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PubMed1997

Effects of octreotide on manometric variables in patients with neuropathic abnormalities of the small bowel.

At present, there are few therapeutic options in patients with chronic intestinal dysmotilities. Octreotide, a long-acting somatostatin analog, has recently been shown to be a potentially useful drug in this setting, being able to start activity fronts (AF) in the small bowel in both healthy subjects and patients with intestinal motor disorders. We studied the effects of octreotide on manometric variables in 10 patients with chronic upper gastrointestinal symptoms and an intrinsic neuropathic disorder of the small intestine. Gastrointestinal manometry was carried out for 6 hr during fasting and 2 hr after a standard 605-kcal mixed meal. Thereafter octreotide, 50 micrograms subcutaneously was administered and the recording session continued for a further hour. Analysis of the tracings during fasting showed that 44% of the AF were abnormal; octreotide significantly increased the hourly number of AF (2 +/- 0.26 vs 0.67 +/- 0.14, P < 0.0001) and their duration (8.33 +/- 1.3 vs 6.12 +/- 0.34 min, P < 0.05) with respect to the baseline (fasting) period, and the propagation velocity also significantly slowed (3.4 +/- 0.4 vs 11 +/- 0.6 cm/min, P < 0.05). After the drug, 80% of patients displayed two AF and 10% more than two AF; the first AF after octreotide was always abnormally propagated. An almost complete inhibition of small bowel postprandial contractile activity was observed in 80% of patients, and the remaining 20% showed decreases. In three subjects, octreotide injection evoked the appearance of pylorospasm. From these results we conclude that octreotide could be of some benefit in patients with neuropathic disorders of the small bowel, although it remains to be established whether it is most useful in patients with more severe conditions, characterized by the complete absence of AF. The appearance of pylorospasm may contribute to the delayed gastric emptying observed after the drug is administered.

Adult↗
PubMed1989

Incidence of infantile hypertrophic pyloric stenosis in Saskatchewan, 1970-85.

We reviewed the incidence rates of infantile hypertrophic pyloric stenosis (IHPS) and pylorospasm in Saskatchewan from 1970 to 1985 and found a marked decrease in the rates after 1976. As expected, there was a preponderance of males among those with IHPS and among those with pylorospasm discharged from hospital between 1 and 3 months of age. No seasonal pattern was observed. We believe that the decrease in incidence rates was related to environmental influences, such as changes in the methods of feeding observed since 1977.

Female↗
PubMed2002

Congenital hypertrophic pyloric stenosis.

Congenital hypertrophic pyloric stenosis, an important cause of intractable vomiting in infants is diagnosed clinically and confirmed ultrasonographically. Other useful interventions are plain radiography and barium study. Differential diagnosis includes pylorospasm and gastroesophageal reflux. Management protocol includes correction of dehydration and electrolyte imbalance and either Fredet Ramstedt pyloromyotomy or medical treatment with atropine sulphate. Atropine is initially given intravenously till vomiting is controlled and then orally at double the effective i.v. done for another 3 weeks. Atropine sulphate is generally well tolerated and side effects are few like tachycardia, raised SGPT and hyperthermia. Atropine sulphate is very effective, cheap, safe and perhaps more acceptable treatment option for CHPS.

Atropine↗
PubMed2006

Minimally invasive esophagectomy for cancer: prospective evaluation of laparoscopic gastric mobilization.

