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Biomedical subjects

H Mertz

Publications and source records attributed to H Mertz.

At least 19 recordsLinked to original sources
PubMed2006

Physician knowledge of Rome symptom criteria for irritable bowel syndrome is poor among non-gastroenterologists.

Rome I criteria are highly specific for irritable bowel syndrome (IBS) when red flag signs and symptoms are absent. Physician knowledge of Rome criteria may reduce diagnostic testing. We assessed: (i) physician knowledge of Rome criteria among internists, gastroenterologists and surgeons; (ii) laboratory and endoscopical testing suggested by physicians for sample IBS patients. Physicians of all training levels in internal medicine, gastroenterology, and surgery completed an anonymous questionnaire at a University Medical Center. Subjects were asked to identify Rome criteria among distracters. Sample IBS patients were presented, and physicians were asked to suggest a diagnostic workup based on the choices provided on the questionnaire. Rome knowledge was highest among gastroenterologists and lowest among surgeons. Physicians suggested endoscopical procedures in 67% of IBS patients with diarrhoea and in 46% with constipation. There was no difference among specialties in amount of laboratory or endoscopical testing suggested. Knowledge and use of the Rome criteria or their positive predictive value (PPV) for IBS did not correlate with reduced diagnostic testing. Education regarding the Rome criteria should be extended to surgical specialists who are likely to evaluate and operate on IBS patients. Endoscopical evaluation of IBS patients may be excessive.

Colorectal Surgery↗
PubMed2005

Amitriptyline reduces rectal pain related activation of the anterior cingulate cortex in patients with irritable bowel syndrome.

BACKGROUND AND AIMS: Irritable bowel syndrome (IBS) is a disorder of intestinal hypersensitivity and altered motility, exacerbated by stress. Functional magnetic resonance imaging (fMRI) during painful rectal distension in IBS has demonstrated greater activation of the anterior cingulate cortex (ACC), an area relevant to pain and emotions. Tricyclic antidepressants are effective for IBS. The aim of this study was to determine if low dose amitriptyline reduces ACC activation during painful rectal distension in IBS to confer clinical benefits. Secondary aims were to identify other brain regions altered by amitriptyline, and to determine if reductions in cerebral activation are greater during mental stress. METHODS: Nineteen women with painful IBS were randomised to amitriptyline 50 mg or placebo for one month and then crossed over to the alternate treatment after washout. Cerebral activation during rectal distension was compared between placebo and amitriptyline groups by fMRI. Distensions were performed alternately during auditory stress and relaxing music. RESULTS: Rectal pain induced significant activation of the perigenual ACC, right insula, and right prefrontal cortex. Amitriptyline was associated with reduced pain related cerebral activations in the perigenual ACC and the left posterior parietal cortex, but only during stress. CONCLUSIONS: The tricyclic antidepressant amitriptyline reduces brain activation during pain in the perigenual (limbic) anterior cingulated cortex and parietal association cortex. These reductions are only seen during stress. Amitriptyline is likely to work in the central nervous system rather than peripherally to blunt pain and other symptoms exacerbated by stress in IBS.

Adult↗
PubMed2003

Review article: visceral hypersensitivity.

Visceral hypersensitivity is highly prevalent in all functional bowel disorders. Most also demonstrate wider patterns of somatic referral of intestinal pain or discomfort. This hypersensitivity may explain the symptoms as the sensitive gut can be more easily provoked by normal or abnormal motor events in the gut. Visceral hypersensitivity may increase during psychosocial stress and during periods of symptom exacerbation, although this requires confirmation. Pharmacological therapy to reduce visceral hypersensitivity is now possible using antagonists to neurotransmitters, opening up an exciting new era for the treatment of functional gastrointestinal disorders.

Brain↗
PubMed2002

Role of the brain and sensory pathways in gastrointestinal sensory disorders in humans.

Several features of the irritable bowel syndrome (IBS) suggest involvement of the emotional limbic system in the brain. Abnormalities which upregulate afferent (sensory) signal intensity anywhere in this system, from the gastrointestinal tract to the brain, could induce hypersensitivity, leading to the pain and discomfort that characterise IBS and other functional disorders. Functional gastrointestinal disorders are likely to be heterogeneous given the complexity of the afferent system, and a number of different perturbations are possible. Intestinal hypersensitivity to pain and discomfort and associated reflex alterations in motility might explain the symptoms of functional bowel diseases.

Animals↗
PubMed2001

Rapid maturation of gastric relaxation in newborn infants.

