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Biomedical subjects

S S Shay

Publications and source records attributed to S S Shay.

At least 19 recordsLinked to original sources
PubMed2001

New techniques in measuring nonacidic esophageal reflux.

New techniques in esophageal monitoring are allowing for better differentiation in the role of different gastric refluxates in esophageal mucosal damage and patient symptoms. The Bilitec 2001 (Synectics, Stockholm, Sweden) is a portable spectrophotometer that measures bilirubin as a surrogate marker for bile reflux and multichannel intraluminal impedance (MII) (Sandhill Scientific Inc, Highlands Ranch, CO) is a new technique allowing measurement of esophageal volume refluxate. Both techniques assess the role of nonacidic esophageal reflux. Despite their novel approach in assessing nonacid reflux, both methods have limitations. Future studies in this area, however, will prove beneficial in identifying their role in diagnosis and management of patients with suspected nonacid reflux disease.

Animals↗
PubMed2001

Esophageal motility in the assessment of esophageal function.

Esophageal manometry assesses lower esophageal sphincter (LES) pressure and its relaxation. In addition, it detects the ability of the esophageal body to initiate a peristaltic contraction and the contraction's amplitude in response to a water bolus. The study is indicated in patients with symptoms suggestive of an esophageal motor disorder and to assist in the diagnosis of some miscellaneous disorders. The most common disorders diagnosed by esophageal manometry are the primary motility disorders, such as achalasia. Manometry is indicated in the subset of patients with gastroesophageal reflux disease (GERD) who are being considered for antireflux surgery or have symptoms after antireflux surgery.

Esophageal Motility Disorders↗
PubMed2001

Role of differential neuroaxial blockade in the evaluation and management of pain in chronic pancreatitis.

OBJECTIVES: Chronic pancreatic pain is difficult to treat. Surgical and medical therapies directed at reducing pain have met with little long-term success. In addition, there are no reliable predictors of response including pancreatic duct diameter. A differential neuroaxial blockade allows characterization of chronic abdominal pain into visceral and nonvisceral pain origins and may be useful as a guide to the treatment. Pain from an inflamed, and scarred pancreas should be visceral in origin. The purpose of our study was to determine the frequency with which patients with chronic pancreatitis have visceral pain and whether our modified differential neuroaxial blockade technique using thoracic epidural analgesia can accurately predict which patients will respond to medical or surgical therapy. METHODS: We retrospectively reviewed the medical records of patients with a firmly established diagnosis of chronic pancreatitis (Cambridge classification, calcifications) who had undergone a differential neuroaxial block for their chronic abdominal pain evaluation. Patient demographics and medical or surgical treatment for pancreatic pain was recorded. Response to therapy was defined by a 50% reduction in pain by verbal response score. RESULTS: A total of 23 patients were identified. Alcohol was the most common etiology for chronic pancreatitis (15 of 23, 55%). Surprisingly, the majority of chronic pancreatitis patients had nonvisceral pain (18 of 23, 78%) and only 22% (5 of 23) had visceral pain by differential neuroaxial block. Four of five patients (80%) with visceral pain responded to therapy, whereas only 5 of 17 (29%) of patients with nonvisceral pain responded. CONCLUSIONS: Surprisingly, patients with chronic pancreatitis commonly have nonvisceral pain. Differential neuroaxial blockade can predict which patients will respond to therapy.

Analgesia, Epidural↗
PubMed2001

A randomized, double blind study of interleukin 10 for the prevention of ERCP-induced pancreatitis.

OBJECTIVES: Inflammatory cytokines are released during acute pancreatitis. Interleukin 10 (IL-10) is a potent antiinflammatory cytokine with immunosuppressive and antiinflammatory activities. IL-10 has been shown to attenuate pancreatitis in an animal model. A double blind, placebo-controlled pilot study was conducted to evaluate the safety and efficacy of low dose IL-10 for the prevention of ERCP-induced pancreatitis. METHODS: Patients were randomized to receive a single i.v. dose of recombinant human IL-10 (8 microg/kg) or a placebo i.v. bolus injection 15 min before the procedure. Pancreatitis was defined as abdominal pain radiating to the back associated with elevated amylase or lipase two or more times the upper limit of normal requiring hospitalization for > or =2 days. Severity of pancreatitis was based on days of hospitalization. RESULTS: Two hundred patients were enrolled (101 IL-10, 99 placebo). No difference in age, gender, degree of pancreatic duct filling, therapeutic intervention, or complication was detected between the two groups. Eleven patients in the IL-10 group and nine patients in the placebo group had pancreatitis (p = 0.65). The median length of hospitalization was 4 days in the IL-10 group and 3 days in the placebo group (p = 0.75). CONCLUSIONS: IL-10 at the 8-microg/kg i.v. dose was not effective in reducing the incidence or severity of ERCP-induced pancreatitis. Further investigations are necessary to determine if manipulation of the cytokine pathway can prevent ERCP-induced pancreatitis.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed2000

