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Biomedical subjects

K R DeVault

Publications and source records attributed to K R DeVault.

At least 19 recordsLinked to original sources
PubMed2006

Review article: the role of acid suppression in patients with non-erosive reflux disease or functional heartburn.

When patients with the typical reflux symptoms of heartburn, regurgitation, or both, undergo endoscopy, up to 75% will not have endoscopic oesophagitis or evidence of Barrett's oesophagus. These patients have been described as having endoscopic negative or, more commonly, non-erosive reflux disease (NERD). Patients without oesophagitis, but with a positive pH test, can be diagnosed with gastro-oesophageal reflux disease (GERD). Some experts also consider a response to proton pump inhibitor therapy as proof of GERD in a patient with the correct symptoms and a negative endoscopy. Patients with normal acid exposure, but who report symptoms with a majority of their reflux episodes documented during an ambulatory pH study, have also been considered to have NERD, although others have labelled them as having 'functional heartburn'. Finally, there are some patients who have reflux symptoms and respond to reflux therapy, but have no demonstrable reflux by either endoscopy or ambulatory reflux testing. Whether these patients are part of the GERD spectrum or have another diagnosis is not clear. It seems that the most widely used definition of functional disease (the Rome II criteria) would include these patients as having functional heartburn, as it was defined as 'greater than or equal to 12 weeks of either continuous or intermittent symptoms of burning retrosternal discomfort or pain without pathologic GERD, achalasia, or other motility disorders with a recognized pathologic basis'. This article reviews potential differences in pathophysiology between erosive oesophagitis and NERD; explores whether symptoms can help distinguish NERD patients from erosive oesophagitis patients; and explores the evaluation and therapy of these patients.

2-Pyridinylmethylsulfinylbenzimidazoles↗
PubMed2006

Changes in esophageal motility after porfimer sodium photodynamic therapy for Barrett's dysplasia and mucosal carcinoma.

Esophageal dysmotility is common in patients with Barrett's esophagus. Previously we have reported deterioration of esophageal motility after photodynamic therapy (PDT) in a heterogeneous group of patients with esophageal carcinoma. This prospective study in consecutive patients describes changes in motility noted after endoscopic ablation. Forty-seven patients referred to our institution for endoscopic ablation for Barrett's high grade dysplasia or mucosal carcinoma between August 2001 and May 2003 were prospectively evaluated with esophageal manometry before and after porfimer sodium PDT. Six patients did not complete the study. Manometry results were classified as normal, diffuse esophageal spasm, ineffective esophageal motility, or aperistalsis. Abnormal esophageal motility was found in 14 of 47 (30%) patients at study entry ([diffuse esophageal spasm] DES-3, [ineffective esophageal motility] IEM-7, Aperistalsis-4). After PDT, 11 of 41 patients with paired studies experienced a change in manometric diagnosis. Three patients had an improvement in motility, seven a worsening and one changed diagnosis, but did not particularly worsen or improve. No patient developed new aperistalsis. Therefore, abnormal motility was present in 19 of 41 (46%) patients after PDT (DES-2, IEM-14, Aperistalsis-3). There was a statistically significant (P = 0.016) relationship with longer segment Barrett's esophagus and deterioration of function. Baseline abnormalities in motility can occur in patients with Barrett's high-grade dysplasia or mucosal carcinoma. Changes in esophageal function also may occur following photodynamic therapy, but usually are not clinically significant. Worsening in function was more likely to occur in patients with longer segment Barrett's esophagus.

Adenocarcinoma↗
PubMed2001

Lichen planus involving the esophagus.

Lichen planus is a common mucocutaneus disorder that rarely involves the esophagus. We report two challenging cases presenting with recurrent dysphagia originally suspected due to gastroesophageal reflux. Subsequent evaluation revealed peculiar endoscopic findings of desquamative esophagitis leading to the diagnosis of lichen planus of the esophagus. This disorder should be considered in middle age or elderly women presenting with unexplained dysphagia or odynophagia. In this paper we review the available literature on the subject and summarize every case reported to date.

Aged↗
PubMed2001

Diagnosing gastroesophageal reflux disease.

Gastroesophageal reflux disease (GERD) is a common condition with a variety of clinical manifestations and potentially serious complications. This article reviews available methods for diagnosing GERD. A clinical history of the classic symptoms of GERD, heartburn or acid regurgitation, is sensitive enough to establish the diagnosis in patients without other complications. Esophagogastroduodenoscopy is the best way to evaluate suspected complications of GERD, but endoscopic findings are insensitive for the presence of pathological reflux, and therefore they cannot reliably exclude GERD. The "gold standard" study for confirming or excluding the presence of abnormal gastroesophageal reflux is the 24-hour ambulatory esophageal pH monitoring test, and this study should be used for the evaluation of refractory symptoms and extraesophageal manifestations of GERD. A formal acid-suppression test is helpful in the evaluation of the atypical GERD symptom of noncardiac chest pain. Optimal use of currently available tests for GERD may allow for more efficient diagnosis and better characterization of the pathological manifestations associated with GERD.

