Nobel Prize in Medicine awarded to a Gastroenterologist in 2005.
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Gastritis↗
Biomedical subjects
Joel Richter
Publications and source records attributed to Joel Richter.
Increasing yield also increases false positives and best serves to exclude GERD.
Multiple diagnostic tests always improve diagnostic yield. However, with the addition of more true positives come more false positives. Therefore, positive predictive values likely decrease with additional testing. We show this is true even when no gold standard exists to verify the dual testing's sensitivity and specificity.
Anti-Ulcer Agents↗
Direct comparison of impedance, manometry, and pH Probe in detecting reflux before and after a meal.
Combining GERD tests allows strengths and weaknesses of each method to be identified in detecting and characterizing reflux (RE). Aim of this study was to compare two methods that measure bolus volume of a refluxant (impedance monitoring (Imp) and manometry (common cavity)) to pH monitoring which measures changes in acid concentration of a refluxant. Nineteen symptomatic GERD patients and 10 normal volunteers were studied before and after a meal. All had 2-hr simultaneous manometry, pH, and Imp (six sites: 3, 5, 7, 9, 15, 17 cm above LES). Reflux by pH was a fall in pH from above to below 4. There were 973 RE's in all subjects, but only 19% were detected simultaneously by all three methods. Imp detected more RE's (96%) than manometry (76%) or pH probe (28%). Imp was the only method to detect 15% (144/973) of RE's, while detection only by pH probe (2%) or manometry (2%) was rare. Most RE's detected by Imp were detected simultaneously by manometry (75%,720/937). Those not detected by manometry were usually in blind spots either in the vulnerable period 2-3 sec after a swallow, during a posture change, or during a Valsalva. Most RE's detected by Imp were not detected by the pH probe. Though most liquid RE's fasting were detected by pH, most liquid postprandial RE's were not, due primarily to weakly acidic rather than superimposed acid RE's. Bolus clearing time by Imp and manometry was nearly identical, while acid clearing was threefold longer than bolus clearing by Imp or manometry. In conclusion, impedance monitoring is better than manometry and pH monitoring in RE detection before and after a meal, and manometry in determining RE composition as liquid or gas. The pH probe measures RE acidity and acid clearing. Simultaneous impedance and pH combines the two methods strengths, and is a powerful tool for reflux detection and characterization.
Adult↗
Diagnosis and follow-up of patients with achalasia.
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Deglutition Disorders↗
An unusual presentation of enterocolic lymphocytic phlebitis.
Enterocolic lymphocytic phlebitis (ELP) is a recently described disease characterized by phlebitis in the wall and mesentery of the colon and small bowel. Unlike other systemic or localized vasculitic diseases that can have similar gastrointestinal manifestations, there is no involvement of the arterial system or evidence of systemic vasculitis. The lymphocytic phlebitis affects not only the grossly involved intestinal segment but also the apparently healthy bowel. The diagnosis of ELP is histologic, and other systemic vasculitis must be ruled out. Surgical resection of the bowel not only provides the diagnostic tissue but also leads to resolution of the symptoms. In the literature, ELP has most commonly been reported to present as an acute abdomen. We describe a case of ELP presenting as a large abdominal mass, without evidence of an acute abdomen. This mass was actually diffusely thickened colonic serosa, caused by extensive organizing fat necrosis and marked edema of the serosa and bowel wall.
Aged↗
Acid suppression therapy may not alter malignant progression in Barrett's metaplasia showing p53 protein accumulation.