Gastroenterologist-administered propofol for therapeutic upper endoscopy with graphic assessment of respiratory activity: a case series.

BACKGROUND: Traditional methods of sedation and analgesia for advanced endoscopic procedures can be inadequate and frequently prolong recovery room observation. Propofol is a rapidly acting agent that produces an excellent hypnotic state, but its use is typically limited to anesthesiologist-assisted cases because of the inadequacy of current monitoring standards to reliably detect early stages of respiratory depression. METHODS: Ten patients undergoing advanced upper endoscopic procedures (endoscopic retrograde cholangiopancreatography, endoscopic ultrasound, esophageal stent placement) received a propofol infusion under the control of a second qualified gastroenterologist with advanced cardiac life support skills. Graphic assessment of respiratory activity was made by using a sidestream carbon dioxide detecting cannula. Patient satisfaction was measured with a 100 mm visual analog scale. Recovery scores were measured by standardized scoring of discharge criteria. RESULTS: Monitoring with graphic assessment of respiratory activity detected early phases of respiratory depression, resulting in a timely decrease in the propofol infusion without significant hypoxemia, hypercapnia, hypotension, or arrhythmias. Satisfaction scores were extremely high (median score 92 of 100) and 9 of 10 patients met discharge criteria at 15 minutes after discontinuation of the propofol infusion. CONCLUSIONS: With the use of monitoring by graphic assessment of respiratory activity, propofol infusion by a second qualified gastroenterologist for prolonged upper endoscopic procedures is safe and results in high levels of patient satisfaction with rapid recovery times.

Adult↗
PubMed2000

Sedation for colonoscopy using a single bolus is safe, effective, and efficient: a prospective, randomized, double-blind trial.

OBJECTIVE: Practice guidelines call for the careful titration of sedatives and analgesics during endoscopy, with time taken between incremental doses to assess effect. This approach is time-consuming and has never been validated in a prospective trial. The aim of this study was to compare the safety and efficacy of titration, as outlined in practice guidelines, with a single, rapid bolus of sedatives before colonoscopy. METHODS: Consecutive colonoscopy outpatients were randomized to a single, rapid bolus of meperidine and midazolam or to a titration of doses every 3 min until predefined levels of somnolence were achieved. The colonoscopist was not present during sedation and remained blinded as to which technique was used. Supplemental O2 was given for SaO2 <90% on three or more occasions. Total physician time was calculated from the first injection of sedatives to the removal of the colonoscope. Patient assessments of pain and tolerance were obtained at the time of discharge using visual analog scales of 100 mm (0 = excellent and 100 = unbearable). RESULTS: A total of 101 patients were randomized (49 bolus, 52 titration). Demographic features were similar for both groups. Titration required more physician time than did bolus (32.2 min vs 20.1 min, p < 0.001) and was associated with an increased need for supplemental O2 (44% vs 14%, p = 0.002). Mean tolerance scores were similar (titration 16.3 vs bolus 15.3, p = 0.72). CONCLUSIONS: Rapid bolus sedation for colonoscopy saves significant endoscopist time, is associated with less O2 desaturation, and provides equivalent levels of patient comfort. A revision of the guidelines for sedation and analgesia during endoscopy should be considered.

Adolescent↗
PubMed1998

Importance of additional reflux events during esophageal acid clearing.