We studied gastric volume, wall compliance, sensory perception, and receptive relaxation during the first postnatal 80 h in 17 healthy term infants, using a computer-driven air pump and simultaneously measuring pressure and volume within a latex balloon placed through the oropharynx into the stomach. To evaluate gastric compliance, we measured pressures while we infused air into the intragastric balloon at different rates (10, 20, and 60 mL/min) in random sequence. In all infants, there was a linear relationship between intragastric pressure and volume to the maximum pressure tested, 30 mm Hg. Gastric compliance ranged from 0.2 mL/mm Hg to 3.8 mL/mm Hg. Different infusion rates had no effect on compliance. We calculated gastric receptive relaxation by measuring the volume needed to maintain a constant pressure of 10 mm Hg within the balloon for 5 min. Gastric receptive relaxation ranged from 0.5 mL/min to 54 mL/min. Gastric compliance and receptive relaxation increased with postnatal age (r = 0.70, p < 0.005; r = 0.79, p < 0.001, respectively) and with number of feedings (r = 0.80, r = 0.88, respectively, both p < 0.001). There was no correlation between weight or type of feeding (breast versus formula) and either gastric compliance or relaxation. In conclusion, these results may explain the small feedings that neonates ingest in the first days of life. During the first 3 postnatal d, the newborn stomach becomes more compliant and develops more receptive relaxation, associated with a larger volume capacity.

Humans↗
PubMed2000

Regional cerebral activation in irritable bowel syndrome and control subjects with painful and nonpainful rectal distention.

BACKGROUND & AIMS: Irritable bowel syndrome (IBS) is characterized by visceral hypersensitivity, possibly related to abnormal brain-gut communication. Positron emission tomography imaging has suggested specific central nervous system (CNS) abnormalities in visceral pain processing in IBS. This study aimed to determine (1) if functional magnetic resonance imaging (fMRI) detects CNS activity during painful and nonpainful visceral stimulation; and (2) if CNS pain centers in IBS respond abnormally. METHODS: fMRI was performed during nonpainful and painful rectal distention in 18 patients with IBS and 16 controls. RESULTS: Rectal stimulation increased the activity of anterior cingulate (33/34), prefrontal (32/34), insular cortices (33/34), and thalamus (32/34) in most subjects. In IBS subjects, but not controls, pain led to greater activation of the anterior cingulate cortex (ACC) than did nonpainful stimuli. IBS patients had a greater number of pixels activated in the ACC and reported greater intensity of pain at 55-mm Hg distention than controls. CONCLUSIONS: IBS patients activate the ACC, a critical CNS pain center, to a greater extent than controls in response to a painful rectal stimulus. Contrary to previous reports, these data suggest heightened pain sensitivity of the brain-gut axis in IBS, with a normal pattern of activation.

Adult↗
PubMed2000

Methylene blue staining and endoscopic ultrasound evaluation of Barrett's esophagus with low-grade dysplasia.

This study was performed to determine if either methylene blue staining or endoscopic ultrasound helped direct biopsies in patients with a history of Barrett's esophagus with low-grade dysplasia. Patients underwent radial endoscopic ultrasound scanning to measure esophageal wall thickness, followed by endoscopy with methylene blue staining and biopsies. Mean esophageal wall thickness for squamous mucosa (2.3 +/- 0.2 mm), nondysplastic Barrett's (2.6 +/- 0.2 mm), and Barrett's with dysplasia (2.9 +/- 0.3 mm) were similar. With staining, Barrett's mucosa stained blue more often than gastric epithelium (68% vs 15%, respectively; P < 0.001). The sensitivity and specificity for strong staining detecting Barrett's were 68% and 85%, respectively. Barrett's with low-grade dysplasia stained blue less frequently (52%) than nondysplastic Barrett's (74%; P < 0.05), but the positive predictive value for poor staining indicating dysplasia was 41%. Endoscopic ultrasound was not helpful in directing biopsies in these patients. The utility of methylene blue for detecting dysplasia needs further investigation.

Aged↗
PubMed1999

Prevalence of gastroesophageal reflux after laparoscopic Heller myotomy.