OBJECTIVES: Several previous studies have shown that malignant progression in Barrett's metaplasia (BM) occurs even in patients treated with fundoplication or acid suppression therapy (AST). The aim of this study was to test the hypothesis that AST may not alter malignant progression in BM if key genes involved in DNA repair and cell cycle control, particularly p53, are defective. METHODS: Initial and follow-up biopsies from 21 patients with BM treated with AST and observed for 1-13 yr were entered in the study. All biopsies were graded for dysplasia and evaluated for p53 protein accumulation and oxidative DNA damage by immunohiostochemistry, using antibodies to p53 and to 8-hydroxydeoxyguanosine, respectively. DNA ploidy was determined using image analysis. Statistical analysis was performed using Kaplan-Meier curves, log rank test, and multivariate regression. RESULTS: Patients with p53 positive initial biopsies were more likely to have progression in dysplasia grade (p = 0.022) and DNA ploidy status (p = 0.023) than those with p53 negative biopsies. In eight patients AST resulted in significant reduction in oxidative DNA damage in the five patients with p53-negative initial biopsies, but not the three with p53 positive ones (p = 0.0007). CONCLUSIONS: We conclude that failure of AST to alter malignant progression in BM may be due, at least in part, to defects in DNA repair and cell cycle control resulting from p53 gene mutation, present before AST treatment. Although AST may be effective in preventing further DNA damage, it is unlikely to alter progression in genetically unstable cells.
Barrett Esophagus↗
Multichannel intraluminal impedance accurately detects fasting, recumbent reflux events and their clearing.
Multichannel intraluminal impedance (MII) is a new diagnostic test for gastroesophageal reflux disease (GERD). The objective of this report is to determine the accuracy of MII in detecting individual reflux events (REs) identified by pH probe and manometry, as well as their clearing in patients with severe GERD compared with normal volunteers. Ten severe GERD patients and 10 normal volunteers underwent simultaneous manometry [7 sites: gastric, lower esophageal sphincter, esophagus (4), pharynx], pH, and MII (6 sites in esophagus) for 15 min in the left and right recumbent posture while fasting. We found that patients had 30-fold more REs than normal volunteers (41 +/- 11 vs. 1.3 +/- 0.4), and 95% of all REs were detected by MII. An average 15-fold fall in impedance with liquid and fivefold rise with gas made REs and their composition easy to detect with MII. In the right recumbent posture, nearly all REs detected by MII were liquid (98%, 98/100). In contrast, all 283 REs detected by MII in the left recumbent posture were gas. Nearly all REs detected by MII were cleared (98%, 368/374). Mean acid clearing time was threefold longer (47 s) than clearing time by either manometry (15 s) or MII (13 s), primarily due to acid rereflux, i.e., additional acid REs during acid clearing. We conclude that MII is accurate in detecting REs identified by manometry and/or pH probe, their composition, and their clearing.
Fasting↗
Characterization of long-term outcomes after Toupet fundoplication: symptoms, medication use, and health status.
GOALS AND BACKGROUND: Fundoplication is increasingly used for the treatment of gastroesophageal reflux disease (GERD). Few studies have tracked patient outcomes of the Toupet method for more than 1 year. Further clinical, physiologic, and patient-based outcome measures have not been well characterized for this method. The current study conducts a long-term, comprehensive outcome evaluation in patients receiving Toupet fundoplication. STUDY: Fifty-five patients who had previously undergone fundoplication were examined. In a subset of 24 patients, esophagogastroduodenoscopy was used to assess the severity of reflux esophagitis. Manometry and ambulatory pH monitoring also were performed. RESULTS: Patients were studied 2.9 (+/- 0.7) years after surgery. Sixty-seven percent of the sample reported heartburn, 51% reported postoperative bloating, 33% reported regurgitation, and 20% reported dysphagia. Thirty-three percent reported the use of prescription medications for GERD-related symptoms. Health status was diminished relative to population norms. Degree of GERD severity was associated with symptom reports and medication use. CONCLUSIONS: Although fundoplication is thought to be a curative procedure, the current findings suggest that many patients take symptomatic therapies and report symptoms and diminished health status up to 2 years after the procedure. These outcomes are associated with physiologic findings. Thus, these findings suggest that symptom-free status and absence of medication use cannot be assumed for all patients after Toupet fundoplication.
Endoscopy, Digestive System↗