Decreased swallow frequency and low-amplitude or nonconducted primary peristaltic contractions are reported to prolong acid clearing in gastroesophageal reflux disease (GERD) patients. The aim of this study is to investigate which of these, or other factors, have a dominant role in long-duration pH reflux events (pHRE). Simultaneous manometry and pH monitoring was performed for 40 min before and after (beginning 40 min postprandial) a test meal. We arbitrarily chose 180 sec to divide pHREs into long or short pHREs. Twenty GERD patients with and without esophagitis were studied. Esophagitis patients had threefold more long pHREs than patients without esophagitis. In most (56%) long pHREs, additional reflux events during acid clearing was the only finding. Only 11% of long pHREs had either a decreased swallow rate (3%) or decreased peristaltic contraction amplitude (8%), as the only finding contributing to poor acid clearing. However, 18% of long pHREs had one of these peristaltic dysfunctions in combination with additional reflux events prolonging acid clearing. Only 15% of long pHREs had no apparent reason for poor acid clearing. In interpreting 24-hr pH monitoring, one should not assume prolonged acid clearing is due to peristaltic dysfunction; instead, it is often due to additional reflux events.

Adult↗
PubMed1998

Pretreatment with methylprednisolone to prevent ERCP-induced pancreatitis: a randomized, multicenter, placebo-controlled clinical trial.

OBJECTIVE: Pancreatitis remains the major complication of endoscopic retrograde cholangiopancreatography (ERCP). Uncontrolled data suggest a lower incidence of pancreatitis in patients with a history of iodine sensitivity when given pretreatment with corticosteroids. We conducted a clinical trial to assess the efficacy of a commonly prescribed corticosteroid, methylprednisolone, to prevent ERCP-induced pancreatitis. METHODS: Patients were entered into a randomized, multicenter, double-blind, placebo-controlled study of intravenous methylprednisolone (125 mg) versus a saline placebo immediately before the ERCP. All patients were evaluated for early and late complications. RESULTS: Two hundred eighty-six patients were randomized. Thirty-one randomized patients were excluded for technical reasons at the time of ERCP. Overall, the incidence of pancreatitis was 16 of 129 (12.4%, 95% CI: 6.7-18.1%) in the methylprednisolone group and 11 of 126 (8.7%, 95% CI: 4.4-15.1%) in the placebo group, which was not significantly different (p = 0.34). Although there was a higher rate of sphincterotomy performed in the methylprednisolone group compared to the control group (31.8% vs 16.8%, p = 0.005), the incidence of pancreatitis was not different when patients undergoing sphincterotomy were analyzed separately (13.6% in the methylprednisolone group and 9.6% in the placebo group,p = 0.50). There was no significant difference between the two groups for those with ERCP-induced pancreatitis in hospital length of stay (p = 0.22), days of parenteral analgesia (p = 0.09), or days of parenteral nutrition (p = 0.15). CONCLUSION: Intravenous methylprednisolone is not beneficial in preventing ERCP-induced pancreatitis.

Analgesia↗
PubMed1996

Origin of atypical reflux symptoms. A case study showing the importance of reflux composition and posture.

In summary we evaluated a 39-year-old man two years after partial esophagectomy and gastroesophageal anastomosis. He had developed recurrent Barrett's esophagus and atypical reflux symptoms. We found free reflux and no antireflux barrier at the hiatus or the esophagogastric anastomosis. Three different reflux techniques performed simultaneously demonstrated that the composition of refluxant varied with posture, explaining the atypical nature of the symptoms. In the left recumbent posture, the refluxate was comprised of acidified liquid and gaseous gastric contents with the patient complaining of heartburn and chest pain. In the right recumbent posture the refluxate was composed of only nonacidic gas, and the patient complained of chest pain without heartburn. We propose that multiple reflux tests performed simultaneously in the setting where a patient experiences his atypical symptoms may help clarify their origin. Furthermore, this case illustrates how posture may dramatically influence refluxant composition.

Adenocarcinoma↗
PubMed1996

The effect of posture on gastroesophageal reflux event frequency and composition during fasting.