BACKGROUND: Esophagectomy carries high morbidity, mainly respiratory. Minimally invasive surgery has been demonstrated to improve postoperative outcome in digestive surgery, without impairment of oncological results. A prospective study was conducted to evaluate feasibility, postoperative outcome, and mid-term oncological results of minimally invasive esophagectomy (MIE) in cancer. METHODS: From July 2001 to August 2005, 25 patients underwent esophagectomy with laparoscopic gastric mobilization (LGM) for epidermoid carcinoma (n=15) or adenocarcinoma (n=10). Tumors were located on the cardia (n=6), on the lower third (n=14), or on the median third (n=5) of the esophagus. Following LGM, transthoracic esophagectomy was performed. RESULTS: Complete LGM was achieved in all patients but 1. Mean operative time for LGM was 191+/-49 minutes. Fifteen patients (60%) developed complications, mainly respiratory. Anastomotic leakage occurred in 2 patients, with a favorable outcome. Pylorospasm (n=1) was the only intra-abdominal complication. Median hospital stay was 18 days. Two patients died (8%). Twenty-three patients underwent R0 resection. A mean of 12+/-4 lymph nodes (range 4-19 nodes) were analyzed. With a mean follow-up of 14 months (1-46 months), actuarial survival at 1 and 2 years was, respectively, 73% and 56%. CONCLUSION: Esophagectomy with LGM is feasible with few specific complications. However, no decrease in morbidity and hospital stay could be observed. Mid-term oncological results seem comparable to those of conventional surgery. Further studies are required to evaluate the extent of lymphadenectomy and the oncologic safety of MIE.

Adenocarcinoma↗
PubMed2006

Delayed gastric emptying: whom to test, how to test, and what to do.

Gastroparesis, or delayed gastric emptying, is a common cause of chronic nausea and vomiting as seen in a gastroenterology practice. Diabetic, postsurgical, and idiopathic causes remain the three most common forms of gastroparesis. In addition to nausea and vomiting, symptoms of gastroparesis may include early satiety, postprandial fullness, and abdominal pain. Physiologic changes that may explain symptoms in patients with gastroparesis, in addition to delayed gastric emptying, include impaired fundic accommodation, antral hypomotility, gastric dysrhythmias, pylorospasm, and perhaps visceral hypersensitivity. Diagnosis of gastroparesis is best determined using a radioisotope-labeled solid meal with scintigraphic imaging for at least 2 hours, and preferably 4 hours, postprandially. Most commonly, a 99mTc sulfur colloid-labeled egg sandwich with imaging at 0, 1, 2, and 4 hours is used. Extension of the gastric emptying test to 4 hours improves the accuracy of the test, but unfortunately, this is not commonly performed at many centers. Emptying of liquids remains normal until the late stages of gastroparesis and is less useful. The aims of treatment should be to control symptoms and maintain adequate nutrition and hydration. Patients should be advised to eat small meals and to limit their intake of fat and fiber. Additional dietary recommendations may include increasing caloric intake in the form of liquids. For diabetic patients, control of blood glucose levels is important, as symptom exacerbation is frequently associated with poor glycemic control. Specific treatment often begins with metoclopramide, 10 mg, up to four times daily, after a discussion of possible side effects with the patient. An antiemetic agent, such as prochlorperazine, 5 to 10 mg orally or 25 mg by suppository, can be added on an as-needed basis every 4 to 6 hours to control nausea. If these antiemetic medications are not effective, or if side effects develop, orally dissolving ondansetron, 8 mg every 8 to 12 hours, can be tried on an as-needed basis. If this regimen is unsuccessful, then alternative prokinetic agents--erythromycin, 125 mg, or tegaserod, 6 mg, prior to meals--can be tried. For cases refractory to these treatments, referral to a center with US Food and Drug Administration permission to use domperidone should be considered. Alternatively, symptom modulators such as low-dose tricyclic antidepressants can be tried to reduce symptoms, but these do not improve gastric emptying. In patients for whom all medical therapy fails, other options that are tried at experienced centers include the injection of botulinum toxin into the pylorus, placement of a feeding jejunostomy, and/or placement of a gastric electrical stimulator.

Journal Article↗
PubMed1979

Patterns of postcibal gastroesophageal reflux in symptomatic infants.