BACKGROUND: There is still some controversy over the need for antireflux procedures with Heller myotomy in the treatment of achalasia. This study was undertaken in an effort to clarify this question. METHODS: To determine whether Heller myotomy alone would cause significant gastroesophageal reflux (GER), we studied 16 patients who had undergone laparoscopic Heller myotomy without concomitant antireflux procedures. Patients were asked to return for esophageal manometry and 24-h pH studies after giving informed consent for the Institutional Review Board (IRB)-approved study at a median follow-up time of 8.3 months (range, 3-51). Results are expressed as the mean +/- SEM. RESULTS: Fourteen of the 16 patients reported good to excellent relief of dysphagia after myotomy. They were subsequently studied with a 24-h pH probe and esophageal manometry. These 14 patients had a significant fall in lower esophageal sphincter (LES) pressure from 41.4 +/- 4.2 mmHg to 14.2 +/- 1.3 mmHg, after the myotomy (p < 0.01, Student's t-test). The two patients who reported more dysphagia postoperatively had LES pressures of 20 and 25 mmHg, respectively. Two of 14 patients had DeMeester scores of >22 (scores = 61.8, 29.4), while only one patient had a pathologic total time of reflux (percent time of reflux, 8%). The mean percent time of reflux in the other 13 patients was 1.9 +/- 0.6% (range, 0.1-4%), and the mean DeMeester score was 11.7 +/- 4.6 (range, 0.48-19.7). CONCLUSIONS: Laparoscopic Heller myotomy is effective for the relief of dysphagia in achalasia if the myotomy lowers the LES pressure to <17 mmHg. If performed without dissection of the entire esophagus, the laparoscopic Heller myotomy does not create significant GER in the postoperative period. Clearance of acid refluxate from the aperistaltic esophagus is an important component of the pathologic gastroesophageal reflux disease (GERD) seen after Heller myotomy for achalasia. Furthermore, GERD symptoms do not correlate with objective measurement of GE reflux in patients with achalasia. Objective measurement of GERD with 24 h pH probes may be indicated to identify those patients with pathologic acid reflux who need additional medical treatment.

Digestive System Surgical Procedures↗
PubMed1999

Symptoms and physiology in severe chronic constipation.

OBJECTIVE: Symptoms of constipation have been attributed to slow colon transit, irritable bowel syndrome (IBS), or pelvic floor dysfunction (PFD). Our aim was to determine the existence of symptom-based constipation subgroups and whether these correspond to differences in colonic transit and anorectal sensorimotor function. METHODS: Constipated patients (n = 108) completed questionnaires, and underwent colon transit studies, anorectal manometry, and rectal sensory testing. Factor analysis of symptoms was performed. Factor-based symptom scores were correlated with physiological findings. RESULTS: Three symptom factors were identified as compatible with slow colonic transit, IBS, and PFD. There was a significant correlation between the symptoms of slow transit and total and rectosigmoid colon transit. There were also significant correlations between both the IBS symptom score and the number of Manning criteria with measures of rectal hypersensitivity typical of IBS. Neither PFD symptom scores nor symptoms of straining correlated with any electromyographic or manometric measure of anal defecatory function or with rectosigmoid colon transit. Based on physiological testing patients were classified as slow transit, visceral hypersensitivity (typical of IBS), PFD, or no abnormalities found. As expected, slow-transit patients had symptoms of infrequent stools and patients with visceral hypersensitivity had an increased number of Manning criteria for IBS. Patients with PFD physiology and those with no detectable abnormalities had no specific symptoms. CONCLUSIONS: Three symptom-based subgroups for constipation were confirmed: slow transit, IBS, and PFD. Slow transit and IBS symptoms correlated with expected physiology. Conversely, PFD symptoms and physiology did not correlate.

Anal Canal↗
PubMed1999

Dysplastic gastroesophageal junction nodules--a precursor to junctional adenocarcinoma.

Adenocarcinoma of the gastroesophageal junction is a disease rapidly increasing in prevalence. The origin of these tumors is unclear. Barrett's esophagus, gastric cardia lesions, and mucus glands of the distal esophagus have been implicated. This case report presents two cases of patients who had chest pain leading to esophagogastroduodenoscopy. Both had small, benign-appearing nodules at the gastroesophageal junction in the absence of Barrett' s esophagus or gastric lesions. Biopsies revealed intestinal metaplasia with dysplasia in one patient and dysplasia of the mucus glands of the esophagus in the other. The first patient was followed for 8 months with serial biopsies, during which time the lesion became progressively more dysplastic, culminating in invasive cancer. These cases are presented to show that 1) benign-appearing gastroesophageal junction nodules may have malignant behavior, and 2) junctional cancer and high grade dysplasia can occur in the absence of Barrett's esophagus or gastric cardia lesions. Gastroesophageal junctional dysplasia/carcinoma may occur in small foci of intestinal metaplasia or in the mucus glands of the distal esophagus.

Adenocarcinoma↗
PubMed1999

Physiology of refractory chronic constipation.