Diagnostic Techniques, Digestive System↗
PubMed2001

Esophageal dysmotility in patients undergoing photodynamic therapy.

OBJECTIVE: To study the esophageal motility of patients with esophageal adenocarcinoma or Barrett esophagus with high-grade dysplasia before and after photodynamic therapy. PATIENTS AND METHODS: In this prospective study conducted between January 1998 and October 1999, esophageal motility testing of the lower esophageal sphincter and esophageal body was performed with a water-perfused catheter, 2 days before and at least 3 weeks after patients underwent photodynamic therapy for esophageal adenocarcinoma or Barrett esophagus. Results were classified as normal motility, ineffective esophageal motility, or aperistalsis. RESULTS: Twenty-three patients were studied, 13 with carcinoma and 10 with Barrett esophagus. Overall, 11 patients (48%) had normal motility, 6 (26%) had ineffective esophageal motility, and 6 (26%) had aperistalsis. Five patients with aperistalsis had carcinoma. Follow-up tracings after photodynamic therapy found that 6 patients (26%) had normal motility, 7 (30%) had ineffective esophageal motility, and 10 (43%) had aperistalsis. CONCLUSIONS: Esophageal dysmotility is common in patients with esophageal adenocarcinoma or Barrett esophagus. Photodynamic therapy may worsen esophageal motility in some patients. Dysphagia after photodynamic therapy therefore may be related to underlying esophageal dysmotility and may not always be caused by stricture or underlying carcinoma.

Adenocarcinoma↗
PubMed2001

Gastroesophageal reflux disease: extraesophageal manifestations and therapy.

Gastroesophageal reflux disease (GERD) can present with both typical symptoms such as heartburn and regurgitation as well as atypical symptoms. These symptoms may include chest pain, asthma, chronic cough, hoarseness, otitis media, atypical loss of dental enamel, idiopathic pulmonary fibrosis, recurrent pneumonia, chronic bronchitis and even sudden infant death. The diagnosis of GERD in these patients can often present a challenge and usually requires a combination of selected testing and therapeutic trials. Acid suppression by using proton pump inhibitors remains the treatment of choice in GERD, but some patients will also respond well to antireflux surgery. This article addresses the presentations, diagnostic challenges, and therapeutic opportunities in GERD patients with atypical presentations.

Aged↗
PubMed2000

Recent developments in chest pain of undetermined origin.

The syndrome of angina-like pain with normal epicardial coronary vessels is a very common and expensive clinical problem. Patients suffering from this condition frequently present a diagnostic challenge. Cardiac and musculoskeletal disorders must be excluded prior to identifying the esophagus as the source of pain. The term "chest pain of undetermined origin" (UCP) has been proposed to refer to this condition. Esophageal dysmotility was previously considered a major source for chest pain; however, recent studies indicate that esophageal reflux is the most common cause of esophageal pain. Two controlled trials of acid suppressive agents in patients with chest pain have shown that omeprazole provides effective pain relief for the majority of these individuals. Visceral hyperalgesia and psychologic disturbances are also commonly noted in patients with UCP. Much remains to be learned about the etiology of visceral hyperalgesia and the precise role of psychologic abnormalities in these patients. Until further information is available, treatment with imipramine or trazodone has been shown to offer effective relief of chest pain for subgroups of patients with UCP. Psychologic intervention is also valuable in the management of some patients. Studies of other therapeutic regimens continue to be conducted.

Angina Pectoris↗
PubMed2000

Accurate placement of the esophageal pH electrode for 24-hour pH monitoring using a combined pH/manometry probe.

OBJECTIVE: Accurate placement of a pH electrode requires manometric localization of the lower esophageal sphincter (LES). Combined manometry/pH devices using water-perfused tubes attached to pH catheters and the use of an electronic "LES locator" have been reported. We investigated whether accurate placement of pH probes can be achieved using such a probe, and whether this may reduce the need for the performance of the usual stepwise pull-back manometry. METHODS: Thirty consecutive patients (15 men, 15 women; median age, 56 yr; interquartile range, 42-68 yr) referred for manometry and pH testing were included in the study. The localization of the LES was determined with standard esophageal manometry. After that, a second 3-mm pH electrode with an internal perfusion port was passed into the stomach. Using this catheter, a single stepwise pull-through manometry was performed and the LES position was noted. LES location, mean pressure, and length obtained with standard manometry were compared to data from the combined pH/manometry catheter. Additionally the time necessary to perform each of the procedures was noted and the patient's discomfort caused by the catheter was evaluated using a standardized questionnaire. RESULTS: The LES location with the pH/manometry probe was proximal to that with standard manometry in 19 patients (63%), the same in nine patients (30%), and distal in two patients (7%). The differences were <2 cm in 29 of 30 (97%) patients. The LES location with the pH/manometry probe required a median of 6.5 min (interquartile range: 3.5-8.5 min) versus a median of 21.5 min (interquartile range: 14.5-26.5 min) for standard manometry (p < 0.0001). In addition, LES evaluation using the combined pH/manometry probe provided accurate data on the resting pressure, as well as overall and intraabdominal length of the LES. All patients tolerated the combination probe better than the standard manometry probe (p < 0.001). CONCLUSIONS: Placement of the esophageal electrode for 24-h esophageal pH monitoring using a combined pH/manometry probe is accurate. The technique is simple, time-saving, and convenient for the patients. Because it is possible to accurately evaluate the LES using this technique, it may even replace conventional manometry before pH probe placement.