Symptomatic infants displayed three patterns of gastroesophageal reflux after drinking apple juice (20 ml/kg or 300 ml/m2 of body surface area). The type I pattern occurred in patients who had continuous postcibal gastroesophageal reflux, large hiatal hernias and frequently required an antireflux operation. A functional motility disorder suggesting delayed gastric emptying appeared to be important in infants with discontinuous reflux (type II pattern). These infants had frequent gastroesophageal reflux for only 2 3/4 hours postcibally, antral-pylorospasm, increased low esophageal sphincter pressures, and a high incidence of pulmonary symptoms and non-specific watery diarrhea. The mixed (type III) pattern of gastroesophageal reflux occurred in a small number of infants and exhibited features of both type I and II patterns.

Child, Preschool↗
PubMed1986

Valvuloplasty plus fundoplasty to prevent esophageal regurgitation in esophagogastrostomy after proximal gastrectomy.

To prevent regurgitation esophagitis in esophagogastrostomy after proximal gastrectomy, valvuloplasty plus fundoplasty was carried out in 17 patients with stomach cancer or cancer of the abdominal esophagus. For this purpose, an equilateral triangular flap of 2.5 cm per side was formed at the upper margin of the remaining stomach along the greater curvature. The flap was inverted into the stomach only to serve as a valve. After the esophagogastrostomy was properly performed, fundoplasty was carried out, lifting and suturing the uppermost edge of the stomach to the esophagus along the greater curvature. To prevent pylorospasm as a result of reduced gastric volume, pyloromyotomy was also performed. The results were excellent in those followed for more than 1 year. The technique is simple and effective and, we believe, deserves further clinical evaluation.

Esophagitis, Peptic↗
PubMed2006

[Minimally invasive esophagectomy: prospective evaluation of laparoscopic gastric mobilization].

OBJECTIVE: Esophagectomy carries high morbidity, mainly due to respiratory complications. In digestive surgery, postoperative outcome is generally improved by minimally invasive surgery. A prospective study was conducted to evaluate feasibility and postoperative outcome of minimally invasive esophagectomy (MIE). METHODS: From July 2001 to June 2004, 20 patients underwent esophagectomy with laparoscopic gastric mobilization (LGM) for squamous cell carcinoma (N=11), adenocarcinoma (N=7), Barrett's esophagus with high-grade dysplasia (N=1), and long peptic stricture (N=1). Tumours (N=19) were located on the cardia (N=5), on the lower third of the oesophagus (N=10), on the median third (N=3), and on the upper third (N=1). Following LGM, transthoracic (N=19) or transhiatal (N=1) oesophagectomy was performed. RESULTS: Complete LGM was achieved in all cases. Mean operative time for LGM was 197+/-48 minutes. In the 19 patients operated for tumours, 18 underwent R0 resection. Eleven patients (55%) developed postoperative complications, mainly (30%) respiratory. Intrathoracic anastomotic leakage occurred in 2 patients, with favourable outcome. Pylorospasm (N=1) was the only intraabdominal complication. One patient died (5%). CONCLUSION: Esophagectomy with LGM is feasible with few specific complications. However, no decrease in morbidity could be observed with this technique. Further studies are required to evaluate if thoracoscopy could improve the postoperative course after LGM and to validate oncologic safety of MIE.

Adenocarcinoma↗
PubMed1980

Diagnostic advantages of manual compression fluoroscopy in the radiologic work-up of vomiting neonates.

This paper describes a simple and effective fluoroscopic technique that remarkably improves diagnostic accuracy when evaluating vomiting newborns. The technique also minimizes the time of the examination and the radiation dose to the patient and radiology personnel. Several examples are presented illustrating the superiority of gloved hand or nonopaque compression technique to conventional contrast radiography, emphasizing babies with pyloric stenosis and midgut malrotation. The technical limitations and diagnostic pitfalls of conventional contrast modalities are compared to the highly diagnostic images obtained with manual compression fluoroscopy. All of the classic radiographic signs of pyloric stenosis can be mimicked by antral spasm or pylorospasm. Gloved hand compression overcomes antral spasm and clearly shows the true length and diameter of the pyloric canal in these two conditions. Malposition of the duodenojejunal junction is the only consistently diagnostic sign of midgut malrotation. Nonfixation of the duodenojejunal junction can be competently assessed by compression fluoroscopy, confirming malrotation and midgut volvulus simultaneously and bringing the patient to operation much sooner than with less precise conventional techniques. Gloved hand compression technique also evaluates stenotic areas in the upper gastrointestinal tract, distinguishing spasm from organic marrowing and clearly identifying those which need surgical intervention. Facilitating intubation of the duodenum is a final contribution of compression fluoroscopy.