OBJECTIVE: To examine the influence of three postures (upright and left and right recumbent) on gastroesophageal reflux event (RE) frequency and composition and a possible mechanism for the observations. METHODS: A) Forty fasting patients with (E+, n = 20) and without (E-, n =20) esophagitis were studied. Simultaneous manometry and pH monitoring were conducted in the left and right recumbent (10 min each) as well as the upright posture (20 min). RE were classified by the pH probe and/or the manometry catheter as acid or gas RE. B) In 23 patients referred for UGI series, radiographs were taken in the left and right recumbent and upright postures after barium and Fizzies. RESULTS: A) Upright RE were similar in frequency in E+ and E- patients (2.6 +/- 0.5 vs 3.05 +/- 0.6). However, E+ patients had more recumbent RE (16.3 +/- 3 vs 0.65 +/- 0.2, p = 0.0001) than E- patients; moreover, the left recumbent posture had more recumbent RE than the right (10.9 +/- 2 vs 5.3 +/- 1, p < 0.02). Moving from recumbent to the upright posture had an opposite effect on RE in the two groups; RE decreased sixfold in E+ patients (16.3 +/- 3 vs 2.6 +/- 0.5, p = 0.0001) but increased fourfold in E- patients (0.65 +/- 0.2 vs 3.05 +/- 0.6, p = 0.0001). In examining RE composition in the E+ patients, RE were twofold more likely to be gas in the left recumbent posture (7.6 +/- 2 vs 3.3 +/- 1, p < 0.1); in direct contrast, RE were eightfold more likely to be acid in the right recumbent posture (4.7 +/- 1 vs 0.6 +/- 0.5, p = 0.0001). As expected from this observation, acid exposure was greater in the right than left posture (52 +/- 8 vs 15 +/- 6%, p < 0.0001). Although RE were too infrequent in E- patients to reach statistical significance, the effect of posture on the composition of the few RE that did occur mirrored that of the E+ patients. B) In 17/23 (74%) radiographs in the right recumbent posture, the EG junction was submerged in a barium pool below the air-barium interface in the stomach. In contrast, this occurred in 0/23 patients in the left recumbent and 1/23 patients in the upright postures because the EG junction was in the air above the barium pool. CONCLUSION: Posture has an influence on RE frequency and composition while fasting, and the latter is likely due to whether the EG junction is submerged below liquid gastric contents or in the air above the liquid gastric contents.

Adolescent↗
PubMed1994

Upright refluxers without esophagitis differentiated from bipositional refluxers with esophagitis by simultaneous manometry and pH monitoring conducted in two postures before and after a meal.

OBJECTIVE: To determine whether two dissimilar groups characterized by 24-h esophageal pH monitoring would have individual reflux events that occur under the same or different circumstances when challenged by a meal and monitored in different postures. These groups consisted of upright refluxers without esophagitis (n = 10) versus biopositional refluxers with esophagitis (n = 8). METHODS: Our evaluation consisted of a questionnaire completed prior to simultaneous manometry and pH monitoring. This monitoring was conducted over a 120-min period that incorporated the upright and recumbent postures both before and after a meal. Three of our four criteria for reflux were independent of a classic pH event. RESULTS: From the questionnaire, it was apparent that dyspeptic symptoms almost always occurred in the upright refluxers. In addition, provocation for their heartburn had atypical characteristics regarding posture, and their degree of regurgitation was intensified by the postprandial state. During dual monitoring, the upright posture and the meal provoked an increase in frequency of reflux in the upright refluxers, as opposed to only recumbency in the bipositional refluxers. Moreover, reflux events in the upright refluxers usually were associated with Valsalva maneuvers and were recognized as symptoms, two features that were less true in the bipositional refluxers. A similar percentage of reflux events occurred over a low basal lower esophageal sphincter pressure and after a lower esophageal sphincter relaxation, in both groups. CONCLUSION: The two groups manifested distinctively different reflux characteristics, presumably due to dissimilar mechanisms.

Adult↗
PubMed1994

Alcohol sclerosis for polycystic liver disease and obstructive jaundice: use of a nasobiliary catheter.

We report the use of a nasobiliary catheter in the management of a 55-yr-old female with autosomal dominant polycystic kidney disease who developed obstructive jaundice from a hepatic cyst. The patient presented with a 2-wk history of fatigue, jaundice, nausea, vomiting, and abdominal pain. Physical examination was remarkable for tender hepatomegaly. Computerized tomography revealed multiple hepatic cysts and dilated intrahepatic biliary radicles. Endoscopic stent placement failed to relieve the obstruction. Computerized tomography guided percutaneous aspiration of the obstructing hepatic cyst was successful with the aid of a nasobiliary cholangiogram allowing visualization of the biliary tree and identification of the obstructing hepatic cyst. However, the cyst rapidly accumulated fluid, and the obstruction recurred within 1 wk of simple aspiration. Relief of symptoms was maintained only after alcohol sclerosis of the obstructing hepatic cyst. Review of the literature shows that alcohol sclerotherapy is a safe and effective nonsurgical means of treating symptomatic hepatic cysts.

Catheterization↗
PubMed1992

Prolonged clearance is the primary abnormal reflux parameter in patients with progressive systemic sclerosis and esophagitis.

