal antibdy titres. Six (24%) of dapsone treated patients had thyroid abnormalities, compared to 1 (7%) of the 15 patients treated with diet alone. Two patients became thyrotoxic when on treatment with dapsone. One patient had myxoedema prior to diagnosis of DH and one developed myxoedema while on dapsone. Two patients with asymptomatic goitres at the time of screening were taking dapsone and one patient on dapsone had thyroid antibodies. Thus it seems likely that the increased incidence of thyroid abnormalities in DH may be related to the effects of the sulphonamide on thyroid function.

In the last three decades, esophageal pH monitoring has progressed from an exclusively laboratory-based physiological research tool to a routine outpatient clinical investigation in patients with one of the most common gastrointestinal disorders. Technological advancement has considerably simplified both the procedure and the interpretation of data obtained, and there is currently reasonable consensus as to the parameters that best discriminate between physiological and pathological gastroesophageal reflux. There remains a need for internationally agreed definitions and standards, particularly with regard to calculation of these parameters, which would improve comparability of future research studies from different centers. Clinical applications of the technique have increased with our enhanced knowledge of the protean clinical manifestations of reflux disease. The advent of potent pharmacotherapy and the recognition of a need for ongoing treatment in many patients will ensure that the most sensitive test for the diagnosis of gastroesophageal reflux disease will remain an essential part of the investigation of upper gastrointestinal symptoms.

Introduction CC is classically associated with normal or unremarkable colonoscopy. In the last few years, reports have been published revealing findings that are thought to be characteristic or even pathognomonic of CC, such as alteration of the vascular mucosal pattern, mucosal nodularity and a sequence of mucosal changes from defects/lacerations to cicatricial lesions. The aim of this study was to evaluate the frequency and type of endoscopic findings in patients diagnosed with CC in our centre. Methods Setting: Tertiary hospital, outpatients. Design: Retrospective study. The database of Pathology Department was searched for patients who have been diagnosed with CC between May 2008 and August 2011. Endoscopy reports and endoscopic images were retrieved and reviewed. Results 155 patients were diagnosed with CC in the study period. The indications for colonoscopy were altered bowel habit (acute or chronic diarrhoea) in 126/133; 33 patients reported associated weight loss. The reports from 123 patients (96F/27M; median age 68.7 yrs, range 37–91 yrs) were eventually retrieved and further reviewed. The colonoscopies had been carried out by consultant (medical/surgeons): 47%, nurse endoscopist: 20%, associate specialist: 13% and fellow or registrar: 10%. Of the above cohort, 67 (54.4%) patients had no endoscopic findings and 44 (35.7%) had irrelevant to CC findings such as diverticulosis, polyps or telangiectasias. Twelve ( n =12; 9.75%) had findings previously described as consistent with CC. In particular: 7 (5.7%) had mucosal erythema or oedema (patchy, mild granularity or congestion), 4 (3.25%) had lacerations (cat-scratch mucosa or bigger mucosal breaks) and 1 of them had a few mucosal scars. The sigmoid and the descending colon were the main colonic parts affected (in 7/12 cases) and the rest were found in the caecum-ascending colon area (4/12) while there was only one patient in which the entire large bowel was affected. Conclusion A significant minority of patients with CC (almost 10%) presented endoscopic findings indicative of CC. Furthermore, 4% had findings that are considered pathognomonic for CC. Although still the subject of isolated cases reports, the endoscopic appearances of CC are becoming more familiar among the endoscopic community. Competing interests None declared. Reference 1. Distinct colonoscopy findings of microscopic colitis: Not so microscopic after all? World J Gastroenterol 2011; 17 :4157–65.