False Negative Reactions↗
PubMed1984

Symptomatic gastroduodenal pancreatic rest in children.

Since 1979 nine children have undergone excision of gastroduodenal pancreatic rest. In three, these lesions were incidental findings at the time of unrelated surgery. The remaining six underwent resection for relief of abdominal symptoms. There were four boys and two girls. The ages ranged from 4 months to 13 years. Symptoms were directly related to age. Three children (6 months, 8 months and 4 years) were admitted for recalcitrant post-prandial vomiting. The remaining three (11, 12, and 13 years) were hospitalized for chronic midabdominal pain. Contrast radiographic studies were normal in three. An antral filling defect was noted in one and edematous proximal duodenum with poor peristalsis in the remaining child. Endoscopic examination and biopsy documented pancreatic rest in all six cases. All were located in the immediate vicinity of the pylorus. The size ranged from 0.5 to 2 cm in diameter. Each child subsequently underwent excision with relief of symptoms. Pancreatic rest is functioning pancreas. Its presence in the prepyloric region may incite pylorospasm, delayed emptying and gastric distention and become clinically apparent with vomiting and/or abdominal pain. Documentation of gastroduodenal pancreatic rest in the symptomatic child with an otherwise normal evaluation may warrant excision.

Adolescent↗
PubMed1985

Gastric damage from ingested acid in children.

Acid ingestion occurs relatively rarely and produces a spectrum of injury that is markedly different from the more commonly encountered alkaline burns of the oropharynx and esophagus. Gastric damage results from pylorospasm with pooling of the ingested caustic in a dependent location. Symptoms may be delayed for days or weeks. Perforation and/or strictures may require extensive gastric surgery. Early fiberoptic endoscopy is essential.

Acids↗
PubMed1977

Antral diaphragm--a cause of gastric outlet obstruction in infants and children.

Gastric outlet obstruction in infants and children may be due to a partial, prepyloric antral diaphragm. Twelve new patients are added to the 32 described previously. Onset of symptoms varied from shortly after birth to five years. Nonbilious vomiting was the most common presenting symptom. Radiographic evaluation requires specific technique for demonstration of the web and to differentiate this from pylorospasm and pyloric stenosis. Gastroscopy was employed in three patients. Repair usually consisted of incision of the web and construction of a patulous gastric outlet. All patients remained asymptomatic after operation. The etiology of the webs remains unknown, but they may result from an excessive local endodermal proliferation early in gastric development.

Abnormalities, Multiple↗
PubMed1975

Hypersecretion and length of history in duodenal ulceration.

Maximal gastric secretion, measured by the histamine-infusion test, was, as expected, significantly greater in a group of 81 patients with duodenal ulcer than in a group of 72 controls. After standardising for the effect of stature on maximal secretion, only 24 of the patients were found to be true hypersecretors. However, maximal secretion in the ulcer group increased with length of history of symptoms, and extrapolation back to zero length of history suggested that there was no significant hypersecretion at that time. These facts support the hypothesis that it is the presence of the ulcer that leads to hypersecretion rather than the converse. Possible mechanisms involved are chronic ingestion of antacids to counter dyspepsia, or gastric distension due to pylorospasm.

Adolescent↗
PubMed1978

Emergency management and sequelae of acid ingestion.