The purpose of this study is to determine if frequent reflux events from an incompetent LES or poor clearance from decreased peristalsis is the predominant abnormality in PSS patients with severe reflux esophagitis. Seven patients with both classic manometric findings of PSS and endoscopic findings of esophageal ulcerations and/or Barrett's esophagus were compared to nine patients with similar endoscopic findings but with no evidence of a connective tissue disorder. All patients underwent simultaneous intraesophageal pH monitoring and scintigraphy for a total of 40 min after a radiolabeled meal. Four of the PSS patients and all the non-PSS patients had simultaneous manometry. We found that PSS patients had significantly fewer reflux events (P less than 0.01), but the reflux events had significantly longer duration (P less than 0.01) compared to patients with similar severity of esophagitis and no connective tissue disease. We conclude that decreased smooth muscle peristalsis appears to be the primary contributor to acid exposure and esophageal injury in PSS.

Esophagitis, Peptic↗
PubMed1992

Scintigraphy in gastroesophageal reflux disease: a comparison to endoscopy, LESp, and 24-h pH score, as well as to simultaneous pH monitoring.

We compared scintigraphy to other reflux tests in 45 symptomatic patients. Sensitivity of 24-h pH score was 82%, endoscopy 64%, and LESp 33%. Scintigraphy was insensitive (36%), although 50% of patients with esophagitis had a positive test. Specificity and positive predictive value were good (all greater than or equal to 88%) in discerning patients with an abnormal 24-h pH score and esophagitis. We suggest scintigraphy as the first diagnostic test to confirm frequent reflux events (REs) and normal clearance in the subgroup of patients with severe endoscopic esophagitis, and manometry and 24-h pH monitoring when scintigraphy is negative. We also compared scintigraphy to simultaneously performed pH monitoring in detecting individual postprandial REs and their clearance. The two methods agreed in only 25% of total reflux events. Scintigraphy was superior at detection of reflux of buffered gastric contents and detection of additional REs during acid clearing intervals, whereas only the pH probe detected REs after gastric emptying. We conclude that scintigraphy has a limited role as a diagnostic test in gastroesophageal reflux disease, and much potential as a research tool, especially in combination with the pH probe.

Adult↗
PubMed1991

Simultaneous esophageal pH monitoring and scintigraphy during the postprandial period in patients with severe reflux esophagitis.

To compare reflux events detected by intraesophageal pH monitoring with that of scintigraphy, we simultaneously performed both techniques along with esophageal manometry in nine patients with severe reflux esophagitis. Two hundred eighteen reflux events were detected in the recumbent posture after a meal during a 40-min interval. Both techniques simultaneously detected only 23% of all reflux events. Scintigraphy alone detected 61% of all reflux events as opposed to 16% for pH monitoring. Of those reflux events diagnosed only by scintigraphy, more occurred while the intraesophageal pH was less than 4 (ie, during an acid-clearing interval) than while the intraesophageal pH was greater than 4 (ie, when intragastric contents were neutralized by the meal). Most reflux events occurred during periods of stable, but low LES pressure. While reflux events diagnosed by scintigraphy significantly decreased during the second of two 20-min postprandial intervals, those by pH monitoring tended to increase. That simultaneous scintigraphy and pH monitoring agreed on less than 1/3 of all reflux events not only underscores the fact that both techniques measured different physical components of the esophageal refluxate (ie, volume vs acid concentration, respectively), but also were influenced by different physiologic events such as the ingestion of a meal, gastric emptying, and esophageal acid clearance.

Adult↗
PubMed1991

Benign structural lesions of the esophagus.

This article discusses a wide spectrum of intrinsic benign structural lesions of the esophagus. Additionally discussed are extrinsic benign structural lesions that may cause esophageal symptoms. Because any congenital anomaly or disease of a structure that normally impinges on the esophagus, or is adjacent to it, may distort the esophagus, we review disorders from several different organ systems.

Diverticulum, Esophageal↗
PubMed1990

Suture granuloma masquerading as malignancy of the biliary tract.

Eighteen years after having a duodenal leiomyosarcoma resected, a patient presented with weight loss, pruritus, and abdominal pain. ERCP was consistent with a cholangiocarcinoma with proximal hepatic duct stricture and nonfilling of the cystic duct. CAT scan revealed no extrinsic masses compressing the gallbladder or biliary tract. At surgical exploration, the patient was found to have a suture granuloma with surrounding fibrosis within the common bile duct. There was no evidence of malignancy.

Adenoma, Bile Duct↗