OBJECTIVE: Investigators suggest three distinct pathophysiologies for patients with constipation symptoms: 1) slow colon transit, 2) irritable bowel syndrome (IBS), and 3) pelvic floor dysfunction (PFD). Our aim was to determine the prevalence of the three types of constipation pathophysiology, the degree of overlap, and what interactions exist between pathophysiologies. METHODS: Constipated patients refractory to fiber (n = 131) underwent regional colon transit studies, anorectal manometry/EMG, measurement of rectal compliance, and rectal sensory testing. Correlations were performed examining interactions between the above measures. RESULTS: Visceral hypersensitivity (typical of IBS) was found in 58%, slow colonic transit in 47%, PFD in 59%, and no physiological abnormalities were detected in 24%. Slow transit and visceral hypersensitivity overlapped in half of each group. PFD physiology was found in approximately half of each of the subgroups. There was no correlation between PFD physiology and rectosigmoid transit, total colon transit, or any other physiology. There were no correlations between slow transit and visceral hypersensitivity. Visceral hypersensitivity did correlate with increased rectal compliance, suggestive of increased accommodation reflexes in IBS. CONCLUSIONS: At a tertiary center, slow transit physiology and visceral hypersensitivity typical of IBS are equally common and overlap heavily in constipated patients. PFD physiology does not correlate with slower rectosigmoid colon transit, and is seen equally in all subgroups. No abnormalities were found in 24% of patients. We therefore identify four subgroups in constipation: IBS, slow transit, both, and neither.

Chronic Disease↗
PubMed1998

[Thymoma and pancytopenia].

Thymomas are often associated with a variety of autoimmune disorders including various cytopenias. Rare cases have been associated with pancytopenia. We describe a patient with an invasive thymoma treated with thymectomy and subsequent radiation therapy. A few months later, rapidly progressing pancytopenia developed. Treatment with antibiotics, immunoglobulin, high-dose steroids and granulocyte-colony stimulating factor (G-CSF) had no effect, and the patient died within two months of overwhelming septicaemia complicated with intracranial haemorrhage. We review the literature and discuss therapies.

Fatal Outcome↗
PubMed1998

Gastric metaplasia of the duodenum: identification by an endoscopic selective mucosal staining technique.

BACKGROUND: To understand the pathophysiology of duodenal ulcer disease, it is important to identify and quantitate gastric metaplasia of the duodenum. Methylene blue dye is absorbed well by intestinal mucosa, but not by gastric mucosa. Our aim was to validate a methylene blue staining technique for measurement of gastric metaplasia in the duodenum. METHODS: Eight subjects with chronic duodenal ulcer disease and seven subjects with other upper intestinal disorders underwent duodenal methylene blue staining after application of a mucolytic agent. Biopsy specimens were obtained from blue-stained and pale unstained areas and assessed for gastric metaplasia histologically. RESULTS: Pink or pale unstained duodenal areas had more gastric surface cell metaplasia than blue-stained areas. Unstained duodenum was also more likely to have extensive (more than 25% of the biopsy specimens) gastric metaplasia (60%) than blue-stained areas (9%). Subjects with duodenal ulcer disease had more unstained mucosa than controls. CONCLUSION: Methylene blue staining of the duodenum is useful to identify and quantitate gastric metaplasia.

Aged↗
PubMed1998

Effect of amitriptyline on symptoms, sleep, and visceral perception in patients with functional dyspepsia.

OBJECTIVE: Tricyclic antidepressants in low doses are widely used in the therapy of patients with functional gastrointestinal disorders, yet the mechanism(s) of action of these drugs in these disorders is not known. In the current study, we sought to determine in a group of patients with functional dyspepsia and associated poor sleep how amitryptiline affects digestive symptoms, perceptual responses to gastric distension, and subjective and objective measures of sleep. METHODS: Patients were randomized to 4 wk of amitryptiline 50 mg taken at bedtime versus placebo. There was a 3-wk washout phase, followed by a cross-over to the alternate treatment. Perceptual sensitivity to gastric distention and sleep EEG were recorded at the end of each treatment period. Diaries of symptoms were maintained throughout. RESULTS: Seven of seven patients reported significantly less severe gastrointestinal symptoms after 4 wk on amitryptiline compared to placebo. Five of seven patients had evidence for altered perception of gastric balloon distension during placebo. However, the subjective symptom improvement on amitryptiline was not associated with a normalization of the perceptual responses to gastric distension. Baseline sleep dysfunction in the form of reduced sleep efficiency, increased arousal, or abnormal amounts of REM sleep was found in all seven patients. Amitryptiline significantly reduced absolute and relative amounts of REM sleep, but had no effect on sleep parameters related to nonregenerative sleep. CONCLUSION: The beneficial effect of low dose amitryptiline seen in functional dyspepsia is not related to changes in perception of gastric distension, or to measures of arousal from sleep. An increased tolerance to aversive visceral sensations may play a role in the therapeutic effect.