Because it causes immediate pain when taken into the mouth, strong mineral acid is less often swallowed than corrosive alkali, but psychotic, inebriated or determined individuals may consume lethal amounts. Burns of the oropharynx and glottis may lead to asphyxial death. Acid has only superficial effects upon the esophagus but, upon reaching the stomach, flows along the lesser curvature, induces pylorospasm, and pools in the distal antrum. Pyloric stricture is the most common late complication among survivors. Due to the rapidity with which acid acts, local and systemic therapy must be expeditious. Neutralization and demulcification are recommended but no time should be lost if weak alkali is not readily available. Lavage has limited applicability and induced emesis is strictly contraindicated. Aggressive intravenous fluid therapy, antibiotics, and opiates for pain are needed in most instances. Immediate gastrectomy and steroids are controversial but operative intervention is eventually required following most significant ingestions.

Acids↗
PubMed1999

Botulinum toxin for spastic gastrointestinal disorders.

Botulinum toxin (BTX) is one of the most potent inhibitors of acetylcholine from nerve endings, and this accounts for its toxic properties as well as its therapeutic application in a variety of neuromuscular syndromes. This review focuses on the growing use of BTX in the so-called 'spastic' disorders of the gastrointestinal tract. These include achalasia, for which the short-term efficacy of the intrasphincteric injection of BTX has been well established. However, because of the chronicity of this condition, repeated injections of the toxin may be required at regular intervals. In contrast, the relatively short duration of action may be an advantage in disorders such as chronic anal fissure, where the benefit of this therapy has now been demonstrated in hundreds of patients. There are many other sphincteric and non-sphincteric syndromes in the gut for which the efficacy of this agent is being actively tested. These include non-cardiac chest pain, post-operative pylorospasm and sphincter of Oddi dysfunction. Skeletal muscle sphincters, such as the upper oesophageal sphincter or the external anal sphincter/puborectalis muscle, may also be targeted, with good effect. In some of these conditions, the local injection of BTX may serve as a useful therapeutic trial, facilitating the decision to institute more invasive forms of therapy. The cumulative short-term experience with BTX in the gut to date suggests that it is a relatively simple and safe therapy. The use of BTX represents a novel approach for gastrointestinal motility disorders, and the rapidly expanding list of successful applications holds promise for a more widespread use of similar agents in the future. Additional studies on long-term outcome are eagerly awaited.

Botulinum Toxins↗
PubMed1991

[Balloon dilatation of benign esophageal stenoses].

Benign stenoses of the oesophagus have been conventionally treated by endoscopic bougienage and were operated on in case of failure. Now that balloon catheters with large balloon diameters are available, interventional radiological dilatation of enteric strictures can be easily performed. In case of eccentric high-grade stenosis with or without blind loop, stenosis is often easier to manage and associated with less risk with an angiographic guide wire and catheter than by endoscopy. 53.3% of the patients were referred to balloon dilatation after failed endoscopic bougienage. The indications for balloon dilatation were anastomotic stenosis (66.2%), peptic stenosis (16.9%), achalasia (7%), pylorospasm (5.6%) and stenosis due to pemphigus vulgaris, acid ingestion and (in one case) a Schatzki ring. The complication rate was low at 1%. The experience collected with 297 dilatations in 71 patients with benign oesophageal stenosis, is reported.

Adult↗
PubMed1980

Peptic ulcer disease in early infancy: clinical presentation and roentgenographic features.

Sixteen infants under 11 weeks of age developed documented peptic ulcer disease involving the stomach, duodenum or pylorus during an eight-year period in a Newborn Intensive Care Unit. The precipitous onset of gastrointestinal bleeding and/or perforation commonly associated with ulcer disease in early infancy was present in only seven (44%) of the 16 patients. The remaining nine infants (56%) presented with recurrent emesis, a presentation of peptic ulcer disease rarely described in the first weeks of life. Contrast radiography was used to demonstrate a definite ulcer crate in 13 of these patients. Two had their ulcers diagnosed at surgery and one by endoscopy. Radiographic demonstration of pylorospasm and/or gastric retention was often associated with ulcer craters located in the pyloric channel or gastric antrum. Only two patients required surgery for massive bleeding and perforation. The remainder were successfully managed medically using orogastric suction antacids and gradual resumption of milk feedings. There were no deaths within our population attributable to peptic ulcer disease.

Antacids↗