Adult↗
PubMed2000

Manometry of the upper esophageal sphincter and pharynx is not useful in unselected patients referred for esophageal testing.

OBJECTIVE: We sought to determine whether routinely performing upper esophageal sphincter/pharyngeal (UES/P) manometry in patients referred for esophageal testing alters clinical practice. METHODS: Clinical history along with radiography and manometry studies were reviewed in 470 patients referred for manometry. A total of 435 (92.6%) were found to have adequate evaluation of the UES/P and were included in the study. RESULTS: Of 435 studies, 80 (17.7%) had one or more UES/P abnormalities. Indications for these 80 studies were dysphagia in 30 cases (37.5%), chest pain in 26 (32.5%), both in four (5.0%), and other in 20 (25%). There were 85 manometric abnormalities in the 80 studies: hypertensive UES in 16 cases (18.8%), incomplete UES relaxation in 38 (44.7%), hypertensive pharynx in seven (8.2%), hypotensive pharynx in 15 (17.6%), and abnormal coordination in nine (10.6%). A total of 41 patients had a barium study, which was normal in 11 cases (26%), confirmed the problem in 16 (40%), and suggested another problem in 14 (34%). In 17 patients (21%), there was clinical suspicion for an oropharyngeal disorder before manometry, whereas in 58 cases it was an unexpected finding. Of the 58 patients with an unexpected finding, therapy based on this finding was offered in six (three esophageal dilations, two dietary changes, and one swallowing therapy). If patients with concomitant esophageal body disorders are excluded, in only three patients an unexpected UES finding led to change in management. CONCLUSIONS: An unexpected UES/P finding resulted in a change in therapy in only six of the manometries. Barium esophagogram was diagnostic of the oropharyngeal abnormality in nearly two-thirds of the patients in whom it was clinically suspected. These data, along with limited therapeutic options, suggest limited usefulness for routine UES/P manometry.

Barium↗
PubMed2000

Managed care issues in the treatment of gastroesophageal reflux disease.

The impact that reflux disease has on patients' quality of life is reviewed and some of the managed care issues surrounding treatment, including the step-up/step-down philosophy and a comparison of available proton pump inhibitor (PPI) agents, are explored. PPIs are first-line pharmacotherapy for treating reflux disease. They have shown superior efficacy compared with previously recommended agents. Whereas PPI therapy has some limitations, it offers substantial benefits in terms of clinical and quality-of-life factors.

Cost of Illness↗
PubMed1999

Overview of medical therapy for gastroesophageal reflux disease.

There appears to be a hierarchy in the efficacy of therapies that are directed against GERD. A summary of this hierarchy, including therapies [table: see text] not approved by the U.S. Food and Drug Administration, is presented in Table 4. The individual practitioner must evaluate the appropriate point at which to place each patient on this hierarchy. Whether it is best to begin with the drug with the highest efficacy and step-down as possible for maintenance, never to step down, or to start with a less efficacious therapy and step up must also be individualized because there are no clear data to support a universal approach to all or even most GERD patients.

Antacids↗
PubMed1999

Treatment of achalasia: recent advances in surgery.

Achalasia is an uncommon motility disorder of the esophagus with an uncertain etiology. Considerable debate exists regarding the most effective treatment for long-term relief of symptoms. For decades, pneumatic dilatation has been the primary treatment option, and surgery was reserved for patients who required repeated dilations or for those who were not willing to undergo the risk of perforation associated with dilatation. Recently botulinum toxin injection of the lower esophageal sphincter has been shown to provide substantial short-term relief from dysphagia; however, its effect only lasts for a short period of time. Recently, minimally invasive surgical techniques have been developed to perform a Heller myotomy effectively with an antireflux procedure. This has become a primary treatment option for many patients. We present a review of the outcome of different therapeutic options of achalasia with a special focus on laparoscopic procedures.

Anti-Dyskinesia Agents↗