Adult↗
PubMed1998

Symptoms and visceral perception in severe functional and organic dyspepsia.

BACKGROUND: Hypersensitivity of gastric afferent pathways may play an aetiological role in symptoms of functional dyspepsia. AIMS: To determine whether patients with severe organic dyspepsia (associated with tissue irritation/injury) and those with functional dyspepsia (no detectable tissue irritation) differ in their perception of gastric distension and whether this difference is reflected in differences in their gastrointestinal and psychological symptoms. METHODS: Perceptual thresholds, referral patterns, and gastrointestinal and psychological symptoms were compared in 23 patients with functional dyspepsia, 10 organic dyspeptics, and 15 healthy controls. RESULTS: Fifteen (65%) functional dyspeptics and no organic dyspeptics had reduced perceptual thresholds for fullness, discomfort, or pain (odds ratio (OR) 19.56, 95% confidence interval (CI) 1.95 to 476.09, p = 0.0017). Either reduced perceptual thresholds or altered referral was found in 20 (87%) functional dyspeptics and four (20%) organic dyspeptics (OR 10.0, 95% CI 1.34 to 89.54, p = 0.014). During sham distension fullness, discomfort and pain were reported by healthy controls, organic dyspeptics, and functional dyspeptics. A sham response of pain but no other sensation was more frequent among functional dyspeptics (43%) than healthy controls (7%) (OR 10.77, 95% CI 1.10 to 257.35, p = 0.026). Gastrointestinal and psychological symptoms and gastric compliance were similar in the functional and organic groups. CONCLUSIONS: Alterations in the perception of gastric distension distinguishes between functional and organic dyspepsia, while symptoms do not. A total of 87% of functional dyspeptics studied had evidence of altered visceral afferent function. In this study population, psychological abnormalities or changes in compliance did not explain the findings.

Adult↗
PubMed1998

Subtypes of constipation predominant irritable bowel syndrome based on rectal perception.

BACKGROUND: Patients who complain of constipation can be divided into those who have lost the natural call to stool, but develop abdominal discomfort after several days without a bowel movement (no urge); and those who experience a constant sensation of incomplete evacuation (urge). AIMS: To determine whether the two groups differ in symptoms, colonic transit, and perceptual responses to controlled rectal distension. METHODS: Forty four patients with constipation were evaluated with a bowel symptom questionnaire, colonic transit (radiopaque markers), and rectal balloon distension. Stool (S) and discomfort (D) thresholds to slow ramp (40 ml/min) and rapid phasic distension (870 ml/min) were determined with an electronic distension device. Fifteen healthy controls were also studied. RESULTS: All patients had Rome positive irritable bowel syndrome (IBS); 17 were no urge and 27 urge. Mean D threshold to phasic rectal distensions was 28 (3) mm Hg in no urge, 27 (3) mm Hg in urge (NS), but higher in the control group (46 (2) mm Hg; p < 0.01). Sixty seven per cent of no urge and 69% of urge were hypersensitive for D. Slow ramp distension thresholds were higher in no urge (S: 26 (3); D: 45 (4) mm Hg) compared with urge (S: 16 (2); D: 31 (3) mm Hg; p < 0.01), or with controls (S: 15 (1); D: 30 (3); p < 0.01). CONCLUSIONS: Hyposensitivity to slow rectal distension is found in patients with IBS who complain of constipation and have lost the call to stool even though their sensitivity to phasic distension is increased.

Adult↗
PubMed1997

[Intravascular malignant lymphomatosis].

Intravascular malignant lymphomatosis (IML) is a rare form of extranodal non-Hodgkin lymphoma characterized by proliferation of malignant lymphoid cells within the lumen of small blood vessels. We describe a case of IML presenting with non-specific pulmonary symptoms, weight loss, intermittent fever and a confusing collection of laboratory findings. Later on the patient developed cardiac symptoms, and finally diffuse cerebral symptoms and skin lesions. His condition deteriorated and he died within six months. The diagnosis of IML was made at autopsy. Complete remission and long-term disease-free survival may be obtained with standard chemotherapy directed at high-grade lymphomas. It is important to remember IML in the differential diagnosis of patients with confusing and changing ischaemic symptoms and signs from several organs.

Autopsy↗